HospitalInspections.org

.
Based on observation, medical record (MR) review, document review and interview, the facility failed to:

- Ensure complaints were investigated as per facility policy (See Tag A 0118)

- Prevent an elopement and prevent access to needles in a common area (See Tag A 0144)

- Ensure that patients placed in four-point restraints: (A) Received a 1-hour face to face evaluation from a physician; and (B) Were assessed or monitored by a Registered Nurse (RN)(See Tag A 0179)

- Identify, track, analyze and implement preventive actions for elopements (See Tag A 0286)

- Implement its policies for: (A) Patient Discharge; (B) Patient Elopement; and (C) Constant Observation (See Tag A 1104)

These findings failed to promote each patient's rights.

.
Based on document review and interview, in 1 (one) of 3 (three) complaints reviewed, the facility failed to completely respond to patient grievances as per facility policy.

This failure to completely respond to grievances hinders the prompt resolution of complaints.

Findings included:

The facility policy and procedure (P&P) titled, "Management of Patient Complaints and Grievances," effective 3/27/18, stated the following: " ...a complete response to patient grievances will include the steps taken to investigate the grievance and what the findings and resolutions were ...the department head will maintain a copy of the report investigation with the findings, recommendations and corrective actions taken."

The facility's Grievance Log, dated 8/2019, identified a grievance intake for Patient #1 on 8/6/19.

The Patient/Family Complaint Form, dated 8/6/19, identified the complainant as the Patient #1's spouse, who stated the following: "On August 5th, you released my husband in a paper suit without contacting me, his wife and care taker. How inappropriate is that, since he has Alzheimer's, Dementia, Parkinson's, Depression and Diabetes? He waited outside for me for over an hour until someone brought him inside to the waiting room. He doesn't even know his phone number or address. I finally received a phone call from you at 1:10PM asking if I was coming? Upon getting home I looked over his discharge papers and they were signed by a nurse, but nowhere did I sign agreeing to release him. I called to complain and asked to speak with a superior, someone took my number and never called me back."

The Patient/Family Complaint Form further identified this grievance was "...Closed/Resolved: 8/9/19" and stated the following: "[Staff A (Director of ED/Emergency Department Services)] contacted the complainant on 8/6/19 to clarify the ED discharge paperwork, and communication issues that occurred during [Patient #1's] ED visit. She also shared these concerns with the staff member involved in the patients care."

Per interview of Staff A on 11/10/19 at 2:40PM, Staff A explained that she closed the grievance on 8/9/19 because she spoke to the complainant by phone and apologized to her. Staff A stated that she also spoke with the Registered Nurse who had discharged the patient. Staff A confirmed she did not investigate why the complainant had not been contacted prior to Patient #1's discharge nor why Patient #1 was outside waiting for over an hour. Staff A confirmed no corrective actions to prevent reoccurrence were taken.

There was no documented evidence that Patient #1's grievance investigation or response included the steps taken to investigate the grievance, and the findings and resolutions of the grievance, as per facility policy.

Per interview of Staff B (Director of Quality Improvement) on 11/20/19 at 2:20PM, Staff B confirmed these findings.

.
Based on medical record (MR) review, document review, observation and interview, in 2 (two) of 2 (two) cases reviewed, the facility failed to provide a safe environment for all patients by: (A) Preventing elopements; and (B) Preventing access to needles in a common area.

Findings for (A) included:

Review of Patient #1's MR identified the following: This 66-year-old was brought to the Emergency Department (ED) by ambulance on 8/5/19 at 12:36AM after collapsing and falling in his bathroom. The patient had a history of Alzheimer's Dementia, Parkinson's, Diabetes and Depression. Patient #1's spouse signed the consent forms for admission, treatment and the patient bill of rights. The Physician History and Physical on 8/5/19 at 1:35AM stated, "...a complete history and physical exam was unobtainable secondary to cognitive impairment...the patients wife is present and she reports he has had intermittent worsening confusion..." The patient was later evaluated by cardiology and cleared for discharge. Physician orders dated 8/5/19 at 10:35AM stated, "discharge patient to home." Discharge nursing note dated 8/5/19 identified Patient #1 signed his discharge instructions at 11:02AM. The patient was provided with paper scrubs to wear, and without his wife/representative receiving notification of his discharge, Patient #1 was released into his own care.

