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Based on interview, record review, and policy review the facility failed to follow physician orders for a 1:1 sitter (continual observation for safety) for one discharged patient (#3) of one patient reviewed with a 1:1 sitter order, that allowed her to successfully elope (escape) from the facility and to provide nursing oversight to ensure that the proper elopement precautions were in place to prevent the elopement.

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Nursing Services. The facility census was 337.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 01/10/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect all patients.

As of 01/10/18, at the time of the survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Action Item #1: Immediate action to be taken on Wednesday 01/10/18 was to conduct an assessment for all inpatients that are currently on elopement precautions and/or 1:1 sitter to ensure elopement precautions are in place appropriately and according to policy, and sitter is knowledgeable of this policy and patient's current condition. This will be completed at all three campuses. Daily audits will be conducted in real time every shift. Patient's current condition and sitter verbalization of understanding has been added to the daily audit spreadsheet. Audit process already includes patient with self-harm, suicide and safety issues. Address any issues in real time and follow -up with appropriate manager. Compliance will be reviewed weekly with the Chief Nursing Officer (CNO) and rounding log maintained by Nursing Operations.
- Action Item #2: Reeducate all staff prior to the start of their next shift (current day shift staff on 01/10/18 prior to them leaving shift) on the following: Elopement Risk Policy; Observation Policy; Elopement scenarios; Code Purple. This will be completed at all three campuses. Annual Patient Safety will be provided to all staff, including new hires to include the above elements. Leaders responsible to facilitate education include senior leadership from all three campuses.
- Action Item #3: Implement revised huddle template to include constant observation and safety risk to include suicide/psychiatric and elopement risk. This is to be utilized on all inpatient nursing units as the pre-shift huddle reports. All huddle sheets will be submitted to the CNO for review following huddle, and reviewed and reconciled with the rounding logs in Action #1.
- Action Item #4: Immediate action to be taken on 01/10/18 PM shift (allowing for education to be provided to current and oncoming shifts). Mock Code Purple drills will be conducted at a minimum daily every shift for two weeks and if 100% compliance is achieved then mock Code Purple Drills will be conducted daily, alternating shifts until survey team returns for revisit. Evaluation form is to be filled out and reviewed in tandem with Quality and Security departments. Real time education and feedback will be provided to involved unit/department leader.

Based on observation, interview, record review, and policy review the facility failed to follow physician orders for 1:1 sitter (continuous observation of patient by a staff member) for one discharged patient (#3) of one discharged patient reviewed with an order for 1:1 sitter. Facility staff also failed to recognize the elopement risk of the patient that resulted in her elopement (escape) from the facility. The facility census was 337.

Findings included:

1. Record review of Patient #3's History & Physical (H&P) showed:
-She was admitted on 12/14/17 through the Obstetrics service in the Women's Services Emergency Area;
-Her primary complaint at admission was heavy vaginal bleeding for one hour, she was 36 weeks, six days gestational (the carrying of an embryo or fetus inside the uterus) age via ultrasound;
-She admitted to having had limited prenatal care (preventative healthcare, regular check ups during pregnancy to prevent any potential health care issues or problems) during this pregnancy;
-She reported two previous pregnancies that both resulted in cesarean sections (C-section, a surgical intervention to deliver an infant when a vaginal delivery would put the mother or infant at risk), one of them for placental detachment (a serious complication during pregnancy where the placenta detaches or tears away from the uterus which is what supplies the infant with food and oxygen);
-Her past medical history included depression and anxiety;
-She denied any alcohol or drug use, admitted to smoking one pack of cigarettes a week;
-She underwent an emergency C-section for heavy vaginal bleeding and possible placental abruption on 12/14/17 at 10:43 PM with delivery of a male infant at 11:07 PM.

2. Review of the Facility's policy titled, "Behavioral Health: Levels of Observation", revised 08/2016, showed the directive for a 1:1 Observation as being ordered for a patient that is at immediate risk of harm to self and/or others, should have an assigned and dedicated staff member for the patient. Staff member should remain within arm's reach of the patient. No patient is to be left unattended while on 1:1 status.

