HospitalInspections.org

Based on review of facility policy, medical records (MR), and interview with facility staff(EMP), it was determined the facility failed to promote the well being and safety of a confused patient for one of 10 medical records reviewed (MR1).

Findings include:

Review on August 30, 2012, of the facility's policy "Patient Bill of Rights and Responsibilities," last revised July 2011, revealed "Your Rights ... As our patient, you have the right to safe, respectful, and dignified care at all times. ..."

Review on August 30, 2012, of MR1 revealed the patient was admitted to the seventh floor of the hospital on June 18, 2012, after a fall at home. The patient was noted to be getting progressively more confused. Nursing documentation in MR1 noted the patient was identified as at risk for falling. The patient was placed in physical restraints. On June 24, 2012, at 12:00 PM, the restraints were discontinued. The patient's bed alarm remained on, as the patient was still considered at risk for falling.

Continued review of MR1 revealed that on June 25, 2012, the patient was found by maintenance sitting outside the emergency room entrance on the ground floor. The patient was dressed in a hospital gown, had several cuts and abrasions, and a hematoma on their forehead. Further review of MR1 confirmed the patient was a patient from the 7th floor who was reported missing by staff at approximately 4:50 AM. Review of MR1 confirmed the patient sustained two fractured ribs.

Interview on August 30, 2012, with EMP3 confirmed MR1 was confused but cooperative. EMP3 confirmed there was a bed alarm on MR1's bed which did not alarm. EMP3 also confirmed the patient was found missing from their room at approximately 4:50AM, and this was reported to security. Maintenance discovered the patient at approximately 5:30 AM.

Interview on August 30, 2012, with EMP2 confirmed they reviewed the security cameras. It was identified the patient did not access the elevator on the seventh floor. EMP2 confirmed the cameras did not identify the patient until they passed a camera on the ground level hallway.