HospitalInspections.org

Based on record review and interview, the provider failed to ensure:
*The safety of one of one cognitively impaired sampled patient (16) who eloped from the building.
*Failed to develop policies and procedures to prevent the elopement of patients.
*Failed to implement policies and procedures to prevent the elopement of patients.
Findings include:

1. Review of patient 16's 2/25/13 history and physical revealed:
*He had been admitted on 2/25/13.
*His admission diagnoses included chest pain and lightheadedness.
*He had other diagnoses that included Alzheimer's dementia.
*He was a resident in a memory care nursing home.
*Medications he received at the memory care unit in the nursing home included:
-Namenda (memory) 10 mg twice daily, donepezil (memory) 10 mg daily, and Remeron (anti-depressant) 7.5 milligrams (mg) daily.
-Quetiapine (affects the mind) 12.5 mg at bedtime and 12.5 mg twice daily as needed for agitation.
-Amlodipine (blood pressure) 2.5 mg daily and Lisinopril (blood pressure) 20 mg daily.
-Aspirin 81 mg daily.
-Simvastatin (cholesterol) 20 mg daily.

Review of the staff notes for patient 16 revealed:
*On 2/26/13 at 10:15 a.m. by registered nurse (RN) A: "Pt. (patient) left floor around 1015 (a.m.) without approval. Unable to find until 1230 (p.m.). Pt. was wearing street clothes as was being discharged but discharge and a test had not been completed. Notified MD (medical doctor), family, security, hospital staff, and police. Pt. found unharmed and stable. Brought back to hospital to complete test and finish discharge."
*On 2/26/13 at 3:00 p.m. by RN A: "Pt. discharged back to NH (nursing home) with all belongings. IV (intravenous device) and tele (telemetry to monitor heart) off. Escorted out by staff and family."

Interview on 4/12/13 at 11:00 a.m. with RN A revealed:*She had been the assigned nurse for patient 16.
*He had been gone from the unit for approximately five minutes before it was noticed he was missing.
*She had notified other staff, and they had searched that floor.
*The charge RN on duty that day had called security.
*Security had searched other floors, and they had called the police.
*He had his saline IV lock in when he had left.
*There was a wandering vest that was bright yellow that could have been used for patients that wandered.
*That had not been used for patient 16.
*The only protocols used for ensuring a patient did not elope was hourly rounding (checking on the patient).

Interview on 4/12/13 at 11:15 a.m. with the assistant director of safety services regarding patient 16 revealed:
*The security department had received a call from the charge RN to report the patient was missing.
*They initiated a search of the hospital and hospital grounds.
*A report had come in the patient had been in the parking lot.
*The police had been contacted by the security department.
*He had been found at the police department's office.
*He had gotten a ride from an individual to the police department.
*He had reported to the police his car had been stolen.
*He was transported back to the hospital by the security department personnel and a nursing staff member.

Review of a 2/26/13 hospital transport officer call log revealed:
*Officer 26 logged a call at 10:05 a.m. to be advised to be on the look out for a male patient in his 80s that was missing from his room.
*A description was given to the officer.
*He checked the dietary department and the waiting rooms.
*He patrolled down 5th street and Fairmont street.
*At 10:50 a.m. he logged that he had assisted staff to check all floors looking for the lost patient.
*At 11:00 a.m. he logged a call had been placed to the police department to put out an attempt to locate alert on the lost patient.
*At 12:37 p.m. he logged a technician (hospital nursing staff person) was transported to the police department.
*At 12:45 p.m. he logged patient 16 was transported back to the hospital and was escorted back to his room.

Review of the in-house officer call log revealed at 10:11 a.m. officer 24 had logged an internal check and search for the missing patient.

Review of the out security log for officer 11 revealed at 11:55 a.m. he logged an internal/external check had been done for the missing patient. The patient had been found at the police department at that time.

Review of the provider's staff education for a missing patient revealed:
*When a patient was missing from their normal location and unaccounted for a condition E was to be announced.
*If the patient was not located quickly contact the local law enforcement.
*If the employee was unsure of their role in a condition E they were to have consulted their supervisor.

Review of the provider's revised September 2005 Elopement/Wandering of Patient policy revealed the policy applied to all of the hospital owned property. The policy however only addressed those patients at the rehabilitation part of the hospital.

Interview on 4/12/13 at 12:45 p.m. with the director of safety services revealed the above education for staff and the policy did not follow what was done for a missing patient. He stated there was no condition E announced when a patient was missing. The policy only applied to patients and staff at the rehabilitation hospital.

