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Based on interview, record review, review of the facility's policies and documents, and review of the Emergency Medical Services (EMS) report, it was determined the facility failed to provide care in a safe setting for one (1) patient, Patient #1, who eloped from the facility on 08/07/16. (see A0144) Patient #1 had initially come to the facility on 06/09/16 with multiple trauma including multiple fractured ribs, fractured lumbar vertebrae, a fractured radius, and a right frontal lobe brain injury. He/she was discharged to a comprehensive physical rehabilitation hospital (CPRH) on 07/01/16 and returned on 07/03/16 with altered mental status, disorientation, and not responding to commands. At the time of this discharge, on 07/13/16, to the CPRH, he/she was diagnosed with acute encephalopathy. Patient #1 was then readmitted to the facility on 07/21/16 with seizure-like activity; combative, agitated behavior; not following commands; and disorientation. Patient #1 had a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach through the abdominal wall to provide nutrition or medications) from the initial admission. Patient #1 had a Patient Safety Companion (PSC) ordered to prevent harm to self and others from 07/21/16 at 10:38 AM to 08/07/16 at 8:30 PM, when a seventy-two (72) hour emergency hold became effective. A PSC's duty was to constantly monitor the patient, not being more than an arm's length away from the patient, at all times.

On 08/07/16, at approximately 12:30 PM, Patient #1 did not have a PSC and had not had one for approximately three (3) and one-half (1/2) hours. At that time, Patient #1's nurse, Registered Nurse (RN) #1, had been sitting outside of Patient #1's room which had a glass wall which allowed for visibility of the patient, but was greater than an arm's length away. RN #1 left Patient #1's bedside to give a medication to another one of her patients. When she returned, approximately five (5) minutes later, Patient #1 was not in his/her room, and subsequently could not be found in the facility.

EMS report, on 08/07/16 at 2:21 PM, revealed Patient #1 was found at a nearby football stadium, approximately one (1) mile from the facility, sitting at a picnic table. To get to the stadium, Patient #1 would have had to cross a four (4) lane highway. When he/she was found, it was reported the patient was dressed in blue hospital scrub pants without a shirt, shoes, or socks. Also, it was reported the PEG tube was visible due to no shirt, and it had a small amount of blood surrounding it. There was also a small amount of blood from his/her right arm that appeared to be where he/she pulled an intravenous (IV) catheter out. He/she was agitated and oriented to person only. Patient #1 stated he/she left the facility to go home to his/her spouse. At this point, EMS took Patient #1 back to the facility.

Review of the facility document, "Chandler, Sitter Request Board," for Friday, August 12, 2016 through Sunday, August 14, 2016, revealed there were eleven (11) to twelve (12) patients that required a PSC with diagnoses ranging from anorexia to suicidal ideation. Of these patients, three (3), Unsampled Patient A, B, and C, were reviewed for PSC presence. All of these patients had periods when there was not a PSC assigned to the patients, but "unit coverage". From chart documentation and staff interviews, it was determined when there was "unit coverage", patients could not always have constant monitoring, within an arm's length as ordered.

Failure of the facility to provide a safe environment and adequate nursing supervision, placed Patient #1, Patient A, Patient B, and Patient C at risk for serious injury, harm, impairment or death. The facility was notified on 08/15/16, Immediate Jeopardy existed related to Patient Rights.

Based on interview, medical record review, review of the facility's policies and documents, and review of the Emergency Medical Services (EMS) report, it was determined the facility failed to ensure patients were in a safe environment by inadequate supervision of one (1) of ten (10) sampled patients (Patient #1) and three (3) of three (3) unsampled patients (Patient A, Patient B, and Patient C). The facility failed to ensure Patient #1 was prevented from eloping from the facility, and the facility failed to ensure unsampled Patients A, B, and C did not have the potential for facing serious injury, harm, impairment or death. These patients had a physician order for constant monitoring, within an arm's length, and this was not provided to them.

The findings include:

Review of the University of Kentucky website, "Your Rights and Responsibilities as a UK Healthcare Patient," undated, revealed patients had the right to feel safe at the facility.

Review of the facility policy titled, "Patient Safety Companion," policy number NU01-08, effective date 10/08/14, revealed the patient safety companion (PSC) was a member of the nursing team and worked under the supervision of the Registered Nurse (RN). Further review revealed the PSC provided constant observation for patients at risk for harming self and others, and the PSC was expected to remain with the patient at all times except if the patient should go to the cath lab, operating room, or outside to smoke.

Review of the facility guideline titled, "Patient Safety Companion," guideline number gNU-57, effective date 08/11/14, revealed a PSC was ordered by a doctor when he/she felt the patient was at risk for harming themselves or others. Further review revealed the PSC must be in the room at arm's length of the patient and never leave the room before coverage arrived because the patient could not be left unattended. Also, the guideline stated the PSC should never leave the patient alone in the bathroom, so the bathroom door must be cracked with the patient in view. In addition, the PSC must give his/her full, undivided attention to the patient at all times.

Review of the facility policy titled, "Suicide Assessment and Intervention," policy number NU10-09, effective date 10/08/14, revealed an intervention for a patient at risk for suicide was constant observation defined as continuous visual observation between the hospital staff PSC in attendance. The policy also revealed the continued need for constant observation and the reason for discontinuation of constant observation needed to be documented.
Review of the Emergency Medical Services (EMS) report, dated 08/07/16, assessment time 2:00 PM, revealed there were three (3) emergency medical technicians (EMT) that arrived at the football stadium responding to a 911 call made by an individual who saw Patient #1 wandering around the stadium shirtless and bleeding. Upon arrival at the scene, the EMS crew was also notified a patient had walked away from the facility. The stadium was approximately one (1) mile from the facility across a four (4) lane highway. The report also stated Patient #1 had been bleeding from the right arm (which appeared to be an intravenous (IV) access that was pulled out) and a small amount of bleeding noted from a feeding tube. Patient #1 was assessed and placed on a stretcher for transport back to the facility, and he/she arrived back to the floor at 2:36 PM. Per EMT assessment, Patient #1 was confused and only oriented to person.

