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Based on record review and interview, the facility failed to ensure the safety of 1 of 1 Patient (Patient #1) who was determined to be incompetent for decision-making and who had a history of elopement from other healthcare facilities, to elope from the facility resulting in the patient's death in a sample of 10.

Findings include:

The facility failed to ensure patients were receiving care in a safe setting. (See tag A-0144)

The cumulative effects of the violation of patient rights resulted in the hospital's failure to ensure the safety of the patient who was at risk for elopement.

Immediate Jeopardy was determined on 6/12/2018 at 2:05 PM regarding the facility failing to ensure all patients receive care in a safe environment. The facility did not have a policy to assess the patients who were at risk of for elopement from the facility. An incompetent patient with a history of elopement from facilities eloped from the hospital and was not located until the following day. The patient was found deceased by the Police Department.

The Risk Director I, Compliance N, and Director of Quality A was notified of the Immediate Jeopardy on 6/12/2018 at 2:05 PM.

The Immediate Jeopardy was removed on 6/12/2018 at 3:40 PM with the following actions: 1). All nursing staff currently working completed education regarding patient elopement. All other nurses and nursing assistants will complete elopement education prior to their next scheduled shift. 2). Nurses were educated to use existing care plans to address elopement risk in the Patient Plan of Care. 3). All team members were educated on elopement precautions, including door signage for patients at risk, use of a virtual patient monitor, and use of safety beds (beds located closer to nurses station and are within direct vision) for patients with a known elopement risk. Nursing will document elopement risks into electronic documentation within the daily assessment flow sheets. 4). All current patients of the facility were assessed for an elopement risk. 5). Policy for inpatient elopement was updated to include preventative actions and definitions for patients at risk for elopement. These actions were completed prior to exit of survey, but the noncompliance remained at the Condition Level.

Based on record review and interview, the facility failed to monitor and to implement interventions to protect 1 of 1 Patient (Patent #1), who was deemed incapacitated to make his own decisions and had a history of elopement from other healthcare facilities, from eloping from the hospital in a sample of 10.

Findings include:

Review on 6/11/2018 at 2:40 PM of the policy titled "Decision Making Capacity for Adult Patients" revealed "Incapacity (non-decisional): "Incapacity" means "the inability to receive and evaluate information effectively or to communicate decisions to such an extent that the individual lacks the capacity to manage his or her health care decisions." "Incapacity" is determined by physicians or psychologists." and "Incompetent: The legal determination made by a court in which a person loses the right to make decisions for him or herself. If the court, finds the person incompetent, a guardian is appointed to make personal and/or financial decisions."

Patient #1's medical record was reviewed on 6/11/2018 at 10:30 AM. Review of the History and Physical dated 4/5/2018 revealed, "[Patient #1] was admitted recently at [Hospital P] for confusion, altered mental status and secondary to medication noncompliance. As per the past medical records, [Patient #1] was deemed to be incompetent to make medical decisions and has an activated POA (Power of Attorney). At that time the Department of Aging was involved and the eventual plan was to get [gender] for placement. While awaiting placement the patient eloped form [Hospital P]. As per the social worker, the Department of Aging has been looking for [gender] since then but was unable to find [gender]."

Review of the Emergency Department Provider Note dated 4/5/2018 revealed "I spoke with the social worker regarding the patient's presentation, and how [gender] lives in a tent on the Indian Reservation. We discussed [gender] hyperglycemia and possible placement. Social Worker agrees to contact the Indian Health Service. On 4/5/2018 at 10:20 AM, "I spoke with [social worker E], who informed me that the patient does have a activated POA (Power of Attorney) and [gender] is not considered competent to make [gender] own decisions. [Social Worker E] contacted the Ho-Chunk Indian reservation, who stated that the department of aging has been searching for [gender]." On 4/5/2018 at 11:45 AM, "I spoke with [Social Worker E] who informed me that [Social Worker E] spoke with the social worker from the Department of Aging and they are working on guardianship with protective placement for the patient."

