HospitalInspections.org

Based on observations, interviews, and record reviews, the facility failed to meet the Condition of Participation (CoP) for Patient Rights by failing to protect and promote each patient's rights as evidenced by the following:

1.The facility failed to communicate with the legal guardian of one (1) patient with diminished capacity out of fifteen (15) patients sampled who eloped out of the Emergency Department. See Tag 131.


2.The facility failed to provide care in a safe setting by failing to implement interventions and communicate elopement risks for four (4) out of fifteen (15) patients evaluated by psychiatry or law enforcement as being risks to themselves or others and needing temporary detention under FD-12 that eloped out of the Emergency Department. See Tag 144.


49189

49189

Based on hospital policy review, medical record review, and interview, the facility failed to communicate with the legal guardian of one (1) patient who lacked capacity to make decisions out of fifteen (15) patients sampled who eloped out of the emergency department (Patient #5).

The Findings Include:

Review of the facility's "Patient Rights and Responsibilities" policy, last revised 03/2022, revealed:
"The hospital, its employees, medical staff, volunteers, and visitors have an obligation to observe the rights of each inpatient, outpatient, neonate, child, incapacitated or incompetent patient or the legal representative of the same. Patients of [Facility's Name] have the right to:

1. Receive complete and current information concerning diagnosis, treatment, and prognosis in terms that they can be reasonably expected to understand.

2. Designate an individual to represent them in making decisions regarding treatment and health care."

Review of the facility's "Elopement Procedures & Precautions" policy, effective 08/2023, revealed: "Procedure for Patient Elopement: A progress note outlining the event, patient status, assessment of potential harm, attempt to find the patient and notification of appropriate party."

Record Review of Patient #5's Medical Record from 08/16/2023 to 08/18/2023 revealed that Patient #5 presented to the facility's Emergency Department on 08/16/2023 from a Skilled Nursing Facility for evaluation of Anemia, Elevated White Blood Cell, and High Serum (Blood) Calcium.

ED [Emergency Department] Physician Record from 08/16/2023 revealed: "43-year-old female presenting today from her outpatient rehab facility, unsure of the exact reason she came in; the patient is a poor historian, states initially that she just wants to leave and does not want anything done to her ..." Further review shows "History of bipolar, paranoid schizophrenia, chronic anemia, TUD [tobacco use disorder] ...her new surrogate decision-maker is her father [name] at [phone number] she was discharged to long term care with hospice plan after she was made DNR/DNI [do not resuscitate/intubate] after discussion with palliative care."

Further review of ED Physician Record from 08/16/2023 shows a capacity assessment performed on Patient #5 with the following assessment:

1. The patient does not believe they have an illness/condition that may impact their health.

2. The patient cannot describe the proposed treatment.

3. The patient cannot describe the purpose of the treatment.

4. The patient cannot state the basic risks to refusing the treatment (which may be as serious as death).

5. The patient cannot state the alternative approaches (including no treatment) and discuss their risks/benefits (such as, with no treatment the condition will get worse).

6. The patient cannot explain their decision-making process (ie engage in rational process of manipulating the relevant information to make a decision.).

The assessment outcome is as follows: "Accordingly, as a licensed physician, it is my clinical judgement that the patient does not have capacity to refuse blood transfusion or further workup of her abnormal vital signs at this time."

Patient #5 was admitted to the facility for intravenous antibiotics and blood transfusions on 08/17/2023 at 5:04 AM.

Nursing Case Management Note from 08/17/2023 revealed: "Pt [patient] accepted to return back to [Rehab Facility]. SW (Social Work) notified pt's guardian [name and phone number] who is aware and in agreement with d/c [discharge] there today."

Nursing Note from 8/17/2023 at 6:00 PM revealed "Pt eloped out of the ED. When this RN went ot [spelling, to] re-evaluate pt and offer her food prior to her discharge home, pt was not found in her room. Security, Charge nurse and nurse manager was notified. Pt left through the ambulance [exit] approximately @ 1730 [at 5:30 PM]." No documentation of Patient #5's Guardian or Rehab Facility being notified at the time of the elopement.

