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Based on interview, policy review, clinical record review, and facility's security video, the facility failed to have an effective system in place to supervise, assess and ensure the safety of 4 of 12 patients reviewed (1, 2, 11, 12) and potentially affects all current patients and future admissions.
Findings include:
Patient #1 eloped from the hospital on 05/07/11 despite a physician order for constant supervision. This patient was gone for over 21 hours, reportedly sleeping in a garage, when returned to the hospital by a grand parent on 05/08/11. Nine days later, Patient #2 eloped from the hospital on 05/15/11 and was returned to the facility by a parent on 05/15/11 at 3:00 pm, 2 hours and 49 minutes later. During survey on 05/18/11, a fifteen month old infant, Patient #11 was observed unattended in their patient room by nursing staff or family. Patient #12 was observed to be missing from their patient room and not listed on the sign out sheet for having left the unit. Interviews with security revealed the hospital does not supervise who exits the hospital and does not staff the exit desk on the weekend when both patients eloped.
Based on these findings and the lack of appropriate and immediate action by the facility to ensure the safety of all current and future children, it was determined that immediate jeopardy existed.
On 05/17/11, at 11:26 A.M., the Chief Operating Officer, Director of Quality Improvement Services, Chief Medical Officer, and the Administrative Surgical Director were notified of the determination of immediate jeopardy affecting all current and future children. The census was 298 patients.

Please refer to A 144 for findings.

Based on observations, staff interview and medical record review, the facility failed to ensure the safety and supervision of four patients. This affected 4 of 12 patients reviewed (Patient #1, #2, #11 and #12). The facility census at the time of the survey was 298.

Findings included:

1. On 05/17/11, Patient #1's clinical record review was completed. The clinical record review revealed the patient was admitted to the facility on 04/22/11 with a diagnosis of trauma. The clinical record review revealed a social worker note dated 04/23/11 that stated the social worker interviewed the only family present with the patient at that time of admission which was his/her maternal grandparent. The note said:
"Maternal grandmother reported that patient has been placed into a foster home in Licking County. However patient ran away (AWOL) from Licking County foster home in December 2010. Maternal grandmother reports that patient whereabouts where (sic) not known by family from Dec. 2010 until last week. Maternal grandmother reported that patient arrived at biological mother's home here in Franklin Co. Last week, however states that when biological mother told patient that the police had to be called about his/her whereabouts, patient ran away from biological mother's home."
The clinical record review revealed a psychology consult note dated 04/28/11 at 2:58 P.M. that stated the patient is currently in the custody of family services. The note stated the patient had been admitted for a traumatic brain injury after getting hit by car while being a pedestrian. The note stated the patient was placed in foster care as a result of both truant behavior and auto theft, and the grandparent reported the patient ran away from his/her placement on at least five occasions. The note stated the grandparent reported the patient could not tell time, count money, or read well. The note stated the grandparent reported the patient "continues to be confused and he needs to be reminded where he is and why."
The record review revealed a physician's order dated 05/05/11 at 5:35 P.M. that stated the patient was to have staff in "constant attendance" with him/her. The patient eloped from the hospital on 05/07/11, was missing for over 21 hours, and was returned to the hospital by grandparent on 05/08/11. According to a physician's progress note dated 05/09/11 at 4:04 P.M. the patient was transferred to a local psychiatric hospital. The note stated the patient "remains confused and has a very poor memory at this time." Review of an undated physician discharge summary report relating to the patient's hospitalization beginning on 04/22/11, revealed Patient #1 had a history of repeatedly running away from home and foster care.
A physician's progress note dated 04/28/11 at 11:42 A.M. revealed the patient was able to crawl out of his/her lap belt while in a session with speech therapy. The clinical record review revealed a physician's order dated 04/28/11 at 3:36 P.M. that directed the nursing staff to place a wanderguard bracelet on the patient.
The Director of Quality Improvement stated information to explain why the patient was placed into a lap belt could not be located in the clinical record during interview on 05/19/11 at 1:00 P.M.
The clinical record review revealed a physician's progress note dated 04/29/11 at 10:23 A.M. that stated the patient took his/her wanderguard off and then a physician's order dated 04/29/11 at 10:30 A.M. to discontinue the wanderguard bracelet, after it was revealed he/she had taken it off. The record review revealed a physician's order dated 05/05/11 at 5:35 P.M. that stated the patient was to have staff in "constant attendance" with him/her. The clinical record review did not reveal whether the patient was assessed as a flight risk and did not reveal a care plan to address a flight risk nor did the review reveal a nursing care plan that addressed the usage and discontinuation of a lap belt, wanderguard, or constant attendant.

Staff Nurse A was interviewed on 05/16/11 at 2:45 P.M. Staff Nurse A, the nurse attending to the patient when elopement occurred, stated he/she recalled a wanderguard being requested, but wasn't used. Staff Nurse A stated the Patient Care Associate #1 was sitting with the patient at the nursing station. Staff Nurse A stated the patient was left under constant supervision of Patient Care Associate #1 at the nursing station when he/she went to assist another nurse. Staff Nurse A said that was the last time he/she saw the patient. Staff A said he/she did not know Patient #1 had disappeared until it was reported by Patient Care Associate #1.