1. Review of Patient #1's medical record revealed he/she was admitted to the facility on 07/21/16 from a comprehensive physical rehabilitation hospital (CPRH) with diagnoses which included New Onset Seizures and Agitation, likely secondary to a previous traumatic brain injury. He/she had a past medical history of Cerebral Vascular Accident (CVA or stroke); Acute Myocardial Infarction (heart attack), Coronary Artery Disease, Type 2 Diabetes Mellitus; Traumatic Brain Injury of the Lateral Right Frontal Lobe secondary to a motorcycle accident on 06/09/16 (treated at the facility); Multiple Rib Fractures from the accident; Lumbar Vertebrae Fractures from the accident; and Right Distal Radius Fracture from the accident. The Physician Discharge Summary also included Mental Illness Secondary to General Medical Condition. Patient #1 also arrived with a percutaneous endoscopic gastrostomy (PEG) tube (used to give nutrition or medications) which had been inserted during the initial admission of 06/09/16. The History and Physical also revealed Patient #1 was unable to give any family or social history to the Physician because of his/her mental status. The record also revealed a Physician's order, in effect from 07/21/16 at 10:38 AM until 08/07/16 at 8:30 PM, for a PSC to prevent harm to self and others. The order was discontinued because it was superceded by a seventy-two (72) emergency hold order which became effective at the time of discontinuation which required supervision by security personnel. Continued review revealed, on 08/07/16 at 8:00 AM, RN #2, the nurse from the previous shift, was at the patient's bedside, and the House Operations Administrator (HOA) and Central Staffing had communicated there was no PSC at this time. Patient #1's mental status was confused; disoriented to place, time, and situation; cognitively illogical, and behavior was agitated and impulsive. At 11:55 AM, Nursing Care Technician (NCT) #1, documented a blood glucose result of 445 milligrams/deciliter (mg/dL), and her notification of the result to RN #1. The record also revealed at 11:56 AM, RN #1 communicated this critical value to Physician #1 and also revealed Patient #1 had refused his/her morning insulin dose of Lispro 100 units/milliliter, three (3) unit dose, subcutaneously. Physician #1 ordered an additional dose of ten (10) units and to give the noon dose of three (3) units, both subcutaneously. These were both given by RN #1 at 12:04 PM. The next insulin dose of three (3) units subcutaneously was given at 5:33 PM, after Patient #1 had returned. At that time, the additional sliding scale dose was not needed because his/her glucose result was less than 150 mg/dL. The record also revealed at 11:55 AM, per NCT #1, Patient #1 could ambulate thirty (30) feet with stand by assist and had audible bed alarms on. At this time, NCT #1 gave handoff report to RN #1. The record then showed, at 12:30 PM, but entered at 2:53 PM by RN #1, Patient #1 had four (4) side rails up, bed alarm on, and sitter at the bedside with 1:1 observation due to behavioral issues. The next documentation, for 2:30 PM but entered at 2:55 PM by RN #1, revealed Patient #1 was alert but confused; disoriented to place, time, and situation; was cognitively illogical, and his/her behavior was agitated and impulsive. An immediate Physician order for restraints, nonviolent patient, was given at 2:28 PM for altered mental status, and two (2) point soft limb restraints were applied. The PEG tube showed serosanguinous drainage, and the site was cleansed with soap and water and flushed with water with no resistance met. A glucose reading was obtained at 2:31 PM by NCT #1 and the result was 117 mg/dL, and Patient #1 had stable vital signs (blood pressure, temperature, respirations, oxygen saturation level). At 4:00 PM, Patient #1 had a glucose level of 83 mg/dL, and he/she continued to have stable vital signs. The restraints continued, and a PSC was at the bedside. Additional review revealed, at 7:25 PM, the HOA requested to place Patient #1 on a seventy-two (72) hour hold because of his/her elopement and behaviors of combativeness, rudeness to nursing staff and PSC's, and potential danger to self. At 8:00 PM, the record revealed Patient #1 threw medications at the nurse and cursed, asking for a knife. His/her cognitive status was confused; disoriented to time, situation, and place with behaviors of agitation and anger. Patient #1 continued to have the bed alarm on, four (4) side rails up, and two (2) point soft limb restraints. An order for the seventy-two (72) hour emergency hold was obtained at 8:30 PM, and security came to constantly monitor the patient at 9:25 PM. This continued until Patient #1 was discharged to a long-term care traumatic brain injury unit for rehabilitation on 08/09/16.

Review of the facility document titled, "Chandler, Sitter Request Board," revealed the date of the request to the Central Staffing Office for the PSC for Patient #1 was 07/21/16 at 10:40 AM. From this time until a seventy-two (72) hour emergency hold order became effective on 08/07/16 at 8:30 PM, Patient #1 had a PSC approximately seventy-five (75) percent of the time and unit staff coverage approximately twenty-five (25) percent of the time. The diagnosis for the order was harm to self and others. On the day of the elopement, 08/07/16, the document revealed there was no PSC from 7:00 AM until 6:00 PM; however, it then stated the RN on the floor confirmed a PSC was on the floor for Patient #1 prior to his/her returning from the elopement, and when the seven-two (72) emergency hold order was obtained, security personnel took over constant monitoring of the patient.

Interview with Physician #1 on 08/12/16 at 1:52 PM, revealed she made rounds on Patient #1 on 08/07/16 at 8:30 to 8:45 AM. She revealed Patient #1 was mildly to moderately agitated and made some bizarre statements but was not psychotic or delusional. She further revealed she assumed he/she had a PSC. Physician #1 then stated she did not discontinue the PSC order because Patient #1 had been agitated that morning. She then revealed she was informed around 1:00 PM that Patient #1 was not in his/her room. Physician #1 stated she was assured the HOA and security had been notified, and another Physician came and called Patient #1's daughter and spouse. When Patient #1 returned, Physician #1 revealed his/her physical condition was stable. She further revealed it was her understanding Patient #1 did not have a PSC when he eloped because there was not one available. However, she stated, from a medical standpoint, there was nothing in Patient #1's mental status to warrant not having a PSC. Physician #1 then revealed Patient #1 remained agitated after the elopement and she was concerned about delusional behavior and the danger to self if he/she left the hospital, so a seventy-two (72) hour emergency hold order was obtained. Physician #1 stated there was definitely a potential for harm to self by Patient #1 from his/her elopement because of impaired judgment and his/her inability to care for self. She then revealed Patient #1 had never voiced suicidal ideation but had voiced his/her desire to go home several times. Physician #1 stated Patient #1 had impulsive behavior.

Telephone interview with NCT #1, on 08/12/16 at 3:00 PM, revealed she was assigned to care for Patient #1 on 08/07/16 from 7:00 AM to 7:30 PM. She revealed Patient #1 eloped around 12:30 PM and returned around 2:30 PM. NCT #1 then stated Patient #1's behavior was erratic, sometimes calm and sometimes aggressive and agitated when nothing could calm him/her. She revealed, on 08/07/16, the staff tried to get a PSC; in fact, RN #1 called central staffing several times, but a PSC was not available. She stated RN #2, the nurse from the previous shift, stayed until 9:00 AM to give the oncoming staff time to assess the patients, get vital signs, and give medications. When RN #2 left, Patient #1 was napping. Before Patient #1 eloped, RN #1 and NCT #1 would trade-off sitting outside Patient #1's door where he/she could be seen. NCT #1 then stated she made sure the bed alarm was on which would alarm on her phone if the patient attempted to get out of bed. She also made sure Patient #1's four (4) bed rails were up. She then stated she went to take a lunch break and informed RN #1 that she was leaving, and during her lunch break, Patient #1 eloped. NCT #1 stated she believed Patient #1 turned the bed alarm off, because he/she had turned it off in the past and because it did not alarm. She then stated when Patient #1 returned to the unit, he/she was changed into a purple gown and wrist band that was used for patients that had eloped, and Patient #1 appeared to be stable.