Nursing Note from 08/18/2023 at 8:00 AM revealed "this RN called [Rehab Facility] unit to inquire if pt had returned to nursing home. At this time, pt has not returned to nursing home.

Nursing Note from 08/18/2023 at 11:23 AM revealed "Sgt [Sergeant Name] spoke w/ [with] MPD [Metropolitan Police Department] and asked for update on missing person case. No updated at this time and investigation is still ongoing."

Nursing Note from 08/18/2023 at 1:00 PM revealed "this RN spoke w/ pt's guardian [name and number]. Guardian has not spoken w/ pt since elopement from ED." Total time since elopement 19 hours and 30 minutes.

ED Physician Record from 08/19/2023 from Patient #5's inpatient Physician revealed "Patient was admitted and was planned to discharge to [Rehab Facility] where she had a bed, but patient eloped to the street prior to transport. A missing person report was filed."

On 09/25/2023 at approximately 12:30 PM, the surveyor conducted a face-to-face interview with Employee #9 Manager of Nursing Administration and Operations confirmed that there is no documentation that Patient #5's guardian was notified of their elopement at the time of discovery.

Based on medical record reviews, hospital policy reviews, video footage review, and interviews the facility failed to provide care in a safe setting by failing to recognize, communicate, and implement elopement prevention strategies for four (4) patients out of (15) were evaluated by psychiatry or law enforcement as being a risk to themselves or others and needing involuntary detention under FD-12. (Patient #1, 2, 3, and 4). These four identified patients eloped from the Emergency Department.

An Immediate Jeopardy (IJ) was identified on 09/28/2023 and presented to the facility leadership on 09/28/2023 at 1:52 PM. The facility submitted a plan of removal on 09/28/2023 at approximately 7:29PM.

The Findings Include:

Review of the facility's "Elopement Procedures & Precautions" policy, effective date 08/2016, revealed: "4. Appropriate Intervention for At Risk Patient: Patient who is pending transfer to an involuntary psychiatric unit will be placed on elopement precautions and line of sight observation with a sitter." And "5. Placing the At-Risk Patient on Elopement Precautions Notify Security to place the patient on the security special attention list."

Review of the facility's "Sitter: Care and Observation of the Patient by Sitter" policy, effective date 03/2019, revealed: "Patients Pending Transfer to an Involuntary Psychiatric Unit (FD-12): Any patient who is pending transfer to an involuntary unit will be placed at a minimum with a 1:1 observation for ED [emergency department] and admitted patients."

Record review of Patient #1's Medical Record dated 09/14/2023 revealed that Patient #1 was transferred from a psychiatric hospital for medical clearance of a wrist fracture at 8:26 AM.

A review of the transferring psychiatric hospital's memorandum of transfer dated 9/14/23 showed the patient had an active FD-12 form in place upon arrival at 8:26 AM.

A nursing note dated 9/14/23 at 9:12 AM indicated that Patient #1 eloped from the facility.

Review video footage for Patient #1's elopement on 09/14/2023 revealed:

1. At 8:03 AM Patient #1 presented with Ambulance staff and the transferring psychiatric hospital's staff.

2. At 8:17 AM Patient #1 was moved to a room and ambulance staff departed. No sitter from the facility was seen entering the room.

3. At 8:22 AM Patient #1 is seen exiting the room and followed by transferring hospital's staff.

4. At 8:24 AM Patient #1 elopes out of the facility's main lobby.

Total time Patient #1 is in the facility is less than 1 hour.

Record review of Patient #2's Medical Record dated 07/30/2023 showed that Patient #2 presented at 11:19 PM accompanied by police for suicidal ideation with orders for a mental health hold.

Further review of Patient #2's medical record shows an FD-12 completed and orders for a Mental Health Hold.

A review of the Columbia Suicide Severity Rating Scale revealed Patient #2 was at high risk for Suicidal Behavior.

Nursing note from 12:35 AM revealed Patient #2 attempting to elope from the facility and that security did not intervene on Patient #2's elopement highlighting: "Patient refused to provide labs or change into green psych scrubs. MD's x3 [Medical Doctor's three times] interviewed patient and determined there was a video made by police indicating patient was indeed attempting to harm self by jumping from the bridge. Patient was made FD-12 and sitter, [sitter's name], was attempting to move the patient into a room for medications to be administered when patient ran out the back bay door to ED. [Sitter's name] yelled to the 2 security guards sitting at the door not to allow patient to leave due to Patient was FD-12. Security guard raised his arms and said "he is not in green scrubs, nothing we can do."