During interview of Staff D (RN/Registered Nurse) on 11/21/19 at 11:30 AM, Staff D stated that Patient #1 had been placed in the ED Walk-In Waiting Room by a nurse, and was later found outside in the walkway adjacent to an active building construction zone. Staff D stated, "when I was told that he was still waiting, I went to reassess him and found him outside, confused and disoriented."

During interview of Staff A (Director of ED Services) on 11/21/19 at 1:30PM, Staff A acknowledged that the nurse made some errors in failing to notify the patients caregiver of the disposition, and that discharge procedures were not followed.

Staff A confirmed that the facility did not identify Patient #1 as a risk for elopement, although he met criteria as per facility policy, and the facility did not implement elopement precautions for this patient.

The facility P&P titled, "Elopement," last revised 01/2017 stated, "Elopement is defined as when a patient with decreased mental capacity leaves the unit...Assessment findings to identify patients at risk are: History of dementia, history of Psychiatric [illness], has a legal guardian, is a danger to self or others, lacks ability to make decisions, any mental or cognitive impairment..."
.
.
Findings for (B) included:

Observations in the facility's Adult ED during a tour on 11/19/19 at approximately 11:40AM identified that a blood specimen collection cart with venipuncture equipment (including sharps such as needles used for intravenous access) was left unattended and unlocked. The cart was in the hallway next to Patient #13, who was on a 1:1 constant observation at the time of observation.

Review of Patient #13's MR identified this patient had diagnoses of Alcoholic Intoxication and Suicidal Ideation. Leaving the unattended cart with sharps within reach of this vulnerable patient increased the potential risk of harm for this patient.

This finding was discovered in the presence of Staff A on 11/19/19 at 11:40AM, who confirmed the phlebotomist cart should have been locked when not in use.

.
Based on medical record (MR) review and interview, the facility failed to ensure that patients placed in four-point restraints: (A) Received a 1-hour face to face evaluation from a physician, in 3 (three) of 3 (three) MRs reviewed; and (B) Were assessed or monitored by a Registered Nurse (RN) in 2 (two) of 3 (three) MRs reviewed.

These failures potentially placed patients at increased safety risk.

Findings for (A) included:

The facility policy and procedure (P&P) titled, "Restraints," dated 4/22/17, stated the following: "Level two restraint will be used only upon a physician's order based on the results of an examination of the patient by the physician within one hour of giving a telephone order and the implementation of restraint. The physician's initial mental status assessment shall include the clinical justification for use. The results of the examination shall be documented in the medical record..."

Review of Patient #17's MR identified the following information: This 53 year old was admitted to the Emergency Department (ED) for a psychiatric evaluation on 10/31/19 at 6:04PM. Physician documentation at 7:16PM stated that the patient was hearing voices and reported that people wanted to steal her money and kill her.

Nursing documentation dated 11/01/19 at 10:20AM stated, "The patient [was] becoming physically aggressive with staff and is a harm to self and those around her and was placed in four-point restraints."

A Physician order identified four-point restraints were initiated at 10:34AM. However, there was no documented evidence of the physician's 1-hour face to face evaluation for Patient #17.
.

Review of Patient #18's MR identified the following information: This 31 year old presented to the ED accompanied by police on 9/11/19 at 4:44PM. Physician documentation at 5:48PM stated that the patient was brought in by the police and was confused, combative and agitated.

Nursing documentation dated 9/11/19 at 6:50PM stated, "Patient agitated, a threat to himself and others. 4-Point restraint initiated."

A physician order identified the four-point restraints were initiated at 6:43PM. However, there was no documented evidence of the physician's 1-hour face to face evaluation for Patient #18.
.

Review of Patient #19's MR identified the following information: This 42 year old was admitted to the ED for a psychiatric evaluation on 11/7/19 at 5:16PM. Physician documentation at 5:49PM stated that Patient #19 "was having a breakdown, couldn't go on and wanted to kill herself."

Nursing documentation dated 11/8/19 at 2:14AM stated, "The patient becoming physically aggressive and was placed in four-point restraints for safety due to verbal and physical aggression toward staff."

