HospitalInspections.org

Based on review of facility documents, staff interviews, and observations, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Conditions of Participation:

CFR 482.13 Patient Rights

CFR 482.23 Nursing Services

Based on observation, staff and patient interviews, it was determined that the facility failed to protect and promote the rights of patients.

Findings include:

1. The facility failed to ensure the right to a sign language interpreter was provided to a patient that is hearing impaired. (Cross refer to Tag 0117).

2. The facility failed to ensure patients were provided care in a safe setting. (Cross refer to Tag 0144)

Based on a patient and family member's interview, staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to provide a patient with the right to a sign language interpreter.

Findings include:

Reference: Facility policy and procedure Language Services - Issue No. 831-200-073 states "... RESPONSIBILITY: It is the responsibility of all University Hospital staff, physicians, volunteers and students to ensure language services are provided as appropriate for effective communication. DEFINITIONS: ... Hearing/Speech Impaired (HSI)- An individual who has had loss of hearing, e.g. is deaf or hard of hearing and/or who is unable to speak or speak clearly enough to be understood. ... Video Remote Interpretive (VRI) - Means an interpreting service that uses video conference technology over dedicated lines or wireless technology offering high-speed, wide-bandwith video connection that delivers high-quality video images ... POLICY: 1) No person shall be denied access to services based on his/her ability to communicate in the English language or due to a hearing / speech impairment. ... Despite any barriers that may arise, it is essential to patient safety that steps are taken to promote effective communication. It is the obligation of the -[facility name]- to ensure that effective communication assistance shall be provided to LEP and HSI persons and companions so that they have a complete understanding of information regarding medical condition, treatment and payment requirements. ... TIME OF ASSESSMENT: 1) ... Each patient will be asked to complete the UH Language Services form. Information noted in the form will be used to guide the provision of language services. The UH Language Services form will be maintained in the patient's medical record. ... PROVISION OF LANGUAGE SERVICES: ... 6) The VRI system is available at the following locations: [summary: bed management and emergency department within the hospital 24 hours/7 days a week, and patient relations office 9 am-5 pm Monday through Friday]. ... 9) When an in-person interpreter is needed, staff should contact the Patient Relations Department ... DOCUMENTATION OF LANGUAGE SERVICES: ... 2) Whenever interpreting services are offered and declined by the patient, this shall be documented in the patient's medical record. ... ADDITIONAL INFORMATION: ... 2) Family members and/or friends are not to be used as interpreters unless in emergency situations. If a patient refuses an interpreter and requests a family member or friend interpret, the patient's preference of an interpreter must be documented on the patient's record."

1. On 6/17/15 Unit 1 Blue/ Telemetry was toured in the presence of Staff #1 and #3. Patient #10 was observed in Room 1210 with his/her mother at the bedside at 12:15 PM. When speaking to Patient #10, it was observed the he/she was hearing impaired, and his/her mother signed to translate the surveyor's questions. Per Patient #10's and his/her mother's interview, no interpretive services had been offered to the patient. Per the mother, the facility is relying on her to sign/translate for the patient, and she is not at the facility all of the time. The mother stated she voiced to the facility that it is a patient's right to have an interpreter.

a. Per the above referenced policy, family members and/or friends are not to be used as interpreters unless there is an emergency situation.

2. Review of Medical Record #10 indicated, in the 'ADL Screening' section of the Admission assessment, that the patient was deaf in his/her right and left ears. The 'Learning Assessment' indicates hearing and language were identified as barriers to learning, but that an interpreter was not required.

a. There was no evidence of a completed UH Language Services form in the medical record, or documentation of offering the patient interpreter services, and/or the patient declining.

i. Staff #1 confirmed that the UH Language Services form was not within Medical Record #10.

b. There was no evidence on the care plan, communicating that the patient was hard of hearing, or on the plan of care, to address his/her hearing impairment.

i. Staff #12 and Staff #1 confirmed that the patient's hearing/language barrier was not identified on the care plan.

ii. Staff #12 stated in interview that as part of his/her hand off communication from the prior shift, he/she was told the patient uses his/her cell phone to text, and also writes on a pad to communicate with staff.

3. The facility was unable to provide evidence that they provided Patient #10, a sign language interpreter.

A. Based on observation, staff interview, medical record review, and review of facility policy and procedure, it was determined that the facility failed to implement its policy and procedure for patient observation.

