HospitalInspections.org

Based on review of hospital policies and procedures, job descriptions, medical records, incident files, personnel files, orientation training material, and staff interview, the hospital's governing body failed to
ensure a safe environment for patients, promotion of patients' rights and adequate nursing supervision by failing to identify safety and security risks associated with visitation and ensuring nursing supervision to prevent escape during visitation.

The finding include:

1. The hospital's nursing staff failed to protect and promote patients' rights for a safe environment for patients during visitation as evidenced by failing to monitor, evaluate and assess an adolescent patient who escaped during visitation.

~cross refer to 482.13 Patients' Rights, Condition Tag A0115

2. The hospital's nursing staff failed to demonstrate an organized nursing service as evidenced by failing to ensure a safe environment of care during visitation to prevent escape.

~cross refer to 482.23 Nursing Services, Condition Tag A0385

Based on review of hospital policies and procedures, job descriptions, medical records, incident files, personnel files, orientation training material, and staff interview, the hospital's nursing staff failed to protect and promote patients' rights for a safe environment for patients during visitation as evidence by failing to monitor, evaluate and assess an adolescent patient who escaped during visitation.

The findings include:

The hospital's nursing staff failed to ensure a safe environment of care by failing to assess, evaluate and monitor an adolescent patient during visitation to prevent escape for 1 of 1 adolescent patients who escaped (#2).

~cross refer to 482.13(c)(2) Patients' Rights Standard: Tag A0144

Based on review of hospital policies and procedures, job descriptions, medical records, incident files, personnel files, orientation training material, and staff interview, the hospital's nursing staff failed to ensure a safe environment of care by failing to assess, evaluate and monitor an adolescent patient during visitation to prevent escape for 1 of 1 adolescent patients who escaped (#2).

The findings include:

Review of the hospital's policy, "Visitation Policy", revised 12/11/2007 revealed, "PURPOSE: To provide regulations that will: (1) assist patients' relatives/friends when they visit (Hospital A); and (2) promote a safe, secure, and sanitary environment for visitors, patients and staff. ...4. POLICY: ...4. Visitors are to identify themselves with a picture ID and sign the Visitors' Sign-In and Confidentiality Agreement Log. Responsible staff must initial when a visitor is signed in and out. ...15. Visitation will be supervised at all times in all units. ...16. Visiting areas for each unit are designated by the Unit Director. Visitation will only be allowed in these designated areas. ...".

Review of the hospital's policy, "Escapes/Elopements", revised 01/05/2010, revealed, "PURPOSE: To establish procedures for managing escapes and unauthorized absences. ...IV. Escape Procedures for Patients Escaping Off Campus while Supervised by (Hospital A) Staff A. Any staff member who observes a patient attempting to escape should try to verbally redirect the patient. ...C. Staff follows the patient and continues to attempt to redirect the patient as long as the situation is considered safe. ...".

Review of the hospital's job description for a registered nurse revealed, "I. ...B. Primary Purpose of Position: The primary purpose of this position is to apply the nursing process to insure timely, safe and appropriate Nursing Care, treatment and services. ...7. Provide safe...environment. ...II. Other Position Characteristics: ...7. Visual Attention, Mental Concentration and Manipulative Skills: Careful visual attention and mental concentration is required. Ability to think critically and respond quickly is required. Meticulous attention to detail is required. Must be alert for changes in patient condition or behavior at all times. ...".

Review of the hospital's orientation training material dated August 2009 revealed a copy of a power point presentation with the title"Training for staff to create a CULTURE OF SAFETY. All staff must be involved to create an organization wide CULTURE OF SAFETY. Every day, in every department, on all shifts- We want YOU to embrace a CULTURE OF SAFETY. YOU are needed to make our hospital a safe environment for patients, staff and visitors - we want you to be a SAFETY SUPER HERO. ...Visitation...Supervise visitors carefully. ...SAFETY SUPER HEROES monitor visitation closely and act to protect patients...".

Observation during tour of the U4/Adolescent Unit on 03/31/2011 at 1400 revealed a locked entrance opening into the lobby from outside the building. Observation revealed a room marked "Visitation" opening into the lobby and another room marked "Visitation" across the hall and behind the reception desk. Further observation revealed unlocked lockers to the left of the exit door used for visitors to secure belongings. Observation of the furnishings in the lobby included a couch and several chairs. Observation of the furnishings in the visitation rooms included a table with chairs and a couch with several single chairs.

