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Based on interview and document review, the facility failed to maintain a safe environment through adequate supervision for one of three patients (P1) reviewed for close observations when multiple staff had varying definitions of how to perform closed observations.

Findings include:

In an electronic chart message was sent to P1's outpatient care provider on 2/4/25 at 7:57 a.m., family member (FM)-A indicated P1 was hallucinating, and he was concerned for his safety. On 2/4/25, a clinic staff member instructed FM-A to have P1 evaluated at the emergency department (ED) for hallucinations.

P1 presented to the ED on 2/4/25 at 2:34 p.m. for dizziness and altered mental status. P1's past medical history included restless leg syndrome, cerebrovascular accident, and iron deficiency anemia.

A provider note dated 2/4/25 at 5:58 p.m., indicated P1 had experienced increased hallucinations and confusion over the past several weeks. The note indicated P1 had been found wandering in town, was engaging in paranoid behaviors, and endorsed visual and auditory hallucinations. P1 was admitted to the hospital for further evaluation and consideration of placement.

A psychiatric consult dated 2/5/25 at 11:21 a.m. indicated P1 had been experiencing cognitive decline over approximately two years, which was accelerated by a motor vehicle accident on 12/31/24. The note indicated P1 was hospitalized voluntarily, and did not meet criteria for psychiatric hospitalization.

A nursing noted dated 2/5/25 at 8:17 p.m. indicated staff discovered P1 was not in her room at approximately 4:10 p.m., and security was notified. The note indicated P1 returned to her room at approximately 4:45 p.m. and reportedly taken herself to a local restaurant. The note indicated nursing staff-initiated video monitoring, and a "wander guard wristband" was placed on P1.

A provider order dated 2/5/25 at 4:20 p.m. indicated P1 was placed on a 72-hour hold. This order lapsed on 2/10/25 at 4:20 p.m.

A nursing order dated 2/5/25 at 4:49 p.m. indicated P1 was placed on video monitoring for elopement risk concerns.

A provider note dated 2/5/25 at 6:46 p.m. indicated P1 was a high elopement risk, and was placed on a 72 hour hold due to the danger she posed herself.

In a nursing note dated 2/10/25 at 1:44 p.m., the unit manager indicated P1 had accused unnamed black male staff of sexually assaulting her at unknown times and dates. The unit manager indicated P1 was placed on individual assignment, and only white, female staff would provide care until her delusions resolved.
The note indicated the video monitoring would remain in place in addition to the individual assignment for the safety of staff and P1.

A nursing order dated 2/10/25 at 5:14 p.m. indicated P1 was placed on independent assignment. The order indicated one staff will monitor one patient.

In a nursing note dated on 2/10/25 at 6:17 p.m., registered nurse (RN)-A indicated P1 was on close observation, and video monitoring.

Flowsheet documentation on 2/11/25 at 1:00 p.m. indicated P1 had safety checks once every 30 minutes by nursing assistant (NAR)-A

On 2/11/25 at 1:53 p.m., the care provider was informed P1 had eloped.

A provider order dated 2/11/25 at 2:04 p.m. indicated P1 was placed on a 72-hour hold.

In a nursing note dated 2/11/25 at 5:47 p.m., RN-A indicated at approximately 1:30 p.m., she was informed by RN-B that P1 was no longer in her room. The note indicated video monitoring staff, NAR-B and NAR-C, were unaware P1 had left her room, and security was notified. The note indicated P1 was brought back to the facility at approximately 2:15 p.m. by the local police department, and a 72-hour hold was placed. The note indicated a "WanderGuard" was placed, and P1 remained on video monitoring and independent assignment.

During an interview on 2/18/25 at 2:35 p.m., RN-C stated an individual assignment is when staff will sit in the room with a patient to monitor them. RN-C stated video monitoring is when staff virtually observe a patient through a camera unit.