Video Record Review of Patient #2's elopement from 07/30/2023 revealed:

1. At 11:17 PM Patient #2 presents with Metropolitan Police.

2. At 11:50 PM Officers leave Patient #2 in the care of the facility. No facility's sitter is seen assigned to Patient #2. No sitter is seen with Patient #2 currently.

3. At 12:20 AM a facility's sitter is seen with Patient #2 on their personal cell phone with face down viewing screen. Patient #2 is seen on their personal cell phone with a charger cord plugged in.

4. At 12:21 AM Sitter is seen walking away from Patient #2 to plug in their cell phone, sitter has their back turned to Patient #2. Patient #2 is still using their own personal cell phone with a cord plugged in.

5. At 12:23 AM Patient #2 is seen walking out of the facility's Ambulance Bay in direct view of 2 security guards and followed by a nurse and doctor.

Total time Patient #2 was in the facility is 1 hour and 16 minutes.

Record Review of Patient #3's Medical Record from 06/18/2023 at 2:55 PM revealed the patient presented with the Metropolitan Police Department for Mental Health evaluation under an FD-12.

Physician Orders from 06/18/2023 at 8:11 PM included mental health hold and constant observation. Further review of Physician Orders revealed Transfer order placed at 9:13 PM.

Physician's Record from 5:08 PM revealed: "34-year-old male presenting to the emergency department brought in by police custody. He was found in Dupont Circle [locality within Washington D.C], reportedly assaulting individuals and spitting on people that were walking by. He was placed in handcuffs and brought to the hospital under an FD 12. Patient endorses to me that his first name is [name], states that he does not want to stay here in the emergency department. He requires frequent redirection, is unable to cooperate with exam, keeps stating "i don't want to be here".

Further review of the Physician Record revealed under Assessment/Plan: "34 yo M presenting w AMS [altered mental status], question psychosis vs intoxication, appears atraumatic, no prior records on my review. Will not answer questions regarding medical hx, SI, HI [suicidal ideation, homicidal ideation] . Received haldol and versed upon arrival for agitation, screening labs ordered, will discuss w psychiatry team for evaluation. Sitter ordered at time of ED arrival. 06/18/2023 20:09 Pt has been seen by the Psychiatry team, will not talk or discuss his care w team; anticipate continuation of police FD12, possible transfer to [psychiatric hospital]."

Further review of the Physician Record revealed under ED Course: "06/18/2023 21:27 At approximately 9:20 PM, the patient eloped from the emergency department. Psychiatric team updated regarding this. Discussed with Charge RN and bedside RN, as well as sitters. Discussed w security, as well as security leader, and attending, DC PD made aware given situation that he was an FD12 and eloped. TH: patient had been in room 14, with anticipated continuation of police FD-12 but eloped before treatment plan was completed."

A review of Patient #3's patient observer sheet lacked documentation of constant observations from 5:00 PM to 9:20 PM.

A nursing note for 9:54 PM indicated that Patient #3 eloped out of the hospital's emergency department.

Review of video footage for Patient #3's elopement on 06/18/2023 revealed:

1. At 9:18 PM and 21 seconds Patient #3 is seen leaving his room, no sitter seen with Patient #3.

2. At 9:19 PM and 20 seconds, Patient #3 walked out of the facility's Emergency Department and went to the radiology department.


3. At 9:19 PM and 30 seconds Patient #3 is seen redirected back to the Emergency Department by security.

4. At 9:21 PM and 20 seconds PM Patient #3 is seen eloping from the Emergency Department's ambulance bay.

Total time Patient #3 was in the facility was 6 hours and 59 minutes.

Record review of Patient #4's Medical Record from 04/06/2023 to 04/08/2023 revealed that the patient presented for suicidal ideation and was placed on an FD-12 after evaluation by psychiatry.

