HospitalInspections.org

Based record review, observation and interview, the hospital failed to ensure prevention of patient elopement and security of facility door for 2 of 22 patients (Patient # 3 & 10). (See Tag A-0144)

These failed practices resulted in the elopement of patient # 10 which resulted in death and patient # 3 which resulted in patient driving off facility premises and had the potential for all patients to be at risk for care in an unsafe setting thereby increasing risk of elopement.


On 11/05/18 at 2:00 pm, surveyors identified an Immediate Jeopardy for patient rights and nursing services.

On 11/06/18 at 2:52 pm, the CEO and members of the hospital leadership team were notified of the Immediate Jeopardy.


On 11/07/18 at 1:30 pm, the facility submitted a plan of removal which included the following elements for patient rights and nursing services:

1. On 11/02/18, the facility replaced the door on the unit to prevent elopement.

2. The nursing staff have been provided with specific prompts for calling the code and a walkie talkie for alternate means of communication.

3. On 11/07/18, the staff were reeducated on completing the hand off communication to recognize signs and symptoms of increased agitation, and restlessness.

4. The staff were reeducated on the "Elopement Policy" which states staff should follow the patient to the perimeter of the hospital.


On 11/08/18 at 10:15 am, the surveyors accepted the plan of removal.


On 11/08/18 at 11:40 am, the surveyors verified the hospital's Plan of Removal of the immediacy by reviewing revised policy and procedure, interviewing nursing staff for their knowledge of the elopement and deescalation process, and observed the replaced door on the unit.

Based on record review, observation, and interview, the hospital failed to ensure prevention of patient elopement and security of facility door for 2 of 22 patients (Patient # 3 & 10) as evidenced by:

I. Failed to monitor, intervene or deescalate patients at risk for elopement.

II. Failed to ensure the security of the door on the unit.

These failed practices resulted in the elopement of patient # 10 which resulted in death and patient # 3 which resulted in patient driving personal vehicle off facility premises, and had the potential for all patients to be at risk for care in an unsafe setting thereby increasing risk of elopement.


Findings:


A policy titled "Management of Assaultive-Combative Patients" stated in the event a patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients, and staff with the least restrictive interventions possible based on the level of acuity and patient needs.


A policy titled "Elopement" stated "patients who leave the facility without notice ("Elopement") should have every attempt made to be provided with follow-up care to ensure that they are safe and not an imminent danger to self, others or gravely disabled...Staff will make an immediate search of the Facility grounds."


Patient # 3

Deescalation

Timeline of patient # 3's escalation:

A progress note dated 03/14/18 at 4:00 pm stated, patient # 3 as paranoid with auditory hallucinations. There was no intervention/deescalation documented.

A progress note dated 03/15/18 at 3:00 pm stated, patient # 3 as paranoid and grandiose with auditory hallucinations and quoted statement documented "I plan on dying shortly after I get out of here." There was no intervention/deescalation documented.

A progress note dated 03/16/18 at 10:50 am stated, patient # 3 as paranoid with auditory hallucinations and quoted statement documented "I just don't give a shit." There was no intervention or deescalation documented.

A progress note dated 03/17/18, with no time noted, stated patient # 3 as paranoid/bizarre and stated the patient "wants to leave; he is noted to be irritable this morning. Minimizing symptoms because he wants to leave." There was no intervention/deescalation documented.

A shift nursing assessment dated 03/17/18 at 3:21 pm showed patient # 3's mood/affect as calm; the narrative showed patient # 3 as irritable and patient stated "he wants to go home and see his dog." The same narrative note stated, "patient broke out window and eloped".

A root cause analysis, with no date and time documented, "patient # 3 was pacing the halls then became agitated and loud on 03/17/18 and findings included: 1) Findings: "The Registered Nurse was going to call a Code 100, requesting extra assistance from staff, but another Registered Nurse on the unit told her to wait." 2) Action Item: "Re-emphasize to all staff to call a code anytime they feel a patient is escalating and extra assistance is necessary." There was no intervention or deescalation documented.


Elopement

A root cause analysis with no date and time documented that "at 12:00 pm patient # 3 hit the plexi glass/door on the unit, took a chair and broke the plexi glass window of the door, climbed through and went out of the fire door exit. Patient # 3 then got into their vehicle and drove away."

A review of close observation record dated 03/17/18 at 12:00 pm showed "AWOL" (absent without leave).


Patient # 10

Deescalation

On 11/05/18 at 12:30 pm, surveyors observed a recorded video dated 10/29/18 to show patient # 10's elopement from the hospital:

7:54 am - Patient # 10 was sitting in the day area. Patient declined breakfast and was left on the unit with Staff K and Staff G.

7:56 am - Patient # 10 paced the day area.

8:00 am - Patient # 10 became restless by moving feet and fidgeting.

8:01 am - Patient # 10 escalated by tearing up magazines and throwing the papers around the day area.

There was no verbal attempt observed in the video to deescalate patient # 10 by Staff G and Staff K in the day room.


Elopement

8:02 am - Patient # 10 went to the nurse's station then walked away.