Interview with RN #1, on 08/15/16 at 9:30 AM, revealed she was charge nurse on the unit on 08/07/16 from 7:00 AM to 7:30 PM and was Patient #1's nurse. She also revealed she had four (4) total patients that day. RN #1 stated when she arrived on the unit, Patient #1 was very agitated and walking in the hallway with a PSC. Patient #1 did not like having PSC's. She revealed she called Central Staffing and the HOA, and both stated they were actively seeking a PSC but did not have one yet. RN #1 revealed the unit sometimes would have a patient with a PSC order and not have a PSC available. She also revealed she asked RN #2 to stay, and she did until 9:00 AM when she had to leave. RN #1 stated she and NCT #1 tried to stay as close as possible to Patient #1, and he/she had very close observation until the elopement by them sitting outside his/her room which had a glass panel for viewing the patient. She also stated either she or NCT #1 was at arm's length of Patient #1 until the elopement. RN #1 then revealed Patient #1 had de-escalated as the morning progressed and had eaten breakfast and taken medications, except the insulin dose which was refused. She revealed she gave the noon insulin dose, and he/she was in bed being very quiet. RN #1 stated NCT #1 asked to take a lunch break, and RN #1 sat outside Patient #1's room, with him/her in full view. She stated while she was doing this, a Physician came to see one (1) of her other patients and asked her to give the patient a medication. She went to give the medication, which, she revealed, took approximately five (5) minutes. When she returned, Patient #1 was gone. RN #1 stated she searched the floor, stairs, and lobby and instructed the unit clerk to call security while she called the HOA, the Physician, and the police. RN #1 revealed this occurred around 12:30 PM, Patient #1 was wearing blue scrub pants and red socks, and had a PEG tube but no IV's. She then stated Patient #1 returned to the unit around 2:30 PM on a stretcher, his/her glucose level was 83 mg/dL, vital signs were stable, and he/she had no bruises or lacerations. RN #1 revealed the Physician ordered two (2) point soft limb restraints, and a PSC was already on the floor for Patient #1. She then stated for the rest of the shift, until 7:30 PM, there were no further events. RN #1 stated in hindsight she would not have left Patient #1, but at the time, he/she had de-escalated, the bed alarm was on, and he/she appeared to be sleeping. She also stated it was a difficult, careful balance when there was a patient that required constant monitoring, no PSC was available, and there were additional patients to be cared for.

Interview with RN #2, on 08/15/16 at 10:13 AM, revealed she was Patient #1's nurse on 08/06 and 08/07/16 from 7:00 PM to 7:30 AM. She revealed Patient #1 had erratic behavior, being sometimes nice and sometimes combative to staff and PSC's. RN #2 stated Patient #1 had PSC's on both of her shifts, but he/she was awake all night from 7:00 PM on 08/06/16 to 9:00 AM on 08/07/16 when she left. She also revealed Patient #1 was very agitated on 08/07/16 and thought the PSC's would hurt him/her; therefore, Patient #1 sat with her and talked with her. She stated Patient #1 had taken a sleeping medication, but it did not phase him/her. That morning, she revealed, Patient #1 wanted to call his/her spouse and/or daughter, so she assisted in this. The telephone call to his/her daughter made him/her more agitated. RN #2 then revealed when she left Patient #1 at 9:00 AM on 08/07/16, NCT #1 came to sit with him/her, and she thought he/she would go to sleep. She further revealed, the night and morning of 08/07/16 she did not feel she could leave him/her for any amount of time. RN #2 stated one (1) to one (1) observation required the patient be in constant sight, and it would have been difficult to care for her other five (5) patients, even with an NCT helping, if there had not been a PSC for Patient #1. RN #2 revealed around 5:30 AM to 6:00 AM, or sometimes later, the staff would get information from Central Staffing about PSC availability for the next shift. If there was not one (1) available, the unit clerk and/or the HOA would try to get staff. If extra staff was not available, the current staff would have to adjust to try and care for all the patients in addition to the patient(s) that required constant monitoring. The morning of 08/07/16, RN #2 stated she thought she got the information about no PSC for the next shift around 6:30 AM.

Interview with the Patient Care Manager (PCM), Neuroscience Unit, revealed Patient #1 was a patient on the unit on 08/07/16. She further revealed Central Staffing assigned PSC's, and the HOA's played a part also. Then, she stated suicidal ideation (SI) patients got first priority in assignment. The PCM stated the shifts usually got the information about PSC's around 5:30, and it was a constant process to get a PSC if one (1) was not available. The PCM revealed Patient #1 got agitated having a PSC in his/her room so the staff tried to sit outside the room. She stated Patient #1 would yell and threaten the PSC's. She then revealed she was notified on 08/07/16 about Patient #1's elopement and felt the staff followed policy in notifying the appropriate people and calling security and the police to locate the patient. The PCM stated there was a process for providing constant monitoring of patients, but if no PSC was available, there could be problems. She then revealed she thought staff did the best they could for every situation, but it was not ideal as evidenced by Patient #1's elopement. The PCM stated her expectation was for staff to constantly watch patients that had a PSC Physician order, and Patient #1 should have been supervised/observed at all times. The PCM then revealed usually when there was a patient with a PSC ordered, there was not one (1) available at all times, and staff had to assume the supervision.

Interview with the Director of Neurosciences, on 08/15/16 at 11:53 AM, revealed the unit did not frequently have patients that had a PSC ordered. She revealed the unit would have confused patients, but staff was trained to care for these patients by using therapeutic measures. She further revealed when PSC's were used on the unit, it typically was for patients that were at risk for pulling out tubes and/or lines. The Director stated PSC's were preferable to restraints in protecting patients from dislodging tubes or lines. She revealed the main use for PSC's would be for patients with SI. The Director stated the PSC for Patient #1 was ordered to prevent him/her from dislodging the PEG and not to prevent elopement. She revealed when there was no PSC, the floor was notified, and staff assumed care. For Patient #1, elopement was not a high consideration. The Director then stated RN #1, rightly or wrongly, made a judgment call that she could leave Patient #1 for a brief time to give a medication because she believed the patient was asleep.

