HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to:
- Follow its policy and procedures to prevent one discharged patient (#8) of one patient from elopement from the Emergency Department (ED); (A-0144)
- Thoroughly investigate one patient's (#8) elopement from the ED to determine the cause and to prevent further patient elopements; (A-0144)
- Ensure all patients who received care in the Delbert Day Cancer Institute (DDCI), outpatient infusion clinic, were provided information regarding their patient's rights. (A-0117)
- Ensure all patients admitted to the Center for Psychiatric Services (CPS) unit were provided contact information needed to file a grievance. (A-0118)

The severity and cumulative effects of these systemic practices resulted in the overall non-compliance with CFR 482.13, Condition of Participation: Patient's Rights that resulted in a patient elopement, prevented patients from understanding their rights as a patient, including the right to formulate a grievance and also prevented patients from obtaining contact information necessary to file a complaint or grievance. The hospital census was 104 with a census of 16 on the CPS unit.

Based on observation, interview, and policy review, the hospital failed to ensure that patients receiving care in the Delbert Day Cancer Institute (DDCI) received information regarding their patient's rights. This failure had the potential to prevent all patients receiving outpatient cancer care services from understanding their rights as a patient. The hospital census was 104.

Findings included:

Review of the hospital's policy titled, "Patient Right and Responsibilities," reviewed 07/28/20, showed that the hospital's Patient's Bill of Rights would be made available to all patients through brochures, wall posters, and booklets.

Review of the hospital document titled, "Patient Rights and Responsibilities," revised 03/2011, showed that the patient had the right to be informed of the hospital's policies about their rights and health care and the right to know the hospital's grievance process.

Review of the hospital document titled, "Consent for Medical Treatment and Conditions of Admission," reviewed 07/16/21, showed that when signed, patients acknowledged they received a copy of the hospital's Patient Rights and Responsibilities information.

During an observation on 05/24/22 at 2:22 PM an 8-inch by 10-inch poster was observed on the wall outside the entrance to the infusion unit of the DDCI titled "Patient Rights and Responsibilities" which contained contact information for the Center for Medicare and Medicaid Services (CMS). The sign did not contain contact information for the State of Missouri Bureau of Hospital Standards. No other patient's rights signage was observed in the lobby or infusion unit.

During an interview on 05/24/22 at 2:25 PM, Staff CC, Patient Service Representative, stated that patients were asked if they wanted a copy of their rights during registration and that it was not automatically given to patients. Staff CC could not locate a brochure or pamphlet which contained the Patient Rights and Responsibilities. Staff CC provided a document that she stated was given when patients requested information regarding patient rights. The document contained information on unexpected charges and surprise billing and did not include information about the rights of patients or the complaint/grievance process.

There was no clear process of informing the patients in the DDCI of their patient's rights.

Based on interview, record review, and policy review, the hospital failed to ensure patients admitted to the Center for Psychiatric Services (CPS) unit were provided the information needed to file a grievance either directly with the hospital or with the State Agency. These failures limit the opportunity for patients to exercise their right to file a complaint/grievance with the appropriate agency and had the potential to affect all the patients assigned to this unit in the facility. The hospital census was 104 with the CPS census of 16.

Findings included:

Review of the hospital policy titled, "Patient Rights and Responsibilities," revised 03/2011 showed that patients had the right to know the hospital's grievance process and if they had a grievance or concern that they could contact the state agency with address and phone number listed.

Review of hospital policy titled, "Patient/Visitor Complaint Grievance Process," revised 10/19 showed that patients will receive information upon admission/registration to the hospital about the hospital's complaint/grievance process and state contact information.

Review of the hospital document titled, "The Center for Psychiatric Services Patient/Legal Guardian Handbook," revised 10/06/21 showed patient's legal and human rights on page 12 with no contact number or process to file a grievance or to contact the state agency.

During an interview on 05/24/22 at 2:40 PM, Staff FF, Registered Nurse (RN), stated that all patient rights information regarding their rights and who to contact for a complaint or grievance was listed inside the green folder given to patients upon admission to the unit.






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Based on observation, interview, record review, and policy review, the hospital failed to follow its policy and procedures to prevent one discharged patient (#8) of one discharged patient reviewed who successfully eloped (when a patient makes an intentional, unauthorized departure from a medical facility) from the Emergency Department (ED) while being observed by a patient sitter and failed to thoroughly investigate the elopement to determine how it occurred and how to prevent it from occurring again. These failures had the potential to place all patients at risk for their safety while being observed by a patient sitter. The hospital census was 104.

