HospitalInspections.org

Based on Observation, Record Review and Interview the hospital failed 3 of 3 Patients, (Patient #4, #5, and #6), by failing to maintain compliance with applicable Federal and State laws related to health and safety of patients. The hospital failed to report hospital incidents to the department as required by their own policies to ensure compliance.





Findings Include:

During Observation of hospital video footage, Patient #4, was expeience an agitation, anxiety episode and kicked the back exit door open and eloped out of the hospital.

During Record Review hospital Staff #2, reported the hospital completed a investigation and video footage was observed with Patient #4. Patient #4 was having an episode. His room was the last room on the hallway next to the exit door. Patient #4 did have precautions in place upon admissions into the hospital. The patient was observed walking free in the unit. He did not say much to anyone on the unit according to interviews. The patient then was being watched by the tech as he walked down the hallway. Instead of entering his room he walked to the exit door and kicked the push bar 3x's and the door opened. Patient Thomas eloped at that time and failed to return. The staff attempted to go out the door and retrieve Patient Thomas, but he left the hospital

During Record Review it was reported by a Staff no longer employed by the hospital Patient #4 verbally reported that he wanted to leave and did not believe he belonged there and threatened to leave. The hospital did not change Precaution levels at that time.

During Interivew with Staff #2 it was reported that their were no change in Precautions for Patient #4, due to Patient #4 receiving verbal redirection on initial verbal threat and changing his behavioral pattern overnight.

Policy

The hospital Policy on Abuse 11/2022, revealed, "It is the policy of the facility that clinical staff will assess for abuse and neglect, including physical, emotional, and sexual abuse as well as neglect and/or exploitation and appropriate handle such cases in a manner that protects privacy, dignity, and safety."

The hospital Policy on Patients off the Unit including Elopement 03/01/2022, revealed "The hospital has established guidelines of Elopement Precautions and responding to patient elopements in the event that an elopement happens. The policy of the hospital is to ensure safety and security reasons ...The hospital patients generally are prohibited from leaving the unit and hospital other than for medically ordered treatment, procedures or appointments. Physicians prescribers may write an order permitting patients to be off the unit in accordance with this policy. Patients to be off the unit in accordance with this policy. Patients are informed at admission about the hospital's policy prohibiting leaving the hospital in the absence of a physician order to receive medically necessary procedures/treatments."

The hospital Policy on Incident and Event Reporting 11/2022 revealed, "All event reports, including staff, patients and visitors, are reviewed monthly by the Quality Council and other relevant committees as part of the hospital's quality assurance and performance improvement program.
Hospital personnel are responsible for reporting events in a timely and efficient manner through the Event Reporting System. Event reports are business records and are not part of the patient's medical record and maintained separately in a confidential file by the DQM or designees. Incident Reports or documentation from an incident/event may not be copied or provided to any external entity without prior written approval b the HSC Operations Team."