Post-survey telephone interview with the police officer, on 08/16/16 at 10:48 AM, revealed she responded to a call from an athlete at the football stadium concerning an individual (Patient #1) walking around wearing hospital clothes. She revealed this occurred on 08/07/16, exact time unknown, and when she approached him/her she realized he/she was wearing a hospital identification bracelet, had a feeding tube, and a cut on the right arm with a small amount of dried blood. The police officer stated Patient #1 was sitting on a bench under a tree. The dispatcher had also called EMS, and three (3) EMT's arrived. Patient #1 stated he/she was trying to go home to see his/her sick spouse. The police officer revealed the EMT's did a patient assessment and he/she was oriented only to person, and his/her behavior became agitated. The EMT's then left with Patient #1 per stretcher to take him/her back to the facility.

2. Review of unsampled Patient A's medical record revealed he/she was admitted on 07/12/16 with a diagnosis of Chronic Confusion with Vision Changes. The record further revealed there was a Physician ordered PSC, on 08/04/16 at 7:32 PM, to prevent harm to self and others. There was no documentation there was a PSC or constant monitoring in the medical record.

Review of the facility document titled, "Chandler, Sitter Request Board," revealed the date of the request to the Central Staffing Office for the PSC for unsampled Patient A was 08/04/16. From 08/05/16 to 08/07/16 and from 08/12/16 to 08/14/16 (both periods were Friday to Sunday), Patient A had a PSC approximately sixty-four (64) percent of the time and unit staff coverage approximately thirty-six (36) percent of the time. The diagnosis for the order was Harm to Self and Others.

Interview with RN #3, on 08/15/16 at 4:30 PM, revealed she was a float nurse that was caring for Patient A. She further revealed she believed Patient A did have an order for a PSC when she came on duty, but she received an order from the patient's Physician to discontinue it because he/she no longer needed constant supervision. RN #3 also revealed there were times when there was an order for a PSC, and one (1) was not available. She further revealed if a patient did not have constant monitoring and a PSC was ordered, he/she could find a way to leave the room or inflict self-harm. RN #3 then stated there was a system for staffing PSC's with SI patients getting top priority.

3. Review of unsampled Patient B's medical record revealed he/she was admitted on 07/03/16 with a diagnosis of Gastrointestinal Bleed. The record further revealed, on 08/02/16 at 1:59 PM, there was a Physician order for a PSC to prevent harm to self and others. Continued review revealed, on 08/06/16, Patient B verbalized SI and was placed on suicide precautions.

Review of the facility document titled, "Chandler, Sitter Request Board," revealed the date of the request to the Central Staffing Office for the PSC for unsampled Patient B was 08/02/16. From 08/05/16 to 08/07/16 and from 08/12/16 to 08/14/16, Patient B had a PSC approximately seventy-six (76) percent of the time and unit staff coverage approximately twenty-four (24) percent of the time. The diagnosis for the order was High Fall Risk.

Interview with the Interim Patient Care Manager, Fifth Floor, on 08/15/16 at 3:15 PM, revealed if a PSC was not available, a NCT would be used to monitor the patient with a constant monitoring order. She further revealed, Central Staffing tried to continuously find a PSC. Then, she stated if there was no PSC, frequent rounding would be done, and the patient would be moved across from the nurses station where the end of the bed could be visualized but not the entire patient. The Manager then stated there was not a specific place on the medical record to document a PSC, and she could not determine if suicide precautions had been discontinued on Patient B. She then revealed if a PSC was ordered for a patient and the patient did not have one, something negative could potentially happen to the patient, but she could not speculate on what that might be.

4. Review of unsampled Patient C's medical record revealed he/she was admitted on 08/10/16 to an epilepsy monitored unit with cameras in patient rooms with a diagnosis of Encephalopathy, and the patient was disoriented. The record further revealed, on 08/12/16 at 6:51 PM, there was a Physician order for a PSC to prevent harm to self and others for confusion. Further review revealed, on 08/12/16 at 9:08 PM, a nurse had documented there was one (1) to one (1) observation; on 08/13/16 at 9:39 PM the same nurse documented Patient C had camera monitoring; and on 08/14/16 at 9:00 PM the same nurse documented Patient C had camera monitoring. On 08/12/16 and 08/13/16, Patient C had an IV. The PSC order was discontinued on 08/15/16 at 11:10 AM.

Review of the facility document titled, "Chandler, Sitter Request Board," revealed the date of the request to the Central Staffing Office for the PSC for unsampled Patient C was 08/12/16. From 08/12/16 to 08/14/16, Patient C had a PSC approximately twelve (12) percent of the time and unit coverage approximately eighty-eight (88) percent of the time. The diagnosis for the order was Confusion.

Interview with RN #4, on 08/15/16 at 3:00 PM, revealed Patient C had been disoriented and confused since admission, but his/her mental status had improved. She also revealed PSC's did not document time spent with the patient, and there was no specific place in the medical record to document one (1) to one (1) observation of the patient except under fall risk screen interventions. RN #4 stated if she saw on a document that a patient had unit coverage instead of a PSC, it meant the unit staff already scheduled
would try to provide the intense coverage.

Interview with RN #5, on 08/15/16 at 3:25 PM, revealed if a patient needed a PSC and one (1) was not provided, the staff would work short on the floor to keep the patient safe. She further revealed the staff would just have to pick up the slack. RN #5 also stated if there was no PSC, the staff could not ensure someone would be in with the patient at all times, especially within arm's length. She also revealed there was no extra staff on 08/12/16, 08/13/16, or 08/14/16. Then, RN #5 stated Patient C's nurse on 08/14/16 told Central Staffing a PSC was not needed for him/her, even though an active order for a PSC was in effect until 08/15/16 at 11:10 AM. She revealed a Physician's order was required to discontinue a PSC order. RN #5 stated if a PSC was ordered and not available, the patient could get out of bed and fall or pull out tubes.

Interview with NCT #2, on 08/15/16 at 3:35 PM revealed he worked on 08/13/16 and 08/14/16, and Patient C had not had one (1) to one (1) staff coverage or a PSC on those days. NCT #2 stated he was sent home early, at noon, on 08/13/16 because the epilepsy patients that needed monitoring had been discharged.

Interview with Patient Care Manager Float Pool, Central Staffing, on 08/15/16 at 11:31 AM, revealed the process for providing PSC's was to get the Physician order and try to fill it from PSC's and NCT's. If no one was available, the unit was notified, and Central Staffing would continue to try and get a PSC. She revealed the office was staffed at all times, and PSC's were scheduled in advance, calling the PSC back if the order was discontinued or the patient was discharged. The Manager estimated ten (10) percent of the time, a PSC could not be scheduled, and the unit would have to assume the extra care. She also revealed weekends were more difficult to cover. In addition, the Manager stated there were fifty-five (55) PSC's currently, which was probably the most the facility had ever had, and they were hard to recruit. She revealed this process had been in effect for several years, and the office also encouraged existing PSC's to work more days. She also revealed the process was re-evaluated frequently for its effectiveness.