Findings included:

Review of the hospital's policy titled, "Elopement of a Patient," revised 04/2016 showed that the purpose of the policy was to establish guidelines for safe and effective management of patients at risk for elopement. A patient was assessed for behaviors that could indicate an elopement risk such as if the patient lacked decision making capacity (has a court ordered legal guardian, had a significant diagnosis of mental or behavioral health problem) and a physician may order a bedside sitter at any time during the care of a patient.

Review of the hospital's policy titled, "Patient Sitter," revised 07/2021 showed the following direction:
- Staff were to utilize the policy to guide the care of a patient that exhibited behaviors that placed the patient at risk for harm.
- A sitter was defined as an individual designated to be at the bedside of a patient to provide physical or monitored (camera) observation.
- A sitter was to maintain visual contact with the patient at all times.
- If the sitter was assigned to sit with more than one patient they cannot leave the sitter position for any reason and must maintain constant observation for both patients at one time.

Review of the hospital's undated document titled, "Patient Sitter Job Details," showed that an essential duty and responsibility was to provide constant observation to those requiring 1:1 sitter, working with the patient care team to ensure seamless safety coverage.

Observation on 05/24/22 at 1:40 PM, of the hospital ED, showed Staff HH, ED Technician seated at a small table and chair located next to a wall approximately four feet from the corner of the nursing station. Located on the wall right of the table and chair was a window that visualized the inside of ED room #8 (psychiatric safe room). ED rooms #4 and #5 were located directly across from the nursing station and approximately 12' in front of the sitter's table and chair.

During an interview on 05/23/22 at 2:11 PM, Staff HH, ED Technician stated that she was sometimes utilized as a patient sitter if there was no sitter availability. She stated that sitters were expected to observe up to three patients at one time and that the window next to the sitter table allowed for visualization into room #8. She stated that if someone stood in the view of rooms #4 and/or #5 she asked them to step aside as she had to observe all patients at all times.

During an interview on 05/24/22 at 2:20 PM, Staff II, ED Physician stated that he had no concerns for three patients being observed at one time by one sitter. He stated that he remembered the patient that had eloped in 08/2021 and that the patient successfully eloped because he had positioned himself in a corner of room #8 and the sitter wasn't able to see him. Staff II stated that the patient wasn't a known elopement risk because the nursing home he came from had not informed the ED that he had attempted elopement in the past.

Review of Patient #8's History and Physical (H&P) dated 08/26/21, by Staff II, ED Physician, showed that the patient presented to the ED via ambulance for a psychiatric evaluation with a known history of schizoaffective disorder (mental illness that is characterized by symptoms of mania, depression and mood disturbances). The patient resided at a nursing home and was a ward of the state (refers to a person who is under the legal protection of some arm of the government due to mental capacity, persons who are imprisoned or children who are without parents) since 2007. The nursing home had reported that they had found a noose made from t-shirts that the patient had torn up but the patient had informed them it was a headband and they had also found sharp rocks in his room and the patient reported that those were not weapons but decorative items. The nursing home administrator felt the patient was a danger toward himself and to others and sent an affidavit (a written statement confirmed by oath, for use as evidence in court) for the patient to have a mental health evaluation.

Although requested the hospital failed to provide a suicide risk observation flow sheet (patient sitter documentation) or an affidavit from the nursing home for Patient #8's first ED visit on 08/26/21.

Review of Patient #8's ED timeline showed that the patient presented to the ED at 4:23 PM on 08/26/21 and was placed in ED Room #8. Triage began at 4:41 PM by former hospital Staff XX, Registered Nurse (RN) and a patient sitter was implemented at 4:47 PM. At 5:23 PM Staff XX documented that the patient sitter (Staff KK) "had gotten up" and went to room #8 then asked anyone if they had taken room 8 and stated that the patient was not in the room. Hospital staff began to look for Patient #8 at that time. At 5:35 PM Staff XX, RN documented that the main entrance screener had advised that someone fitting the patients description was seen outside of the building as he walked across the parking lot. Local law enforcement was notified at this time. Patient disposition was documented as elopement at 6:56 PM as the patient had not been located or returned to the hospital at this time.

Review of Patient #8's second ED record dated 08/26/21 showed that the patient returned to the ED with law enforcement at 7:19 PM and was placed into ED room #8.