Reference: Facility policy and procedure Subject: Patient Observation states, "PURPOSE: To establish guidelines for patients at risk for danger to self, others, and property. CLINICAL CRITERIA 1:1 Observation is used for the following: 1. Demonstrated overt suicidal, homicidal, or destructive behavior 2. Verbal expression of a suicidal or homicidal plan 3. Inability to contract for safety (patient is unable to notify staff of suicidal/destructive thoughts) and with either of the above criteria 4. Pulling out medical devices, and/or prevention of injury ... POLICY: ... 3. The patient is kept within arms reach of the caregivers at all times ... a. the patient will not be left unattended when on 1:1 or 1:2 Observation. Direct relief must be provided for the caregiver. b. the caregiver assigned to observe the patient shall not read, study, socialize, sleep, or attend to anything but the patient. ... DOCUMENTATION REQUIREMENTS 1. Every patient on 1:1 Observation, 1:2 Observation, and 15 minute Checks will have documentation on the Patient Observation Record... every 15 minutes ... 3. The following information is documented on the Patient Observation Record by placing a check mark and initials in the corresponding boxes: a. Date and time of observation in 15 minute increments b. Location/Behavior c. Vital signs/PO Intake/ Toileting d. Activity/Meals/snacks 4. The Patient Observation Record is to accompany the patient at all times. ..."

1. On 6/17/15 at 12:00 PM, Unit H-Green on the eighth floor was toured in the presence of Staff #2, and Staff #4. Patient #7 was observed in Room #414 with a staff sitter at the bedside, at 12:00 PM.

a. Upon review, Medical Record #7 contained a physician order dated 6/17/15 at 9:15 AM for 1:1 Patient observation for "Inability to contract for or understand safety."

b. The 1:1 Patient Observation Record provided for review by the sitter, was completed in advance and contained 15 minute checks through 3:00 PM for 6/17/15. The Patient Observation Record was not completed as per Reference #1.


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2. On 6/16/15 at 10:45 AM, Unit H-Green on the eighth floor was toured in the presence of Staff #2, Staff #3 and Staff #4. Patient #3 was observed in Room #410 with a staff sitter at the bedside at 11:00 AM.

a. The 1:1 Observation Record was asked for, for surveyor review. Per the sitter, he/she went on break from 10 AM-10:30 AM and another nursing assistant covered. The sitter did not have the Observation Record at this time, and stated it was not returned to him/her by the covering nursing assistant.

b. The Patient Observation Record did not accompany the patient at all times, as per facility policy and procedure.

3. Staff #2 and Staff #4 obtained the 1:1 Observation form from the covering sitter for surveyor review. The 10 AM, 10:15 AM, and 10:30 AM observation checks were blank. There was no evidence that Patient #3 was attended to by a 1:1 sitter every 15 minutes from 10 AM-10:30 AM.

a. The covering sitter, assigned to observe the patient, failed to attend to anything but the patient as per facility policy.

b. The 10:45 AM and 11:00 AM observation checks were also blank and not completed as the sitter was at the bedside of Patient #3 awaiting the return of the Observation Record from the covering nursing assistant.

4. Review of Medical Record #3 evidenced a physician order dated 6/15/15 at 5:22 PM for 1:1 Patient observation for "Inability to contract for or understand safety."

C# NJ 81618

B. Based on medical record review, staff interview, review of facility policy and procedure, and revuew if additional documentation, it was determined that the facility failed ensure the safety of a patient in the Emergency Department (ED), and failed to immediately implement search procedures and appropriate staff/ authority notifications when it was determined a patient was missing.

Findings include:

Reference #1: Facility policy and procedure Patient Elopement Issue No. 601-100-0554 states, "... PURPOSE: To establish guidelines governing patients who leave the hospital without appropriate authorization. POLICY: ... 2. Notification of an elopement must be made immediately to the following: 1. Public Safety 2. Nurse Manager (or his/her designee) and the Patient Care Coordinator 3. Patient's physician 4. Patient's family. 3. The elopement is documented in: 1. Daily Assessment Flow Sheet (or Nursing Progress note), including 1. Time the patient was last observed on the unit 2. Time the patient was noted to be missing 3. The names of the individuals who were notified 4. Response of the family/significant others & relationship to patient 5. Any additional follow-up information. 2. Elopement Tracking log in the Staffing Office 3. Patient Safety Net (PSN) ... PROCEDURE: Unit RN/LPN Responsibilities 1. Immediately notify the Department of Public Safety to begin search of public areas ... 2. Conduct a search of all rooms on the unit. ... 3. Notify the Director of Patient Care Services/Nurse Manager/Patient Care Coordinator on duty of the elopement. They will organize and coordinate a search of other patient care areas. 4. Contact the patient's family/significant other and advise of the patient's absence. If unable to contact, notify the Nurse Manager/Patient Care Coordinator who will continue attempts to contact the family/significant other. 5. Document all pertinent information in the Nursing notes: (sic) ... NURSE MANAGER/PATIENT CARE COORDINATOR RESPONSIBILITIES ... 3. Nurse Managers or covering Nurse Manager/Patient Care Coordinator must log in elopements that occur during their tour of duty on the Tracking Log in the Staffing office. ..."