Review of the History and Physical dated 4/5/2018 revealed, "[Patient #1] was admitted recently at [Hospital P] for confusion, altered mental status an secondary to medication noncompliance. As per the past medical records, [Patient #1] was deemed to be incompetent to make medical decisions and has an activated POA (Power of Attorney). At that time the Department of Aging was involved and the eventual plan was to get [gender] for placement. While awaiting placement the patient eloped form [Hospital P]. As per the social worker, the Department of Aging has been looking for [gender] since then but was unable to find [gender]."

Review of the Geriatric Consultation Summary for Psychological Evaluation, dated 4/9/2018, revealed, "As per the past medical records,[gender] is deemed to be incompetent to make medical decisions and has activated POA (Power of Attorney). At that time the Department of Aging was involved and the eventual plan was to get [gender] placement. While awaiting placement the patient eloped from [Hospital P] . As per social worker, the Department of Aging has been looking for [gender] since then but was unable to find [gender]. [Patient #1] was previously evaluated by the evaluator 2/19/2018 and determined to lack the capacity for medical decision making at that time. [Patient #1] left the hospital AMA (against medical advice) on 2/22/2018. Since that time, [gender] was treated in an Aurora ER (Emergency Room) 9 times in addition to his current hospitalization for hyperglycemia, elevated ammonia, and noncompliance with medication."

Review of the Physician Progress note dated 4/20/2018 revealed, "Seen by psychologist and patient is deemed lacking the capacity to make medical decisions, [Patient #1] has temporary guardian as [gender] activated POA (Power of Attorney) did not want to pursue decision making for now, once [patient #1] patient has protective placement, [gender] activated POA will assume decision making for patient as per social worker."

Review of the Progress Note (Social Worker E) on 4/26/2018 revealed, "Spoke with supervisor at Milwaukee County Department of Aging today regarding stalemate over funding between Milwaukee County and HoChunk Nation. Milwaukee County petitioned for protective placement because of the emergency nature of the situation, however the HoChunk Nation is obligated to fund long term care needs for any of their tribal nation members. County of Aging is suspicious the HoChunk may not have a means of providing for this obligation since the patient is not currently on the reservation.

Review of the Medication Administration Record dated 5/26/2018 revealed that the last documented contact with Patient #1 was at 2:13 PM for medication administration.

Review of the Discharge Summary dated 5/26/2018 4:00 PM revealed, "At around 4:30, RN (Registered Nurse) called me to inform that patient was not found in the room, not on the floor. Security was immediately notified and conducted the search all over the hospital but could not find [gender]. Police Department was then notified as patient appeared to have eloped from the hospital. It appeared that, [gender] did not take any of his belongings from [gender] room. The staff did notify the risk management, Department of Aging. Staff attempting to notify family members."

Review of the Progress Note by Registered Nurse on 5/26/2018 at 5:00 PM revealed, "Patient checked on last at 4:30 PM to do blood sugar and patient not in room, staff last saw patient at 4:00 PM. Patient not on floor. Security called they have checked all over the hospital and surrounding area of hospital. Police Department called and are checking all areas of hospital including parking structure. Risk Management called and told police department needed to be involved who were called. Department of Aging called and voice message left, will not be in until Tuesday. Doctor called and stated if found by police department will have to come in through Emergency Department. Tried to leave message with niece who is POA but phone number given was disconnected.

Review of the Root Cause Analysis dated 6/1/2018 revealed on 5/27/2018 at 3:12 PM, "Police Department called to report the [Patient #1] was found deceased in the alley."

During an interview on 6/12/2018 at 8:50 AM Risk Director I stated, "Rounding was completed at 3:00 PM and [Patient #1] was not in room. Staff just assumed patient was walking in the halls. The staff continued with rounds and at 3:30 went back to the room and the patient was not seen again. The Certified Nursing Assistant informed the Registered Nurse, and when the Registered Nurse went to the patients room to complete the blood sugar check the patient was still gone and the staff starting looking for the patient. At 4:30 PM the Loss Prevention was informed of the missing patient."

During an interview on 6/11/2018 at 12:04 PM with Director of Quality A confirmed the last time Patient #1 was seen was at 2:13 PM during medication administration.