During an interview on 2/18/25 at 3:03 p.m., RN-D stated if a patient is wandering or becomes a risk to themselves, the nurse can order an individual assignment. RN-D stated they have mounted wall cameras in the room, which are different from the camera units used to monitor patients on video monitor. RN-D stated the mounted cameras are not used for monitoring patient safety.

During an interview on 2/18/25 at 4:14 p.m., RN-E stated patients can be monitored for safety via video monitoring or an independent assignment. RN-E stated the video monitoring is completed by trained staff who work remotely in another building. RN-E stated an individual assignment is when the staff sits in the room with the patient. RN-E stated the updated name for a 1:1 is individual assignment, but they are the same interventions with the same expectations.

During an interview on 2/19/25 at 8:52 a.m., RN-F stated the type of patient monitoring is dependent on their presentation and ability to be redirected. RN-F stated if a patient is on a 1:1, the NAR always stays in the room. RN-F stated if a patient's 1:1 is sitting outside the room, it is referred to as a close observation. RN-F stated video monitoring is used if the patient can respond to the NAR talking to them through the unit and are redirectable.

During an interview on 2/19/25 at 9:36 a.m., P1 stated she was delusional earlier, and that no one is hurting her. P1 stated she was comfortable with the nurses, and they take her for walks. P1 stated she knew where she was going, what she was doing, and was no longer confused. P1 stated she had left the hospital unattended three times since she was admitted four weeks ago.

During an interview on 2/19/25 at 9:55 a.m., clinical nurse specialist stated the wander guard system is formally named Real Time Location Service (RTLS) and is a tracking system pilot program. The clinical nurse specialist stated this system works by attaching a wristband to a patient which pings off Bluetooth towers plugged into outlets around the unit to track patient location. The clinical nurse specialist stated if these patients get too close to an exit, the nurses, behavioral emergency response team, and security receive pages immediately.

During an interview on 2/19/25 at 10:13 a.m., RN-G stated on 2/11/25, NAR-A was performing close observation on P1 when another patient had a medical emergency. RN-G stated NAR-A answered the call light of the other patient, and P1 eloped from the unit. RN-G stated she was surprised the RTLS system did not page her since P1 had recently been wearing a RTLS wristband. RN-G stated close observation means staff can monitor patients from outside their room, either via direct line of sight, or through the mounted wall cameras. RN-G stated staff assigned to a close observation patients can answer nearby call lights. RN-G stated NARs assigned to independent assignments cannot leave the patient's room to answer call lights.

During an interview on 2/19/25 at 10:34 a.m., NAR-D stated independent assignment means staff stay in the room with a patient. NAR-D stated when completing an independent assignment, staff cannot answer other patient call lights. NAR-D stated close observation means staff can monitor the patient from outside the room, and only need to see them once per hour. NAR-D stated he can use the mounted wall cameras to complete observations of a patient on close observation. NAR-D stated staff assigned to close observation can answer other patients' call lights. NAR-D stated he completes either an independent assignment or close observation based on the nurse's direction.

During an interview on 2/19/25 at 11:08 a.m., RN-H stated close observation is when staff sits outside of the patient room in line of sight with the patient or uses the wall mounted camera to monitor the patient. RN-H stated staff assigned to close observation should see their patients every 15 minutes and complete flowsheet documentation in real time. RN-H stated independent assignment means staff must stay in the room with the patient and chart hourly. RN-H stated independent assignments are based on orders in the electronic medical record (EMR) placed by a nurse or a provider. RN-H stated staff know to perform independent assignments or close observation based on nurse instruction.

During an interview on 2/19/25 at 11:36 p.m., NAR-B stated on 2/11/24 he was watching P1 via video monitoring because NAR-C needed to go to break. NAR-B stated before he left, NAR-C told him P1 was most likely in the bathroom. NAR-B stated he then saw RN-A and RN-B come into the room via the video monitor and inform him P1 had eloped. NAR-B stated when staff operating the video monitors see their patient attempting to leave the room, they will press an alert button that causes the video monitoring unit to alarm loudly. NAR-B stated they were reeducated by their manager immediately and reinforced their training on watching all patients through video monitoring. NAR-B stated P1 is now kept up on all video monitoring staff screens to ensure she stays in her room.