Reference #2: Patient Care Incident Reporting- Including Adverse Drug Reactions & Mediation Errors issue No. 831-200-057 states, "...DEFINITIONS: ... Patient Safety Net: an electronic database maintained by --[facility name]-- Healthcare Consortium, ... for reporting, tracking, and trending incidents POLICY: 1) The objective of incident reporting is to communicate reportable information to management for appropriate assessment action, if indicated. ... 2) --[facility's initials]-- maintains a culture of accountability and fairness which is intended to promote the reporting of incidents. ... Failure to report an incident, however, may be cause for disciplinary action. 3) --[facility's initials]-- Patient Safety Net is to be used for all written documentation of incidents involving patients, ... 4) Incidents are to be reported by the person or persons who are directly involved in the circumstance and by those who observe or discover the event. ... [Attachment] ... F. Complication of Procedure /Treatment/Test ... 3. Emergency Department ... d. Left before visit completed e. Other ... K. Other/Miscellaneous ... 4. Elopement/AWOL ..."

1. On 6/16/15 a review of Medical Record #1 was conducted and indicated the following:

a. Per the Triage notes, the patient was triaged on 6/10/15 at 0948 for a chief complaint of joint swelling. The patient came to the ED from a nursing home for evaluation of his/her right ankle. The triage nurse assigned the patient to an acuity level of four (4). After triage, the patient was brought to the main ED area at 0949 and placed in room A-Hall 5.

b. The New Jersey Universal Transfer Form from the sending nursing home indicated this eighty (80) year old patient had a secondary diagnosis of dementia, and in the restraint section of the form, 'yes' was checked off and a 'wanderguard' was described/ identified in the description section for restraint. The mental status section of the form indicated the patient was alert with periods of confusion.

c. The medication list from the nursing home listed Risperdone 0.25 milligrams daily for dementia.

2. A tour of the ED was completed on 6/16/15 at 12:00 PM and Hallway Stretcher Bed #5 is located directly in front of the nurses station.

3. A second tour of the ED was completed on 6/17/15 at 1:10 PM. Staff #17, an ED staff nurse, was interviewed. He/ she stated he/ she is the triage nurse sometimes. He/ she confirmed the triage nurses give report to the ED nurses receiving a patient. He/ she stated he/ she reviews any nursing home documentation. Staff #17 stated if a patient was not in his/ her bed he/ she would look for the patient, notify the charge nurse, complete a Patient Safety Net (PSN) report, and notify Public Safety at the facility if needed.

4. Further review of Medical Record #1 indicated the following:

a. The physician's medical screening examination was initiated on 6/10/15 at 1013 and noted at 1054.

b. The assigned primary ED nurse, Staff #9, completed and documented an assessment of the patient's pain, 7 [on a 1 (low) to 10 (severe) scale], at 1138, and airway, breathing/ respiratory, cough, circulation, and gastrointestinal assessments at 1140, as WNL (within normal limits).

i. Staff #9 did not document his/ her neuro assessment, of WNL, until 1925.

c. Per the 'ED Events' section of the medical record, the patient was at X-Ray at 1139.

i. In interview on 6/16/15, Staff #7 stated the ED physician saw the patient in Hallway Stretcher Bed #5 sometime after the x-ray was completed, prior to writing the discharge order at 1307 on 6/10/15.

d. Staff #9 documented the following late entries in the medical record:

i. Filed time 6/10/15 at 7:24 PM, a note time for 6/10/15 at 1:40 PM "Pt. is not on her stretcher."

ii. Filed time 6/10/15 at 7:24 PM, a note time for 6/10/15 at 4:00 PM, "Pt didn't return to ED."

iii. Filed time 6/10/15 at 7:29 PM, a note time for 6/10/15 at 11:40 AM, "Pt complains of right ankle pain upon walking. skin is intact. No deformity is noted."

5. Staff #9 observed that the patient was not on his/ her stretcher on 6/10/15 at 1:40 PM, and then at 4:00 PM observed the patient did not return to the ED. There was no evidence in the medical record of looking for the patient, reporting him/ her missing to the charge nurse, or inquiring about the patient's location during this two hour and twenty minute period.