3. Review of the Facility's policy titled, "Code Purple-Patient Elopement (Precautions, Patient Safety, and Reporting)", revised 11/2016, directed staff members to implement the following interventions to reduce the risk of patients wandering or leaving the facility: signage on the door and chart, removal of shoes, issuance of blue paper scrubs, bed alarm, and/or use of 1:1 sitter.

4. Review of Patient #3's medical record showed that there was a physician order for 1:1 observation, ordered on 12/15/17 at 12:48 PM, and to be continued on transfer to Four West due to acute psychiatric break (a harsh and abrupt disconnect or break from reality or episode of psychosis). Patient #3 had been involved in a Code White (overhead page alerting all available personnel and security to respond and aide in assisting fellow staff with a violent patient) on 12/15/17 while on the post-partum (following childbirth or birth of young) unit when she became acutely agitated with staff and threw an entire tray of food at them, pulled out her own urinary catheter, and became verbally abusive towards staff. Patient #3 was transferred from post-partum unit to Four West on 12/15/17 at approximately 5:30 PM.

Medical record review of Consultation Note, dated 12/15/17, from Patient #3's medical record showed:
- She was admitted and delivered an infant via C-section (12/14/17 at 11:07 PM), her third child;
- Consult was initiated by her behavior the morning after her C-section, she became acutely agitated with staff and threw an entire tray of food at them, pulled out her own urinary catheter, became verbally abusive towards staff, and remained loud and threatening, patient verbalized that she felt that she was being attacked when staff responded to the Code White;
-She had been previously hospitalized in the Psychiatric Center for a few days during this pregnancy;
-Most recent admission for psychiatric issues was related to feeling harassed whenever she was on public transportation; she was treated for depression and only provided with an antidepressant medication;
-She had also been hospitalized at another psychiatric facility during this same pregnancy for depression and trouble with her temper;
-She denied having had any previous hallucinations or delusions, but exhibited suspicious thinking, over valued ideas, with insight and judgement impairment;
-Multiple psychiatric admissions during the last year in multiple facilities exhibited a chronic psychiatric illness history;
-Recommendations made by Psychiatry included: 1:1 sitter, moving to a medical-surgical floor (off Post-partum unit), move to psych unit when post-operative day #3, patient not be allowed to leave Against Medical Advice (AMA, when a patient leaves the hospital against the advice of their doctor), and staff to fill out affidavit to hold the patient.

Review of Patient #3's medical record showed:
- An Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours dated 12/15/17, and signed by the patient's physician;
- The Affidavit noted that she had been yelling at hallucinations (an experience involving the apparent perception of something not present) of people in her room whom were spraying her;
- She had been talking about devil worshipers, and throwing objects endangering herself and staff members;
- Family members reported that she had a history of Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly, a disconnect from reality) and a previous history of use of psychiatric medications.

Review of the facility's document titled, "The Frequent Monitoring Flowsheet", dated 12/15/17 showed:
- That the first documentation of Patient #3's behavior was noted at 7:00 PM;
- The observation level marked on the form directed staff that Patient #3 was "Safety and Dignity" (the need for a safety sitter to prevent injury to the patient);
- There was no notation for the 1:1 status.

5. Review of the facility's document titled, "The Frequent Monitoring Flowsheet", dated 12/16/17, had no observation level marked to direct staff and no notation for the 1:1 status.

6. During an interview on 01/09/18 at 1:32 PM, Staff II, Chief Nursing Officer, stated that the expectation is that staff members/nurses, are to follow doctor's orders. That the physician's order, for Patient #3, directed for patient to be 1:1 with a sitter and that she had actually been assigned as a 2:1, with the sitter sitting in the doorway between both rooms.

During an interview on 01/09/18 at 10:00 AM, Staff K, RN, Four West Manager, stated that it was expected that all elopement risk patients and 1:1 patients be identified during shift huddles (brief staff meetings that are held daily on each shift and unit, to communicate patient issues). She stated that on the day of the elopement, it was passed on in huddle that the patient was a 2:1 patient (or patient requiring a sitter for safety). Staff K also stated that all staff are educated yearly through Healthstream (computer education) regarding elopement risks and proper use of safety sitters.

