HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #3) clinical record reviewed for monitoring a patient with suicidal ideation, the Hospital failed to ensure that the patient received care in a safe setting by not monitoring as required .

Findings included:

1. The Hospital's policy titled, "Suicide Risk Screening & Precautions for Patients" (revised 6/2020) was reviewed and required, "...Suicide Precautions include continuous observation and documentation of the patient ... The RN will perform and document ongoing safety assessments every 4 hours ... in the Suicide Observation Flow Sheet."

2. On 4/13/22, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted to the Hospital 3/30/22, with diagnosis of "Trauma due to Jump from window." The clinical record included:

- Psychiatric Consultation note dated 3/31/22 at 3:38 PM, included, "Reason for Consultation: SI (suicidal ideation) and HI (homicidal ideation) ... was admitted for jump from 2nd story building ... Plan: Certified for inpatient psychiatric admission ... SI (suicidal ideation) precautions."

-Physician's order dated 4/1/22, included, "Constant Observation for Suicide, 24 hours until specified ... Patients with suicidal ideation or intentions-requires ... continuous monitoring by a qualified person ... refer to policy 'Suicide Risk Screening & Precautions'..."

-Suicide/Homicide Observation Flow Sheets dated 4/2/22 at 4:00 AM through 4/4/22 at 10:45 PM. The flow sheets indicated that the Safety Assessments (must be completed by RN every 4 hours) were not completed as required. The Safety Assessments during this time were completed the following dates and time: on 4/3/22 at 12:00 AM, 4:00 AM, and 4/4/22 at 12:00 AM.

3. On 4/13/22 at approximately 11:50 AM, findings were discussed with the Unit Manager (E #13). E #13 stated that patient's that are suicidal require that an RN complete a Safety Assessment every 4 hours, even if a patient is on one to one observation. E#13 confirmed that Pt.#1's clinical record indicated that the Safety Assessments were not conducted every 4 hours as required.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #6) clinical records reviewed for restraints, the Hospital failed to ensure that the least restrictive intervention was used based on the individualized assessment of the patient, as required.

Findings include:

1. The Hospital's policy titled "Restraints and Seclusion" (revised 10/21), was reviewed and required, "Restraint or Seclusion may only be imposed in emergency situations if needed to protect the patient, a staff member, or others from harm ... II. 4) ... Restraints must be discontinued at the earliest possible time, even if the order has not yet expired ... IV. Monitor, Assess, and Re-evaluate ... 2) ... The changes in the patient's behavior or clinical condition that are needed to initiate the removal of Restraints, and whether the patient meets the criteria for removal ..."

2. On 04/13/22, the clinical record of Pt. #6 was reviewed. Pt.#6 was admitted on 2/16/22, with diagnosis of Psychosis. Pt. #6's clinical record included the following:

-Restraint Order Form dated 02/16/22 at 6:48 PM, included, "Restraints Violent/Self-Destructive Behavior towards self or others ... Locked All extremities ... RN to monitor/assess ... Criteria to discontinue restraints: patient no longer at risk ... 4 Hours ...Initiated 02/16/22 at 6:00 PM"

-Restraint Flowsheet dated 02/16/22 from 6:00 PM to 7:14 PM, included, "... Violent Patient Monitoring (every 15 minutes): 6:00 PM-Delusional; Ready for Discontinuation? NO ... 6:45 PM, Patient Asleep; Ready for Discontinuation? No ... 7:00 PM, Patient Asleep; Ready for Discontinuation? No ... 7:14 PM, Alert, Calm, Cooperative. Ready for discontinuation? Yes ..."

3. On 04/15/22 at approximately 9:40 AM, an interview was conducted with the ED Patient Care Manager
(E #4). E #4 stated that if a patient was sedated and is sleeping from effects of medication, the patient should be released from restraints.

A. Based on document review and interview, it was determined that for 1 of 7 employees (E #15), with religious exemptions to receiving the COVID-19 vaccine, the Hospital failed to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff not fully vaccinated for COVID-19.

Findings include:

1. The Hospital's policy titled, "COVID-19 Vaccine Employee Requirements" (revised 4/2022), was reviewed and required, "All staff & faculty ... working at (name of Hospital) are required to be vaccinated against COVID-19 infection ... Employees may apply for an exemption for... religious reasons ... exempt employees are enrolled in the exempt employee weekly testing program ..."

2. The Hospital's FAQ (frequently asked questions) COVID-19 Mandatory Weekly Testing" (undated) document was reviewed and included, "3. Who must undergo weekly testing? All (name of Hospital organization) employees who received an approved exemption from vaccine and whose jobs require them to work at (name of Hospital organization) site must undergo weekly testing .... Employees who work one or more days in a given week and who fail to undergo testing that week as required by the order will be issued discipline ... Such employees may not return to the workplace the following week until they participate in testing ..."

3. On 4/15/2022, the "COVID-19 Vaccination Exemption Requests" were reviewed. There was one (1) employee (E #15) with a religious exemption. There was no documentation of weekly testing for E #15.

