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Based on viewing of the video recording, interview, and document review, in two (2) of 25 medical records reviewed, it was determined the Governing Body failed to ensure that the corrective action plan from a prior survey was fully implemented. Specifically, the facility failed to ensure all staff who provide patient care are trained in de-escalation techniques for the management of patients exhibiting aggressive behavior, and (b) staff implement appropriate actions to reduce the risk of patients from eloping from the facility. (Patient #1, Patient #2).



Findings include:

(a) Review of the video recording of Tower 8 Medical-Surgical Unit dated 1/20/17 15:05 (3:05 PM) showed at approximately 15:32 (3:32 PM), Patient #1 approached Staff A, Behavioral Health Associate (BHA), and grabbed the BHA's hair. Staff A responded by reaching for the patient's left hand and a few seconds later, both went off camera. The video showed several staff, including Staff B, RN Charge Nurse and Staff E, Social Worker, were standing at the nursing station, however none assisted Staff A.
There was a five (5) minute gap from the occurrence at 15:32 (3:32 PM) until 15:37 (3:37 PM) when Patient #1 reappeared on video escorted by Staff A and Staff C back to her room.


Staff E, Unit Social Worker was interviewed on 2/10/17 at 3: 04 PM. Staff E recalled that on 1/20/17 patient was being disruptive all day and walking around the unit. Staff E stated that she was sitting at the desk when she observed the patient grab hold of the BHA's hair and that the BHA grabbed at the patient's hand. She stated that they started to tussle with the patient still holding on to the BHA's hair. She stated that a staff placed a chair to the wall and the BHA was able to let patient sit down on the chair. Staff E stated that she asked staff (nurses) on the unit to assist the BHA and they told her, "They were not to touch the patient until they have training."


On 2/13/17 at approximately 11:10 AM, a telephone interview was conducted with Staff A, BHA assigned to the patient. Staff A confirmed that she was assigned 1:1 observation for Patient #1. Staff A stated that Patient #1 at that time was agitated, "We tried to talk to her and calm her down as best as we can. I reported patient's behavior to the RN Charge Nurse (Staff B). All of a sudden at the nursing station, the patient grabbed my hair. I attempted to hold her hand but she did not want to let go of my hair. She was still yanking my hair. There were lots of people. Finally, I got hold of her hand and let her sit on a chair. A Code Assist-13 was called. Another BHA (Staff C) helped me and we took her to her room."


On 2/13/17 at approximately 11:54 AM, during a telephone interview, Staff B, RN Unit Charge Nurse, acknowledged recollection of the patient. Staff B stated that she was at the desk completing discharges when she heard a commotion and she saw the patient and the BHA (Staff A) tangled, and the patient choking the BHA. She explained that she did not touch the patient because she was not trained for de-escalation.


On 2/13/17 at approximately 12:07 PM, interview with Staff D, Unit Nurse Manager was conducted. Staff D acknowledged and confirmed that the unit staff did not respond because they were not trained for de-escalation.


Review of the De-escalation Training Record/Attendance Sheet from January 14, through February 8, 2017, indicated that Tower 8 Medical-Surgical Unit Staff (including Staff A, B, C, D, and E) did not receive training on de-escalation techniques. (See Tag A115)




(b) Review of medical record for Patient #2 identified a 62-year-old Nursing Home patient who was admitted on 1/10/17 with the diagnoses of altered mental status, sepsis and pneumonia. The patient's past medical history included dementia, and bipolar disorder. The patient was scheduled for discharged on 1/13/17.

On 1/13/17 at 1:15 PM, Social Worker documented that discharge and transportation needs of the patient had been arranged.
At 3:30 PM, Social Worker noted that Staff G, RN Staff Nurse, informed her that the patient had eloped from the unit.

An addendum written by Staff G, on 1/13/167 at 7:57 PM, stated that the patient was confused; he had been discharged, and was awaiting transportation to the Nursing Home. Nurse stated "Patient expressed desire to go out of the hospital. Explained that transportation personnel will pick him up in an hour. Patient became agitated, encouraged to remain calm and stay in the unit. Patient refused to comply and went to the elevator area, Security personnel alerted immediately of patient's status."

During interview on 2/18/17 at approximately 2:16 PM, Staff G acknowledged that patient eloped on the day of discharge at approximately 2:30 PM. Staff G further stated that patient walked past her and went into the elevator; she then called security personnel and Staff D, Nurse Manager.