Closed medical record review of Patient #2 revealed a 15 year-old admitted 03/06/2011 per involuntary commitment for conduct disorder, substance abuse and suicidal ideation. Record review revealed Patient #2 was in custody of the Department of Social Services in his county of residence prior to admission. Review of the initial nursing assessment dated 03/06/2011 at 1240 revealed, "... Escape Risk...Does patient verbalize intent or do behaviors suggest risk for escape? (checked) No...". Record review revealed Patient #2 was placed on suicide precautions and every 15 minute checks on admission. Record review revealed an order dated 03/07/2011 at 1500 to discontinue suicide precautions and 03/09/2011 to discontinue 15 minute checks. Record review revealed a letter dated 03/10/2011 from the patient's county of residence social worker to Hospital A. Review of the letter revealed, "On March 9, 2011, the Honorable (name of judge) issued an order continuing the above named (Patient #2) minor in the custody of (Name of County) Department of Social Services. She further ordered that any outside visitation be at the discretion of the Department. At this time the following persons are allowed visitation with (Patient #2) not to exceed two visits per week: (Name of uncle), (Visitor A) [friend], and (Visitor B) [friend]...". Review of nursing documentation on the progress notes written by RN (registered nurse) #1 dated 03/12/2011 at 2015 revealed, "Called to lobby by visitation staff. When (Patient #2's) visitors went out to smoke, (Patient #2) ran out the door behind them. Team E, Code S called at 8:18 pm. Search initiated. ...". Record review revealed Patient #2 was returned to the hospital by the police on 03/22/2011 (10 days later).

Review of an "Incident/Accident Report" dated 03/12/2011 revealed "Time of Incident/Discovery: 8:13 pm...Type of Incident/Accident: (checked) Elopement...Witnesses: (checked) Yes Names of Witnesses: (Registered Nurse #1). Location of Incident: (checked) Other: (handwritten) lobby. Description of Incident/Accident: patient was preparing for his 'brother' (Visitor A) to leave while female friend (Visitor B) stayed until 9 pm to continue visiting. Female friend got cigarette (and) lighter out of purse to go outside and smoke, when door was opened to allow 'brother' and female friend to go outside, patient ran through front door. ...".

Review of the "Visitor's Sign-In and Confidentiality Agreement Log" for the U4 building revealed, "Date 3/12, Visitor's Name (handwritten) (Visitor B) Valid ID (blank) Relationship to Patient (handwritten) friend Patient's ID # (blank) Time In 6pm Locker Key 15 Time Out (blank) Return Key (blank) Staff Initials (HCT #2)". Review of the log revealed no documentation that Visitor A was signed in as a visitor.

Interview on 03/30/2011 at 1515 with RN #2 revealed the nurse is an agency nurse and has been working at Hospital A since 12/05/2010. Interview revealed the nurse works in the float pool. Interview revealed, "when I got here on March 12 about 7 pm, the CNO (central nursing office) asked me to go to U4 (unit 4- adolescent unit). I went downstairs to the lobby to relieve the health care tech (technician) about 7:30 to do visitation. When I got there, the tech (HCT #1) pointed out (Patient #2) and his two visitors (Visitors A and B). Another man came into visit (another adolescent patient) and I put them in the same room. (Patient #2) kept getting up stretching and left his visitors to come talk to me. He showed me his tattoos, took a tack off the bulletin board in the lobby and told me he was going to hurt himself with it. The guy I thought was his brother asked to go outside and make a phone call. (Patient #2) and the girl (Visitor B) were sitting in the lobby. I told him (Visitor A) he couldn't keep going in and out". Interview further revealed, "At about 8:00, (Patient #2) came over and told me his 'brother' was leaving and (Visitor B) was staying until visitation was over at 9. I told them again I couldn't keep opening the door. So, I opened the door and his 'brother' left. The girl had her purse and was fumbling around in her purse for the key to the locker. She asked me to open the door so she could get (Visitor A) to bring the key back. I tapped on the door, opened it and she yelled at him to come back. He (Visitor B) came back and I opened the door for him to come back in. That's when (Patient #2) pushed past me while I was holding the door open and ran". Interview further revealed, "the girl was on the porch and was pushing the key fob to her car. When I asked her to come back in, she told me she was afraid someone would break into her car so she had to lock it. She came in for a minute and then she left". Interview revealed, "I saw him run past the (building name - next door to U4). I didn't go out after him". Interview further revealed, "I had a gut feeling that I couldn't trust them and when they started asking about the key, I knew it was planned because she already had her pocketbook out so why was she looking the locker key". Interview further revealed, "I was upset with myself. I didn't get report when I got to the unit. I was told to go do visitation and I didn't know anything about the patients. When he ran, I had to call the unit to find out his name. This was only the second time I had ever done visitation". Interview further revealed, "I was not familiar with the visitation policy and I didn't know of any boundaries related to the door. I guess I felt like he would listen to me". During the interview, RN #2 demonstrated that Pt #2 was standing on her right side within arm's reach when she opened the door from the lobby to the outside of the building.