Based on interview, record review, review of the facility's policies and documents, and review of the Emergency Medical Services (EMS) report, it was determined the facility failed to ensure adequate staffing and delivery of nursing care in order to provide care in a safe setting for one (1) patient, Patient #1, who eloped from the facility on 08/07/16. (see A0392) Patient #1 had initially come to the facility on 06/09/16 with multiple trauma including multiple fractured ribs, fractured lumbar vertebrae, a fractured radius, and a right frontal lobe brain injury. He/she was discharged to a comprehensive physical rehabilitation hospital (CPRH) on 07/01/16 and returned on 07/03/16 with altered mental status, disorientation, and not responding to commands. At the time of this discharge, on 07/13/16 to the CPRH, he/she was diagnosed with acute encephalopathy. Patient #1 was then readmitted to the facility on 07/21/16 with seizure-like activity; combative, agitated behavior; not following commands; and disorientation. Patient #1 had a percutaneous endoscopic gastrostomy (PEG) tube (a tube inserted into the stomach through the abdominal wall to provide nutrition or medications) from the initial admission. Patient #1 had a Patient Safety Companion (PSC) ordered to prevent harm to self and others from 07/21/16 at 10:38 AM to 08/07/16 at 8:30 PM, when a seventy-two (72) hour emergency hold became effective. A PSC's duty was to constantly monitor the patient, not being more than an arm's length away from the patient, at all times.

On 08/07/16, at approximately 12:30 PM, Patient #1 did not have a PSC and had not had one for approximately three (3) and one-half (1/2) hours. At that time, Patient #1's nurse, Registered Nurse (RN) #1, had been sitting outside of Patient #1's room which had a glass wall which allowed for visibility of the patient, but was greater than an arm's length away. RN #1 left Patient #1's visibility to give a medication to another one of her patients. When she returned, approximately five (5) minutes later, Patient #1 was not in his/her room, and subsequently could not be found in the facility.

EMS report, on 08/07/16 at 2:21 PM, revealed Patient #1 was found at a nearby football stadium, approximately one (1) mile from the facility, sitting at a picnic table. To get to the stadium, Patient #1 would have had to cross a four (4) lane highway. When he/she was found, it was reported the patient was dressed in blue hospital scrub pants without a shirt, shoes, or socks. Also, it was reported the PEG tube was visible due to no shirt, and it had a small amount of blood surrounding it. There was also a small amount of blood from his/her right arm that appeared to be where he/she pulled an intravenous (IV) catheter out. He/she was agitated and oriented to person only. Patient #1 stated he/she left the facility to go home to his/her spouse. At this point, EMS took Patient #1 back to the facility.

Review of the facility document, "Chandler, Sitter Request Board," for Friday, August 12, 2016 through Sunday, August 14, 2016, revealed there were eleven (11) to twelve (12) patients that required a PSC with diagnoses ranging from anorexia to suicidal ideation. Of these patients, three (3), Unsampled Patient A, B, and C, were reviewed for PSC presence. All of these patients had periods when there was not a PSC assigned, but were assigned "unit coverage". From chart documentation and staff interviews, it was determined when there was "unit coverage", patients could not always have constant monitoring, within an arm's length.

Failure of the facility to provide adequate staffing and delivery of nursing care to ensure a safe environment placed Patient #1, Patient A, Patient B, and Patient C at risk for serious injury, harm, impairment or death. The facility was notified on 08/15/16 of Immediate Jeopardy related to Nursing Services.

Based on interview, medical record review, review of the facility's policies and documents, and review of the Emergency Medical Services (EMS) report, it was determined the facility failed to ensure patients had adequate staffing and delivery of nursing care for of one (1) of ten (10) sampled patients (Patient #1) and three (3) of three (3) unsampled patients (Patient A, Patient B, and Patient C). The facility failed to ensure Patient #1 was prevented from eloping from the facility, and the facility failed to ensure unsampled Patients A, B, and C did not have the potential for facing serious injury, harm, impairment or death. These patients had a physician order for constant monitoring, within an arm's length, and this was not provided to them.

The findings include:

Review of the facility policy titled, "Patient Safety Companion," policy number NU01-08, effective date 10/08/14, revealed the patient safety companion (PSC) was a member of the nursing team and worked under the supervision of the Registered Nurse (RN). Further review revealed the PSC provided constant observation for patients at risk for harming self and others, and the PSC was expected to remain with the patient at all times except if the patient should go to the cath lab, operating room, or outside to smoke.

Review of the facility guideline titled, "Patient Safety Companion," guideline number gNU-57, effective date 08/11/14, revealed a PSC was ordered by a doctor when he/she felt the patient was at risk for harming themselves or others. Further review revealed the PSC must be in the room at arm's length of the patient and never leave the room before coverage arrived because the patient could not be left unattended. Also, the guideline stated the PSC should never leave the patient alone in the bathroom, so the bathroom door must be cracked with the patient in view. In addition, the PSC must give his/her full, undivided attention to the patient at all times.

Review of the facility policy titled, "Suicide Assessment and Intervention," policy number NU10-09, effective date 10/08/14, revealed an intervention for a patient at risk for suicide was constant observation defined as continuous visual observation between the hospital staff PSC in attendance. The policy also revealed the continued need for constant observation and the reason for discontinuation of constant observation needed to be documented.

Review of the Emergency Medical Services (EMS) report, dated 08/07/16, assessment time 2:00 PM, revealed there were three (3) emergency medical technicians (EMT) that arrived at the football stadium responding to a 911 call made by an individual who saw Patient #1 wandering around the stadium shirtless and bleeding. Upon arrival at the scene, the EMS crew was also notified a patient had walked away from the facility. The stadium was approximately one (1) mile from the facility across a four (4) lane highway. The report also stated Patient #1 had been bleeding from the right arm (which appeared to be an intravenous (IV) access that was pulled out) and a small amount of bleeding noted from a feeding tube. Patient #1 was assessed and placed on a stretcher for transport back to the facility, and he/she arrived back to the floor at 2:36 PM. Per EMT assessment, Patient #1 was confused and only oriented to person.

