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Based on medical record reviews, review of hospital policies, review of hospital documentation, observations and interviews for two of six patients who resided on the behavioral unit and had exit seeking behaviors (Patients #11, #13), the hospital failed to maintain a safe and secure environment. The finding includes:

a. Patient #11 was admitted to the secured behavioral unit on 8/3/12. The physician's emergency certificate (PEC) dated 8/3/12 identified a diagnosis of dementia with wandering, delusional and exit seeking behaviors. The nursing assessment dated 8/3/12 noted that the patient had a history of elopement, a potential for elopement and verbalized an intense desire to leave. Although the patient had an increased elopement risk, the patient was placed on every 15 minute checks as per unit routine for all patients, with no increased monitoring ordered/initiated. The nursing narrative dated 8/5/12 indicated that Patient #11 was anxious, restless, forgetful and continually asking for a ride to a distant location. The close observation sheet dated 8/5/12 identified that the patient was monitored every 15 minutes from midnight to 12:15 PM and from 1:30 PM to 3:00 PM, but was not monitored from 12:30 PM to 1:15 PM. Nursing narratives and/or hospital documentation dated 8/5/12 indicated that Patient #11 was observed off of the locked unit between 2:00 PM- 2:15 PM and was found lying on the ground outside of the facility by a visitor at approximately 2:45 PM. Patient #11 sustained bruises to both knees and left shoulder per the nursing narratives, was immediately sent to the emergency room per physician's order and returned later that evening (additional injuries were not noted). Although the close observation sheet identified that Patient #11 was observed on the secured unit at 2:15 PM, 2:30 PM, and 2:45 PM by nurse aide (NA) #2, the documentation was inaccurate as the Patient was observed off of the unit during this time period (1/2 hour).

Observation on 4/3/13 at 9:03 AM noted that the unit doors required key pad code entry and a key or nursing station button press to exit the unit.

Interview with the Vice President (VP) of Nursing on 4/3/13 at 1:35 PM noted that Patient #11 must have exited the secured unit when the door was opened by laundry or dietary staff. She/he further indicated that the close observation sheet was inaccurately completed by NA #2 and that NA #2 was no longer employed by the facility.

The hospital elopement precaution policy identified that all patients are restricted to the unit unless clinically indicated, medically necessary or accompanied by staff. The hospital policy for observing/close monitoring identified that staff observe patients at least every 15 minute and document on the close observation form. Subsequent to the event, staff was reeducated regarding unit safety to include ensuring complete door closure upon unit entry and exit.


b. Patient #13 was admitted to the secured behavioral unit on 8/9/12. The PEC dated 8/9/12 identified that the patient had dementia with behavioral disturbances, was a danger to self and took flight outside. The nursing assessment dated 8/9/12 noted that the patient had a history of elopement and a potential for elopement. The patient was placed on every 15 minute checks as per unit routine for all patients. The close observation sheet dated 8/12/12 identified that the patient was monitored every 15 minutes from midnight to 3:30 PM. Nursing narratives and/or hospital documentation dated 8/12/12 indicated that Patient #13 was on the unit at 3:30 PM, could not be located on the unit at 3:45 PM check, and was found outside in the parking lot near the woods. The patient returned to the unit with staff and no injury was noted.

Interview with the VP of Nursing on 4/3/13 at 1:35 PM noted that it was believed the patient followed a visitor out of the unit when staff pressed the button at the nursing station to let the visitor out.

The hospital elopement precaution policy identified that all patients are restricted to the unit unless clinically indicated, medically necessary or accompanied by staff. Subsequent to the event, staff was reeducated to observe the exit door the entire time the door remains open when the button is pressed to allow for unit exit.

Based on medical record reviews, review of hospital policies, review of hospital documentation and interviews for two of six patients who resided on the behavioral unit and identified as at risk for elopement (Patients #11, #13), the hospital failed to maintain adequate patient supervision. The finding includes:
a. Patient #11 was admitted to the secured behavioral unit on 8/3/12. The physician's emergency certificate (PEC) dated 8/3/12 identified a diagnosis of dementia with wandering, delusional and exit seeking behaviors. The nursing assessment dated 8/3/12 noted that the patient had a history of elopement, a potential for elopement and verbalized an intense desire to leave. Although the patient had an increased elopement risk, the patient was placed on every 15 minute checks as per unit routine for all patients, with no increased monitoring ordered/initiated. The nursing narrative dated 8/5/12 indicated that Patient #11 was anxious, restless, forgetful and continually asking for a ride to a distant location. The close observation sheet dated 8/5/12 identified that the patient was monitored every 15 minutes from midnight to 12:15 PM and from 1:30 PM to 3:00 PM, but was not monitored from 12:30 PM to 1:15 PM. Nursing narratives and/or hospital documentation dated 8/5/12 indicated that Patient #11 was observed off of the locked unit between 2:00 PM- 2:15 PM and was found lying on the ground outside of the facility by a visitor at approximately 2:45 PM. Patient #11 sustained bruises to both knees and left shoulder per the nursing narratives, was immediately sent to the emergency room per physician's order and returned later that evening (additional injuries were not noted). Although the close observation sheet identified that Patient #11 was observed on the secured unit at 2:15 PM, 2:30 PM, and 2:45 PM by nurse aide (NA) #2, the documentation was inaccurate as the Patient was observed off of the unit during this time period (1/2 hour).