6. Staff #9 was interviewed on 6/17/15 at 2:45 PM. Per Staff #9, he/ she did not know Patient #1 was a nursing home patient until he/ she eloped. He/ she confirmed that the Intake Nurse gave him/ her a report of the patient, and he/ she did receive training on the chain of command at the facility. He/ she described that when he/ she first saw the empty stretcher he/ she checked the medical record and noticed the patient was due to be discharged. Staff #9 then asked other staff if they knew where the patient was. The Intake Nurse gave him/ her a telephone number to call the nursing home, but it was the wrong number. Staff #9 stated that the patient did not return to the ED so he/ she was made an elopement. Staff #9 stated he/ she notified three (3) other nurses in the ED that Patient #1 was missing, because he/ she could not find the charge nurse to report this, as it was the end of the shift. Staff #9 confirmed that any unusual event is reported to the charge nurse, and that he/ she should have paiged him/ her [the charge nurse] at the time. Staff #9 reported that the Intake Triage Nurse never gave him/ her the Universal Transfer form from the nursing home.

7. Staff #9 indicated in the above interview, that Patient #1 was made an elopement after he/ she spoke with other ED staff.

a. The Elopement policy and procedure (Reference #1) was not implemented as follows:

i. There was no evidence that the ED staff notified Public Safety, the Nurse Manager (or his/ her designee), the Patient Care Coordinator, the patient's physician, or the patient's family/ nursing home of the patient's elopement from the ED.

ii. There was no evidence of documentation of the elopement in the nurse's progress notes, the time the patient was last observed in the ED, or the names of the individuals (staff or other) who were notified.

iii. There was no evidence that Staff #9 notified the Nurse Manager/ Patient Care Coordinator when he/ she was unable to contact the nursing home to advise of the patient's absence so that the Nurse Manager/ Patient Care Coordinator could continue attempts to contact the nursing home or family/ significant other(s).

b. The Patient Care Incident Reporting (Reference #2) policy and procedure was not implemented. The Staff member(s) directly involved in determining the patient could not be located in the ED, the patient left the ED before discharge arrangements were made, and the patient eloped, did not complete a PSN report.

8. Per facility documentation provided by Staff #1, a PSN report for Patient #1 was completed on 6/10/15 at 23:55. The report indicates the facility received a phone call from the patient's nursing home stating he/ she had not returned from the ED. Review of the medical record from the prior day shift presumed that the patient eloped. Per the report, the Patient Care Coordinator and the facility's Public Safety were notified.

9. Without immediate notification of Patient #1's absence from the ED to the ED Charge Nurse, and failure to implement facility policies and procedures, the facility was not able to immediately react to a missing person to ensure the safety and well being of
Patient #1.

10. Per documentation provided by the facility, Patient #1 was found in Jersey City at approximately 0013 on 6/12/15. Patient #1 was identified from his/ her hospital and wanderer identification bands. The patient was brought to a local hospital for evaluation and to await transport back to his/ her nursing home.

C. Based on observation, it was determined that all patient bathrooms are not equipped with call bells to ensure patient safety in the event of a fall.

Findings include:

1. On 6/17/15, Unit 1 Blue/ Telemetry was toured in the presence of Staff #1 and Staff #3. The patient bathrooms in Room #1206 and #1210 were not within reach of a patient in the event of a fall within the bathroom.

a. The bathroom nurse call cord in Room #1206 was approximately two (2) to two and a half (2- 1/2) feet off the floor.

b. The bathroom nurse call cord in Room #1210 was greater than five (5) feet off the floor.

Based on medical record review, staff and patient interview, and review of facility documentation, it was determined that the facility failed to have an organized nursing service.

Findings include:

1. The facility failed to ensure a chain of command for the nursing service provided in the Emergency Department (ED). (Cross refer Tag 0386).

2. The facility failed to supervise and evaluate the nursing care for each patient. (Cross refer Tag 0395).

C# NJ 81618
Based on staff interview and review of facility documentation, it was determined that the facility failed to have a clear chain of command in the Emergency Department (ED).

Findings include:

1. On 6/17/15 at 3:45 PM Staff #1 confirmed in interview, that the ED does not have a policy and procedure for a chain of command for the ED.

i. An e-mail from Staff #24 to Staff #1 dated 6/17/15 at 3:44 PM, indicated the RN would report to the ED Flow Manager or Charge RN, then to the ED Assistant Director, to the Executive Director of PCS (Patient Care Services), then to the Chief Nursing Officer (CNO), Mondays thru Fridays. After hours and on weekends, the RN would report to the ED Flow Manager or Charge RN, then to the Patient Care Coordinator (PCC), then to the Executive Director of PCS, and finally to the CNO.