Interview on 03/31/2011 at 0930 with HCT #1 revealed she was monitoring visitation on U4 on 03/12/2011 at 1900 when RN #1 came to relieve her at 1930. Interview revealed, "they were already signed in. (HCT #2) had already signed them in when I got there". Interview further revealed, "the nurse that came to relieve me didn't ask me about (Pt #2). I just left when she got there".

HCT #2 was not available for interview.

Interview on 03/31/2011 at 1400 with HCT #3 while on tour of the U4 building revealed the HCT had been employed by Hospital A for 30 years. Interview revealed HCT #3 retired and now works part-time. Interview revealed, "I do visitation. It is not acceptable to have visitors and patients in this lobby because if they're in the lobby, they're closer to the door. We are told in orientation training not to let patients near the door. We're also trained on elopement risks like going back and forth to the door, whispering. It's just common sense". The staff member stated that patients should always be in the visitation rooms and not in the lobby when the staff member unlocks the door to ensure safety.

Interview on 03/31/2011 at 1145 with administrative nursing staff revealed, "visitation for U4 has been located in the lobby for at least seven years. U4 building is the only building where visitation is located in the lobby".

Interview on 03/31/2011 at 1015 with the nurse manager of U4 revealed, "(HCT #2) did not have both visitors sign in. They kept calling the male visitor (Pt #2's) brother but he was just a friend. He was later identified as the visitor named in the letter from DSS (Department of Social Services) who could visit". Interview confirmed the hospital policy for visitor sign-in was not followed. Interview further revealed, "I have talked with (RN #2) about the incident but have not done a formal write-up". Interview further revealed, " the only education we've done is to review the visitation policy". Interview further revealed, "one of our big issues in our RCA (root cause analysis) discussion was environmental. We are looking at moving visitation to another area, possibly on the second floor, so the visitation area is not near an exit door".

Review of RN #2's personnel file revealed the RN was hired as an agency nurse on 12/06/2010. Further review revealed the RN attended new employee orientation and agency nurse orientation on 12/06/2010 and nursing orientation on 12/07/2010.

Consequently, Patient #2 was allowed to visit in the lobby of U4/Adolescent Unit on 03/12/2011 beginning at 1800. Interview with the registered nurse assigned to monitor the visitation revealed the door exiting the building was opened for the visitors to go outside and return three times between 1900 and 2013, with Patient #2 standing within arms reach of RN #2 when the door opened. Interview further revealed Patient #2 pushed past the nurse, ran out of the building at 2013 and was not found until 03/22/2011 (10 days later).

Based on review of hospital policy and procedures, job descriptions, orientation training material, observation during tour, medical records, incident files, visitor log, staff interview and personnel file review, the hospital's nursing staff failed to demonstrate an organized nursing service as evidenced by failing to ensure a safe environment of care during visitation to prevent escape.

The findings include:

The hospital's nursing staff failed to assess, evaluate and monitor an adolescent patient during visitation to prevent escape for 1 of 1 adolescent patients who escaped (#2).

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

Based on review of hospital policy and procedures, job descriptions, orientation training material, observation during tour, medical records, incident files, visitor log, staff interview and personnel file review the hospital's nursing staff failed to assess, evaluate and monitor an adolescent patient during visitation to prevent escape for 1 of 1 adolescent patients who escaped (#2).

The findings include:

Review of the hospital's policy, "Visitation Policy", revised 12/11/2007 revealed, "PURPOSE: To provide regulations that will: (1) assist patients' relatives/friends when they visit (Hospital A); and (2) promote a safe, secure, and sanitary environment for visitors, patients and staff. ...4. POLICY: ...4. Visitors are to identify themselves with a picture ID and sign the Visitors' Sign-In and Confidentiality Agreement Log. Responsible staff must initial when a visitor is signed in and out. ...15. Visitation will be supervised at all times in all units. ...16. Visiting areas for each unit are designated by the Unit Director. Visitation will only be allowed in these designated areas. ...".

