HospitalInspections.org

The Hospital was out of compliance for the Quality Assessment & Performance Improvement (QAPI) Condition of Participation.

Findings include:


1.) The Hospital failed for 1 (Patient #3) of 10 sampled patients to ensure investigation and implementation of preventative actions after Patient #3 eloped from the Hospital.

Refer to TAG: A-0286.

The Hospital failed to ensure that an investigation to track and analyze adverse events was performed and corrective actions were implemented after 1 (Patient #3) of 10 medical records reviewed was able to elope while being evaluated for psychiatric care in the Emergency Department.

Findings include:

Review of the Hospital's Patient Care Assessment Plan, undated, indicated that the Patient Care Assessment Coordinator is responsible for the investigation and analysis of the frequency and causes of general categories and specific types of all required internal incident reports and any other incident reports. He is further responsible for:

1. Reviewing and acting upon incident reports to assure follow-up with individuals involved in the incident.

2. The regular and systemic reviewing of all incidents reports for the purpose of identifying trends or patterns as to time, place and person. Upon emergence of any trend or pattern, the Patient Care Assessment Coordinator develops written recommendations for appropriate corrective actions and patient protection/risk management/quality management education and training.

Review of the Hospital's Care of a Suicidal Patient policy, dated 2/2020 indicated that The Policy is to provide guidelines for staff caring for patients when there is a reasonable risk the patient may endanger themselves and/or others.

- 2:1 safety precautions: One trained staff member will be assigned to two patients to ensure their safety.

Patient #3 is a 31 year old Patient who was brought into the Hospital by ambulance in 1/2022 in the custody of the local police after attempting to light his/her apartment on fire. On arrival to the Emergency Department, Patient #3 was yelling incoherently, kick and spitting at staff. Patient #3 was chemically restrained for both the patient's and staff member's safety.

Review of Emergency Department Patient Report dated 1/13/22 - 1/15/22 indicated that Patient #3 was triaged on 1/13/22 at 11:51 P.M., registered as a patient on 1/14/22 at 12:11 A.M., a mental health evaluation was pending on 1/14/22 at 9:29 A.M., a behavioral health bed search was implemented on 1/14/22 at 10:43 P.M., on 1/15/22 at 5:21 P.M., Patient #3 was in his/her room., at 5:34 P.M. Patient #3 was pending a mental health evaluation and at 6:00 P.M., Patient #3 left the department.

Review of the Vitals-Pain-Notes indicated that on 1/14/21 at 1:59 A.M., Patient #3 remained on a 2:1 safety watch.

Review of the Vitals-Pain -Notes indicated that on 1/15/22 at 12:52 P.M., constant observation in place.

Review of the Vitals- Pain- Notes indicated that on 1/15/22 at 4:18 P.M. Patient was awaiting a re-evaluation from crisis and constant observation remains in place.

Review of the Vitals-Pain-Notes indicated that on 1/15/22 at 6:00 P.M. Patient #3 was seen eloping the department.

During an interview on 1/25/22 at 1:15 P.M, the Safety Officer said that the Nurse Manager of the ED is performing the investigation of the elopement. She said that the Nurse Manager is not working but the Director of the Emergency Department could help with questions regarding Patient #3's elopement on 1/15/22.

During an interview on 1/25/22 at 1:20 P.M. the Director of Emergency Services said that he has only reviewed the Patient record and that Quality is working on the investigation. He said that Patient #3 left through the Emergency Department towards the Fast Track Unit. He has been told that Patient #3 may have been able to exit through PET scan door, but that is unlikely since it is locked at all times. He said it is more likely that she left through an emergency exit door beyond the nursing station of the Fast Track Unit. He said that there have been no implemented changes as the elopement is still being looked at.

During a tour of the Emergency Department on 1/25/22 at 1:20 P.M., the Surveyor observed the egress in which was identified by the Director of Emergency Services as the doors that Patient #3 eloped from. It was identified that Patient #3 was able to exit out of the Emergency Department by the side doors which lead to the Fast Track Unit. The initial door leaving the Emergency Department was open to a hallway. To the right are double doors which are open and lead to the Fast Track Unit which is the presumed path Patient #3 took to elope. The PET scan doors were locked and only able to be opened by card access. Around the corner, to the right, is the emergency exit door, just beyond the nursing station, which is the alternate door that the Director of Emergency Services believes Patient #3 could have eloped from. This door is unlocked at all times.

During an interview on 1/26/22 at 9:00 A.M. Registered Nurse (RN) #1 said that she was assigned to be the constant observer of Patient #3 on 1/15/22. She said that she was responsible to watch Patient #3 and another Patient in the hallway. RN#1 said that Patient #1 was initially in 1 of the 2 psychiatric safe rooms in the emergency department, but due to a new patient coming in, Patient #3 was moved to the hallway on a stretcher for continued observation for safety. RN #1 said that she didn't get a full report on Patient #3, just form that that identified that Patient #3 was on 2:1 safety watch. RN #1 said that she was observing two behavioral health patients in the Emergency Department and placed her chair and table in between the two stretchers that Patient #3 and the other patient were in to observe both at one time. RN #1 said that she has been working at the Hospital since 7/2021 and has not received training or education on the observation policies or procedures at the Hospital. RN #1 said that she has not been informed of any education that has been provided to staff as a result of this elopement and that there was not a meeting or any information provided about the elopement as of 1/26/22.

During an interview on 1/26/22 at 11:10 A.M., RN #2 who was the Registered Nurse assigned to care for Patient #3 at the time of the event said that she saw Patient #3 in the hallway. She had discussed the plan to have another mental health crisis evaluation with Patient #3 prior to the elopement. RN #2 said that soon after the discussion, Patient #3 eloped to the Fast Track Unit. RN #2 said that she had not had any updates regarding the investigation or education regarding the elopement to prevent another elopement from taking place.

The Hospital failed to identify events that could have contributed to the elopement of Patient #3 when Patient #3 was provided with an observer who was not trained to be 2:1 constant observer by the Hospital.

The Hospital failed to implement an investigation and to provide education to staff members after Patient #3 was able to elope from the Hospital while on safety watch to prevent a like occurrence from happening in the future.