2. Review of Medical Record #1 on 6/16/15 and 6/17/15 indicated the patient was missing from the ED. In interview with Staff #9 on 6/17/15, he/ she reported that he/ she reported the missing patient to other nursing staff in the ED at the time. There was no indication Staff #9 was familiar with or followed the above chain of command delineated by Staff #24.

C# NJ 81618

A. Based on medical record review, staff interview, review of facility policy and procedure, and review of additional documentation, it was determined that the facility failed to supervise and evaluate the care of a patient in the Emergency Department (ED).

Findings include:

Reference #1: Facility policy and procedure ISSUE NO: Nursing Administration-03, DEPARTMENT: Emergency Department, Subject: Nursing documentation: Electronic and Paper documentation in Patient Medical Record states, "... Procedure A. Nursing Documentation ... General Nursing Assessment: ... Reassessment will done (sic) no longer than every two hours, and in response to any nursing intervention including medication. ... Upon receiving (sic) of new patient the RN will perform a complete assessment, regardless of previous assessments."

Reference #2: Facility policy and procedure Patient Elopement Issue No. 601-100-0554 states, "... PURPOSE: To establish guidelines governing patients who leave the hospital without appropriate authorization. POLICY: ... 2. Notification of an elopement must be made immediately to the following: 1. Public Safety 2. Nurse Manager (or his/her designee) and the Patient Care Coordinator 3. Patient's physician 4. Patient's family. 3. The elopement is documented in: 1. Daily Assessment Flow Sheet (or Nursing Progress note), including 1. Time the patient was last observed on the unit 2. Time the patient was noted to be missing 3. The names of the individuals who were notified 4. Response of the family/significant others & relationship to patient 5. Any additional follow-up information. 2. Elopement Tracking log in the Staffing Office 3. Patient Safety Net (PSN) ... PROCEDURE: Unit RN/LPN Responsibilities 1. Immediately notify the Department of Public Safety to begin search of public areas ... 2. Conduct a search of all rooms on the unit. ... 3. Notify the Director of Patient Care Services/Nurse Manager/Patient Care Coordinator on duty of the elopement. They will organize and coordinate a search of other patient care areas. 4. Contact the patient's family/significant other and advise of the patient's absence. If unable to contact, notify the Nurse Manager/Patient Care Coordinator who will continue attempts to contact the family/significant other. 5. Document all pertinent information in the Nursing notes: (sic) ... NURSE MANAGER/PATIENT CARE COORDINATOR RESPONSIBILITIES ... 3. Nurse Managers or covering Nurse Manager/Patient Care Coordinator must log in elopements that occur during their tour of duty on the Tracking Log in the Staffing office. ..."

Reference #3: Patient Care Incident Reporting- Including Adverse Drug Reactions & Mediation Errors issue No. 831-200-057 states, "...DEFINITIONS: ... Patient Safety Net: an electronic database maintained by --[facility name]-- Healthcare Consortium, ... for reporting, tracking, and trending incidents POLICY: 1) The objective of incident reporting is to communicate reportable information to management for appropriate assessment action, if indicated. ... 2) --[facility's initials]-- maintains a culture of accountability and fairness which is intended to promote the reporting of incidents. ... Failure to report an incident, however, may be cause for disciplinary action. 3) --[facility's initials]-- Patient Safety Net is to be used for all written documentation of incidents involving patients, ... 4) Incidents are to be reported by the person or persons who are directly involved in the circumstance and by those who observe or discover the event. ... [Attachment] ... F. Complication of Procedure /Treatment/Test ... 3. Emergency Department ... d. Left before visit completed e. Other ... K. Other/Miscellaneous ... 4. Elopement/AWOL ..."

1. On 6/16/15, a review of Medical Record #1 was conducted and indicated the following:

a. Per the Triage notes, the patient was triaged on 6/10/15 at 0948 for a chief complaint of joint swelling. The patient came to the ED from a nursing home for evaluation of his/ her right ankle. The triage nurse assigned the patient to an acuity level of four (4). After triage, the patient was brought to the main ED area at 0949 and placed in room A-Hall 5.

b. The New Jersey Universal Transfer Form from the sending nursing home indicated this eighty (80) year old patient had a secondary diagnosis of dementia, and in the restraint section of the form, 'yes' was checked off and a 'wanderguard' was described/ identified in the description section for restraint. The mental status section of the form indicated the patient was alert with periods of confusion.

c. The medication list from the nursing home listed Risperdone 0.25 milligrams daily for dementia.