Review of Patient #41's ED record showed that he presented to the ED on 08/26/21 at 3:50 PM with chief complaint of addiction problems and suicidal ideations (SI, thoughts of causing one's own death) and was placed into ED room #4. The suicide risk observation flow sheet showed documentation by Staff KK, Patient Sitter from 3:15 PM to 6:00 PM.

Review of Patient #42's ED record showed that he presented to the ED on 08/26/21 at 3:50 PM with chief complaint of SI and laceration to the right foot. The suicide risk observation flow sheet showed documentation by Staff KK, Patient Sitter from 3:45 PM to 6:00 PM.

Staff KK, Patient Sitter was assigned to observe Patient #8, Patient #41 and Patient #42 on 08/26/21 between 4:47 PM and 5:23 PM when Patient #8 successfully eloped from the ED.

Review of the hospital's document titled, "Safety Event Manager," dated 08/26/21 showed the report was completed by Staff GG, ED Manager. The report showed that Staff XX, ED RN had reported that Staff KK, Patient Sitter had gotten up and went to room #8 and notified Staff XX, RN that the patient was no longer in the room. Security was notified and immediately began to look for the patient. One security officer reviewed the security footage. The screener at the main entrance informed ED staff that someone fitting the patient's description was seen outside the hospital walking across the parking lot toward the street. Local law enforcement was called to help locate the patient. The investigation summary showed that the patient (#8) was in line of sight of sitter who was watching three patients, two on SI precautions and one (Patient #8) on safety precautions. The sitter recognized that the safety precaution patient wasn't visible in the room so he got up from his chair and went to check the room and the patient was not visualized. The sitter returned to his desk and then contacted ED staff that the patient was no longer in his room. The patient was not found in the department and the camera footage was viewed by security the patient was viewed to have walked out of the department without staff assistance. Patient was later found and returned to the ED by law enforcement. Staff GG, ED Manager documented that the patient had not been appropriately monitored by the sitter and that re-education to staff on the sitter policy with expectations and to alert staff immediately, no delays, if patient was not in line of sight. The safety event report was closed on 09/23/21 by Staff TT, Risk Manager.

Review of the hospital document titled, "Root Cause Analysis (RCA) Tool Packet," dated 2022 showed that a root cause analysis was a process to identify basic factors or caused that produced variation in performance (problem or system failure). Goals of the RCA were to determine what happened, why it happened and how to prevent it from happening again.

Although requested the hospital failed to provide an RCA for Patient #8's elopement.

Although requested the hospital failed to provide video recording of Patient #8's elopement.

Review of the ED beginning of shift report titled, "BOSH," dated 09/15/21 showed a reminder to the sitters that it was not appropriate to play on their cell phones while sitting with a patient and with the sitter policy attached for their review.

Patient #8 eloped from the ED on 08/26/21 and education to the ED staff was not done until 09/15/21, 20 days after the event occurred.

During an interview on 05/25/22 at 8:06 AM, Staff GG, ED Manager stated that Staff TT, Risk Manager had viewed the camera footage and informed Staff GG that Patient #8 had left through the main entrance of the hospital. Staff GG stated that when she viewed it Staff KK, Patient Sitter was seated at the table with three papers in front of him on the table while he observed Patient #8 in ED room 8 and two additional patients in ED rooms #4 and #5. She stated that she re-educated the ED staff with a reminder to staff that it was not appropriate for sitters to be on their phones while sitting. She stated this re-education was given during a beginning of shift report and that Staff KK did not receive this education from her as he was in the "sitter pool" and that education would have come from his supervisor. She stated that she had no specific reason for the cell phone re-education, as Staff KK was not seen to have been on his phone, but just felt it was a good reminder. Staff GG, RN, ED Manager, stated that there had been no process change in the sitter duties since that patient (#8) had eloped from the ED.

During an interview on 05/25/22 at 8:51 AM, Staff QQ, RN, Patient Sitter Director stated that she expected patient sitters to observe no more than two patients at one time. She was not aware of any problems with Staff KK or any issues with his sitting abilities and wasn't aware that she was to provide him with any re-education after a patient elopement.

During an interview on 05/25/22 at 2:05 PM, Staff KK, Patient Sitter stated that he was the sitter in the ED last August when a patient had "escaped" the ED. He stated that he remembered he looked through the window into room #8 and didn't see the patient so he got up and walked around the corner to the room and looked inside and the patient was gone. He stated that when seated at the sitter table the corner behind the door of room #8 wasn't able to be viewed so sometimes he felt patients were able to get into that corner. Staff KK stated that it wasn't unusual for sitters to observe three patients at one time. He stated that he felt capable of observing three at one time except that sometimes there was a glare on the sliding glass doors of rooms #4 and #5 and it was hard to see inside when staff turned the lights off inside of those rooms. He stated he didn't recall that he had received any education after the patient elopement and was never interviewed by any leadership staff regarding the elopement.

