HospitalInspections.org

Based on observation, medical record review, incident report review, review of policies and procedures, and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of services by failure to establish an elopement/wander assessment for patients on admission; failure to develop a policy and procedure for elopement; failure to educate and document staff education on new interventions implemented for patients at risk for wander/elopement; failure to follow CAH policy for patient assessments for alcohol withdrawal; and failure to thoroughly investigate patient elopement (Refer to C271). Failure to ensure the provision of services resulted in a patient elopement from the CAH and has the potential to result in reoccurring elopements and possible patient injury or harm.




37620

Based on observation, medical record review, incident report review, review of policies and procedures, and staff interview, the Critical Access Hospital (CAH) failed to provide care and services in accordance with appropriate written policies for 1 of 1 inpatient (Patient #1) who eloped from the CAH. Failure to establish an elopement/wander assessment for patients on admission; failure to develop a policy and procedure for elopement; failure to educate and document staff education on new interventions implemented for patients at risk for wander/elopement; failure to follow policy for patient assessments for alcohol withdrawal; and failure to thoroughly investigate patient elopement resulted in a patient elopement from the hospital and has the potential to result in reoccurring elopements and possible patient injury or harm.

Findings include:

Review of the policy titled "Occurrence Reporting Online Using Healthcare Safety Zone Portal" occurred on 04/04/18. This policy, revised March 2018, stated, "Purpose: To improve the safety and quality of patient care, visitor, employees, and volunteers. To provide a record of the occurrence. To provide data base for Quality Improvement activities. To identify unsafe conditions and allow for investigation and corrective action. Definition: An occurrence is defined as a happening not consistent with the routine operation of the facility, the routine care of a patient, the routine service of a department. This includes unusual occurrences, accidents and situations which could or did result in injury to patient, visitor, volunteer, or employee. . . . Procedure: . . . Finish the report by answering all questions, being as complete and accurate as possible. . . . All occurrences will be thoroughly investigated. . . . It is the expectation of each Department Manager to review reports weekly, follow up as needed, assign tasks as warranted, and complete follow up in portal. . . . Develop an Action Plan as needed to correct the identified trends. . . . Track and monitor issue until resolved. . . ."

Review of the policy titled "Acute/Chronic Alcohol Intoxication" occurred on 04/04/18. This policy, dated January 2016, stated, "Process: The patient will be closely observed/monitored while under the influence of alcohol/chemicals. Nursing will complete a CIWA-Ar [Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised] score every hour until the score is less than 8; then reassess CIWA-Ar score every 2-4 hours and PRN [as needed]. . . ."

Review of Patient #1's medical record occurred on 04/04/18 and identified the CAH admitted the patient on 01/07/18 for alcohol intoxication and concern for withdrawal. An admission History and Physical, dated 01/07/18 at 5:17 p.m., identified the patient presented with alcohol intoxication with an alcohol level of 0.31% (blood alcohol results equal to or above 0.08% - legally intoxicated; 0.08% to 0.40% - increasing impairment and depression of central nervous system likely; greater than 0.40% - loss of consciousness likely, potentially fatal). The record indicated Patient #1 had just come from a bar and wanted to go to alcohol rehabilitation. The documented last drink occurred 30 minutes prior to entering facility. The patient's history included over 40 years of drinking, drinking about 1.75 liters of hard liquor daily, methamphetamine three days prior, and history of alcohol withdrawals. A physical exam identified intoxication with slurred speech, unsteady balance, anxiety, cognition and impaired memory.