On 05/16/11 at 3:00 P.M. an interview was requested with the active employee, Patient Care Associate #1 , who had been assigned to provide constant attendance with the patient. The Patient Care Associate #1 confirmed he/she was sitting with the patient at the nursing station and not in the patient's room and did not keep the patient in view at all times. The Patient Care Associate #1 said he/she turned away from the patient to label some laboratory specimens. The Patient Care Associate #1 said the last time the patient was seen, he/she was bouncing a basketball. The Patient Care Associate #1 turned back to look for the patient when he/she no longer heard the sound of the basketball. The Patient Care Associate #1 said by then the patient was gone, and Staff Nurse A was notified.

The facility's undated "constant attendance" guidelines was reviewed on 05/17/11. The policy stated staff are to sit four to five feet between the patient and the door to his/her room, and view the patient at all times.
On 05/13/11 administrative staff presented a timeline of Patient #1's elopement, or walking out of the hospital and not telling anyone. Review of the timeline was completed 05/16/11 and revealed Staff A was not seated between the patient and his/her room door and did not have him/her in full view at all times. The timeline revealed a code Adam was requested on 05/07/11 at 1:20 P.M. The timeline revealed at 1:23 P.M. three security officers reported to the patient's unit to assist with searching for him/her. The timeline revealed at 1:35 P.M. a second request for a code Adam was made. At 1:50 P.M. code Adam is announced and code Adam procedures were initiated approximately 30 minutes after the initial request. The timeline of Patient #1's elopement revealed he was returned to the facility by a grandparent over 21 hours later on 05/08/11 at 11:00 A.M. Neither the timeline nor the clinical record review indicated where Patient #1 was during that time. A review of local police report #110374630 also did not indicate where the patient was during the 21 hours he/she had left the facility.

Policy number XI-15:35, revised 04/10, was reviewed on 05/19/11, entitled Runaway Patients/Patient elopement. The review revealed the policy stated upon learning of the patient's departure, "staff shall immediately ...call a Code Adam."

Policy number XI-5:32, revised 10/10, entitled Missing Child/Child Abduction was reviewed. The review revealed when a code Adam is called security will conduct an immediate search of the entire hospital campus, staff will monitor exits, and watch for suspicious individuals getting on or off the elevators.

The review of the facility's security video footage of Patient #1's elopement on 05/07/11 took place on 05/17/11. The footage revealed on 05/07/11(a Saturday) at 1:20 P.M. Patient #1 (a 12-year-old adolescent) left the facility by walking past an unmanned desk by the C lobby door. He/she then went out the C lobby door with a basketball and wearing street clothes and a backpack. That was the exact time a Code Adam was requested from, but not implemented, by security.
Observation of activity at a desk on 05/13/11 at 10:40 A.M., at the bank of elevators that leads to C lobby revealed Security Officer #1 and a desk attendant (Desk Attendant #1) were observed. Desk Attendant #1 was observed to interview visitors before they got on the elevator to go visit a patient. He/she said if they know a code word given by the family, then they are permitted to get on the elevator. Security Officer #1 was observed monitoring the activity at the desk. The Security Officer #1 was interviewed during the above observation and stated his/her job is to ensure no one gets on the elevator who is not authorized to see a patient. Security Officer #1 said he/she does not monitor who gets off the elevator.

On 05/13/11 at 12:45 P.M. in an interview, the Director of Security stated Security Officer #1 was at the desk when Patient #1 eloped. He/she said the main focus was monitoring people getting on the elevator, not off. He/she said security was not aware that Patient #1 was a flight risk. There was no policy to confirm if security was to be informed of patients who are potential flight risk.
The Director of Security stated in interview on 05/17/11 at 3:35 P.M. that Patient #1 reached the C lobby using a bank of elevators that did not require the use of a key card to operate. He/she said a code Adam should have been called when first requested. He/she said he/she believed the patient had spent the night in a garage.
On the afternoon of 05/13/11, the Director of Quality Improvement was interviewed. The Director of Quality Improvement stated their investigation into the incident was incomplete and they had not yet taken any measures to prevent any additional elopements.
2. During the survey on 5/16/11 administrative staff revealed a second elopement had occurred of another patient. (Patient #2)
The clinical record review for Patient #2 was completed on 05/17/11. The patient, a 17-year-old adolescent, was admitted 05/10/11 with a diagnosis of Crohn's Disease. The clinical record review revealed a nursing progress note dated 05/15/11 at 8:30 A.M. that stated he/she was crying. The note stated he/she was frustrated from his/her hospitalization and the diarrhea he/she had been having.