Review of the in-house officer call logs from 11/1/12 through 2/10/13 revealed:
*On 11/1/12 a patient had been reported missing. The patient was not located by security staff. Later informed that the patient had made it back to his room.
*On 1/4/13 at 1:13 p.m. security was called to report a patient leaving the hospital in a wheelchair. The patient was going to a local gas station to buy a lighter.
*On 1/4/13 at 1:23 p.m. security was called to report a patient possibly leaving the property with a wheelchair. The patient was found outside smoking.
*On 1/9/13 assisted staff with a confused patient. The patient was returned to his room.
*On 2/10/13 at 9:15 a.m. security was notified that a patient had left. Staff had found her IV (intravenous) pole on the first floor by the dialysis unit.

Interview on 4/12/13 at 12:15 p.m. with the director of risk management and accreditation/certification revealed:
*Condition E did not exist in a policy for the hospital.
*Condition E was an online education program provided to all staff for the management of missing or wandering patients.
*The incident that involved patient 21 had not been followed in any quality assurance process.
*There had been no new process initiated for missing patients.

Based on record review and interview, provider failed to ensure:
*Elopements were included in any of their performance improvement risk management (PIRM) studies.
*The contracted Enhanced Intensive Care Unit (eICU) service was included in the PIRM studies.
Findings include:

1. Review of the PIRM studies for 2012 and 2013 revealed the provider had not conducted a study of patient elopements or missing patients. Further review of the PIRM reports failed to show any studies had been completed on the contracted eICU service.

Refer to A115 and A385.

Based on record review, interview, and policy review, the provider failed to ensure nursing staff promptly responded to a patient care alert for low oxygen saturation for 1 of 17 sampled patients (4) on the medical intensive care unit (MICU). Findings include:

1. Review of the incident and investigation document prepared by the director of risk management and accreditation/certification regarding patient 4 revealed she:
*Had been admitted on 2/21/13 with diagnoses that included a urinary tract infection, history of pulmonary fibrosis, and chronic obstructive pulmonary disease.
*Had been on a ventilator (breathing machine) from 2/27/13 until 3/9/13 at 2:50 p.m.
*Had received oxygen (O2) via an oximyzer at twelve liters per minute (l/pm) to keep her oxygen saturations (SpO2) between 88 and 92%.
*Was alert and oriented when removed from the ventilator.
*Became more confused during the night of 3/9/13 through 3/10/13.
*On 3/10/13 at 11:20 a.m. was noted to have had wrist restraints in place to not remove tubes due to her confusion and inability to follow directions.
*Had removed her O2 delivery device.
*Sustained low SpO2 for nine minutes and the following had occurred:
-The alarm sounded at a yellow alert level (an intermittent alert sound).
-The assigned nurse was caring for another patient.
-The other three nurses in the MICU were also in patient's rooms.
-Patient 4's heart rate decreased and then stopped which produced a red alarm (high pitched tone)
-All of the nurses responded to the alarm and a code blue (interventions to restart the heart) was initiated.

Review of the 3/10/13 nurses schedule for the MICU revealed there were six patients in the unit. There were three nurses, one nurse who was doing orientation, and a health unit coordinator scheduled for those six patients. One of those patients was on a ventilator. RN B was assigned to patient 4 and a 7:00 a.m. new admission to that unit. The shift for the staff was from 7:00 a.m. through 7:00 p.m.