Patient #1's medical record identified the following:
* 01/07/18 at 5:44 p.m.: A flowsheet identified the following fall interventions: Offer bathroom every 2 hours, remind to call for assist, call light within reach.
* 01/07/18 at 6:13 p.m.: "Pt [patient] admitted for observation for acute alcohol intoxication. . . ."
* 01/07/18 at 7:39 p.m.: Staff completed a CIWA with a score of 14.
* 01/07/18 at 9:00 p.m.: Staff completed a CIWA with a score of 12 (1 hour and 21 minutes apart).
* 01/07/18 at 9:06 p.m.: ". . . bed alarm is on and call light is within reach."
* 01/07/18 at 10:51 p.m.: Staff completed a CIWA with a score of 14 (1 hour and 51 minutes apart).
* 01/08/18 at 1:32 a.m.: The flowsheet identified a fall risk assessment score of 15 (starting from zero with no risk of falls). The record failed to identify additional fall interventions.
* 01/08/18 at 3:51 a.m.: Staff completed a CIWA with a score of 10 (5 hours apart).
* 01/08/18 at 4:00 a.m.: "CIWA score 10 at the present time. Patient has awoke to almost constant hallucinations stating that immobile objects in his room are moving all the time. He is lucid and able to carry on a conversation. Wonders what will happen to him in the morning. . . ."
* 01/08/18 at 5:23 a.m.: ". . . He [Patient #1] states that he needs to cut down but doesn't know if he could take being at a treatment facility. . . He is showing more anxiousness this morning. Will continue to monitor his behaviors. . . ."
* 01/08/18 at 5:40 a.m.: Staff completed a CIWA with a score of 16 (2 hours from last CIWA).
* 01/08/18 at 9:01 a.m.: Staff completed a CIWA with a score of 17 (3 hours and 20 minutes from last CIWA).
* 01/08/18 at 9:21 a.m. (Social Worker note): "LSW [licensed social worker] filled out the application for involuntary committal paperwork . . . to get the ball rolling for help for his addiction therapy. Patient will stay at [CAH] until he is medically stable to handle the ride [to another facility]."
* 01/08/18 at 11:48 a.m.: "Pt found across the street from the hospital on someone's porch sitting in a chair. Pt has no shoes or sock on, does have a hospital gown, robe, and coat on. Did rip his IV [intravenous] out. Pt asked what he was doing? Reports that he was leaving and going home and he wasn't going to go to treatment. . . . Pt asked to get into the wheelchair. Pt's feet wrapped with a coat and taken back into the hospital. Elopement paperwork filled out. PA [physician assistant] informed of the elopement and DON [director of nursing]. Police present to help get the pt back into the hospital. . . . Pt last checked on by nursing staff at 1005 [10:05 a.m.], observed in bed at that time. Pt moved to room 104 across from the nurses' station, bed and chair alarms utilized. . . ."
* 01/08/18 at 2:31 p.m.: "Pt has been very hard to redirect throughout morning. Pt has been stating he wants to leave . . . Pt oriented to person only at this time; does not know where he is at, what time it is, or the current situation. . . ."
* 01/08/18 at 5:07 p.m.: ". . . Pt is oriented to person only; bed alarm is in place for safety. . . . Poor judgement; Poor safety awareness; Inconsistent in following commands; Unable to follow commands; Hallucinating . . . "
* CAH staff completed and notarized an application for Evaluation and Emergency Admission on 01/08/18.
* 01/09/18 at 10:03 a.m.: "Pt's CIWA at 0934 [9:34 a.m.] was 24. . . . Pt is sitting on the side of the bed, picking at the air, insistent that he is going home. . . ."
* 01/09/18 at 11:00 a.m.: A fall risk assessment score identified 19. Interventions included: offer the bathroom every 2 hours, remind to call for assist, call light within reach, and needs assistance with activities of daily. The interventions failed to include a bed/chair alarm or sitter in room.
* 01/09/18 at 2:08 p.m.: "pt's bed alarm activated, when writer entered the room pt observed standing by the foot of the bed. . . . trying to hit at this time. Additional staff called to the room. . . ."
* 01/09/18 at 8:45 p.m.: A fall risk assessment score identified 21. Interventions included: offer bathroom every two hours, remind to call for assist, call light within reach and hourly checks.
* 01/10/18 at 12:00 a.m.: "2300 [11;00 p.m.] Pt's bed alarm went off. Nurses and a certified nurses assistant (CNA) entered the room to find pt trying to crawl over railing. . . ."
* 01/11/18 at 6:05 a.m.: " . . . 2200 [10:00 p.m.] Pt agitated, trying to crawl out of bed and go home. . . . Pt stated that he wanted to go home and that nurse needed to let him leave. 0000 [midnight] Pt restless. Continues to try and climb out of bed. Pt states that he wants to go home and that we have "kidnapped me". . . . Pt was continually trying to crawl out of bed and go home. Pt stated again that we couldn't keep him here. . . . Bed and chair alarms in place. Hourly rounding in place. . . ."
* 01/13/18 at 2:25 p.m.: "Found patient on the floor in front of his bed after I herd [sic] a grunting noise. Bed alarm failed to turn on. . . ."
* 01/14/18 at 1:03 p.m.: ". . . around 0010 [12:10 a.m.] patient became restless . . . intent on leaving and did not seem able to understand that he was in the hospital . . . "
* 01/14/19 at 6:58 a.m.: ". . . a CNA stayed at his bedside . . ."
* 01/14/18 at 11:00 a.m.: ". . . He is wanting to go for a drive in his car and smoke a cigarette. Staff tries to reason with him. One staff at bedside at all times."
* 01/15/18 at 12:45 a.m.: ". . . Bed and chair alarms on at all times, he almost always had a sitter at bedside. . . ."