- E #15 is a Full-time (1.00 FTE) Registered Nurse,

4. On 04/15/2022 at 12:50 PM, an interview was conducted with the Director of Human Services (E #18). E #18 stated that exempted non-vaccinated Hospital staff should have weekly COVID-19 testing before reporting to work.


B. Based on document review and interview, it was determined that the Hospital failed to ensure compliance regarding COVID-19 vaccination of all staff, as part of the Hospital's infection prevention and control program. This potentially affected any patient or staff for cross infection.

Findings include:

1. On 4/15/22, the Hospital's policy titled, "COVID-19 Vaccine Employee Requirements" (revised 4/2022), was reviewed and required, "All staff & faculty ... working at (name of Hospital) are required to be vaccinated against COVID-19 infection ... Employees may apply for an exemption for ... religious reasons..."

2. On 4/15/22, the CMS (Centers for Medicare and Medicaid) Guidance for the Interim Final Rule -Medicare and Medicaid Program; Omnibus COVID-19 Healthcare Staff Vaccination, dated 12/28/2021, was reviewed and included, "Vaccination enforcement... Facility staff vaccination rates under 100% constitute non-compliance under the rule... Within 30 days after issuance of this memorandum, if a Facility demonstrates that... Less than 100% of all staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted a qualifying exception, or identified as having a temporary delay, as recommended by the CDC (Centers for Disease Control and Prevention), the facility is non-compliant under the rule..."

3. On 4/15/22, the Hospital's staff vaccination data (dated 4/13/22) was reviewed. The document indicated that there were two staff (E#16/Cook and E#20/Agency RN) who were listed as non-compliant and have not received at least one dose of COVID-19 vaccination. There was no documentation for the staff regarding pending request for either medical or religious exemption or having temporary delay to receive the vaccine.

4. On 4/15/22 at approximately 1:00 PM, an interview was conducted with E #18 (Director of Human Services). E #18 stated that for these two staff (E#16, and E#20), the Hospital could not provide documentation regarding either medical or religious exception or having temporary delay for the staff. E #18 stated that due to a breakdown in communication, E#16 did not show up on the non-compliant list and was allowed to work up until 4/14/2022. E#18 stated that E#16 has been taken off the schedule.

Based on document review, observation, and interview, it was determined that for 1 (Pt.#2) of 3 Emergency Department (ED) clinical records reviewed, the Hospital failed to provide emergency care in accordance with acceptable standard of practice, which resulted in the elopement of Pt. #2. As a result, the Condition of Participation, 42 CFR 482.55, Emergency Services was not met.

Findings inlude:

1. The Hospital failed to provide emergency care by failing to adequately monitor a patient with an altered mental status (AMS) in the Emergency Department (ED). See deficiency at A-1104.

Based on document review, video surveillance review, and interview it was determined that for 1 of 3 (Pt. #2) clinical records reviewed for elopement, the Hospital failed to provide emergency care by failing to adequately monitor a patient with an altered mental status (AMS) in the Emergency Department (ED). This could potentially affect the safety of all of the patients with an altered mental status receiving care in the ED.

Findings include:

1. The Hospital's policy titled, "Patient Rights and Responsibilities (2/2020)" was reviewed and included, "... Patients have the right to ...x. receive visitors ... as long as they do not interfere with care..."

2. The Hospital's policy titled, "Triage (revised 2/2019) was reviewed and included, " ...Procedure: Rapid Assessment Unit (RAU) ...1. During the arrival process, the PIVOT (triage) nurse will obtain the following information and or additional information needed ...in order to assign ESI (emergency severity index) acuity ...3. The patient will be moved to the Rapid Assessment Unit for evaluation by a Licensed Independent Provider... 4. When there is no available space in the treatment area, patients will be directed to the waiting room and the responsibility of the Pivot Nurse... 7. As the patient's condition may improve or deteriorate during the wait for entry into the treatment area, the patient will be reassessed by Pivot Nurse at appropriate intervals while waiting to be taken to the treatment area. ESI Level 2: high risk situations based on nursing assessment, for instance ... Cardiac history, New onset confusion... or disorientation..."

3. On 04/13/2022, the clinical record of Pt. #2 was reviewed. Pt. #2 was brought to the Emergency Department on 3/8/2022 with chief complaint of loss of consciousness (LOC). The clinical record included the following:

- ED Triage Note dated 3/9/2022 at 1:12 PM, included, "Pt coming from (outpatient building) Dr. Cart (Rapid Response Code). (Pt.#2) was sitting with niece and passed out... Pt alert and oriented to person and place. No facial droop, no drift, no slurred speech. Denies any pain. Pt with hx (history) of dementia, bladder CA (cancer) with radiation tx (treatment), pacer (heart implant to regulate heart rhythm) ...Z #1 (Name of Pt. #2 Power of Attorney) and (phone number)."

-ED Physician Note dated 3/8/2022 at 1:41 PM, included, "Triage: after (Pt. #2) had LOC in lobby. Pt doesn't recall events, states he was feeling fine this morning prior to arrival... No infectious sxs (signs and symptoms), no headache, no chest pain. EKG (electrocardiogram) atrial paced, no ischemic changes. Labs (laboratory reports) from clinic reviewed and additional labs ordered. To tx (treatment) area when space available."