2. A tour of the ED was completed on 6/16/15 at 12:00 PM and Hallway Stretcher Bed #5 is located directly in front of the nurses station.

3. A second tour of the ED was completed on 6/17/15 at 1:10 PM.

a. Staff #16, an Intake Triage Nurse was interviewed and reported that each ED nurse has assigned beds. He/ she goes to the nurse to give his/ her triage report. He/ she confirmed the triage nurse looks at the documentation sent by nursing homes, and he/ she stated a nursing home patient's mentation would "definitely" be included in his/ her report to the ED staff nurse. Staff #16 denied that he/ she or any other triage nurse would just bring a patient back to a bed/ stretcher and walk away without giving the ED nurse a verbal report.

b. Staff #17, an ED staff nurse, was interviewed. He/ she stated he/ she is the triage nurse sometimes. He/ she confirmed the triage nurses give report to the ED nurses receiving a patient. He/ she stated he/ she reviews any nursing home documentation. Staff #17 stated if a patient was not in his/her bed he/ she would look for the patient, notify the charge nurse, complete Patient Safety Net (PSN) report, and notify Public Safety at the facility if needed.

4. Further review of Medical Record #1 indicated the following:

a. The physician's medical screening examination was initiated on 6/10/15 at 1013 and noted at 1054.

b. The assigned primary ED nurse, Staff #9, completed and documented an assessment of the patient's pain, 7 [on a 1 (low) to 10 (severe) scale], at 1138, and airway, breathing/respiratory, cough, circulation, and gastrointestinal assessments at 1140, as WNL (within normal limits).

i. Staff #9 did not document his/ her neuro assessment, of WNL, until 1925.

c. Per the 'ED Events' section of the medical record, the patient was at X-Ray at 1139.

i. In interview on 6/16/15, Staff #7 stated the ED physician saw the patient back in Hallway Stretcher Bed #5 sometime after the x-ray was completed, prior to writing the discharge order at 1307 on 6/10/15.

d. Staff #9 documented the following late entries in the medical record:

i. Filed time [documented time] 6/10/15 at 7:24 PM, a note time for 6/10/15 at 1:40 PM "Pt. is not on her stretcher."

ii. Filed time 6/10/15 at 7:24 PM, a note time for 6/10/15 at 4:00 PM, "Pt didn't return to ED."

iii. Filed time 6/10/15 at 7:29 PM, a note time for 6/10/15 at 11:40 AM, "Pt complains of right ankle pain upon walking. Skin is intact. No deformity is noted."

5. Staff #9 observed the patient was not on his/ her stretcher on 6/10/15 at 1:40 PM, and then at 4:00 PM observed the patient did not return to the ED. There was no evidence of looking for the patient, reporting him/ her missing to the charge nurse, or inquiring about the patient's location during this two hour and twenty minute period within the medical record.

6. A final note in Medical Record #1 stated in the 'ED Disposition Section', "Patient discharged home in stable condition. Discharge Instructions given."

a. Staff #7 stated in interview on 6/16/15 that Staff #9 entered this and he/ she did not use the correct drop down box for the patient's disposition in the electronic medical record.

b. Per the 'ED Events' section of the medical record, two entries were made by Staff #9 at 1930 that stated "Patient Discharged" and "Patient departed from ED".

7. Staff #9 was interviewed on 6/17/15 at 2:45 PM. Per Staff #9, he/ she did not know Patient #1 was a nursing home patient until he/ she eloped. He/ she confirmed that the Intake Nurse gave him/ her a report of the patient, and he/ she did receive training on the chain of command at the facility. He/ she described that when he/ she first saw the empty stretcher he/ she checked the medical record and noticed he/ she was due to be discharged. Staff #9 then asked other staff if they knew where the patient was. The Intake Nurse gave him/ her a telephone number to call the nursing home, but it was the wrong number. Staff #9 stated that the patient did not return to the ED so he/ she was made an elopement. Staff #9 stated that he notified three (3) other nurses in the ED that Patient #1 was missing, because he/ she could not find the charge nurse to report this to, as it was the end of the shift. Staff #9 confirmed that any unusual event is reported to the charge nurse, and that he/ she should have paiged him/ her [the charge nurse] at the time. Staff #9 reported that the Intake Triage Nurse never gave him/ her the Universal Transfer form from the nursing home.

a. Staff #9 confirmed in the above interview that discharge instructions were not provided to Patient #1 as indicated in the medical record.