An Incident Report, dated 01/08/18 at 11:28 a.m., stated, "Severity Scale: C. Mild harm . . . Describe the event: Pt found across the street from the hospital sitting in a chair on someone's proh [sic] outside. Pt ripped out his IV, has a gown, robe, and coat on with no shoes or socks. Pt asked what he was doing? Reports that he was going home and he didn't want to get treatment. Pt explained to that it is the middle of the winter and he cannot just walk without shoes or winter gear, and that there is a high risk of hypothermia and frostbite. PA informed of elopement and event. Cause of Event: NO ANSWER. Witness(es): Elopement not witnessed by staff. Found by . . . RN (registered nurse), . . . LPN (licensed practical nurse), and . . . HUC (health unit coordinator). Police officers present. . . . Supervisor Comments: [dated 1/18/18 at 3:00 p.m.] Pt here for detox, moved closer to nurses station, sitter implemented. Researching Wander Guard/similar."

The incident report failed to address whether Patient #1 had a functioning bed alarm at the time of elopement; when CAH staff had last seen the patient; how staff were alerted to the patient's elopement; documentation of the nurses' assessment upon return; and any staff interviews.

At the request of the surveyor, CAH staff called police dispatch regarding the time the call was originated on 01/08/18. Dispatch stated the call came into the department at 10:58 a.m. from a resident on the street where the patient was found.

Observation of the nurses station on 04/04/18 at 2:16 p.m. identified camera screens that showed real-time video of the parking lot, emergency room entrance (side and main), the emergency waiting room, the back door, and the hallway between the clinic and hospital. During an interview at 2:30 p.m., the administrative nurse (#1), stated the cameras have the ability to display past recordings and the CAH staff identified the ambulance door as the door they thought Patient #1 exited from, but confirmed they did not review the camera recordings from the time of the elopement. She also stated the ambulance door does not alarm.

An interview with a facility staff member (#4) at 2:30 p.m. on 04/04/18 stated the CAH installed alarms/locks on the double doors located by rooms 101 and 104 on 02/15/18 (approximately one month after Patient #1's discharge). Rooms 101 through 104 are located across from the nurses station.

Review of Patient #1's record identified staff last documented they completed one-hour rounding on 01/08/18 at 1:32 a.m. The medical record identified no further documentation of hourly checks until the patient returned to the facility after the elopement. The medical record identified nursing staff documented they completed a nursing assessment after Patient #1 returned to the facility, but failed to document the actual assessment.

During an interview on 04/04/18 at 3:31 p.m., an administrative nurse (#1) identified the following:
* Her understanding of the incident is that staff heard a page on the law enforcement radio at the nurse's station regarding a man found at a house across the street from the hospital.
* After hearing the page, the CAH staff immediately went to Patient #1's room and then to the house address.
* The CAH staff arrived at the home at the same time as the police.
* She was unsure if the bed alarm sounded when the patient eloped, and stated she would have to interview staff to know if the alarm had sounded. She stated the bed alarm is built into the bed, and if the bed alarm is turned off, staff have to manually turn the alarm back on. She stated staff do not complete audits of the functioning of the alarms, but the CAH has a company that comes every three months to check the alarms.
* Nursing staff should place patients in rooms 101-104 if they are at risk for elopement or if they need more frequent monitoring.
* The CAH's expectation of staff is to notify administration, the immediate supervisor, the provider, look for the patient, and notify law enforcement if an elopement occurs.
* All patients at the CAH are on one-hour rounding and staff document once a shift that they have completed hourly rounding.
* She confirmed the CAH does not currently have a wander/elopement risk assessment policy, an hourly rounding policy,or an elopement/safety policy in place that states the above expectations. She stated nursing staff use their judgement if patients need interventions for wandering, such as bed alarms. She stated she had informed staff of the expectations, but provided no documentation of staff education.




19410