Review of patient 4's medical record from 2/21/13 through 3/10/13 revealed:
*Patient 4 had been admitted on 2/21/13.
*Her diagnoses included a urinary tract infection and hyponatremia (low sodium).
*She had been on a ventilator (machine to help with breathing) from 2/27/13 at 11:30 p.m. until 3/9/13 at 3:00 p.m.
*On 3/9/13 at 3:26 p.m. until 3/10/13 at 11:00 a.m. she received oxygen through an oximyzer device between six and twelve l/pm. Her SpO2 ranged between 86- 91%.
*On 3/9/13 at 6:25 p.m. her restraints had been discontinued.
*On 3/9/13 at 7:00 p.m. "Pt. (patient) is confused and agitated, pulled SpO2 off finger, oriented to person only. Pt. states she is not in hospital and needs to leave. The soft wrist restraints were re-ordered and put in place."
*On 3/9/13 at 8:00 p.m. "Pt. awake and watching television. Pt. is confused and states she is not in a hospital. Pt. pulled SpO2 off finger. Pt. not oriented to place or time."
*On 3/9/13 at 8:07 p.m. the wrist restraints were discontinued.
*On 3/9/13 at 10:00 p.m. the wrist restraints were removed and reapplied. "Pt. has loose restraints on at this time. Pt. is confused, states she is not in the hospital and needs to leave. Pt. tried getting out of bed. Pt. pulled SpO2 off finger at 8:00 p.m."
*On 3/10/13 at 12:00 midnight her wrist restraints were removed and reapplied "Pt. has restraints on at this time. Pt. pulled off BP cuff with loose restraints on, so they have been applied appropriately."
*On 3/10/13 at 2:00 a.m. her wrist restraints were removed and reapplied "Pt. has restraints on at this time. Pt. is confused, states she is in Chamberlain and needs to go."
*On 3/10/13 at 3:00 a.m. a physician order was received for Benadryl 12.5 milligram intravenous. "Pt. not sleeping and hasn't slept in 2 days."
*On 3/10/13 at 4:00 a.m. "Pt. awake and watching television. Pt. is confused and states she is not in a hospital. Pt. pulled BP cuff off again. Pt. is not oriented to place or time."
*She had bilateral soft wrist restraints on. The restraint review documentation on 3/10/13 at 11:00 a.m. revealed "Pt. (patient) is confused and agitated, pulled BP (blood pressure) cuff off arm, oriented to person only. Pt. states she is not in hospital and needs to leave."
*At 3/10/13 at 11:23 a.m. a code blue was performed. Review of the code blue report revealed:
-She had no respirations and her heart rhythm was asystole (no heart beat).
-She regained a heart beat at 11:34 a.m.
-She was again placed on a ventilator at 11:38 a.m.
*Review of a 3/10/13 physician's progress note revealed:
-"Pt. was coded for asystole and hypoxia (low oxygen level) at 11:23 a.m. Code done for 15 minutes when she had pulse. As per covering RN (registered nurse), the alarm went off for hypoxia. She did not have her O2 (oxygen) IN PLACE. She was sleeping this am. She was saturating around 89-90%".
*Review of the ventilator flow sheet for 3/10/13 revealed she had been removed from the ventilator at 2:50 p.m.
*Change of status documentation on 3/10/13 at 5:00 p.m. by RN B revealed "Pt. has vitals signs that show no respiration or heart tones."
Review of the three telemetry strips from 3/9/13 at 10:40 p.m. through 3/10/13 at 5:00 p.m. revealed:
-The 11:40 p.m. strip revealed a heart rate of 75 beats per minute (BPM), respirations of 17 per minute, and oxygen saturation at 88%.
-The second strip had no vital sign information.
-The third strip was written on by RN A and stated no heart rate and no breath tones.
*There was no documentation or telemetry strips that indicated when her heart rate, respiratory rate, or oxygen saturation had changed after the 11:00 a.m. charted vital signs.

Interview on 4/12/13 at 12:15 p.m. with the director of risk management and accreditation/certification revealed:
*There were no telemetry strips for the nine minutes the provider had stated patient 4 had been without her oxygen.
*The charge RN and RN B had apparently disposed of them.
*She agreed those strips should have been included in patient 4's medical record.

Review of a eICU (enhanced intensive care unit) document revealed:
*The provider had requested documentation regarding alarms for patient 4 preceding the code blue on 3/10/13.
*The alert history had been reviewed and revealed:
-11:07 a.m. an oxygen saturation of 86% had been cleared by the eICU physician.
-11:16 a.m. an oxygen saturation of 68% had been cleared by the eICU physician.
-11:17 a.m. an oxygen saturation of 73% had been cleared by the eICU physician.
-11:20 a.m. an oxygen saturation of 66% had been cleared by an eICU RN. The RN had activated the camera and had noted a code blue was in progress.
-The eICU physician activated the camera at 11:27 a.m.
*A follow-up had been completed by the eICU medical director and the eICU physician on duty on 3/10/13 that stated he had not received a report on patient 4 and had not realized there was a concern about her oxygen saturations.

Review of the revised December 2006 Avera eICU CARE physician documentation policy revealed:
*The Avera eICU physician was responsible to document discussions had with another physician regarding the clinical status or care of any patient monitored, any discussion of clinical significance with an onsite caregiver, or any order written from the Avera eICU CARE facility.

Based on record review, interview, and policy review, the provider failed to ensure the care plan was individualized and updated for 1 of 17 sampled patients (16) with dementia. Findings include:

1. Review of patient 16's medical record for his 2/25/13 admission revealed:
*He had diagnoses that included Alzheimer's dementia.
*He was a resident of a memory care unit in a nursing home.

Review of patient 16's 2/25/13 at 1:30 p.m. medical questionnaire completed by registered nurse (RN) F revealed he had dementia.

Review of the admission assessment completed on 2/25/13 at 12:55 p.m. for patient 16 revealed:
*He lived in a memory care nursing home.
*He had a learning barrier to teaching due to his altered cognition.
*He had a history of Alzheimer's disease.
*He had a history of dementia.
*He had aggressive behavior with the dementia.
*He was not oriented to place or time.
*He was to have received reality orientation with each staff encounter.