Nursing note from 04/07/2023 at 4:30 PM revealed that Patient #4 eloped out of the Emergency Department and was found at a nearby park smoking.

Patient #4 was brought back to the hospital and transferred on 04/08/2023 to a psychiatric hospital.

On 09/25/2023 at 1:07 PM, the surveyor conducted a face-to-face interview with Employee #11 Clinical Nursing Supervisor Emergency Department. Employee #11 reports that nursing's responsibilities during elopement precautions include changing the patient, handing belongings to security, and calling for a sitter to initiate line-of-sight observation. Employee #11 reported that the Charge Nurse's responsibilities included awareness of the patient's presentation, ensuring that the sitter remains with the patient, and ensuring proper documentation. When questioned about patients under FD-12, Employee #11 confirmed that nursing is expected to communicate the patient's status with security to notify them that the patient cannot leave the Emergency Department. When questioned about verifying the FD-12 status on a patient from a psychiatric hospital, Employee #11 reported that the FD-12 is presented to the Emergency Department in a packet, but nursing does not review it. The physician will review all documents in the packet and notify nursing of the patient's FD-12 status. Employee #11 acknowledged that nursing has first contact with the patient and that there could be a delay in the physician performing an assessment and identifying the patient's FD-12 status.

An Immediate Jeopardy (IJ) was identified on 09/28/2023 and presented to the facility leadership on 09/28/2023 at 1:52 PM. The facility submitted a plan of removal on 09/28/2023 at approximately 7:29PM that included the following:

1. Triage nurse screens patients for FD 12 status upon arrival from an outside BH facility. Interventions will start on 09/28/2023, will be ongoing, and will be continuously monitored.

2. Security officer screens any patient on arrival by law enforcement regarding FD 12 status and law enforcement is required to stay with the patient until hand off of care occurs. Triage nurse also screens law enforcement patients for FD 12 status. Interventions will start on 09/28/2023, will be ongoing, and will be continuously monitored.


3. Triage nurse notifies the Security Supervisor about any FD 12 patient. Interventions will start on 09/28/2023, will be ongoing, and will be continuously monitored.


4. Security Supervisor adds FD 12 patients to the Special Attention list and will have increased presence and rounding on FD 12 patients. Interventions will start on 09/28/2023, will be ongoing, and will be continuously monitored.


5. Triage nurse initiates elopement precautions and assigns a staff member to the patient for 1:1 observation. The triage nurse remains with the patient until staff member is identified for 1:1 observation. The sitter must be with the patient at all times. If the sitter needs to take a break, the sitter must call another staff member to provide constant observation of the patient during the sitter's break. Interventions will start on 09/28/2023, will be ongoing, and will be continuously monitored.


6. Reinforce education through in services to 100% ED staff through attestation regarding elopement precautions and workflow, with ongoing education and anticipated 21 days completion. Interventions will start on 09/28/2023, will be ongoing, and will be continuously monitored.


7. All FD 12 patients from the ED being discharged/transferred must be escorted by hospital security, and the security officer must stay with the patient until the patient is off hospital premises. Interventions will start on 09/28/2023, will be ongoing, and will be continuously monitored.


8. Critical components of the elopement precautions for patients in FD 12 status are being tracked for compliance through the daily Lean Daily Management board. Critical components are: Sitter order, FD12 (if applicable), Suicide precautions, and Sitter documentation. A monitoring tool is implemented to measure compliance. Interventions will start on 09/28/2023, will be ongoing, and will be continuously monitored.


The survey team returned on 10/02/2023 to validate the facility's plan and the Immediate Jeopardy was lifted on 10/02/2023 at 3:56 PM.



49189

Based on adverse event review, hospital policy review, and staff interviews the facility's Quality Assessment Performance Improvement program failed to measure, analyze, and track quality indicators impacting patient safety related to High-Risk elopements for three (3) out of fifteen (15) patients sampled (Patient #2, 3, and 4).

The Findings Include:

Review of the facility's "Quality Assessment and Performance Improvement Plan", from [no month] 2023, revealed:
"Strategic Objectives: 1. Maximize patient safety through daily comprehensive analysis of adverse patient events, Implementing preventive mechanisms through active feedback and learning involving all stakeholders of each event to promote co-ownership of the process and engagement."