During an interview on 2/19/25 at 1:10 p.m., RN-I stated on 2/5/25, the provider was updated of P1's elopement and determined P1 was holdable. RN-I stated when P1 returned to the unit, they placed an RTLS wristband on her and initiated an independent assignment. RN-I stated a staff member needed to be in the room to monitor her because P1 was becoming restless.

During an interview on 2/19/25 at 1:25 p.m., RN-B stated RN-B stated 1:1 assignment is dependent on the patient's need. RN-B stated 1:1's are completed in the patient's room, but if they are attempting to lower the level of supervision for whatever reason, they will change the 1:1 to close observation. RN-B stated close observation can be completed from outside the room. RN-B stated close observation needs to have direct line of sight with the patient and not be down the hallway. RN-B stated staff can use the mounted wall cameras to complete close observation monitoring. RN-B stated they can also initiate a wander guard for monitoring. RN-B stated on 2/11/25, the health unit coordinator informed her P1 had just walked off the unit and she called security. RN-B stated she informed RN-A and NAR-B of the elopement. RN-B stated the video monitoring unit never alarmed, and NAR-B was unaware P1 had left the unit. RN-B stated per morning report, P1 was on close observation and NAR-A was assigned to watch her. RN-B stated NAR-A was down the hall helping other staff and patients at the time P1 eloped. RN-B stated she frequently sees staff completing 1:1's out of the designated patient's room and answering other call lights on the unit.

During an interview on 2/19/25 at 2:45 p.m., RN-A stated independent assignment is when staff are watching patient in the room continuously, charting every 15 minutes. RN-A stated it is the responsibility of the nurse to ensure the staff assigned to the independent assignment are appropriately monitoring the patient. RN-A stated on 2/11/25, she was caring for another patient who had been experiencing a medical emergency when RN-B informed her P1 had eloped. RN-B stated at the time of the elopement, P1 had an independent assignment and the video monitor in place. RN-B stated she did not know where the wander guard was, and that P1 was not wearing one at the time of elopement. RN-B stated she wanted NAR-A to be in the room with P1 as per the individual assignment responsibilities, however she did not know where NAR-A was. RN-A stated during morning report, NAR-A was told to stay in P1's room. RN-A stated she received immediate reeducation from her managers after the event to make sure the video monitoring, the independent assignment, and the wander guard were all in place.

During an interview on 2/19/25 at 4:02 p.m., NAR-A stated when completing an independent assignment, staff must sit with the patient and cannot answer other call lights. NAR-A stated close observation is when staff are not needed to watch them continuously and can answer other patient call lights. NAR-A stated she knows if she needs to perform independent assignment or close observation based on the order in the computer and the nurse's instruction based on their assessment. NAR-A stated during report, she was told P1 was close observation and was instructed to help on the unit if she was able. NAR-A stated RN-B knew NAR-A was not in P1's room and was not completing an independent assignment. NAR-A stated on 2/11/25, she was watching another staff's close observation patient when she was informed P1 had eloped. NAR-A stated when P1 returned, she completed an individual assignment with her for the rest of the shift. NAR-A stated she received immediate reeducation from the nurse manager. NAR-A stated she needs to clarify with the nurse or charge nurse to ensure she is completing the right type of patient monitoring.

During an interview on 2/19/25 at 4:33 p.m., physician assistant (PA-A) stated the decision to have a patient on 1:1 or close observation is dependent on patient needs and is left to nursing discretion.