During an interview on 05/26/22 at 8:31 PM, Staff TT, Risk Manager stated that she did not recall this event of a patient elopement but an elopement would usually classify as a safety event that would include a root cause analysis (RCA) but wasn't able to find one for this event. She also stated that staff interviews would generally be completed with such an event and wasn't sure why no staff were interviewed with this event. Staff TT stated that the hospital policy stated that sitters were able to observe up to three patients at one time just no more than three.

Staff KK, Patient Sitter was responsible for the observation of three patients (#8, #41 and #42) at the same time while they were patients within the ED. During this time Patient #8 successfully eloped from the ED. The hospital internal investigation did not include any staff interviews, or an RCA to determine the cause of the patient elopement or how to prevent it from occurring again and no formal education was given to patient sitters.

Based on observation, interview and policy review the hospital failed to follow their policy and procedure regarding face coverings (masks) and failed to ensure contracted service employees were appropriately approved for vaccine exemptions. These failures placed all patients, staff and visitors at risk for their health and safety. The hospital census was 104.

Findings included:

Review of hospital policy titled, "Mandatory COVID-19 (highly contagious and sometimes fatal virus) Vaccination," revised 02/2022 showed that the policy applied to all hospital staff and that they were to be fully vaccinated for COVID-19 regardless of clinical responsibility or patient contact, unless exempted consistent with law. Evidence that a person was fully vaccinated against COVID-19 was required as a condition of employment at the hospital and as a condition to work, volunteer, train or provide contracted services at the hospital. General requirements with the policy of "staff" who must be fully vaccinated included hospital employees, and individuals who provided care, treatment, or other services for the hospital or its patients (e.g. contracted construction teams, contracted maintenance personnel, etc.) All exemptions to mandatory vaccination must be submitted to Occupational Health for approval.

Review of an untitled hospital document dated 04/20/22 showed that if there was a significant increase in COVID-19 in the area that the hospital may return to universal masking protocols for all employees. Hospital employees were required to wear masks for patient-facing employees. Masks were optional for employees who worked in non-patient facing units and non-vaccinated employees were required to wear a disposable, surgical mask.

Observation on 05/24/22 at 8:50 AM, on the Surgical Orthopedic 4th floor inpatient unit, showed Staff A, Registered Nurse (RN), Unit Manager, without a mask as she stood in the unit hallway in the doorway of a patient's room. Staff A returned to the nursing station and placed a mask on her face.

Observation on 05/24/22 at 2:22 PM, showed Staff CC, Patient Service Representative, without a mask at the open, plexiglass-free registration desk of the Delbert Day Cancer Institute (DDCI) registering a patient for services in the infusion unit.

During an interview on 05/26/22 at 9:01 AM, Staff M, RN Occupational Health Director stated that the hospital had recently lessened the mask requirements and vaccinated staff had the option to wear a mask unless they were face to face with a patient or had COVID-19 symptoms. She stated that the change in mask requirements were directly related to the low positivity rate in the community. She stated that all unvaccinated staff were to wear a mask at all times while in the hospital unless eating or drinking. Staff M stated that she did not have a "master" list of contracted services or vendors and that she expected the directors over those departments to obtain the information and send it to her, but she didn't always receive it. She stated that she was to review all exemption requests for appropriate approval.

Record review with concurrent interview on 05/26/22 at 10:15 AM, showed the vaccine status for six employees of a current contracted service (McCarthy Construction Company). Two employees were vaccinated and four employees had religious exemptions. All four religious exemptions were on hospital letterhead, dated 11/24/21 and signed by each construction company employee. Staff VV, Facility and Support Services Director stated that he had asked the construction company about their employees vaccine status when they started work on the hospital project a few months ago and was told it was a Health Insurance Portability and Accountabilty Act (HIPPA, a federal law created to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) violation to give that information and was informed "verbally" by the construction company that the construction company employees, that were on-site, were vaccinated or exempted. He stated that he had given the construction company employees the hospital exemption form to complete after they informed him that they were not vaccinated. Staff VV stated that he did not send these exemptions to Staff M, RN Occupational Health for her or committee approval. He stated that the two construction company's vaccinated employee vaccination dates were obtained this morning after he was made aware that the survey team would need to see this information.