"QI [Quality Improvement] Teams and Departments develop interdisciplinary measures for quality and safety in conjunction with the appropriate disciplines by the following actions at a minimum: 1. Reviewing significant variances and trends identified though individual departmental reports and provide assistance in opportunity identification and action plans with monitoring."

"Major processes and functions are assessed continuously. Results of these assessments are analyzed for stability, adverse trends and improvement opportunities. Examples of continuous assessment include the following: Patient clinical outcomes, Patient safety, Risk management (sentinel events, near miss, unanticipated deaths)."

Review of facility's "Patient Safety Event Reporting" policy, effective, 09/2012, revealed:

"D. Record keeping and trending: 1. The facility Risk Manager assures that all necessary parties, CEO, CNO, and CMO are informed of the event, regardless of severity classification assignment and document notification via proper functioning of STAR worklists. 2. Trending reports will be compiled and distributed to facility leadership staff to allow corrective action strategies to be developed. Review of this trending, corrective process and compliance with the tenets of this policy will occur at the facility Patient Safety Council."

Review of Patient #2's Patient Safety Report from 07/31/2023 reveals that Patient #2 had an elopement event in the Emergency Department.

Review of Patient #3's Patient Safety Report from 06/18/2023 revealed that Patient #3 had an elopement event in the Emergency Department.

Review of Patient #4's Patient Safety Report from 04/07/2023 revealed that Patient #4 had an elopement event in the Emergency Department.

Review of the facility's "Hospital Quality Council Meeting" minutes from 04/25/2023 revealed no mention of the elopement of Patient #4 from the Emergency Department.

Review of the facility's "Hospital Quality Council Meeting" minutes from 07/25/2023 revealed no mention of the elopement of Patient #3 from the Emergency Department.

Review of the facility's "Hospital Quality Council Meeting" minutes from 08/22/2023 revealed no mention of the elopement of Patient #2 from the Emergency Department.

On 09/28/2023 at approximately 4:26 PM, the surveyor conducted a face-to-face interview with Employee # 5 Director of Risk Management. Employee #5 confirmed that the process from a Risk Management standpoint in relation to Adverse Event Reports is to review the event, reach out to nursing leadership to gather more information and to discuss with nursing leadership what issues were identified and plan to prevent if from occurring again. Employee #5 reported that nursing leadership is responsible for monitoring metrics on their individual units and that Risk Management does not trend reports.

On 10/02/2023 at approximately 12:52 PM, the surveyor conducted a face to face interview with Employee #7 Director of Quality Management and Regulatory. Employee #7 confirmed that adverse events and patient safety concerns are managed through the facility's Patient Safety Committee. Employee #2 confirmed that Risk Management is not a member of the Quality Assessment Performance Improvement Council, but is a member of Patient Safety Committee. Employee #7 confirmed that presently the Patient Safety Committee does not communicate recommendations or trending events to Hospital Quality Council.

Based on, interviews and record reviews, the facility failed to meet the Condition of Participation (CoP) for Nursing Services by failing to ensure nursing care is furnished and supervised by the Registered Nurse as evidenced by the following:

1. The facility's nursing staff failed to (1) supervise patient observations and implement suicidal precautions for two (2) out of (15) patients sampled who eloped; (2) the facility's nursing staff failed to complete fall assessment screenings and interventions for four (4) out of (15) patients sampled. See Tag A-395.


49189

Based on hospital policy review, medical record reviews, video footage review, and interviews, The facility's nursing staff failed to (1) supervise patient observations and implement suicidal precautions for two (2) out of (15) patients sampled who eloped (Patient #2 and 3) and (2) the facility's nursing staff failed to complete fall assessment screenings, and interventions for four (4) out of (15) patients sampled (Patient #4, 5, 8, and 9).

The Findings Include:

1. Findings related to failure to supervise patient observations and initiate suicidal precautions:

Review of the facility's "Suicide: Management of the Patient at Risk for Suicide", effective 03/2019, revealed: "Assessing Patients for Suicide:
1. Any patient who is suicidal or expresses suicidal thoughts/intent during the screen or at any other time will be placed on 1:1 observation and on suicide precautions. When a patient is placed on 1:1 observation, the primary nurse or designee will continuously observe the patient until a sitter is assigned."