1. Review of Patient #1's medical record revealed he/she was admitted to the facility on 07/21/16 from a comprehensive physical rehabilitation hospital (CPRH) with diagnoses which included New Onset Seizures and Agitation, likely secondary to a previous traumatic brain injury. He/she had a past medical history of Cerebral Vascular Accident (CVA or stroke); Acute Myocardial Infarction (heart attack), Coronary Artery Disease, Type 2 Diabetes Mellitus; Traumatic Brain Injury of the Lateral Right Frontal Lobe secondary to a motorcycle accident on 06/09/16 (treated at the facility); Multiple Rib Fractures from the accident; Lumbar Vertebrae Fractures from the accident; and Right Distal Radius Fracture from the accident. The Physician Discharge Summary also included Mental Illness Secondary to General Medical Condition. Patient #1 also arrived with a percutaneous endoscopic gastrostomy (PEG) tube (used to give nutrition or medications) which had been inserted during the initial admission of 06/09/16. The History and Physical also revealed Patient #1 was unable to give any family or social history to the Physician because of his/her mental status. The record also revealed a Physician's order, in effect from 07/21/16 at 10:38 AM until 08/07/16 at 8:30 PM, for a PSC to prevent harm to self and others. The order was discontinued because it was superceded by a seventy-two (72) emergency hold order which became effective at the time of discontinuation which required supervision by security personnel. Continued review revealed, on 08/07/16 at 8:00 AM, RN #2, the nurse from the previous shift, was at the patient's bedside, and the House Operations Administrator (HOA) and Central Staffing had communicated there was no PSC at this time. Patient #1's mental status was confused; disoriented to place, time, and situation; cognitively illogical, and behavior was agitated and impulsive. At 11:55 AM, Nursing Care Technician (NCT) #1, documented a blood glucose result of 445 milligrams/deciliter (mg/dL), and her notification of the result to RN #1. The record also revealed at 11:56 AM, RN #1 communicated this critical value to Physician #1 and also revealed Patient #1 had refused his/her morning insulin dose of Lispro 100 units/milliliter, three (3) unit dose, subcutaneously. Physician #1 ordered an additional dose of ten (10) units and to give the noon dose of three (3) units, both subcutaneously. These were both given by RN #1 at 12:04 PM. The next insulin dose of three (3) units subcutaneously was given at 5:33 PM, after Patient #1 had returned. At that time, the additional sliding scale dose was not needed because his/her glucose result was less than 150 mg/dL. The record also revealed at 11:55 AM, per NCT #1, Patient #1 could ambulate thirty (30) feet with stand by assist and had audible bed alarms on. At this time, NCT #1 gave handoff report to RN #1. The record then showed, at 12:30 PM, but entered at 2:53 PM by RN #1, Patient #1 had four (4) side rails up, bed alarm on, and sitter at the bedside with 1:1 observation due to behavioral issues. The next documentation, for 2:30 PM but entered at 2:55 PM by RN #1, revealed Patient #1 was alert but confused; disoriented to place, time, and situation; was cognitively illogical, and his/her behavior was agitated and impulsive. An immediate Physician order for restraints, nonviolent patient, was given at 2:28 PM for altered mental status, and two (2) point soft limb restraints were applied. The PEG tube showed serosanguinous drainage, and the site was cleansed with soap and water and flushed with water with no resistance met. A glucose reading was obtained at 2:31 PM by NCT #1 and the result was 117 mg/dL, and Patient #1 had stable vital signs (blood pressure, temperature, respirations, oxygen saturation level). At 4:00 PM, Patient #1 had a glucose level of 83 mg/dL, and he/she continued to have stable vital signs. The restraints continued, and a PSC was at the bedside. Additional review revealed, at 7:25 PM, the HOA requested to place Patient #1 on a seventy-two (72) hour hold because of his/her elopement and behaviors of combativeness, rudeness to nursing staff and PSC's, and potential danger to self. At 8:00 PM, the record revealed Patient #1 threw medications at the nurse and cursed, asking for a knife. His/her cognitive status was confused; disoriented to time, situation, and place with behaviors of agitation and anger. Patient #1 continued to have the bed alarm on, four (4) side rails up, and two (2) point soft limb restraints. An order for the seventy-two (72) hour emergency hold was obtained at 8:30 PM, and security came to constantly monitor the patient at 9:25 PM. This continued until Patient #1 was discharged to a long-term care traumatic brain injury unit for rehabilitation on 08/09/16.

Review of the facility document titled, "Chandler, Sitter Request Board," revealed the date of the request to the Central Staffing Office for the PSC for Patient #1 was 07/21/16 at 10:40 AM. From this time until a seventy-two (72) hour emergency hold order became effective on 08/07/16 at 8:30 PM, Patient #1 had a PSC approximately seventy-five (75) percent of the time and unit staff coverage approximately twenty-five (25) percent of the time. The diagnosis for the order was harm to self and others. On the day of the elopement, 08/07/16, the document revealed there was no PSC from 7:00 AM until 6:00 PM; however, it then stated the RN on the floor confirmed a PSC was on the floor for Patient #1 prior to his/her returning from the elopement, and when the seven-two (72) emergency hold order was obtained, security personnel took over constant monitoring of the patient.

Interview with Physician #1 on 08/12/16 at 1:52 PM, revealed she made rounds on Patient #1 on 08/07/16 at 8:30 to 8:45 AM. She revealed Patient #1 was mildly to moderately agitated and made some bizarre statements but was not psychotic or delusional. She further revealed she assumed he/she had a PSC. Physician #1 then stated she did not discontinue the PSC order because Patient #1 had been agitated that morning. She then revealed she was informed around 1:00 PM that Patient #1 was not in his/her room. Physician #1 stated she was assured the HOA and security had been notified, and another Physician came and called Patient #1's daughter and spouse. When Patient #1 returned, Physician #1 revealed his/her physical condition was stable. She further revealed it was her understanding Patient #1 did not have a PSC when he eloped because there was not one available. However, she stated, from a medical standpoint, there was nothing in Patient #1's mental status to warrant not having a PSC. Physician #1 then revealed Patient #1 remained agitated after the elopement and she was concerned about delusional behavior and the danger to self if he/she left the hospital, so a seventy-two (72) hour emergency hold order was obtained. Physician #1 stated there was definitely a potential for harm to self by Patient #1 from his/her elopement because of impaired judgment and his/her inability to care for self. She then revealed Patient #1 had never voiced suicidal ideation but had voiced his/her desire to go home several times. Physician #1 stated Patient #1 had impulsive behavior.

Telephone interview with NCT #1, on 08/12/16 at 3:00 PM, revealed she was assigned to care for Patient #1 on 08/07/16 from 7:00 AM to 7:30 PM. She revealed Patient #1 eloped around 12:30 PM and returned around 2:30 PM. NCT #1 then stated Patient #1's behavior was erratic, sometimes calm and sometimes aggressive and agitated when nothing could calm him/her. She revealed, on 08/07/16, the staff tried to get a PSC; in fact, RN #1 called central staffing several times, but a PSC was not available. She stated RN #2, the nurse from the previous shift, stayed until 9:00 AM to give the oncoming staff time to assess the patients, get vital signs, and give medications. When RN #2 left, Patient #1 was napping. Before Patient #1 eloped, RN #1 and NCT #1 would trade-off sitting outside Patient #1's door where he/she could be seen. NCT #1 then stated she made sure the bed alarm was on which would alarm on her phone if the patient attempted to get out of bed. She also made sure Patient #1's four (4) bed rails were up. She then stated she went to take a lunch break and informed RN #1 that she was leaving, and during her lunch break, Patient #1 eloped. NCT #1 stated she believed Patient #1 turned the bed alarm off, because he/she had turned it off in the past and because it did not alarm. She then stated when Patient #1 returned to the unit, he/she was changed into a purple gown and wrist band that was used for patients that had eloped, and Patient #1 appeared to be stable.