A physician order identified the four-point Behavioral restraints were initiated on 11/8/19 at 1:41AM. However, there was no documented evidence of the physician's 1-hour face to face evaluation for Patient #19.
.
.
Findings for (B) included:

The facility P&P titled, "Restraints," dated 4/22/17, stated: "The following will be documented on the Restraint Flow Sheet ...name of staff member who initiated the restraint ... the RN will document skin assessment and care done, and range of motion, positioning and readiness for discontinuation of restraints."

The Restraint Flow Sheet dated 9/11/19 did not contain the name of the RN staff member who initiated the 4-point restraint at 6:43PM, or any documented evidence that a RN assessed and monitored Patient #18 for skin integrity and range of motion while restrained from 6:43PM to 10:13PM.

The Restraint Flow Sheet dated 11/1/19 did not contain the name of the RN staff member who initiated the 4-point restraint on Patient #18 at 10:34 AM, as per facility policy.
.
These findings were acknowledged by Staff B (Director of Quality Improvement) on 11/25/19 at 3:15PM.

.
Based on medical record (MR) review, document review and interview, in 3 (three) of 3 (three) MRs reviewed, the facility failed to identify, track, analyze and implement preventive actions for elopements from the Emergency Department (ED).

This failure may place patients at increased risk for adverse outcomes.

Findings included:

The facility P&P titled, "Elopement," last revised 01/2017 stated the following: "An occurrence report will be completed for ALL patient elopements."

Review of the MRs for Patients #9, #10 and #11 identified these patients had eloped from the ED.

The facility's Occurrence Log dated 5/1/19 through 10/31/19 revealed no elopements from the Emergency Department (ED) were identified. No associated occurrence reports for the elopements of Patients #9, #10 or #11 could be found.

The facility could not furnish any documented evidence that occurrence reports had been completed for patient elopements from the ED.

During interview with Staff B (Director of Quality Improvement) 11/19/19 at 3:15PM, Staff B stated, "No Incident Reports are made for the elopements from the ED."

During interview with Staff B on 11/25/19 at 3:15PM, Staff B confirmed ED elopement data was not analyzed to identify trends or need for corrective actions. Staff B stated that although monthly ED reports for the volume of ED visits, including patients that left against medical advice, left without being seen and elopements, are uploaded to the corporate level, Staff B confirmed this facility had not developed and implemented site-specific corrective measures for patient elopements based on that data.

The facility's Performance Improvement Plan was requested but was not furnished.

.
Based on medical record (MR) review, document review and interview, the facility failed to implement its policies for: (A) Patient Discharge, in 2 (two) of 16 (sixteen) MRs reviewed; (B) Patient Elopement, in 3 (three) of 16 (sixteen) MRs reviewed; and (C) Constant Observation, in 1 (one) of 16 (sixteen) MRs reviewed.

These failures placed patients at increased risk of adverse events.

Findings for (A) included:

The facility's Emergency Department (ED) policy and procedure (P&P) titled, "Process for Patient Discharge [ED]," last reviewed 10/3/19 stated the following: "All patients discharged from the Emergency Department will have a documented plan of care reflecting the patient's needs. This plan will be discussed with the patient or responsible adult/designee prior to discharge...the Nurse will complete the following process: Complete discharge documentation, review instructions with patients/designee and assure understanding, obtain patient/designee signature on discharge instructions and give patient a copy."

Review of Patient #1's MR identified the following: This 66 year old male with a history of Dementia presented to the Emergency Department (ED) via ambulance on 8/5/19 at 12:33AM. The patient's spouse was documented as his designated representative and provided his medical history and signed all consents. The physician noted at 1:35AM stated that the patient could not provide his own history because of his cognitive impairment...the patients wife was present, and she reported his confusion has been worsening and that he has a history of Alzheimer's Dementia, Parkinson's, Diabetes and Depression."

Physician orders on 8/5/19 at 10:35AM ordered Patient #1 to be discharged home. The Nurse Disposition Note at 11:42AM identified that Patient #1 signed his discharge instructions and was released home.