"Caring for Patients on Suicide Precautions: ...
2. Have the patient change into a green gown or green paper scrubs.

4. Take the patient's belongings and secure them in an enclosed bag. A. In the ED, place the belongings in a locker or security. Belonging location will be documented in the medical record.

9. Suicide Precautions will be documented in the medical record. The RN should document observations of behavior, affect, and verbalizations."

"Appendix B: Examples of restricted personal items: Chargers (cell phone, tablet, etc.)"

Review of the facility's "Sitter: Care and Observation of the Patient by Sitter" policy, effective date 03/2019, stipulates the following: "Patients Pending Transfer to an Involuntary Psychiatric Unit (FD-12): Any patient who is pending transfer to an involuntary unit will be placed at a minimum with a 1:1 observation for ED [emergency department] and admitted patients. Patient Care: 13. The sitter must document on the Sitter Observation Flowsheet every 15 minutes."

Record Review of Patient #2's Medical Record from 07/30/2023 showed that Patient #2 presented at 11:19 PM accompanied by police for suicidal ideation under an FD-12 detention.

Further review of Patient #2's medical record shows an FD-12 completed and orders for a Mental Health Hold.

Review of Columbia Suicide Severity Rating Scale revealed Patient #2 is high risk for Suicidal Behavior.

Nursing note from 12:35 AM revealed Patient #2 attempting to elope from the facility and that security did not intervene on Patient #2's elopement highlighting: "Patient refused to provide labs or change into green psych scrubs. MD's x3 [Medical Doctor's three times] interviewed patient and determined there was a video made by police indicating patient was indeed attempting to harm self by jumping from the bridge. Patient was made FD-12 and sitter, [sitter's name], was attempting to move the patient into a room for medications to be administered when patient ran out the back bay door to ED. [Sitter's name] yelled to the 2 security guards sitting at the door not to allow patient to leave due to Patient was FD-12. Security guard raised his arms and said "he is not in green scrubs, nothing we can do."

Video Record Review of Patient #2's elopement from 07/30/2023 revealed:
1. At 11:17 PM Patient #2 presents with Metropolitan Police.

2. At 11:50 PM Officers leave Patient #2 in the care of the facility. No sitter is seen assigned to Patient #2. No sitter is seen with Patient #2 currently.

3. At 12:20 AM a sitter is seen with Patient #2 on their personal cell phone with face down viewing screen. Patient #2 is seen on their personal cell phone with a charger cord plugged in.

4. At 12:21 AM Sitter is seen walking away from Patient #2 to plug in their cell phone, sitter has their back turned to Patient #2. Patient #2 is still using their own personal cell phone with a cord plugged in.

5. At 12:23 AM Patient #2 is seen walking out of the facility's Ambulance Bay in direct view of 2 security guards and followed by a nurse and doctor.

Review of Patient #3's Medical Record from 06/18/2023 at 2:55 PM revealed the patient presented with the Metropolitan Police Department for Mental Health evaluation under an FD-12.

Physician's Record from 5:08 PM revealed: "34-year-old male presenting to the emergency department brought in by police custody. He was found in Dupont Circle [locality within Washington D.C], reportedly assaulting individuals and spitting on people that were walking by. He was placed in handcuffs and brought to the hospital under an FD 12. Patient endorses to me that his first name is [name], states that he does not want to stay here in the emergency department. He requires frequent redirection, is unable to cooperate with exam, keeps stating "i don't want to be here".

Further review of the Physician Record revealed under Assessment/Plan: "34 yo M presenting w AMS [altered mental status], question psychosis vs intoxication, appears atraumatic, no prior records on my review. Will not answer questions regarding medical hx, SI, HI [suicidal ideation, homicidal ideation] . Received haldol and versed upon arrival for agitation, screening labs ordered, will discuss w psychiatry team for evaluation. Sitter ordered at time of ED arrival. 06/18/2023 20:09 Pt has been seen by the Psychiatry team, will not talk or discuss his care w team; anticipate continuation of police FD12, possible transfer to [psychiatric hospital]."