- Nurses note dated 3/8/2022 at 8:00 PM included, "Patient called ...no response."

-Nurses note dated 3/8/2022 at 8:12 PM, ED disposition set to left without being seen."

Pt. #2 was documented as left without being seen (LWBS). However, patient eloped from the Hospital at 4:35 PM, on 3/8/2022. There was no additional documentation of Nursing assessments from 1:12 PM to 8:00 PM (approximately 7 hours and 47 minutes).

4. On 04/15/2022 at approximately 11:30 AM, the video surveillance footage dated 3/8/2022 was reviewed with E #7/Regulatory Compliance Manager. The video surveillance was from a surveillance camera in the ED waiting room. At 1:57:38 PM (hour/minute/seconds) Pt. #2 is wheeled into the ED waiting room lobby (by E #17-Registered Nurse) and positioned near the Public Safety Officer (PSO) desk where he remains until 4:07 PM. At 4:07:32 PM-Pt. #2 stands up from his wheelchair and walks towards the ED main treatment area off-camera view; 4:35:10 PM-Pt. #2 walks back into view of the camera of the ED waiting room lobby; 4:35:37 PM-Pt. #2 is standing against the wall directly across from the triage desk, adjusting his clothing and zipping his coat; 4:36:41-Pt. #2 walks off camera towards ED main treatment area; 4:37:17-Pt. #2 returns into the view of the ED waiting room camera and walks toward the front door; 4:37:35 PM-Pt. #2 exits the hospital by walking out of the ED lobby main entrance. The video footage did not show any interaction from ED staff with Pt. #2.

5. On 04/15/2022, the Hospital's document titled "Patient Safety Improvement Plan (undated)" was reviewed and included, "Safety & Quality Improvement measures (action) ...1. Educational Factor: Educate all ED nursing staff that the Charge RN (registered nurse) must immediately be notified if any patient has confusion or altered mental status to facilitate immediate rooming in the back assignment or assignment of a dedicated sitter in the waiting area ...Target date ...4/6/2022 ...Status: completed ...As of 4/6/2022, education completed at staff huddles. 2. Education Factor: Educate all RRT (rapid response team) staff of the following: Visitors may be allowed in... ED for confused/AMS patients and decision should be at the discretion of ED Charge RN. All DR. CART or RRT patients should be brought to back of ED for direct handoff to ED Charge RN ...Target date 4/8/2022 ...Status...completed...As of 4/8/2022, education completed via email memorandum." The Hospital was unable to provide supporting documentation of the number of nursing staff that have received education related to care of patients with AMS in the ED.

6. On 04/13/2022, at approximately 12:15 PM, E #2/Executive Director of Adult Emergency Services and Trauma was interviewed. E #2 stated that a patient with Dementia or an altered mental status cannot make the decision to leave without being seen or against medical advice.

7. On 04/13/2022, at approximately 2:00 PM, an interview was conducted with E #3/Registered Nurse. E #3 stated that if a patient has a diagnosis of dementia, they are usually allowed to have a support person or visitor...The patients are in the waiting room where they are being monitored and we usually sit them near the desk with us. I do not recall seeing Pt. #2 leave...I do not specifically recall being re-educated or re-in serviced about caring for a patient with the dementia in the ED.

8. On 04/14/2022 at approximately 2:30 PM an interview was conducted with E #12 (Registered Nurse-RRT). E #12 stated, "I was the nurse that responded to the Dr. CART. When I got to the patient, he was alert and responsive but didn't know why everyone was surrounding him and was asking for water ...I checked his vitals and walked him down to the ED. I took him to the triage desk and gave report to the triage nurse. I relayed to (Z #1) what I believed was the policy that the ED didn't allow visitors. (Z #1) told me (Pt.#2) had a history of dementia. I put (Z1) phone number on the Facesheet and told the triage nurse that she was waiting (update on patient status) ..."

9. On 04/15/2022 at approximately 10:30 AM, an interview was conducted with E #4 (Emergency Department Patient Care Manager). E #4 stated that during the daily huddles the nursing staff are provided re-education on monitoring patients with AMS while in the ED. E #4 stated that she did not have an actual percentage of staff that had been in-serviced or re-educated.

10. On 04/15/2022 at approximately 11:00 AM, an interview was conducted with E #17 (RAU RN assigned to Pt. #2). E #17 stated that she does not recall Pt. #2 but stated that the protocol has always been that patients with dementia are roomed immediately or monitored by staff if placed in the ED waiting room. E #17 stated that if she was aware of Pt. #2's diagnosis she would have assessed further. E #17 stated that since Pt. #2's elopement from the Hospital on 3/8/2022. She has not received any re-education or in-services from the nursing management at the hospital. E #17 stated, "no one has talked to me about this until today".

11. On 4/15/2022, at approximately 11:30 AM, an additional interview was conducted with E #2. E #2 stated, "We are doing these nursing huddles every day to provide education at 7:00 AM and 7:00 PM and at some point, everyone should receive the information ... I really think there was a gap in the communication, there was a breakdown that we need to shore up with the parties involved and department wide ..."