There was no documented evidence that Staff G implemented appropriate actions to prevent the elopement of this patient with dementia and altered mental status. (See Tag A 144)

Based on document review, interview, and viewing of facility video recording, in two (2) of 25 medical records reviewed, it was determined that the facility failed to meet the Condition of Participation for Patient's Rights as evidenced by:

(a) Failure to ensure that qualified and trained staff are present throughout the facility to assist in the management of patient exhibiting aggressive behavior, to promote the safety of patients and staff.

(b) Failure of the staff to intervene to de-escalate a situation with a patient who exhibited aggressive behavior.

(c) Failure to ensure that debriefing was conducted after Assist 13 incidents, as required by the facility's protocol.

See Tag A 144.

These failures place patients at risk for potential harm.


Findings include:

Review of the video recording of Tower 8, Medical-Surgical Unit, dated 1/20/17 15:05 (3:05 PM) showed Patient #1 walking up and down the unit hallway to the nursing station with Staff A, Behavioral Health Associate (BHA), and talking to other unit staff. At approximately 15:32 (3:32 PM), Patient #1 approached Staff A and grabbed hold of her the hair. Staff A responded by reaching for the patient's left hand and a few seconds later, both went off camera. The video showed that several staff, including Staff B, RN Unit Charge Nurse and Staff E, Social Worker, were standing at the nursing station and looking at the occurrence.
There was a five (5) minute gap from occurrence of 15:32 (3:32 PM) until 15:37 (3:37 PM) when Patient #1 reappeared on video escorted by Staff A and Staff C back to her room.


Staff E, Unit Social Worker was interviewed on 2/10/17 at 3: 04 PM. Staff E recalled that on 1/20/17 patient was being disruptive all day and walking around the unit. Staff E stated that she was sitting at the desk when she observed the patient grab the BHA's hair and that the BHA grabbed at the patient's hand. She stated that they started to tussle with the patient still holding on to the BHA's hair. She stated that a staff placed a chair to the wall and the BHA was able to let patient sit down on the chair. Staff E stated that she asked staff (nurses) on the unit to assist the BHA and they told her, "They were not to touch the patient until they have training."


On 2/13/17 at approximately 11:10 AM, a telephone interview was conducted with Staff A, BHA assigned to the patient. Staff A confirmed that she was assigned 1:1 observation for Patient #1. Staff A stated that Patient #1 at that time was agitated, walking back and forth to the nursing station, and talking lots of profanities. "We tried to talk to her and calm her down as best as we can. I reported patient's behavior to the RN Charge Nurse (Staff B). All of a sudden at the nursing station, the patient grabbed my hair. I attempted to hold her hand but she did not want to let go of my hair. She was still yanking my hair. There were lots of people. Finally, I got hold of her hand and let her sit on a chair. A Code Assist-13 was called. Another BHA (Staff C) helped me and we took her to her room."


On 2/13/17 at approximately 11:54 AM, during a telephone interview, Staff B, RN Unit Charge Nurse, acknowledged recollection of the patient. Staff B stated that she was at the desk completing discharges when she heard a commotion. She stated that she saw the patient and the BHA (Staff A) tangled. She stated that she saw the patient choking the BHA. She explained that she did not touch the patient because she was not trained for de-escalation.


On 2/13/17 at approximately 12:07 PM, interview with Staff D, Unit Nurse Manager was conducted. Staff D acknowledged and confirmed that the unit staff did not respond because they were not trained for de-escalation.


Review of the Code Assist 13 Log from January 2017 through February 14, 2017 documentation identified Patient #1 had Assist 13 codes called with entries on 1/19/17 at approximately 4:05 PM, and on 1/20/17 at approximately 4:53 PM.
There was no documentation that debriefing was conducted as required by the facility's protocol.

Review of facility's Assist-13 (Behavioral Health Rapid Response) protocol, effective date 1/13/17, stated that a post incident debriefing of the situation with all Team members will be conducted by the Team Leader to determine the root cause of the escalation and determine opportunities for improvement.


During interview with Staff F, Quality Staff on 1/13/17 AM, Staff F acknowledged that there were no debriefings conducted for Assist 13 codes called on 1/19 and 1/20/17 for Patient #1.

Review of the De-escalation Training Record/Attendance Sheet from January 14, through February 8, 2017, indicated that Tower 8 Unit Staff (including Staff A, B, C, D, and E) did not receive training on de-escalation techniques.

