HospitalInspections.org

Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights by failing to ensure that patients had the right to receive care in a safe setting as evidenced by:
1) failing to ensure that Patient #2 was observed per ordered line of sight observations at all times. As a result, Patient #2 eloped from the hospital and was later found down the street in another business; and
2) failing to ensure that ordered line of sight observations were implemented for Patients #R1, R2, R3, R4, R5, R6, R7 ; and
3) failing to ensure that patient observation logs were current and up to date.
(See findings under Tag A0144)

Based on observation, record review and interview, the hospital failed to ensure patients had the right to receive care in a safe setting as evidenced by:
1) failing to ensure that Patient #2 was observed per ordered line of sight (LOS) observations at all times. As a result, Patient #2 eloped from the hospital and was later found down the street from the hospital in another business; and
2) failing to ensure that ordered line of sight observations were implemented for Patients #R1, R2, R3, R4, R5, R6, R7; and
3) failing to ensure that patient observation logs were current and up to date.
Findings:

Review of the policy titled, Levels of Patient Observation, revealed in part that constant observation is when a patient is maintained in community areas where they can be observed at all times. Patients on a constant observation status must be accompanied if leaving community areas (to bathroom or to change clothes).


1) Failing to ensure that Patient #2 was observed per ordered line of sight (LOS) observations at all times. As a result, Patient #2 eloped from the hospital and was later found down the street from the hospital in another business.

Review of Patient #2's medical record revealed an admission date of 10/12/2023 with diagnoses including major neurocognitive impairment with behavior disturbance/psychosis. Review of the physician orders revealed a line of sight observation level was ordered upon admit on 10/12/2023.

Review of the initial RN admission assessment dated 10/12/2023 revealed that the patient gets up and wanders aimlessly throughout the hallways while holding baby doll. The patient pulls on doors and displays increased bizarre behaviors.

Review of an Abuse/Neglect Initial Report dated 10/13/2023 revealed in part that at 3:21 p.m., the MHT noticed that the patient was unable to be located on the unit. The MHT then asked the nurse to see if the patient could be seen on the camera in the nurses station and staff was unable to locate her on the cameras. The nurse went outside to look for the patient and the staff was able to locate the patient across the street at 3:28 p.m. The patient was returned to the unit without incident. The report further stated that the door that the patient was able to elope from was checked by staff for any malfunction and deemed to be in working order. It further stated the patient apparently slipped out of the door after a family member that was visiting left through that door. All MHTs were re-educated on appropriate line of sight observation procedures.

On 10/16/2023 at 1:37p.m., upon entering the locked unit with S2Compliance Officer, observation revealed Patient #2 standing in the corner at the entrance of the hallway, with no staff in view. At that time, S2Compliance Officer confirmed that the patient was not in line of sight of any staff member.

On 10/16/2023 at 2:45 p.m., S1DON provided Patient #2's observation log, dated 10/16/2023, to the surveyor. The log was to be initialed by the BHT every 15 minutes with the patient's location noted. Review of the log revealed there had been no initials by staff and no documentation of the patient's location since 2:00 p.m.

On 10/17/2023 at 9:40 a.m., when S1DON was asked if the camera recording from the incident on 10/13/2023 had been viewed to determine how the patient eloped, she stated no. Further interview with S1DON at this time revealed that that staff "assumed" that the patient eloped when a family member exited the building. S1DON further confirmed that if Patient #2 had been observed per ordered line of sight observation level, she would not have eloped from the hospital on 10/13/2023.

2) Failing to ensure that ordered LOS observations were implemented for Patients #R1, R2, R3, R4, R5, R6 and R7

Review of the patient daily census form dated 10/16/2023 revealed that Patients # R1, R2, R3, R4, R5, R6 and R7 were on ordered Line of Sight observation levels. On 10/16/2023 at 1:30 p.m., interview with S2Compliance Officer confirmed that the above patients were ordered Line of Sight observation levels. S2Compliance Officer further confirmed that 10 of the 11 patients admitted to the unit were on ordered observation levels of line of sight and one patient was on 1:1 observation level. When asked if this was feasible to do with only 3 BHTs per shift, she stated no.