8:03 am - Patient # 10 walked across the unit. Patient # 10 walked up to a door on unit and began to hit and kicked the plexi glass, dislodged the plexi glass and climbed through the window. Patient # 10 went out the fire door exit. Patient # 10 went out into an open area.

8:03 am - Staff G came out from the nurses station and looks for the patient # 10. Staff G walked to the door that patient eloped from and continued to looked for patient # 10. Staff G went outside through the fire door, he/she looked to the left and right then went back into the facility with no immediate search of the facility grounds completed.

A review of document provided by Staff A the hospital immediately notified law enforcement through a 911 call. It was reported to the hospital that on 10/30/18 a dead body had been found near the hospital. It was confirmed by patient # 10 family that the body was that of patient # 10.

A shift nursing assessment dated 10/29/18 at 8:50 am showed no documentation that a search of the facility grounds was conducted at any time after the patient's elopement.


On 11/06/18 at 12:25 pm, Staff F stated "we can't do nothing; staff can't stop the patient."


On 11/06/18 at 12:52 pm, Staff G stated, they got ready to open door of nurse's station to go talk to patient # 10 but was told "no" and there was a delay in calling a Code 100 (an overhead page for extra staff to assist when a patient behavior escalates). A code was not called until after patient # 10 had torn up two of two books and began to punch the plexi glass. "We can't chase patient's because if the patient runs out into the street and gets hit by a car the facility is liable."


On 11/07/18 at 2:30 pm, Staff J stated, "patient # 3 had previously went out of the same door on unit; the plexi glass had been broken out of."


II. Failed to ensure the security of the door

A review of a document titled "Root Cause Analysis" for the incident that happened on 03/17/18: Action Item # 2: "Explore changing doors on the two that exit directly to outside and not into courtyard."

On 11/05/1818 at 1:07 pm, Staff E stated "the same plexi glass from the elopement on 03/17/18 was re-installed using glue and ribbed nails that were two inches long."

Based on record review, observation and interview, the hospital failed to ensure nursing services assessed and intervened to assist with patient deescalation for 2 of 22 (Patient # 3 & 10) records reviewed. (See Tag A-0395)


This failed practice resulted in the elopement of two patients (Patient # 3 & 10) and placed all patients at risk of no interventions for escalating behaviors.


On 11/05/18 at 2:00 pm, surveyors identified an Immediate Jeopardy for patient rights and nursing services.


On 11/06/18 at 2:52 pm, the CEO and members of the hospital leadership team were notified of the Immediate Jeopardy.


On 11/07/18 at 1:30 pm, the facility submitted a plan of removal which included the following elements for patient rights and nursing services:

1. On 11/02/18, the facility replaced the door on the unit to prevent elopement.

2. The nursing staff have been provided with specific prompts for calling the code and a walkie talkie for alternate means of communication.

3. On 11/07/18, the staff were reeducated on completing the hand off communication to recognize signs and symptoms of increased agitation, and restlessness.

4. The staff were reeducated on the "Elopement Policy" which states staff should follow the patient to the perimeter of the hospital.


On 11/08/18 at 10:15 am, the surveyors accepted the plan of removal.


On 11/08/18 at 11:40 am, the surveyors verified the hospital's Plan of Removal of the immediacy by reviewing revised policy and procedure, interviewing nursing staff for their knowledge of the elopement and deescalation process, and observed the replaced door on the unit.

Based on record review, observation and interview, the hospital failed to ensure nursing services assessed and intervened to assist with patient deescalation for 2 of 22 (Patient # 10) in that:

This failed practice resulted in the elopement of two patients (Patient # 3 & 10) and placed all patients at risk of no interventions for escalating behaviors.

Findings:

A policy titled "Management of Assaultive-Combative Patients" stated in the event a patient escalates and requires intervention, the staff will assess the situation and call for assistance as needed...If the staff available cannot contain the situation, a Code will be paged on the intercom. This policy does not give a time frame of how long nursing staff should wait before calling a code.


Patient # 3

A root cause analysis, with no date and time documented, "patient # 3 was pacing the halls then became agitated and loud on 03/17/18 and findings included: 1) Findings: "The Registered Nurse was going to call a Code 100, requesting extra assistance from staff, but another Registered Nurse on the unit told her to wait." 2) Action Item: "Re-emphasize to all staff to call a code anytime they feel a patient is escalating and extra assistance is necessary." There was no intervention or deescalation documented.


Patient # 10

A review of video showed a delay in calling a code for staff assistance when patient # 10 escalated. Patient # 10 eloped out the window of the door before the nursing staff came to deescalate patient.


On 11/06/18 at 12:25 pm, Staff F stated "we can't do nothing; staff can't stop the patient."


On 11/06/18 at 12:52 pm, Staff G stated they got ready to open door of nurse's station to go talk to patient # 10 but was told "no" and there was a delay in calling a Code 100 (an overhead page for extra staff to assist when a patient behavior escalates). A code was not called until after patient # 10 had torn up two of two books and began to punch the plexi glass. "We can't chase patient's because if the patient runs out into the street and gets hit by a car the facility is liable."