Based on interview, viewing of the video recording, and document review, in two (2) of 25 medical records reviewed, the facility did not: (a) ensure that qualified and trained staff were available to provide intervention for a patient who exhibited aggressive behavior, (b) implement actions to prevent elopement of a patient with dementia and altered mental status (Patient #1, Patient #2).

Findings include:

Review of the video recording of Tower 8 Unit dated 1/20/17 15:05 (3:05 PM) showed at approximately 15:32 (3:32 PM), Patient #1 got close to Staff A, Behavioral Health Associate (BHA), and grabbed the hair of Staff A. Staff A responded by reaching for the patient's left hand and a few seconds later, both went off camera. The video showed several staff, including Staff B, RN Charge Nurse and Staff E, Social Worker, were standing at the nursing station and looking at the occurrence.
There was a five (5) minute gap from occurrence of 15:32 (3:32 PM) until 15:37 (3:37 PM) when Patient #1 reappeared on video escorted by Staff A and Staff C back to her room.

Staff E, Unit Social Worker was interviewed on 2/10/17 at 3: 04 PM. Staff E recalled that on 1/20/17, she was sitting at the desk and she observed the patient grabbed the HA's hair and that the BHA grabbed at the patient's hand. She stated that they started to tussle, with the patient still holding on to the HA's hair. She stated that a staff placed a chair to the wall and the BHA was able let the patient sit down on the chair. Staff E stated that she asked staff (nurses) on the unit to assist the BAH and they told her, "They were not to touch the patients until they have training."

On 2/13/17 at approximately 11:54 AM, during a telephone interview, Staff B, RN Unit Charge Nurse, acknowledged recollection of the patient and the event. She stated that she saw the patient choking the BHA. She explained that she did not touch the patient because she was not trained for de-escalation.

On 2/13/17 at approximately 12:07 PM, interview with Staff D, Unit Nurse Manager was conducted. Staff D acknowledged and confirmed that the unit staff did not respond because they were not trained for de-escalation.

Review of the De-escalation Training Record/Attendance Sheet from January 14, through February 8, 2017, indicated that Tower 8 Unit Staff (including Staff A, B, C, D, and E) did not receive training on de-escalation.

Review of medical record for Patient #2 identified a 62-year-old Nursing Home patient who was admitted on 1/10/17 with the diagnoses of altered mental status, sepsis and pneumonia. The patient's past medical history included dementia, and bipolar disorder. The patient was scheduled for discharged on 1/13/17.

On 1/13/17 at 1:15 PM, Social Worker documented that discharge and transportation needs of the patient had been arranged.
At 3:30 PM, Social Worker noted that Staff G, RN Staff Nurse, informed her that the patient had eloped from the unit.

An addendum written by Staff G, on 1/13/167 at 7:57 PM, stated that the patient was confused; he had been discharged, and was awaiting transportation to the Nursing Home. Nurse stated "Patient expressed desire to go out of the hospital. Explained that transportation personnel will pick him up in an hour. Patient became agitated, encouraged to remain calm and stay in the unit. Patient refused to comply and went to the elevator area, Security personnel alerted immediately of patient's status."

During interview on 2/18/17 at approximately 2:16 PM, Staff G acknowledged that patient eloped on the day of discharge at approximately 2:30 PM. Staff G further stated that patient walked past her and went into the elevator; she then called security personnel and Staff D, Nurse Manager.

There was no documented evidence that Staff G implemented appropriate actions to prevent the elopement of this patient with a history of dementia and altered mental status.

The facility's policy titled "Elopement", last revised 5/2015, stated: "As soon as staff becomes aware that a patient is missing, he/she notifies the Nurse Manager or Designee and Security. The operator should be notified to announce elopement, Code E and location."

There was no documented evidence of a timely response by staff after the patient eloped from the 8th floor unit, rode on an elevator, and exited the building without being intercepted by the search crew.

During interview with Staff D, Nurse Manager, on 2/8/17 at approximately 2:35 PM, staff stated that when Staff G told her that the patient eloped without waiting for transport, she immediately went downstairs to security and assisted in the search. Staff D confirmed that law enforcement agents, found the patient outside the hospital premises and returned to the facility on 1/13/17 at 4:15 PM.

The law enforcement agent found the patient in an area approximately 2.5 miles and 42 minutes' walk from the facility.