Review of the hospital's policy, "Escapes/Elopements", revised 01/05/2010, revealed, "PURPOSE: To establish procedures for managing escapes and unauthorized absences. ...IV. Escape Procedures for Patients Escaping Off Campus while Supervised by (Hospital A) Staff A. Any staff member who observes a patient attempting to escape should try to verbally redirect the patient. ...C. Staff follows the patient and continues to attempt to redirect the patient as long as the situation is considered safe. ...".

Review of the hospital's job description for a registered nurse revealed, "I. ...B. Primary Purpose of Position: The primary purpose of this position is to apply the nursing process to insure timely, safe and appropriate Nursing Care, treatment and services. ...7. Provide safe...environment. ...II. Other Position Characteristics: ...7. Visual Attention, Mental Concentration and Manipulative Skills: Careful visual attention and mental concentration is required. Ability to think critically and respond quickly is required. Meticulous attention to detail is required. Must be alert for changes in patient condition or behavior at all times. ...".

Review of the hospital's orientation training material dated August 2009 revealed a copy of a power point presentation with the title"Training for staff to create a CULTURE OF SAFETY. All staff must be involved to create an organization wide CULTURE OF SAFETY. Every day, in every department, on all shifts- We want YOU to embrace a CULTURE OF SAFETY. YOU are needed to make our hospital a safe environment for patients, staff and visitors - we want you to be a SAFETY SUPER HERO. ...Visitation...Supervise visitors carefully. ...SAFETY SUPER HEROES monitor visitation closely and act to protect patients...".

Observation during tour of the U4/Adolescent Unit on 03/31/2011 at 1400 revealed a locked entrance opening into the lobby from outside the building. Observation revealed a room marked "Visitation" opening into the lobby and another room marked "Visitation" across the hall and behind the reception desk. Further observation revealed unlocked lockers to the left of the exit door used for visitors to secure belongings. Observation of the furnishings in the lobby included a couch and several chairs. Observation of the furnishings in the visitation rooms included a table with chairs and a couch with several single chairs.

Closed medical record review of Patient #2 revealed a 15 year-old admitted 03/06/2011 per involuntary commitment for conduct disorder, substance abuse and suicidal ideation. Record review revealed Patient #2 was in custody of the Department of Social Services in his county of residence prior to admission. Review of the initial nursing assessment dated 03/06/2011 at 1240 revealed, "... Escape Risk...Does patient verbalize intent or do behaviors suggest risk for escape? (checked) No...". Record review revealed Patient #2 was placed on suicide precautions and every 15 minute checks on admission. Record review revealed an order dated 03/07/2011 at 1500 to discontinue suicide precautions and 03/09/2011 to discontinue 15 minute checks. Record review revealed a letter dated 03/10/2011 from the patient's county of residence social worker to Hospital A. Review of the letter revealed, "On March 9, 2011, the Honorable (name of judge) issued an order continuing the above named (Patient #2) minor in the custody of (Name of County) Department of Social Services. She further ordered that any outside visitation be at the discretion of the Department. At this time the following persons are allowed visitation with (Patient #2) not to exceed two visits per week: (Name of uncle), (Visitor A) [friend], and (Visitor B) [friend]...". Review of nursing documentation on the progress notes written by RN (registered nurse) #1 dated 03/12/2011 at 2015 revealed, "Called to lobby by visitation staff. When (Patient #2's) visitors went out to smoke, (Patient #2) ran out the door behind them. Team E, Code S called at 8:18 pm. Search initiated. ...". Record review revealed Patient #2 was returned to the hospital by the police on 03/22/2011 (10 days later).

Review of an "Incident/Accident Report" dated 03/12/2011 revealed "Time of Incident/Discovery: 8:13 pm...Type of Incident/Accident: (checked) Elopement...Witnesses: (checked) Yes Names of Witnesses: (Registered Nurse #1). Location of Incident: (checked) Other: (handwritten) lobby. Description of Incident/Accident: patient was preparing for his 'brother' (Visitor A) to leave while female friend (Visitor B) stayed until 9 pm to continue visiting. Female friend got cigarette (and) lighter out of purse to go outside and smoke, when door was opened to allow 'brother' and female friend to go outside, patient ran through front door. ...".

Review of the "Visitor's Sign-In and Confidentiality Agreement Log" for the U4 building revealed, "Date 3/12, Visitor's Name (handwritten) (Visitor B) Valid ID (blank) Relationship to Patient (handwritten) friend Patient's ID # (blank) Time In 6pm Locker Key 15 Time Out (blank) Return Key (blank) Staff Initials (HCT #2)". Review of the log revealed no documentation that Visitor A was signed in as a visitor.