On 10/16/2023 at 1:50 p.m., observation of Patients #R1, R2, R3, R4, R5, R6 and R7 revealed they were in their rooms and not in view of any staff.

On 10/16/2023 at 1:55 p.m., interview with S3BHT confirmed that the above patients were on ordered line of sight observation levels. When asked how she can continuously observe the patients, she stated that she just walks up and down the hall and checks on them.

3) Failing to ensure that patient observation logs were current and up to date

On 10/16/2023 at 2:40 p.m., S1DON provided all 11 current patient's observation logs, dated 10/16/2023, to the surveyor. The logs were to be initialed by the BHT every 15 minutes with the patient's location noted. Review of the logs revealed there had been no initials of staff and documentation of any of the patient's locations since 2:00 p.m.

On 10/18/2023 at 11:40 a.m., review of Patient #3, R5, R7 and R8's patient observation logs, dated 10/16/2023, revealed there had been no documentation of the patients' locations since 5:45 a.m. that morning. Interview with S4BHT, the tech assigned to these patients, revealed that she does not document on the patient observation logs until after lunch.

On 10/18/2023 at 12:00 p.m., interview with S1DON confirmed that the BHTs should document on the patient observation logs every 15 minutes, noting the patients location and behavior.

Based on record review and interview, the hospital failed to ensure the QAPI program took actions aimed at performance improvement as evidenced by failing to implement a performance improvement plan after a patient (Patient #2) was not observed per ordered line of sight observation level and eloped from the hospital and was found down the street in another business.
Findings:

Review of Patient #2's medical record revealed an admission date of 10/12/2023 with diagnoses including major neurocognitive impairment with behavior disturbance/psychosis. Review of the physician orders revealed an order for Line of Sight observation level was ordered upon admit on 10/12/2023.

Review of the initial RN admission assessment dated 10/12/2023 revealed that the patient gets up and wanders aimlessly throughout the hallways while holding baby doll. The patient pulls on doors and displays increased bizarre behaviors.

Review of an Abuse/Neglect Initial Report dated 10/13/2023 revealed in part that at 3:21 p.m., the MHT noticed that the patient was unable to be located on the unit. The MHT then asked the nurse to see if the patient could be seen on the camera in the nurses station and staff was unable to locate her on the cameras. The nurse went outside to look for the patient and the staff was able to locate the patient across the street at 3:28 p.m. The patient was returned to the unit without incident. The report further stated that the door that the patient was able to elope from was checked by staff for any malfunction and deemed to be in working order. It further stated the patient apparently slipped out of the door after a family member that was visiting left through that door. All MHTs were re-educated on appropriate line of sight observation procedures.

On 10/16/2023 at 1:37p.m., upon entering the locked unit with S2Compliance Officer, observation revealed Patient #2 standing in the corner at the entrance of the hallway, with no staff in view. At that time, S2Compliance Officer confirmed that the patient was not in line of sight of any staff member.

On 10/16/2023 at 2:40 p.m., S1DON provided Patient #2's Observation log, dated 10/16/2023, to the surveyor. The log was to be initialed by the BHT every 15 minutes with the patient's location noted. Review of the log revealed there had been no documentation of staff initials or of the patient's location since 2:00 p.m.

On 10/17/2023 at 9:40 a.m., when S1DON was asked if the camera recording from the incident on 10/13/2023 had been viewed to determine how the patient eloped, she stated no. Further interview with S1DON at this time revealed that they "assumed" the patient eloped when a family member exited the building. S1DON stated that staff have been informed to keep all patients in the day room during family visit times, so that patients cannot sneak out with family that are exiting the building.

On 10/18/2023 at 1:00 p.m., S1DON confirmed that Patient #2 was not being observed at the ordered observation level (line of sight) at the time of the incident on 10/13/2023. S1DON was asked if the hospital had performed any increased monitoring or implemented a QAPI plan to address the adherence of ordered observation levels and she stated no.