b. A written statement by the Intake Nurse, Staff #25, indicated he/ she was approached by Staff #9 on 6/10/15 at approximately 6 PM regarding the whereabouts of Patient #1. Staff #25 was not aware of Patient #1's location and suggested Staff #9 call the nursing home, but did not know if he/ she called the nursing home or not.

c. Staff #25 was interviewed on 6/17/15 at 3:15 PM and reported he/ she recalled this patient in the ED; he/ she was the Intake Nurse that day, 6/10/15, and the nursing home called the ED ahead of time to report they were sending the patient for evaluation of her ankle. The patient arrived with EMS and a packet of papers that he/ she reviewed. He/ she brought the patient to the main ED, gave report to Staff #9 and placed the paperwork in the cubby. Staff #25 confirmed that the nursing home information with the Universal Transfer Form would be placed in the patient's cubby, and the information from the Universal Transfer Form would be reported to the receiving nurse. He/ she reported that the patient's mental status may be mentioned, but the chief complaint is more of a focus in triage. Staff #25 also confirmed that the Charge Nurse has a phone in the ED and can be called at anytime.

d. Facility policy (Reference #1) indicates that the primary nurse will complete a full nursing assessment of the patient regardless of previous assessments. Staff #9 did not complete a neuro assessment of Patient #1 until 1925 on 6/10/15, seven (7) hours and forty (40) minutes after his/ her initial assessment of Patient #1 on 6/10/15 at 1140.

8. Staff #9 indicated in the above interview that Patient #1 was made an elopement after he/ she spoke with other ED staff.

a. The Elopement policy and procedure (Reference #2) was not implemented as follows:

i. There was no evidence that the ED staff notified Public Safety, the Nurse Manager (or his/ her designee), the Patient Care Coordinator, the patient's physician, or the patient's family/ nursing home of the patient's elopement from the ED.

ii. There was no evidence of documentation of the elopement in the nurse's progress notes, the time the patient was last observed in the ED, or the names of the individuals (staff or other) who were notified.

iii. There was no evidence that Staff #9 notified the Nurse Manager/Patient Care Coordinator when he/ she was unable to contact the nursing home to advise of the patient's absence, so that the Nurse Manager/ Patient Care Coordinator could continue attempts to contact the nursing home or family/ significant other(s).

b. The Patient Care Incident Reporting (Reference #3) policy and procedure was not implemented. The Staff member(s) directly involved in determining the patient could not be located in the ED, the patient left the ED before discharge arrangements were made, and the patient eloped, did not complete a PSN report.

9. Per facility documentation provided by Staff #1, a PSN report for Patient #1 was completed on 6/10/15 at 23:55. The report indicates the facility received a phone call from the patient's nursing home stating he/ she had not returned from the ED. Review of the medical record from the prior day shift presumed that the patient eloped. Per the report, the Patient Care Coordinator and the facility's Public Safety were notified.

a. There was no evidence that the Patient Care Coordinator logged the elopement in the Elopement Log in the Staffing office, as per the Elopement policy (Reference #2).

i. Staff #1 confirmed in interview on 6/16/15 at 2:30 PM that the elopements for Patients #1, #2, and #6 also were not entered on the Hospital Administrator Daily Reports for the dates of their elopements.

10. Without immediate notification of Patient #1's absence from the ED to the ED Charge Nurse, and failure to implement facility policies and procedures, the facility was not able to immediately react to a missing person to ensure the safety and well being of Patient #1.

11. Per documentation provided by the facility, Patient #1 was found in Jersey City at approximately 0013 on 6/12/15. Patient #1 was identified from her hospital and wanderer identification bands. The patient was brought to a local hospital for evaluation and to await transport back to his/ her nursing home.

B. Based on observation and review of facility policy and procedure, it was determined that the facility failed to implement its policy for Intravenous (IV) Care.

Findings include:

Reference: Facility policy Subject: Peripheral Intravenous Insertion, Care, and Removal states, "... POLICY: ... 7. IV sites, tubing and dressings are changed every 96 hours or sooner if integrity is compromised. ... PROCEDURE: ... A. Peripheral Cannulation: Action ... 18) Label dressing as follows: [listed] Date, Time, Nurse's Initials, Size of needle catheter. ..."