During an interview on 2/20/25 at 8:22 a.m., NAR-C stated he was observing P1 through video monitoring on the afternoon of 2/11/25. NAR-C stated P1 was on an independent assignment and thought NAR-A was in the room P1. NAR-C stated P1 had been very actively going back and forth between the bed and her bathroom all day. NAR-C stated another patient he was observing through video monitoring was a fall risk and a family member began trying to transfer the patient without staff. NAR-C stated he was speaking through the intercom feature of the video monitor and trying to educate the family member, who then began yelling at him. NAR-C stated he then tried to call a nurse to assist with the patient in question, and by the time he looked back to P1's room, P1 was no longer in bed. NAR-C stated he was then going on break and told NAR-B he believed P1 was in the bathroom and instructed him to call and be sure. NAR-C stated when he returned from break, he and his coworkers were immediately reeducated by their manager. NAR-C stated if any patient has a history of eloping, these patients will be displayed at the top of their video monitoring screens for all staff working as video monitors.

During an interview on 2/20/25 at 2:55 p.m., the nurse manager stated P1's elopement on 2/5/25 was reported to him immediately. The nurse manager stated they placed a wander guard on P1, initiated video monitoring, and initiated close observation. The nurse manager stated on 2/9/25, the RTLS had sent multiple false alarms through the paging system to staff, and to reduce alarm fatigue, they cut off the wander guard bracelet. The nurse manager stated this was not communicated to staff, and no wander guard bracelet was replaced between that time and the elopement on 2/1//25. The nurse manager stated on 2/11/25, he was told P1 had eloped again. The nurse manager stated they determined NAR-A thought P1 was close observation, and while sitting in front of P1's door, had gotten up to help another patient. The nurse manager stated once P1 returned to the units, they applied a wander guard, ensure she had both video monitoring and individual assignment in place, and then convinced her to change from her street clothes into a medical gown. The nurse manager stated he believed the biggest gap in their practice was a failure to get P1 into a medical gown initially, and because she was still wearing street clothes, she was able to walk through the unit and hospital without an issue. The nurse manager stated he reeducated RN-A on her responsibility to ensure staff are completing individual assignment correctly. The nurse manager stated they have been reeducating all staff on individual assignments and responsibilities during report huddles every day, with charge nurses educating staff on the weekends.

During an interview on 2/20/25 at 3:30 p.m., the nurse administrator stated individual assignments are when staff are always in the patient's room with direct line of sight. stated close observation is a loose term used to describe patients who need frequent rounding. The nurse administrator stated it is preferred to have close observation in combination with video monitoring. The nurse administrator stated there is no policy guiding close observation.

During an interview on 2/20/25 at 3:47 p.m., the vice chair of nursing stated individual assignment is when one staff is assigned to one patient, and they are in direct line of sight. The vice chair of nursing stated close observation is when staff perform frequent check on a patient and assist as needed. The vice chair of nursing stated she is unaware if there is a policy standardizing close observation.

A policy titled "Individual Assignment: Patients at Risk for Harm to Self (Unintentional and Intentional)" dated 3/16/21 indicated an individual assignment is defined as when a staff member is to stay in direct line of sight with the patient. The policy indicated it is the discretion of the RN to determine if the staff remains at the patient's bed side.

A policy regarding close observation procedures were requested and could not be provided.

An undated document titled "Resource for Prioritizing Individual Patient Assignments" indicated close observation frequent rounding on a patient, every 15 to 30 minutes.

Based on interview and document review, the facility failed obtain an order for restraints for each episode requiring restraint for one of two patients (P5) reviewed for restraints. The order for restraints did not specify the type of restraints administered and was utilized for two separate episodes of restraints.

Findings Include:

P5 presented to the facility emergency department (ED) for intentional drug overdose on 2/9/25 in the evening. P5's pertinent medical history included bipolar one and a history of prior suicide attempts. P5 was transferred to inpatient medicine on 2/9/25.

A supervisory note dated 2/11/25 at 5:38 a.m. indicated P5 was cleared by inpatient medicine to be transferred to psychiatric services. P5 disagreed with psychiatric hospitalization, and security and the behavioral emergency response team (BERT) responded. P5 was informed she was educated that she was holdable due to the risk she posed to herself. P5 attempted to leave the facility while threatening physical violence. The note indicated an order was placed for the use of physical restraints; however, staff were able to convince P5 to return to her room willingly.