Further review of the Physician Record revealed under ED Course: "06/18/2023 21:27 At approximately 9:20 PM, the patient eloped from the emergency department. Psychiatric team updated regarding this. Discussed with Charge RN and bedside RN, as well as sitters. Discussed w security, as well as security leader, and attending, DC PD made aware given situation that he was an FD12 and eloped. TH: patient had been in room 14, with anticipated continuation of police FD-12 but eloped before treatment plan was completed."

Physician Orders from 06/18/2023 at 8:11 PM included a mental health hold and constant observation. Further review of Physician Orders revealed Transfer order was placed at 9:13 PM.

A review of Patient #3's patient observer sheet lacked documentation of constant observation from 5:00 PM to 9:20 PM.

A nursing note for 9:54 PM indicated that Patient #3 eloped out of the hospital's emergency department.

Review of video footage for Patient #3's elopement on 06/18/2023 showed no sitter present.
1. At 9:18 PM and 21 seconds Patient #3 is seen leaving his room, no sitter seen with Patient #3.

2. At 9:19 PM and 20 seconds, Patient #3 walked out of the facility's Emergency Department and went to the radiology department.


3. At 9:19 PM and 30 seconds Patient #3 is seen redirected back to the Emergency Department by security.

4. At 9:21 PM and 20 seconds PM Patient #3 is seen eloping from the Emergency Department's ambulance bay.

Total time Patient #3 was in the facility was 6 hours and 59 minutes.

On 09/25/2023 at approximately 12:31 PM the surveyor conducted a face-to-face interview with Employee #9 Manager of Nursing Administration and Operations. Employee #9 was confirmed as being oversight for the facility's sitters. The surveyor questioned Employee#9 about Patient #3's reviewed Patient Observer form. Employee #9 confirmed that there is no documentation of sitter observations during the time frame Patient #3 eloped out of the Emergency Department. Employee #9 confirmed that the Emergency Department charge nurse is responsible for rounding on sitter cases in their department to ensure that the sitter is performing the task and documenting accordingly. Employee #9 confirmed that it is the expectation for sitters to always maintain line-of-sight observations of their assigned patients.

On 09/25/2023 at approximately 1:07 PM, the surveyor conducted a face to face interview with Employee #11 Clinical Supervisor Emergency Department. Employee #4 endorsed that a sitter would not be placed on a psychiatric patient if they remained in the custody of the police. If the police depart, the nurse's responsibilities would include changing the patient into a green gown, handing belongings to security, and calling for a sitter to initiate constant observations.

2.Findings related to failure to complete fall assessment screenings and interventions.

Review of the facility's "Fall Prevention" policy, effective 05/2023, revealed: "Each patient is assessed for their risk of falling using an age appropriate, evidence based scale. For adult patients in the emergency department, a registered nurse (RN) will use the KINDER I scale. The Kinder I Fall Risk Assessment Tool was designed by emergency nurses to identify adult patients at risk for falls starting at the point of entry or triage. Intervention strategies are based on the level of fall risk determined by the fall risk assessment, and the nurse's clinical judgment."

Record Review of Patient #4's Medical Record from 04/06/2023 reveals that Patient #4 presents to the Emergency Department for suicidal ideation.

Review of Kinder Fall assessment shows incomplete documentation with the following assessment prompts not answered: "Presented to the ED Because of Falls, Altered Mental Status, Impaired Mobility, Nurse Judgement." Under Assessment Outcome, Patient #4 is documented as "NOT High Risk" for falling.

Record Review of Patient #5's Medical Record from 08/16/2023 reveals that Patient #5 presented to the Emergency Department for Anemia.

Review of Kinder Fall assessment shows incomplete documentation with the following assessment prompts not answered: "Presented to the ED Because of Falls, Altered Mental Status, Impaired Mobility, Nurse Judgement." Under Assessment Outcome, Patient #5 is documented as "High Risk in ED for Falls." No documentation of fall precautions or interventions used in the Emergency Department.

Record Review of Patient #8's Medical Record from 09/22/2023 revealed that Patient #8 is a 20-year-old who presented to the Emergency Department for Alcohol Intoxication.