Review of patient 16's 2/25/13 initiated care plan revealed the adult standard care plan had been implemented. That care plan included nursing assessments for his safety (fall risk), hygiene, activity, nutrition, neurological, cardiovascular, peripheral vascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, and pain. Other care plan area that had been initiated included cardiac pump effectiveness.

Review of the nursing assessments from 2/25/13 at 1:30 p.m. through 2/26/13 at 1:30 p.m. for patient 16 revealed:
*He was not oriented to place or time.
*He was very forgetful related to his dementia.
*He was confused but was calm and cooperative with care.
*He was agitated at times and required frequent reorientation.
*He ambulated independently.

Interview on 4/12/13 at 11:00 a.m. with the administrative director of patient care revealed the confusion care plan had not been initiated for patient 16.

Review of the provider's copy of the computer generated confusion care plan revealed interventions would have included:
*Monitoring for changes in orientation.
*Encourage family/friends familiar to patient to visit.
*Provide for adequate rest/sleep/daytime naps.
*Provide a low stimulation environment.

Review of the provider's revised July 2011 Interdisciplinary Plan of Care policy revealed:
*Charting refected the plan of care based on assessed needs.
*Problem identification was the identification of actual or potential health problems that can be addressed by nursing and/or the interdisciplinary team.
*Interventions were directed at assisting the patient in achieving optimal health outcomes.
*Interventions were the basis of the Interdisciplinary Plan of Care.
*Care providers would participate in identifying additional interventions based upon the patient's health problems to individualize the care plan.

Based on record review and interview, the provider failed to ensure one of one registered nurse (RN) (B) had completed the hospital's intensive care unit (ICU) orientation program prior to assuming care of ICU patients. Findings include:

1. Review of RN B's personnel record revealed:*She had been hired on 9/10/12 as a float pool RN.
*There was no record of her ICU orientation.

Review of the provider's orientation checklist revealed:
*The initial orientation for core departments (medical, oncology, rehabilitation, and the hospice house) included orientation in regards to telemetry, oxygen therapy devices, pulse oximeters, and the recognition of alarms.
*Those alarms included the telemetry alarms and the continuous pulse oximeter alarm.
*The orientation for the ICU included the recognition of alarms for the bedside and central monitors.

Interview on 4/12/13 at 1:30 p.m. with the director and assistant director of clinical coordination of staffing for the float pool revealed:
*All float nurses would have received education and completed competencies before being assigned to work in the ICUs.
*The float nurse would have kept her competency documentation until they had completed the competency.

Interview on 4/12/13 at 2:00 p.m. with the director of risk management and accreditation/certification revealed she would provide a copy of that orientation competency by 4/15/13.

Review of the documents requested from the provider and picked up on 4/15/13 at 9:00 a.m. revealed a handwritten note that stated the orientation competency form for RN B was not available.

Based on record review and interview, the provider failed to ensure telemetry strips for 1 of 17 sampled patients (4) who experienced an adverse event were included in the patient's medical record. Findings include:

1. Review of the incident and investigation document prepared by the director of risk management and accreditation/certification regarding patient 4 revealed she:
*Had been admitted on 2/21/13 with diagnoses that included a urinary tract infection, history of pulmonary fibrosis, and chronic obstructive pulmonary disease.
*Had been on a ventilator (breathing machine) from 2/27/13 until 3/9/13 at 2:50 p.m.
*Had received oxygen via an oximyzer at twelve liters per minute to keep her oxygen saturations between 88 and 92%.
*Was alert and oriented when removed from the ventilator.
*Became more confused during the night of 3/9/13 through 3/10/13.
*On 3/10/13 at 11:20 a.m. was noted to have had wrist restraints in place to not remove tubes due to her confusion and inability to follow directions.
*Had removed her oxygen delivery device.
*Sustained low oxygen saturations for nine minutes and the following had occurred:
-The alarm sounded at a yellow alert level (an intermittent alert sound).
-The assigned nurse was caring for another patient.
-The other three nurses in the medical intensive care unit (MICU) were also in patient's rooms.
-Patient 4's heart rate decreased and then stopped which produced a red alarm (high pitched tone)
-All of the nurses responded to the alarm and a code blue (interventions to restart the heart) was initiated.

Interview on 4/12/13 at 12:15 p.m. with the director of risk management and accreditation/certification revealed:
*There were no telemetry strips for the nine minutes the provider had stated patient 4 had been without her oxygen.
*The charge RN and RN B had apparently disposed of them.
*She agreed those strips should have been included in patient 4's medical record.