Observation on 4/3/13 at 9:03 AM noted that the unit doors required key pad code entry and a key or nursing station button press to exit the unit.

Interview with the Vice President (VP) of Nursing on 4/3/13 at 1:35 PM noted that Patient #11 must have exited the secured unit when the door was opened by laundry or dietary staff. She/he further indicated that the close observation sheet was inaccurately completed by NA #2 and that NA #2 was no longer employed by the facility.

The hospital elopement precaution policy identified that all patients are restricted to the unit unless clinically indicated, medically necessary or accompanied by staff. The hospital policy for observing/close monitoring identified that staff observe patients at least every 15 minute and document on the close observation form. Subsequent to the event, staff was reeducated regarding unit safety to include ensuring complete door closure upon unit entry and exit.


b. Patient #13 was admitted to the secured behavioral unit on 8/9/12. The PEC dated 8/9/12 identified that the patient had dementia with behavioral disturbances, was a danger to self and took flight outside. The nursing assessment dated 8/9/12 noted that the patient had a history of elopement and a potential for elopement. The patient was placed on every 15 minute checks as per unit routine for all patients. The close observation sheet dated 8/12/12 identified that the patient was monitored every 15 minutes from midnight to 3:30 PM. Nursing narratives and/or hospital documentation dated 8/12/12 indicated that Patient #13 was on the unit at 3:30 PM, could not be located on the unit at 3:45 PM check, and was found outside in the parking lot near the woods. The patient returned to the unit with staff and no injury was noted.

Interview with the VP of Nursing on 4/3/13 at 1:35 PM noted that it was believed the patient followed a visitor out of the unit when staff pressed the button at the nursing station to let the visitor out.

The hospital elopement precaution policy identified that all patients are restricted to the unit unless clinically indicated, medically necessary or accompanied by staff. Subsequent to the event, staff was reeducated to observe the exit door the entire time the door remains open when the button is pressed to allow for unit exit.




26703


Based on clinical record review and interviews for 1 (P#12) of 4 patients reviewed for monitoring of fluid intake and urine output, the facility failed to complete a hydration assessment, and failed to notify the physician when P#12 did not meet his/her identified fluid needs. The findings include:

a. Patient #12 was admitted on 9/19/12 to the facility for care of advancing dementia. An admission nutrition risk assessment indicated P#12's daily fluid needs were 2050.0 milliliters (mls). A patient care plan dated 9/19/12 indicated P#12 was to have fluid intake and output (I&O) monitored, staff were to assess for dehydration and document in the nurse's notes, and the physician was to be notified if P#12 did not meet his/her identified fluid needs for two consecutive days.

A review of the medical record identified from 9/20/12 to 10/19/12, I&O documentation was incomplete on 18 days. Review of the I&O's identified from 10/2/12 to 10/3/12 and 10/10/12 to 10/12/12 P#12 did not meet his /her required fluid needs for two or more consecutive days.

Nurse's notes dated 9/19/12 to 10/20/12 identified skin turgor, temperature and moisture were monitored but the medical record lacked documentation that a complete hydration assessment was completed. In addition, the medical record lacked documentation that the physician was notified when P#12 did not meet his/her fluid needs.

During a review of the medical record with the Vice President of Nursing (VP of Nursing) on 4/4/13 at 1:30 PM, the VP of Nursing indicated that the I&O should have been completed and the physician should have been notified when P#12 did not meet his/her fluid requirements.

Based on medical record reviews, review of facility policies, review of facility documentation and interviews for two of six patients who resided on the behavioral unit and were identified as at risk for elopement (Patients #11, #13), nursing staff failed to develop a patient specific behavioral plan of care and/or revise the plan of care following an elopement. The finding includes:

a. Patient #11 was admitted to the secured behavioral unit on 8/3/12. The physician's emergency certificate (PEC) dated 8/3/12 identified a diagnosis of dementia with wandering, delusional and exit seeking behavior. The nursing assessment dated 8/3/12 noted that the patient had a history of elopement, a potential for elopement and verbalized an intense desire to leave. Although the patient had increased elopement risk, the patient was placed on every 15 minute checks as per unit routine for all patients and increased monitoring was not ordered. The initial nursing plan of care dated 8/3/12 did not identify the exit seeking behavior and/or elopement risk as problems and therefore goals and patient specific interventions were not formulated. The nursing narrative dated 8/5/12 indicated that the patient was anxious, restless, forgetful and continually asking for a ride to a distant location. Nursing narratives and/or hospital documentation dated 8/5/12 indicated that Patient #11 was found lying on the ground outside of the facility by a visitor at approximately 2:45 PM and sustained extremity bruises.