Review of Kinder Fall assessment shows incomplete documentation with the following assessment prompts not answered: "Presented to the ED Because of Falls, Altered Mental Status, Impaired Mobility, Nurse Judgement." Additionally, under the assessment prompt "Age > [greater than] 70" the prompt is answered "Yes." Under Assessment Outcome, Patient #8 is documented as "High Risk in ED for Falls." No documentation of fall prevention measures was noted in the medical record.

Nursing note from 9:32 AM states "Md [Medical Doctor] walked pt [patient #8] and he was still unsteady pt assisted back into bed and fel [sic] asleep. will reacess [sic] before d/c [discharge]." No documentation of fall prevention measures noted in medical record.

Record Review of Patient #9's Medical Record from 09/20/2023 revealed that Patient #9 presented to the Emergency Department for a laceration to the face.

Review of Kinder Fall assessment shows incomplete documentation with the following assessment prompts not answered: "Presented to the ED Because of Falls, Altered Mental Status, Impaired Mobility, Nurse Judgement." Under Assessment Outcome, Patient #9 is documented as "NOT High Risk" for falling.

On 09/22/2023 at approximately 3:50 PM, the surveyor conducted a face to face interview with Employee #10 Clinical Supervisor Emergency Department. Employee #10 confirmed that all the Kinder Fall assessment prompts are to be answered by the nurse and then the assessment outcome is determined. Additionally, Employee #10 confirmed that the Emergency Department does have fall prevention interventions that can be used for patients screened as a high risk to fall.

Based on observations, hospital policy reviews, and interviews, the facility's nursing staff failed to provide a safe and sanitary environment by failing to secure sharps and empty medication vials and failing to sanitize items requiring reprocessing for sterilization during the Emergency Department tour.

The Findings Include:

Record review of the facility's "Standard Precautions" policy, reviewed 02/2012, revealed: "Place used disposable syringes and needles including needle-less syringes, scalpel blades, razors, and other sharp items in appropriate puncture-resistant containers, which are located as close as practical to the area in which the items were used, and place reusable syringes and needles in a puncture-resistant container for transport. Sharps should never be discarded in medical waste or regular trash bags."

Record review of facility's "Point of Use Cleaning" policy, effective, 07/2022, revealed: Procedure for Non-Procedural areas: "7. Immediately after equipment and/or instruments are used, place contaminated instruments in a nonpermeable container labeled as biohazard. Transport to designated decontamination room. 8. Once procedure completed, don PPE, if not already on. 9. Open all hinged instruments, flush all lumen instruments, and remove gross contaminants from the instrumentation. 10. Place contaminated equipment and/or instruments into a rigid, leak-proof puncture proof container marked biohazard. 11. Spray instruments with PRE-KLENZTM gel spray. 12. Bring closed red biohazard bin to sterile processing and bring a new, clean bin designated with a plastic bag back to the Clean Supply Room."

On 09/22/2023 at approximately 10:15 AM the surveyors conducted a tour of the Emergency Department in the presence of Employee #10 and Employee #11 Clinical Supervisors Emergency Department. The following were found:

1. One (1) used blunt tip needle on a bedside table in the trauma room.

2. One (1) used blunt tip needle and syringe on the back of stretcher "P"

3. One (1) empty glass vial of famotidine on the back of stretcher "P"

4. Four (4) used clamps covered in dried blood with hinges closed in the sink of the soiled utility room.

On 09/22/2023 at approximately 10:20 AM, the surveyor conducted a face to face interview with Employee #10. The above sharps were identified and Employee #10 confirmed that sharps must be placed in sharp containers after use. Employee #3 promptly disposed of all identified sharps.

On 09/22/2023 at approximately 10:22 AM, the surveyor conducted a face to face interview with Employee #11. The above items were brought to Employee #11's attention and they confirmed that the expected process is that the Emergency Department technician will clean the blood off, place the clamps into a red biohazard container, and spray the clamps with PRE-KLENZTM [provides point of use cleaning of surgical instruments] spray. Employee #11 confirmed that the biohazard container is typically located in the soiled utility room, but was unable to locate it at the time of the interview.