During an interview on 6/11/2018 at 11:55 AM, Security Officer H stated, "After the death was reported, the camera film was reviewed and it was identified that the Patient [Patient #1] was seen exiting the hospital by the Lab entrance at 2:42 PM. We were initially told by the nursing staff the patient had been last seen around 3:30 PM, so we initially starting viewing the camera footage after that time and we never saw patient [#1] exit the building so we thought [gender] was still inside the hospital."

During an interview on 6/12/2018 at 8:45 AM, Director of Quality A stated "Hospital does not have an elopement assessment or prevention policy."

Based on record review and interview, the facility failed to develop and implement individualized care plans for patients based on patient assessments and diagnoses for 5 of 10 patients reviewed (1, 2, 3, 4, and 6) in a sample of 10.

Findings include:

The facility failed to ensure there is a comprehensive care plan that is individualized and based on patient assessment and diagnoses for 5 of 10 patient medical records reviewed (1, 2, 3, 4, and 6) out of a sample of 10. See tag A-396.

The Cumulative effect of these deficiencies potentially affect all patients treated at the facility.

Based on record review and interview, the facility failed to develop and implement individualized care plans for patients based on patient assessments and diagnoses for 5 of 10 patients reviewed (1, 2, 3, 4, and 6) in a sample of 10.

Findings include:

Review on 6/12/2018 at 1:55 PM of the policy titled, "Nursing Documenting" #1008, dated 3/21/2018 revealed, "4.8 All inpatients will have an individualized nursing plan of care initiated within 24 hours of admission and documented in the medical record. 5.2 The plan of care is comprised of age, and gender-appropriate assessments, screenings, diagnosis/patient problems, goals/outcomes, and patient interventions and is documented in the Electronic Health Record."

Review on 6/11/2018 at 10:30 AM of Patient #1's History and Physical dated 4/5/2018 revealed, "History of Presenting Complaint: While awaiting placement (at previous hospital) the patient eloped from [Hospital P]. Geriatric Consultation Summary dated 4/5/2018 revealed, "In reviewing [patient #1's] old record, it seems that the patient has over 20 ER (Emergency Room) visits in the last year by itself between different health care systems. The patient many times before was deemed incompetent by neuropsychological testing and [gender] power of attorney is activated. There is discussion about having guardianship, but apparently patient eloped from the hospital at that time."

Review of the History and Physical dated 4/5/2018 revealed, "[Patient #1] was admitted recently at [Hospital P] for confusion, altered mental status and secondary to medication noncompliance. As per the past medical records, [Patient #1] was deemed to be incompetent to make medical decisions and has an activated POA (Power of Attorney). At that time the Department of Aging was involved and the eventual plan was to get [gender] for placement. While awaiting placement the patient eloped form [Hospital P]. As per the social worker, the Department of Aging has been looking for [gender] since then but was unable to find [gender]."

During an interview on 6/12/2018 at 8:45 AM, Director of Quality A stated "Hospital does not have an elopement assessment or prevention policy."

During an interview on 6/12/2018 at 12:40 PM, Clinical Informatics Educator K stated, "Electronic health record system in place does not have a risk for elopement care plan."

Review on 6/12/2018 at 11:25 AM of Patient #2's History and Physical dated 4/7/2018 revealed Patient #2 was admitted with a diagnosis of altered mental status due to underlying infection and baseline vascular dementia. The care plan does not address alteration in mental status.

Review on 6/12/2018 at 11:55 AM of Patient #3's History and Physical dated 4/26/2018 revealed Patient #3 was admitted with complaints of pain and severe sepsis from right lung base pneumonia. The care plan does not address pain or pneumonia.

Review on 6/12/2018 at 12:45 AM of Patient #4's History and Physical dated 5/8/2018 revealed Patient #4 was admitted with diagnoses of congestive heart failure, bronchitis, and diabetes. The care plan does not address alteration in respiration or diabetes.

Review on 6/12/2018 at 1:10 PM of Patient #6's History and Physical revealed Patient #6 was admitted on 5/30/2018 at 2:35 AM for onset of nausea, vomiting and diarrhea. Patient #6 was discharged on 5/31/2018 at 4:15 PM. There was no care plan initiated.

During an interview on 6/12/2018 at 2:45 PM, Clinical Informatics Educator K stated, "The charts reviewed had care plans that did not address all the patient's diagnosis."