The security camera footage of Patient #2's elopement was completed on 05/17/11. Security camera footage showed Patient #2 walking past the same unmanned desk Patient #1 walked by, and leaving the facility out the same door used by Patient #1 on 05/15/11 (a Sunday) at 11:12 A.M., . Patient #2 was in street clothes and holding a small plastic bag. Review of the footage revealed Patient #2 had used the same bank of elevators used by Patient #1 to get to the C lobby.
On 05/16/11, a timeline of Patient #2's elopement was presented and a review completed. The review revealed on 05/15/11 at 12:11 P.M. a Code Adam was called to alert facility security and staff the patient was missing. Patient #2's elopement timeline revealed he was returned to the facility by a parent on 05/15/11 at 3:00 P.M.
On 05/17/11 at 3:35 P.M. in an interview, the Director of Security said when the Code Adam was called by staff, he/she did not specify who, staff at first gave an incorrect description of Patient #2. He/she said staff later gave a correct description and a photo was taken from the patient's Facebook page. The Director of Security said the security officer does not pay attention to who's leaving the facility from those elevators. He/she said the desk facing the exit doors in C lobby (where Patient #1 and #2 left the building on a weekend) is not staffed on the weekends.

3. Observations were conducted on the four tower floor on 05/18/11 at 11:30 A.M. Patient #11, a fifteen month old infant, was noted to be alone in room T4037. The infant was in a fabric type seat, which was located in the middle of the floor of the patient room. The infant was in the room alone with no family or staff members present. No staff members were present immediately outside the patient's room including the nurse's station and the visible hallways. The Director of Quality Improvement Services and another surveyor confirmed no nursing staff members were present immediately outside the patient's room including the nurse's station and the visible hallways.

Patient #11 was a 15-month-old developmentally delayed child, admitted to the hospital on 03/13/11 for a respiratory illness and dislodgement of j-tube (feeding tube). The patient remained in the hospital for continued problems with the feeding tube. The medical record reviewed on 5/19/11 contained evidence the care plan developed for the patient had no interventions listed related to patient safety or supervision. The care plan did not contain any information to determine if the patient had been assessed as safe to be left alone, the length of time the patient could be left alone, or any interventions the staff were to take when leaving the infant alone to protect him/her from harm including abduction.


Staff Nurse B,the patient's nurse presented to the nursing station at 11:40 A.M. and was interviewed. The nurse revealed it is hard for staff to be in the patient's room all the time and the parents of Patient#1 don't come to visit very often because they have seven other children. Staff Nurse B further stated it is not unusual for infants to be unattended in their patient room.

Staff Nurse B further stated the hospital did not have a policy requiring supervision of patients at all times.

The Clinical Manager of the four tower floor was interviewed on 05/19/11 at 9:30 A.M. The Clinical Manager confirmed the hospital does not have a policy requiring supervision of infants, or preventing infants from being left unattended. The Clinical manager stated staff use a number of factors to determine the frequency they need to check on patients. Upon further questioning, the Clinical Manager was able to state only one factor (parental presence) was used to determine the frequency. The Clinical Manager stated there is no written policy to determine the degree of supervision needed to ensure the safety of patients.

The Director of Security had previously been interviewed on 05/16/11 at 3:35 P.M. regarding the monitoring of individuals leaving the facility. The Director of Security stated security guards did not "pay attention to" who was leaving the facility. The surveyor asked if a visitor could sign in with security and state the intention of going to a patient floor, but get off the elevator on a different floor and abduct a child, would anyone notice the visitor leaving with the abducted child. The Director of Security stated no, security would not be monitoring individuals leaving.



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4. The clinical record review for Patient #12 was completed on 05/20/11. The clinical record review revealed the 10-year-old patient was admitted to the facility with a complaint of nausea and vomiting, and diagnoses of ornithine transcarbamylase deficiency (a rare metabolic disorder that affects the body's ability to get rid of ammonia) and recurrent pancreatitis.
On 05/18/11 at 11:45 A.M., the sixth floor nursing unit was toured with the Nurse Manager A. At 11:50 A.M., the surveyor observed Patient #12's room to be empty. In an interview at that time, Nurse Manager A stated the patient was having a test done, and his/her name would appear on a sign out sheet at the nursing station.
On 05/18/11 at 12:00 P.M., a patient sign-in sheet was observed at the nursing station completely blank, indicating, for the whole morning of 05/19/11, no patient had left the unit for a test. The surveyor and the nurse manager then returned to Patient #12's room, and found the patient there with his/her parent. The parent stated they were having an x-ray performed.
On 05/18/11 at 12:00 P.M. in an interview, Nurse Manager A confirmed between 11:50 A.M. (when the empty room was pointed out to his/her) and 12:00 P.M. no one could be sure where Patient #12 really was, and stated it was highly unlikely that no other children left the unit that morning for a test. He/she said it was more likely they were not signed out on the sign out sheet when they left and when they returned.
On 05/18/11, immediately after the interview with Nurse Manager A, two surveyors heard Clinical Leader A tell the nursing staff if the patient leaves the unit, it was their responsibility to sign the patient out, whether they actually saw the patient leave or not.
On 05/18/11 at 2:00 P.M. the Chief Nursing Officer, the Chief Operations Officer, and the Chief Medical Officer were interviewed. Both the Chief Operations Officer and Chief Nursing Officer concurred that transportation personnel are to sign the patient out when they leave the unit because they are the actual people who are with the patient when he/she leaves the unit. Prior to exit no policy was presented that supported the expectations of signing in and out when the patient leaves the unit.

This substantiates complaint OH00060781.