A physician order dated 2/11/25 at 9:52 a.m. indicated a new instance of P5 needing restraints for violent behavior. The order indicated the patient restraint type was double-security cuff, physical hold, spit hood, and restraint chair. The order indicated the restraint location were bilateral upper extremities and bilateral lower extremities. The order indicated restraints were required due to P5 posing a danger to herself and others.

Flowsheet charting for violent restraints dated 2/11/25 at 9:53 a.m. indicated restraints were initiated on P5, charting indicated the restraints were being monitored. However, the flowsheet charting did not indicate what type of restraint was used on P5.

A BERT nursing note dated 2/11/25 at 11:22 a.m. indicated at 9:28 a.m., P5 had another episode of agitation resulting in staff calling BERT and security. P5 was placed on a 72 hour hold and began threatening staff and tried to push her way off the unit. Staff "went hands on" and P5 was lowered to the ground and "physically restrained." The note indicated P5 received an anti-anxiolytic injection and then returned to her room without further incident.

Flowsheet charting for violent restraints dated 2/11/25 at 12:00 p.m. indicated restraints were initiated on P5. Charting indicated the restraints were being monitored. However, the flowsheet charting did not indicate what type of restraint was used on P5.

A provider note on 2/11/25 at 12:28 p.m. indicated when the provider arrived, P5 attempted to elope from the facility. The note indicated P5 was being escorted back to her room by staff and security in a manual hold.

A nursing note dated 2/11/25 at 2:29 p.m. indicated at 9:50 a.m., P5 refused to return to her room and "security had to hold down" P5 in the hallway. P5 was given an anti-anxiolytic injection while she attempted to escape. Other nursing staff went to get "a hold of restraints." The note indicated in the end of shift summary P5 remained hemodynamically stable, and no restraints were utilized.

A discharge summary dated 2/13/25 at 2:56 p.m. indicated P5 was discharged from the medical service to the psychiatric unit.

P5 was not available for interview.

During an interview on 2/18/25 at 2:35 p.m., RN-C stated restraints cannot be applied to a patient without an order. RN-C stated each time a patient is placed in restraints, they must receive a new order.

During an interview on 2/19/25 at 8:52 a.m., RN-F stated orders for restraints must be obtained with each episode of restraint use.

During an interview on 2/19/25 at 10:13 a.m., RN-G stated orders for restraints must be obtained whenever restraints are applied.

During an interview on 2/19/25 at 11:08 a.m., RN-H stated an order for restraints is necessary every time restraints are used on a patient.

During a chart review on 2/20/25 at approximately 10:00 a.m., the BERT nurse manager stated the primary nurse should have charted the episode of restraint on 2/11/25 at 9:52 a.m. because a manual hold is a type of restraint.

During a chart review on 2/20/25 at approximately 10:00 a.m., the clinical nurse specialist stated the nurses are allowed to increase or decrease the type of violent restraint used without obtaining a new order from the provider.

During an interview on 2/20/25 at 2:55 p.m., the nurse manager stated it is the responsibility of the primary nurse to ensure all details of restraint episodes are charted. The nurse manager stated the orders specify what type of restraint the nursing staff are expected to use. The nurse manager stated restraint removal must also be documented in the restraint flowsheets. The nurse manager stated the best practice for nurses is to chart in real time.

During an interview on 2/20/25 at 3:30 p.m., the nurse administrator stated nursing staff are expected to follow the restraint policy and procedure. The nurse administrator stated the nurse assigned to the patient charts all restraint information in the flowsheets.

During an interview on 2/20/25 at 3:47 p.m., the vice chair of nursing stated the nursing staff must follow the policies and procedures to chart on restraints accurately.

A policy titled "Restraint or Seclusion," dated 3/9/23 indicated when a restraint intervention ends, the RN has no authority to reinstate the intervention without a new order from a provider. The policy indicated the RN must chart the type of restraint intervention used.