HospitalInspections.org

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Based on medical record review, document review, video footage review and staff interview, in two (2) of six (6) medical records reviewed, the facility failed to assess, identify, and implement protective measures for patients who are at risk for elopement (Patient #1 and Patient #2).

See Tag A0144
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Based on medical record review, document review, and interview, nursing staff failed to assess, identify, establish a plan of care, and implement provider's order for observation of patients at risk for elopement.

See Tag: A0396
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Based on medical record review, document review, staff interview, in two (2) of six (6) medical records reviewed, the facility failed to assess, identify, and implement protective measures for patients who are at risk for elopement.

Findings include:

(1) Review of the medical record for Patient #1 identified the following:

Nursing Triage notes on 01/19/2024 at 11:30 AM, indicated the patient was evaluated in the Emergency Department (ED) for shortness of breath. The patient's medical history was significant for Dementia, Alzheimer's disease and she was oxygen dependent.

ED Physician on 01/19/2024 at 06:44 PM documented the patient was admitted to an inpatient unit for medical management.

Nurse Practitioner notes on 01/20/2024 at 04:48 PM, Nurse Practitioner documented that patient is not being compliant with oxygen therapy and is saturating at 70 percent (Normal oxygen saturation levels are 95% and higher); and that the patient is upset and angry.

On 01/20/2024, at 04:48 PM, Nurse Practitioner documented an order to place the patient on enhanced observation and issued a request for Psychiatric consultation citing, "Pt with underlying dementia, lacks capacity..."

Review of facility's policy titled "Constant Observation and Enhanced Observation (ED and Medical Inpatients)" revised 04/2022) stated, "The patient(s) remain within the same vicinity as the employee conducting the observation...If a patient must leave the unit for diagnostic procedures and/or testing, the employee performing the enhanced observation must accompany and remain with the patient during the procedure/test ..."

There was no documentation found that indicated the patient was placed on enhanced observation as ordered by the Nurse Practitioner.

An addendum notes by the ED provider on 01/21/2024 at 05:41 AM documented, "Writer was informed by nursing supervisor that local police authorities found the patient approximately a block away from the hospital and quite unfortunately was found unresponsive and pronounced dead at the scene..."

Review of facility's video footage on 01/31/2024 at 1:00 PM revealed that on 01/21/2024, at 03:47 AM, the patient dressed in street clothing exited the inpatient unit at 03:48 AM. At 03:50 AM, patient walked down the stairway and was seen at the hospital parking lot at 04:01 AM. The patient walked across a road at 04:05 AM.

On 02/01/2024, at 02:09 PM, during an interview with Staff R (Patient's Day nurse from 7AM to 7 PM), she stated the patient was not monitored because she was not aware the provider had written an order for enhanced observation.

On 02/02/2024, at 10:10 AM, during an interview with Staff U (Patient's Night nurse from 7:00 PM to 7:00 AM), stated that she was not informed by Staff R that the patient was on enhanced observation, "I learned about it after the fact,". During her shift in the early morning, she observed that the patient was not in her room. The patient was not found after a facility wide search.


(2) ED physician notes on 11/23/2023 at 4:06 PM, indicated Patient #2 presented with family concerns about wandering and disorientation. The patient was admitted with an impression of cognitive changes.

ED physician on 11/23/2023 at 4:34 PM documented an order for enhanced observation.

The patient was admitted to an inpatient unit on 11/24/2023 at 12:00 AM.

The neurologist evaluated the patient on 11/24/2023 at 8:02 AM for an acute onset of confusion. He documented that the patient's memory, attention, and concentration ranged from moderate to severely impaired.

On 11/24/2023 at 2:36 AM, nursing noted that the patient was on 1:1 for safety as he is a wanderer.
At 7:04 PM, nurse documented the patient verbalized that he wants to go home and he is being observed for safety.

Nursing documentation shows that the patient was on 1:1 observation for safety from 11/24/2023 to 11/27/2023.

Nursing notes on 11/28/2023 at 4:50 AM indicated that the patient is confused and that the 2:1 observation is in place.

Nursing documented on 11/28/2023 at 4:17 PM that the patient had eloped.

During interview with Staff C (AVP Compliance) on 2/7/2024, she stated that on 11/28/2023 at 1:30 PM, Patient Care Technician (PCA) was observing Patient #2 and his roommate when Patient #2 went to the bathroom and eloped while the PCA was attending to the other patient. Staff C added that the patient was later found at home and returned to the facility on 11/28/23 at 4:55 PM.