Review of the patient's record and interview with the Vice President (VP) of Nursing on 4/4/13 at 10:45 AM noted that the patient's plan of care did not address patient behaviors. She/he further indicated that although changes in the patient's medications were made by the physician subsequent to the event, patient specific nursing measures were not identified in the plan of care to prevent recurrence.

b. Patient #13 was admitted to the secured behavioral unit on 8/9/12. The PEC dated 8/9/12 identified that the patient had dementia with behavioral disturbances, was a danger to self and took flight outside. The nursing assessment dated 8/9/12 noted that the patient had a history of elopement and a potential for elopement. The patient was placed on every 15 minute checks as per unit routine for all patients. The initial nursing plan of care dated 8/9/12 and/or 8/10/12 did not identify the exit seeking behavior and/or elopement risk as a problem and therefore goals and patient specific interventions were not formulated. Nursing narratives and/or hospital documentation dated 8/12/12 indicated that Patient #13 exited the unit sometime during the 3:30 PM and the 3:45 PM check and was immediately found outside in the parking lot near the woods.

Review of the patient's record and interview with the VP of Nursing on 4/4/13 at 11:10 AM noted that the patient's initial plan of care did not address patient behaviors and/or risk for elopement however, the patient's plan of care was revised following the incident to include goals and nursing interventions to prevent recurrance.
The hospital policy for interdisciplinary treatment plans directed that the plan be initiated within 24 hours of admission, problems are listed on the plan as they are identified and the plan is reviewed, evaluated and revised as appropriate. The policy also identified that interventions are individualized and relate to the specific objectives which are derived from the identified/presenting problems.



26703


Based on clinical record review and interviews for 1 (P#12) of 4 patients reviewed for monitoring of fluid intake and urine output the facility failed to develop, review, and/or revise a plan of care when P#12 did not meet his/her identified fluid needs. The findings include:
a. Patient #12 was admitted on 9/19/12 to the facility for care of advancing dementia. An admission nutrition risk assessment indicated P#12 daily fluid needs were 2050.0 milliliters (mls). A patient care plan dated 9/19/12 indicated P#12 was to have fluid intakes and outputs (I&O) monitored and the physician was to be notified if P#12 did not meet his/her identified fluid needs for two consecutive days, assess for dehydration, report results with I&O totals to the physician and document in the nurse's notes.
A review of the medical record identified from 9/20/12 to 10/19/12 I&O documentation was incomplete on 18 days. The I&O identified from 10/2/12 to 10/3/12 and 10/10/12 to 10/12/12 P#12 did not meet his /her required fluid needs for two consecutive days or more.
Nurse's notes dated 9/19/12 to 10/20/12 identified skin turgor, temperature and moisture were monitored but the medical record lacked documentation a complete hydration assessment was completed. In addition, the medical record lacked documentation that the physician was notified when P#12 did not meet his/her fluid needs, and the plan of care was not updated.
During a review of the medical record with the Vice President of Nursing (VP of Nursing) on 4/4/13 at 1:30 PM, the VP of Nursing indicated the I&O and Plan of Care should have been completed/updated and the physician notified when P#12 did not meet his/her fluid requirements.

Based on clinical record review and interviews for 1 (P#12) of 4 patients reviewed for monitoring of fluid intake and urine output the facility failed to complete documentation according to facility policy.
Patient #12 was admitted to the facility for care of advancing dementia. A patient care plan dated 9/19/12 indicated P#12 was to have fluid intakes and outputs (I&O) monitored. A review of the medical record identified from 9/20/12 to 10/19/12 I&O documentation was incomplete on 18 days.

Facility policy for I&O indicated all oral and intravenous fluids are to be documented in the proper column of the I&O record. If the patient does not take any oral fluids during the shift a zero is to be documented in the shift total column. The policy indicated the columns of the I&O record should never be left blank. The policy further indicated the nurse is responsible for completing the I&O subtotal at the end of each shift and record it on the Record of Basic Care.

During a review of the medical record with the Vice President of Nursing (VP of Nursing) on 4/4/13 at 1:30 PM, the VP of Nursing indicated the I&O and Plan of Care should have been completed/updated and the physician notified when P#12 did not meet his/her fluid requirements.

Based on a tour of the hospital and staff interview, the facility failed to ensure that the psychiatric care sleeping rooms and units were maintained in such a manner as to promote the safety and well-being of patients.

1. On 04/03/13 at 09:00 AM and various times throughout the day, while touring the adult psychiatric units with the Director of Environmental services the following was observed:

a. The faucet and shower controls, door handles, and privacy curtains, posed a potential hanging hazard and were not designed to a psychiatric/ institutional standard and subsequent interview indicated that a current risk based analysis by the facility prior to this inspection had not been completed.

b. The electric beds throughout the unit had cords that were not shortened and or designed to a psychiatric/ institutional standard.

2. On 04/03/13 at 10:45 AM and various times throughout the day, while touring the hospital dietary department with the Director of Environmental services the following was observed:

a. The walls behind the streamers, convection ovens and cooking line had extensive tile and wall damage.
b. The floors under the cooking line were grease laden and not maintained to ensure a sanitary environment.
c. The walk-in coolers and freezers had broken and missing tiles and cove base.