HospitalInspections.org

Based on medical record review and interview, the facility did not provide care in a safe and secure setting. Lack of safety measures resulted in Patient #1 absconding from the intensive care unit (ICU).

Findings include:

Observation on 10/29/20 at 02:30 PM in the ICU revealed there are 2 entrance/exit double doors to the unit and 12 patient rooms in the layout of a backwards "L" shape. The nursing station is directly across from the patient rooms, also in a backwards "L" shape layout, but ends at ICU room # 5 due to double doors that exit out into the main hallway. ICU room #4 (Patient #1 ' s room) is located diagonally to the right/across from the nursing station (not in direct sight) and directly across from the double doors. To exit the unit, the doors open freely, with no swipe card requirement or alarm notification.

Medical record review on 10/29/20 for Patient #1 revealed the following:
-On 10/03/2020 at 11:43 AM, Patient #1 was found by police and brought to the emergency department (ED) via ambulance due to being naked in the street. She is unable to provide any history, and required IM Versed and Ketamine due to severe agitation including hitting/biting herself and hitting/fighting with staff. Patient #1 was admitted to the ICU in critical condition for agitation requiring sedation, altered mental status, delirium, elevated CPK (indicating injury or stress to muscle tissue) and hypokalemia (low potassium).
-On 10/04/2020 at 10:33 AM, the ICU provider note indicates that Patient #1 is alert and oriented, but thought process is confused. Acute encephalopathy with an unclear etiology-possible laced marijuana. Continue 9.39 status (involuntary psychiatric emergency admission). At 02:00 PM, rounding note indicates Patient #1 wants to go home. At 05:32 PM, Psychiatric Consult indicates that Patient #1 is uncooperative with questioning and discussion. Will be reassessed when she is more sober. Keep Patient #1 in the ICU overnight and have a psychiatrist reassess in the morning. At 09:00 PM, rounding note indicates Patient #1 claims staff are being racist and wants to go home.
-On 10/05/2020 at 06:14 AM, nursing note indicates Patient #1 is alert and oriented x4 (person, place, time, situation), cooperative with vital signs, cardiac monitor, and bloodwork. At 08:00 AM, a cardiology progress note indicates Patient #1 wants to go home and does not believe she had a heart attack. She has flight of ideas, with no judgement. At 08:24 AM, the ICU provider progress note indicates Patient #1 was assessed as alert and oriented, impulsive judgement, flight of ideas, not competent to make decisions at this time, and continue 9.39 status. At 08:30 AM, RN rounding note indicates Staff (C) ICU RN spoke with Patient #1 who took monitor and blood pressure cuff off. Patient #1 states she is fine. At 09:12 AM rounding note by Staff (D) ICU nursing assistant documents "needs met." At 09:23 AM, rounding note indicates Patient #1 was not in her room, and a code gray (patient absconded) was called.

Telephone interview on 11/03/20 at 09:25 AM with Staff (S) Director of the Intensive Care Unit (ICU), revealed the ICU does receive 9.39 status patients at times. Precautions for these types of patients includes notifying all staff of the 9.39 status and usually having 1:1 monitoring if there is sufficient staff.

Review of facility policies revealed no policies and/or protocols were found for the management of patients with an involuntary 9.39 admission status that are admitted to units other than the secure inpatient behavioral health unit.

Based on medical record review, video review, policy review, document review, and interview, the facility did not fully investigate an adverse event involving Patient #1 abconding from the intensive care unit (ICU) in accordance with facility policy.

Findings include:

Medical record review on 10/29/20 for Patient #1 revealed that on 10/03/20, she was admitted to the ICU on a 9.39 involuntary status. On 10/05/2020 at 09:23 AM, staff noted that Patient #1 was not in her room, and a code gray (patient absconded) was called.

Review on 10/30/20 of the facility monitoring video revealed on 10/05/20 at 09:06 AM, Patient #1 is seen walking down the hallway from the ICU towards the elevator in her hospital gown and socks. At 09:07 AM, Patient #1 enters the elevator. At 09:08 AM, Patient #1 is seen exiting the building through the main entrance 4/security post #2 front doors.

Review on 10/30/2020 of policy "Event Reporting" last revised 10/2018 revealed the event report should be completed by the staff who observed the event and be immediately forwarded to the appropriate manager who will be responsible for entering the information into the incident reporting data base. All events will be reviewed by the Director of Quality who will collaborate with the unit manager to determine need for further investigation. All behavioral health reportable and significant incidents will be reported to the Justice Center.

Review on 11/02/20 of policy "Pursuit of Patient Leaving without Permission (Elopement)" last revised 10/2010 indicates when a patient is found missing from a unit, an immediate search of the building is initiated along with the enactment of a code gray. If a patient exits the hospital building, staff should make no attempt to stop them. Staff should report the direction/location of the patient to the Security Officer on duty and notify the Department Director, Administrator Coordinator or designee, the Attending Physician and the responsible family member immediately. The Department Director, Administrator Coordinator or designee will be responsible to notify the Police Department when necessary. Documentation of the event should include the time of the elopement, who was notified, and the condition of the patient upon return and final disposition.

Review on 11/02/2020 of policy "Elopement of Psychiatric Patient from Inpatient Unit" last reviewed 01/2019 revealed any patient elopement must be reported within 24 hours to the Quality Management Department and an incident report will be completed in its entirety by the Department Manager and forwarded to the Quality Manager Department, and entered into the Justice Center data base.

Review on 10/30/20 of confidential facility incident form dated 10/05/20 at 10:10 AM, indicates Patient #1 was in ICU room #704, eloped from the unit, and exited through the main entrance. Staff tried but were unable to locate her. Staff from the ICU notified the police department to attempt to located Patient #1. The report does not include who entered the report, what staff were involved, and whether the attending physician/administration and/or Patient #1's next of kin/emergency contact person were notified. There is no documented evidence that the elopement event was investigated, and that the incident review was completed.

Review on 10/30/20 of internal email dated 10/05/20 at 03:12 PM from Staff (S), Director of the ICU to Staff (B), VP of Quality revealed the escaped person was Patient #1 from the ICU. 9.39 papers were not signed. Staff (S) indicated she spoke with the police and tried to call Patient #1 cell phone.

Interview on 10/30/2020 at 11:04 AM with Staff (B), Vice President (VP) of Quality, revealed she had just started her job as VP of Quality the week before this event with Patient #1 happened. The process in place was to have the floor managers and clinical coordinators take the lead and investigate any incidences which occurred on their floors. Staff (Q), Director of Inpatient Behavioral Health, and Staff (S), Director of the Intensive Care Unit (ICU), were handling the investigation, contacting the police, and filling out the Justice Center report. Staff (B) confirmed an investigation was not completed.

Interview on 10/30/2020 at 11:23 AM with Staff (Q), Director of Inpatient Behavioral Health, revealed that Staff (E), ICU RN Clinical Coordinator, and Staff (S), Director of the Intensive Care Unit (ICU), gathered the information related to Patient #1 absconding. He just helped them fill out the Justice Center form. He is unaware if they completed a facility incident report. Staff (Q) tried to file a missing person's report yesterday (10/29/20) stating the police would not file the report initially. Staff (Q) will file a missing person's report today.

Interview on 10/30/2020 with Staff (E), ICU Clinical Coordinator revealed she did not do an investigation due to being on orientation. Staff (Q), Director of Inpatient Behavioral Health, took all the information from her and Staff (S), Director of the Intensive Care Unit (ICU), to write up the Justice Center form. She is unsure if Staff (S) did an investigation, interviewed staff, and/or filled out a facility incident report.