An Immediate Jeopardy situation was identified on 02/08/2024 at 01:23 PM due to facility failure to assess, identify, and protect patients at risk for elopement.

The facility provided an IJ Removal Plan on 02/08/2024 at 10:30 PM.
The plan included the following:

- Revised policy for enhanced and constant observation that indicated that observer may not leave the patients unattended at any time, and documentation of patient's behavior every hour.

- The Missing Patients/ Elopement policy was revised to include elopement screening, identification of patients at risk for elopement, and assignment of staff to elopement watch stations.

IJ was removed on 02/09/2024 at 04:12 PM based on onsite verification of revised policies and procedures, staff interviews, and verification of staff education to revised policies and procedures.

100% of staff interviewed on 02/09/2024 received education on the IJ removal plan and verbalized knowledge of elopement screening, observation of patients, and staff responsibilities regarding an eloped patient.
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Based on medical record review, document review, and interview, it was verified that nursing staff failed to assess, identify, establish a plan of care, and implement provider's order for enhanced observation for patients at risk for elopement.

Findings include:
Nursing Triage notes on 01/19/2024 at 11:30 AM, indicated the patient was evaluated in the Emergency Department (ED) for shortness of breath. The patient's medical history was significant for Dementia, Alzheimer's disease and was oxygen dependent.

ED Physician on 01/19/2024 at 06:44 PM documented the patient was admitted to an inpatient unit for medical management.

There was no documentation found that indicated the patient was assessed for elopement risk.

Nurse Practitioner notes on 01/20/2024, at 04:48 PM, documented that patient is not compliant with oxygen therapy and she is saturating at 70 percent (Normal oxygen saturation levels - 95% and higher); and that the patient is upset and angry.

On 01/20/2024 at 04:48 PM, Nurse Practitioner documented an order to place the patient on enhanced observation and issued a request for Psychiatric consult citing, "Pt with underlying dementia, lacks capacity..."

Review of facility's policy titled "Constant Observation and Enhanced Observation (ED and Medical Inpatients)" revised 04/2022 stated, "The patient(s) remain within the same vicinity as the employee conducting the observation...If a patient must leave the unit for diagnostic procedures and/or testing, the employee performing the enhanced observation must accompany and remain with the patient during the procedure/test ..."

There was no documentation found that indicated the patient was placed on enhanced observation by the nurse as per Nurse Practitioner's order on 01/20/2024 at 04:48 PM.

Review of Code Gray (Code for security assistance) report dated 01/20/2024 revealed that at 05:06 PM, the patient was dressed in street clothing and attempted to elope, she was agitated, loud and refused to take her medication.

There was no documented evidence that a nursing care plan was developed to maintain the patient's safety.

ED provider on 01/21/2024 at 05:41 AM documented "Writer was informed by nursing supervisor that local police found the patient approximately a block away from the hospital and quite unfortunately was found unresponsive and pronounced dead at the scene..."

On 02/01/2024, at 02:09 PM, during an interview with Staff R (Patient's Day nurse from 7AM to 7 PM), she stated the patient was not monitored because she was not aware the provider had written an order for enhanced observation.

On 02/02/2024, at 10:10 AM, during an interview with Staff U (Patient's Night nurse from 7:00 PM to 7:00 AM), stated that she was not informed by Staff R that the patient was on enhanced observation, "I learned about it after the fact,". During her shift in the early morning, she observed that the patient was not in her room. The patient was not found after a facility wide search.

An Immediate Jeopardy situation was identified on 02/08/2024 at 01:23 PM due to facility failure to assess, identify, develop a safety care plan, and implement physician order for enhanced observation for patients at risk for elopement.

The facility provided an IJ Removal Plan on 02/08/2024 at 10:30 PM.
The plan included the following:

- Revised policy for enhanced and constant observation that indicated that observer may not leave the patients unattended at any time, and documentation of patient's behavior every hour.

- The Missing Patients/ Elopement policy was revised to include elopement screening, identification of patients at risk for elopement, and assignment of staff to elopement watch stations

- Process change initiated that includes acknowledgement and handoff report of Providers Orders including Enhanced Observation orders in the electronic medical record.

- Implementation safety measures for patients with confusion, substance use disorder, suicide, and delirium in the Nursing Plan of Care.

IJ was removed on 02/09/2024 at 04:12 PM based on onsite verification of revised policies and procedures, staff interviews, and verification of staff education to revised policies and procedures.

100% of staff interviewed on 02/09/2024 received education on the IJ removal plan and verbalized knowledge of new and revised policies and procedures.