Per interview of Staff D (RN/Registered Nurse) on 11/20/19 at 11:50AM, Staff #D confirmed she had provided the Discharge Instructions to the patient, had documented the inaccurate disposition of the patient, and stated she did not notify the patient's representative because, during her encounter with the patient, Patient #1 was alert and oriented. Staff D stated she saw the discharge order and provided paper scrubs to Patient #1 because he had no clothes except for a diaper on presentation. Staff D stated she had "assumed" that the patient had telephoned his family for a ride. After Patient #1 signed his discharge instructions, Staff D placed him in the ED waiting room area of the walk-in entrance at approximately 11:00AM. Between 12:00PM to 1:00PM, Staff D was informed by another staff member that Patient #1 was still in the ED waiting area and was creating commotion due to his confused and disoriented state. Staff D stated "I had forgotten about him but I went out to see what was going on. That's when I found him outside acting confused...he was mistaking people for someone named Kathy and he was not easily redirectable..." The patient's spouse/legal representative was then notified, and she returned to the ED to collect the patient. Staff D stated she did not go over the discharge instructions with the patient's spouse or fill out an incident report or document an addendum to the MR regarding the patient disposition.

There was no documented evidence that the plan of care was discussed with Patient #1's responsible adult/designee prior to discharge. There was no documented evidence that the designee was provided with post-discharge instructions.

Review of Patient #15's MR identified that this patient presented to the ED 9/4/19 at 12:10PM, with a chief complaint of a Fall. The patient was evaluated and treated for an injured shoulder, abrasion, and pain in the wrist, knee and neck. Patient #15 was discharged at 7:38PM, but there was no documented evidence of signed discharge instructions.

These findings were acknowledged by Staff B (Director of Quality Improvement) on 11/21/19 at 11:20AM.
.
.
Findings for (B) included:

The facility P&P titled, "Elopement," last revised 01/2017 stated the following: "Elopement is defined as a patient who is aware that he/she is not permitted to leave but does so with intent, or when a patient with decreased mental capacity leaves the unit...Patients are assessed for elopement risk on admission ... assessment findings to identify patients at risk are: History of dementia, history of Psychiatric [illness], has a legal guardian, is a danger to self or others, lacks ability to make decisions, any mental or cognitive impairment...The Registered Nurse (RN) determining the patient is high-risk for elopement will communicate to the charge nurse and will explore options to prevent elopement. If a patient is missing, a search will be conducted. An occurrence report will be completed for ALL patient elopements."

Review of the MRs for Patients #9, #10 and #11 identified these patients had eloped. These patients were not assessed for elopement risk nor were occurrence reports completed, as per facility policy.

There was no documented evidence that the ED staff had received education/training on the current elopement policy.

These findings were confirmed by Staff B (Director of Quality Improvement) on 11/21/19 at 11:20 AM.
.
.
Findings for (C) included:

The facility policy and procedure (P&P) titled, "Constant Observation and Enhanced Supervision," last reviewed 01/3/17 stated, "1:1 Constant Observation is prescriber driven and a written order must be instituted and discontinued by a physician...The staff member ratio to patient must be one to one (1:1) ...visual contact is always required and maintained at a distance not to exceed six (6) feet with no physical barrier present. The assigned staff must not leave until another assigned staff member is in attendance. The staff assigned to monitor the patient must document the patient's behavior/activities a minimum of every 30 minutes on the Observation Flowsheet...RN assessment/reassessment must be documented in the medical record and an update on the patient's progress, a statement that the patient remained on uninterrupted observation throughout the shift, and any deviations from the plan of care" recorded.

During observations in the facility's ED during a tour on 11/19/19 at 11:30AM identified that Patient #9 was observed by a 1:1 sitter (continuous observation) for safety.

Review of Patient #9's MR identified that this patient presented to the ED 11/19/19 at 9:07AM, with a chief complaint of Anxiety. The Physician Order for 1:1 Constant Observation was dated 11/19/19 at 10:17AM.

The Continuous Observation Flowsheet dated 11/19/19 was initiated at 10:00AM and discontinued at 1:00 PM. There was no physician order to discontinue the 1:1 constant observation, and no documented evidence was found as to why it had been discontinued.

Per interview of Staff A (Director of ED Services) on 11/22/19 at 4:15PM, Staff A stated, "there should be something documenting why the 1:1 was no longer needed [indicated]."

Patient was later identified by the facility as having eloped on 11/19/19 at 3:25 PM.