1. On Wednesday, 6/17/15, Unit 1 Blue/ Telemetry was toured in the presence of Staff #1 and #3. The following observations were made that are not in accordance with the facility's intravenous policy referenced above:

a. Patient #9 was observed in Room #1217 with an intravenous (IV) site that did not identify the date and time of IV insertion, the nurse's initials, or the size of the needle.

b. Patient #10 was observed in Room #1210 with a right chest wall porta-cath that did not indicate the date and time of insertion, or the nurse's initials.

i. The IVPB tubing for his/ her Vancomycin antibiotic, and the main IV tubing for 0.9% Normal Saline each had a sticker label dated 6/12/15 [Friday], and to change the tubings on Tuesday. The tubing was not changed on Tuesday 6/16/15.

2. The nursing staff failed to implement the facility's policy for IV care and maintenance.

C# NJ 81652

C. Based on observation, staff interview, and review of facility documentation, it was determined that the facility failed supervise and evaluate the nursing care for each patient.

Findings include:

Reference: Facility's Nursing Improvement Initiative document for Intentional Rounding states, "... At --[facility name]--, nursing leadership identified hourly rounds as being critical to our patients' improved overall health and therefore has made it a priority to implement a standardized process on all the medical-surgical units. The goal is to have our nurses and nursing assistants round on our patients hourly to identify and address patient needs proactively. ... Lessons learned for other improvements: Continued Nursing Leadership presence and rounding on the units, continued verbalization of hourly rounding as a priority and standard of practice."

1. On 6/16/15 at 10:45 AM, Unit H-Green on the eighth floor was toured in the presence of Staff #2, Staff #3, and Staff #4. Staff #5 was interviewed at 11:00 AM regarding patient rounding. Per Staff #5, the patients are rounded on every one hour by the nurses and nursing assistants alternately. Staff #5 stated that the nurses round on the patients and document these rounds on the odd numbered hours [7-9-11-1-3-5-7], and the nursing assistants nurses round on the patients and document these rounds on the even numbered hours [8-10-12-2-4-6]. Staff #5 reported there is a rounding log that the nurses and nursing assistants complete and file in a binder as per their nurse manager's instruction.

a. The binder was reviewed for the completed rounding logs by the nurses and the nursing assistants for the day shift of 6/12/15 [7 AM-7 PM], and the night shift [7 PM-7 AM] of 6/12/15-6/13/15 [Note: Patient #2 eloped from this unit of the facility on 6/13/15 at 6:30 AM while under police surveillance]. There were four (4) rounding sheets for the day shift. One (1) hourly rounding form for the night shift was found.

b. The surveyor asked Staff #5 if he/ she could find the rest of the 6/12/15-6/13/15 night shift's rounding logs for review in the binder.

c. Per Staff #4 on 6/16/15 at 11:25 AM, he/ she and Staff #5 could not find any other rounding logs for 6/12/15-6/13/15, in addition to the one found. Documentation of the remaining rooms/ patient hourly observations could not be located. [The log sheet that includes Patient #2's room observation was among the missing].

2. Staff #2 provided the above referenced document on 6/16/15 at 12:45 PM. Per Staff #2, the facility did not formulate a policy and procedure for the hourly rounding because it is an initiative that is used as a standard of practice. Staff #2 reported that the facility does not require the staff to complete a log of the patient hourly rounds, and it is up to to the unit managers as to whether or not documentation of the hourly rounds is required on their unit.

3. On 6/17/15 Unit 1 Blue/ Telemetry was toured in the presence of Staff #1 and Staff #3. Staff #14 was interviewed at 12:45 PM regarding the nursing staff's hourly rounds.

a. Per Staff #14, frequent hourly rounds are done by the nurses and nursing assistants. The nurses do the odd number hourly rounds and the nursing assistants complete the even number hourly rounds. Staff #14 reported his/ her rounding sheet is not up to date when the surveyor asked to review it.

b. In interview on 6/17/15 at 1:00 PM, Staff #11 reported he/ she does require his/ her unit staff to document their patient rounding on the rounding logs and file the logs. Per Staff #11, he/ she reviews the logs monthly for completion.

c. Staff #11 was asked to provide the logs for 3/30/15 [Note: Patient #6 eloped from this unit of the facility on 3/30/15 while under police surveillance], and was able to locate the completed requested logs.

4. The facility has a standard of practice in place without a policy. Per Staff #2's above interview, it is up to the unit managers to determine if documentation of hourly rounds is required. The nurse managers of two units surveyed require documentation of the hourly rounds, but completion of the documented rounding logs is not consistent. Without a policy and procedure in place, without universal guidelines for all hospital units to follow, and without consistent implementation of documentation of hourly rounds on units that require documentation, it cannot be determined if the nursing staff is supervising the care of each patient in accordance with facility policy and acceptable standards of practice.