During an interview on 01/10/18 at 9:06 AM, Staff KK, Patient Care Technician (PCT) stated:
- On the day that Patient #3 eloped, she was the sitter assigned to her, in addition to one other patient;
- That she was positioned in the hallway facing both rooms (4124, Patient #3's room, 4123, second patient's room), and that both beds were in her line of site;
- That when she was given her assignment from the night shift PCT, she was told that she was to be a 2:1 sitter (a staff member assigned to watch and keep safe two patients; prevent them from falling or injuring self);
- Patient #3 was on a "psych hold" (an involuntary confinement to hospital for suspected mental disorder in which a person is a danger to themselves, a danger to others, or gravely disabled) due to her behavior on Post partum ward;
- The second patient was an Alzheimer's (senile dementia, a progressive disease that destroys memory and other important mental functions) patient;
- They did tell her that the Alzheimer's patient was impulsive, and up and down frequently, either to the bedside commode or to the door, setting off the bed alarm each time;
- Patient #3's behavior was appropriate, and she had been calm and cooperative, until the Division of Family Services (DFS) worker had gone in to see her;
- She could hear Patient #3 crying, she was upset because DFS wanted her to be cleared by a Psychiatrist prior to any contact with her newborn child;
- When Staff MM, Registered Nurse (RN) entered the room, she removed the DFS worker to the hallway, trying to diffuse the situation;
- At that time, the Alzheimer's patient, began getting out of bed, and could not be directed from the hallway, so Staff KK had to go into the room at the bedside;
- Staff KK stated that there had been other staff members present, and that Patient #3 had been sitting on her bed;
- When she returned to the hallway, approximately 6 minutes later, she checked the room of Patient #3, and was not able to locate her;
- She immediately called the Charge Nurse, Staff LL, whom "hit the panic button" and called a Code Purple (overhead announcement to let all staff know that a patient has eloped/escaped from a unit);
- When asked how Patient #3 was dressed, Staff KK stated that she had a hospital gown on, and that Staff MM, RN, had provided the patient with pajama bottoms and slipper socks;
- Staff KK also stated that it was impossible to watch Patient #3 in her room, at the same time she was assisting the second patient in her room.

Observation on 01/09/18 at 09:15 AM showed that the room that Patient #3 had occupied was located at the entrance to the Four West unit. The room was approximately five feet from the double fire doors, 10 feet from the nurses' station, and less than 20 feet from the visitor elevators to the lobby.

During a telephone interview on 01/10/18 at 1:50 PM, Staff LL, RN, stated that when she came on shift that morning, it was relayed to her by the Night Charge Nurse, that the patients in rooms 4124 and 4123, were being monitored by a 2:1 sitter. Patient #3 was described to her as being "subdued", she was told that the patient had been medicated prior to transferring to the unit, and had slept all night. The second patient in room 4123, was described as being more of a "Fall Risk", and confused at times. Staff LL stated that Staff KK, PCT, was positioned in the hallway, "straddling" both rooms. Staff LL stated that it was never relayed to her that Patient #3 was an Elopement Risk.

During an interview on 01/10/18 at 2:05 PM, Staff MM, RN, stated that:
- She was assigned to Patient #3 on the day that she eloped from the facility; - That she was never informed that Patient #3 was an Elopement Risk, she was told that she was 2:1 with a sitter for her behavior on Post Partum;
- Patient #3 had initially been cooperative with the assessment, and any care provided that morning;
- Staff MM stated that she received a phone call from Patient #3 requesting that she come to the room to assist her;
- Staff MM stated that when she entered, the DFS worker was at the bedside, along with the physician, and they were attempting to explain options for temporary placement of Patient #3's newborn;
- Patient #3 became increasingly upset, and that she asked the DFS worker to leave the room;
- She was under the impression that her sister was the person that called the DFS hotline, and that if her newborn could not be placed with the uncle she lived with, they could just put him up for adoption;
- She was adamant that her sister not be allowed temporary custody ;
- Staff MM stated that had she known that Patient #3 was an Elopement Risk, she would not have supplied her with the pajama bottoms or the slipper socks;
- Patient #3 did not have shoes with her or in the room, she was not sure about a personal cell phone, but she didn't think she had one; she had witnessed her using the hospital phone in the room.

Patient #3 was assessed as an elopement risk but was not on elopement precautions which included 1:1 observation and successfully eloped from the facility 33 hours after she had undergone and emergency C-section for the delivery of her infant. This placed her at a higher risk of post-surgical complications and risk for her safety.