Interview with RN #1, on 08/15/16 at 9:30 AM, revealed she was charge nurse on the unit on 08/07/16 from 7:00 AM to 7:30 PM and was Patient #1's nurse. She also revealed she had four (4) total patients that day. RN #1 stated when she arrived on the unit, Patient #1 was very agitated and walking in the hallway with a PSC. Patient #1 did not like having PSC's. She revealed she called Central Staffing and the HOA, and both stated they were actively seeking a PSC but did not have one yet. RN #1 revealed the unit sometimes would have a patient with a PSC order and not have a PSC available. She also revealed she asked RN #2 to stay, and she did until 9:00 AM when she had to leave. RN #1 stated she and NCT #1 tried to stay as close as possible to Patient #1, and he/she had very close observation until the elopement by them sitting outside his/her room which had a glass panel for viewing the patient. She also stated either she or NCT #1 was at arm's length of Patient #1 until the elopement. RN #1 then revealed Patient #1 had de-escalated as the morning progressed and had eaten breakfast and taken medications, except the insulin dose which was refused. She revealed she gave the noon insulin dose, and he/she was in bed being very quiet. RN #1 stated NCT #1 asked to take a lunch break, and RN #1 sat outside Patient #1's room, with him/her in full view. She stated while she was doing this, a Physician came to see one (1) of her other patients and asked her to give the patient a medication. She went to give the medication, which, she revealed, took approximately five (5) minutes. When she returned, Patient #1 was gone. RN #1 stated she searched the floor, stairs, and lobby and instructed the unit clerk to call security while she called the HOA, the Physician, and the police. RN #1 revealed this occurred around 12:30 PM, Patient #1 was wearing blue scrub pants and red socks, and had a PEG tube but no IV's. She then stated Patient #1 returned to the unit around 2:30 PM on a stretcher, his/her glucose level was 83 mg/dL, vital signs were stable, and he/she had no bruises or lacerations. RN #1 revealed the Physician ordered two (2) point soft limb restraints, and a PSC was already on the floor for Patient #1. She then stated for the rest of the shift, until 7:30 PM, there were no further events. RN #1 stated in hindsight she would not have left Patient #1, but at the time, he/she had de-escalated, the bed alarm was on, and he/she appeared to be sleeping. She also stated it was a difficult, careful balance when there was a patient that required constant monitoring, no PSC was available, and there were additional patients to be cared for.

Interview with RN #2, on 08/15/16 at 10:13 AM, revealed she was Patient #1's nurse on 08/06 and 08/07/16 from 7:00 PM to 7:30 AM. She revealed Patient #1 had erratic behavior, being sometimes nice and sometimes combative to staff and PSC's. RN #2 stated Patient #1 had PSC's on both of her shifts, but he/she was awake all night from 7:00 PM on 08/06/16 to 9:00 AM on 08/07/16 when she left. She also revealed Patient #1 was very agitated on 08/07/16 and thought the PSC's would hurt him/her; therefore, Patient #1 sat with her and talked with her. She stated Patient #1 had taken a sleeping medication, but it did not phase him/her. That morning, she revealed, Patient #1 wanted to call his/her spouse and/or daughter, so she assisted in this. The telephone call to his/her daughter made him/her more agitated. RN #2 then revealed when she left Patient #1 at 9:00 AM on 08/07/16, NCT #1 came to sit with him/her, and she thought he/she would go to sleep. She further revealed, the night and morning of 08/07/16 she did not feel she could leave him/her for any amount of time. RN #2 stated one (1) to one (1) observation required the patient be in constant sight, and it would have been difficult to care for her other five (5) patients, even with an NCT helping, if there had not been a PSC for Patient #1. RN #2 revealed around 5:30 AM to 6:00 AM, or sometimes later, the staff would get information from Central Staffing about PSC availability for the next shift. If there was not one (1) available, the unit clerk and/or the HOA would try to get staff. If extra staff was not available, the current staff would have to adjust to try and care for all the patients in addition to the patient(s) that required constant monitoring. The morning of 08/07/16, RN #2 stated she thought she got the information about no PSC for the next shift around 6:30 AM.

Interview with the Patient Care Manager (PCM), Neuroscience Unit, revealed Patient #1 was a patient on the unit on 08/07/16. She further revealed Central Staffing assigned PSC's, and the HOA's played a part also. Then, she stated suicidal ideation (SI) patients got first priority in assignment. The PCM stated the shifts usually got the information about PSC's around 5:30, and it was a constant process to get a PSC if one (1) was not available. The PCM revealed Patient #1 got agitated having a PSC in his/her room so the staff tried to sit outside the room. She stated Patient #1 would yell and threaten the PSC's. She then revealed she was notified on 08/07/16 about Patient #1's elopement and felt the staff followed policy in notifying the appropriate people and calling security and the police to locate the patient. The PCM stated there was a process for providing constant monitoring of patients, but if no PSC was available, there could be problems. She then revealed she thought staff did the best they could for every situation, but it was not ideal as evidenced by Patient #1's elopement. The PCM stated her expectation was for staff to constantly watch patients that had a PSC Physician order, and Patient #1 should have been supervised/observed at all times. The PCM then revealed usually when there was a patient with a PSC ordered, there was not one (1) available at all times, and staff had to assume the supervision.

Interview with the Director of Neurosciences, on 08/15/16 at 11:53 AM, revealed the unit did not frequently have patients that had a PSC ordered. She revealed the unit would have confused patients, but staff was trained to care for these patients by using therapeutic measures. She further revealed when PSC's were used on the unit, it typically was for patients that were at risk for pulling out tubes and/or lines. The Director stated PSC's were preferable to restraints in protecting patients from dislodging tubes or lines. She revealed the main use for PSC's would be for patients with SI. The Director stated the PSC for Patient #1 was ordered to prevent him/her from dislodging the PEG and not to prevent elopement. She revealed when there was no PSC, the floor was notified, and staff assumed care. For Patient #1, elopement was not a high consideration. The Director then stated RN #1, rightly or wrongly, made a judgment call that she could leave Patient #1 for a brief time to give a medication because she believed the patient was asleep.