Interview on 03/30/2011 at 1515 with RN #2 revealed the nurse is a agency nurse and has been working at Hospital A since 12/05/2010. Interview revealed the nurse works in the float pool. Interview revealed, "when I got here on March 12 about 7 pm, the CNO (central nursing office) asked me to go to U4 (unit 4- adolescent unit). I went downstairs to the lobby to relieve the health care tech (technician) about 7:30 to do visitation. When I got there, the tech (HCT #1) pointed out (Patient #2) and his two visitors (Visitors A and B). Another man came in to visit (another adolescent patient) and I put them in the same room. (Patient #2) kept getting up stretching and left his visitors to come talk to me. He showed me his tattoos, took a tack off the bulletin board in the lobby and told me he was going to hurt himself with it. The guy I thought was his brother asked to go outside and make a phone call. (Patient #2 and the girl (Visitor B) were sitting in the lobby. I told him (Visitor A) he couldn't keep going in and out". Interview further revealed, "At about 8:00, (Patient #2) came over and told me his 'brother' was leaving and (Visitor B) was staying until visitation was over at 9. I told them again I couldn't keep opening the door. So, I opened the door and his 'brother' left. The girl had her purse and was fumbling around in her purse for the key to the locker. She asked me to open the door so she could get (Visitor A) to bring the key back. I tapped on the door, opened it and she yelled at him to come back. He (Visitor B) came back and I opened the door for him to come back in. That's when (Patient #2) pushed past me while I was holding the door open and ran". Interview further revealed, "the girl was on the porch and was pushing the key fob to her car. When I asked her to come back in, she told me she was afraid someone would break into her car so she had to lock it. She came in for a minute and then she left". Interview revealed, "I saw him run past the (building name - next door to U4). I didn't go out after him". Interview further revealed, "I had a gut feeling that I couldn't trust them and when they started asking about the key, I knew it was planned because she already had her pocketbook out so why was she looking the locker key". Interview further revealed, "I was upset with myself. I didn't get report when I got to the unit. I was told to go do visitation and I didn't know anything about the patients. When he ran, I had to call the unit to find out his name. This was only the second time I had ever done visitation". Interview further revealed, "I was not familiar with the visitation policy and I didn't know of any boundaries related to the door. I guess I felt like he would listen to me". During the interview, RN #2 demonstrated that Pt #2 was standing on her right side within arm's reach when she opened the door from the lobby to the outside of the building.

Interview on 03/31/2011 at 0930 with HCT #1 revealed she was monitoring visitation on U4 on 03/12/2011 at 1900 when RN #1 came to relieve her at 1930. Interview revealed, "they were already signed in. (HCT #2) had already signed them in when I got there". Interview further revealed, "the nurse that came to relieve me didn't ask me about (Pt #2). I just left when she got there".

HCT #2 was not available for interview.

Interview on 03/31/2011 at 1400 with HCT #3 while on tour of the U4 building revealed the HCT had been employed by Hospital A for 30 years. Interview revealed HCT #3 retired and now works part-time. Interview revealed, "I do visitation. It is not acceptable to have visitors and patients in this lobby because if they're in the lobby, they're closer to the door. We are told in orientation training not to let patients near the door. We're also trained on elopement risks like going back and forth to the door, whispering. It's just common sense". The staff member stated that patients should always be in the visitation rooms and not in the lobby when the staff member unlocks the door to ensure safety.

Interview on 03/31/2011 at 1015 with the nurse manager of U4 revealed, "(HCT #2) did not have both visitors sign in. They kept calling the male visitor (Pt #2's) brother but he was just a friend. He was later identified as the visitor named in the letter from DSS (Department of Social Services) who could visit". Interview confirmed the hospital policy for visitor sign-in was not followed. Interview further revealed, "I have talked with (RN #2) about the incident but have not done a formal write-up". Interview further revealed, " the only education we've done is to review the visitation policy".

Review of RN #2's personnel file revealed the RN was hired as an agency nurse on 12/06/2010. Further review revealed the RN attended new employee orientation and agency nurse orientation on 12/06/2010 and nursing orientation on 12/07/2010.

Consequently, Patient #2 was allowed to visit in the lobby of U4/Adolescent Unit on 03/12/2011 beginning at 1800. Interview with the registered nurse assigned to monitor the visitation revealed the door exiting the building was opened for the visitors to go outside and return three times between 1900 and 2013, with Patient #2 standing within arms reach of RN #2 when the door opened. Interview further revealed Patient #2 pushed past the nurse, ran out of the building at 2013 and was not found until 03/22/2011 (10 days later).