Post-survey telephone interview with the police officer, on 08/16/16 at 10:48 AM, revealed she responded to a call from an athlete at the football stadium concerning an individual (Patient #1) walking around wearing hospital clothes. She revealed this occurred on 08/07/16, exact time unknown, and when she approached him/her she realized he/she was wearing a hospital identification bracelet, had a feeding tube, and a cut on the right arm with a small amount of dried blood. The police officer stated Patient #1 was sitting on a bench under a tree. The dispatcher had also called EMS, and three (3) EMT's arrived. Patient #1 stated he/she was trying to go home to see his/her sick spouse. The police officer revealed the EMT's did a patient assessment and he/she was oriented only to person, and his/her behavior became agitated. The EMT's then left with Patient #1 per stretcher to take him/her back to the facility.

2. Review of unsampled Patient A's medical record revealed he/she was admitted on 07/12/16 with a diagnosis of Chronic Confusion with Vision Changes. The record further revealed there was a Physician ordered PSC, on 08/04/16 at 7:32 PM, to prevent harm to self and others. There was no documentation there was a PSC or constant monitoring in the medical record.

Review of the facility document titled, "Chandler, Sitter Request Board," revealed the date of the request to the Central Staffing Office for the PSC for unsampled Patient A was 08/04/16. From 08/05/16 to 08/07/16 and from 08/12/16 to 08/14/16 (both periods were Friday to Sunday), Patient A had a PSC approximately sixty-four (64) percent of the time and unit staff coverage approximately thirty-six (36) percent of the time. The diagnosis for the order was Harm to Self and Others.

Interview with RN #3, on 08/15/16 at 4:30 PM, revealed she was a float nurse that was caring for Patient A. She further revealed she believed Patient A did have an order for a PSC when she came on duty, but she received an order from the patient's Physician to discontinue it because he/she no longer needed constant supervision. RN #3 also revealed there were times when there was an order for a PSC, and one (1) was not available. She further revealed if a patient did not have constant monitoring and a PSC was ordered, he/she could find a way to leave the room or inflict self-harm. RN #3 then stated there was a system for staffing PSC's with SI patients getting top priority.

3. Review of unsampled Patient B's medical record revealed he/she was admitted on 07/03/16 with a diagnosis of Gastrointestinal Bleed. The record further revealed, on 08/02/16 at 1:59 PM, there was a Physician order for a PSC to prevent harm to self and others. Continued review revealed, on 08/06/16, Patient B verbalized SI and was placed on suicide precautions.

Review of the facility document titled, "Chandler, Sitter Request Board," revealed the date of the request to the Central Staffing Office for the PSC for unsampled Patient B was 08/02/16. From 08/05/16 to 08/07/16 and from 08/12/16 to 08/14/16, Patient B had a PSC approximately seventy-six (76) percent of the time and unit staff coverage approximately twenty-four (24) percent of the time. The diagnosis for the order was High Fall Risk.

Interview with the Interim Patient Care Manager, Fifth Floor, on 08/15/16 at 3:15 PM, revealed if a PSC was not available, a NCT would be used to monitor the patient with a constant monitoring order. She further revealed, Central Staffing tried to continuously find a PSC. Then, she stated if there was no PSC, frequent rounding would be done, and the patient would be moved across from the nurses station where the end of the bed could be visualized but not the entire patient. The Manager then stated there was not a specific place on the medical record to document a PSC, and she could not determine if suicide precautions had been discontinued on Patient B. She then revealed if a PSC was ordered for a patient and the patient did not have one, something negative could potentially happen to the patient, but she could not speculate on what that might be.

4. Review of unsampled Patient C's medical record revealed he/she was admitted on 08/10/16 to an epilepsy monitored unit with cameras in patient rooms with a diagnosis of Encephalopathy, and the patient was disoriented. The record further revealed, on 08/12/16 at 6:51 PM, there was a Physician order for a PSC to prevent harm to self and others for confusion. Further review revealed, on 08/12/16 at 9:08 PM, a nurse had documented there was one (1) to one (1) observation; on 08/13/16 at 9:39 PM the same nurse documented Patient C had camera monitoring; and on 08/14/16 at 9:00 PM the same nurse documented Patient C had camera monitoring. On 08/12/16 and 08/13/16, Patient C had an IV. The PSC order was discontinued on 08/15/16 at 11:10 AM.

Review of the facility document titled, "Chandler, Sitter Request Board," revealed the date of the request to the Central Staffing Office for the PSC for unsampled Patient C was 08/12/16. From 08/12/16 to 08/14/16, Patient C had a PSC approximately twelve (12) percent of the time and unit coverage approximately eighty-eight (88) percent of the time. The diagnosis for the order was Confusion.

Interview with RN #4, on 08/15/16 at 3:00 PM, revealed Patient C had been disoriented and confused since admission, but his/her mental status had improved. She also revealed PSC's did not document time spent with the patient, and there was no specific place in the medical record to document one (1) to one (1) observation of the patient except under fall risk screen interventions. RN #4 stated if she saw on a document that a patient had unit coverage instead of a PSC, it meant the unit staff already scheduled
would try to provide the intense coverage.

Interview with RN #5, on 08/15/16 at 3:25 PM, revealed if a patient needed a PSC and one (1) was not provided, the staff would work short on the floor to keep the patient safe. She further revealed the staff would just have to pick up the slack. RN #5 also stated if there was no PSC, the staff could not ensure someone would be in with the patient at all times, especially within arm's length. She also revealed there was no extra staff on 08/12/16, 08/13/16, or 08/14/16. Then, RN #5 stated Patient C's nurse on 08/14/16 told Central Staffing a PSC was not needed for him/her, even though an active order for a PSC was in effect until 08/15/16 at 11:10 AM. She revealed a Physician's order was required to discontinue a PSC order. RN #5 stated if a PSC was ordered and not available, the patient could get out of bed and fall or pull out tubes.

Interview with NCT #2, on 08/15/16 at 3:35 PM revealed he worked on 08/13/16 and 08/14/16, and Patient C had not had one (1) to one (1) staff coverage or a PSC on those days. NCT #2 stated he was sent home early, at noon, on 08/13/16 because the epilepsy patients that needed monitoring had been discharged.

Interview with Patient Care Manager Float Pool, Central Staffing, on 08/15/16 at 11:31 AM, revealed the process for providing PSC's was to get the Physician order and try to fill it from PSC's and NCT's. If no one was available, the unit was notified, and Central Staffing would continue to try and get a PSC. She revealed the office was staffed at all times, and PSC's were scheduled in advance, calling the PSC back if the order was discontinued or the patient was discharged. The Manager estimated ten (10) percent of the time, a PSC could not be scheduled, and the unit would have to assume the extra care. She also revealed weekends were more difficult to cover. In addition, the Manager stated there were fifty-five (55) PSC's currently, which was probably the most the facility had ever had, and they were hard to recruit. She revealed this process had been in effect for several years, and the office also encouraged existing PSC's to work more days. She also revealed the process was re-evaluated frequently for its effectiveness.