HospitalInspections.org

Based on observation, interview and record review, the governing body failed to ensure patient rights were protected when facility staff failed to:

A. 1. Allow the patient to make informed decisions, request, or refuse treatment regaurding his or her care in 2(1 and 6) of 3(1,6, and 8) patient charts reviewed.

2. prevent an incapacitaed individual from signing legal consents for treatment and medications in 1(#7) of 4 (1, 6, 7, and 8) patient charts reviewed.

Refer to Tag A0131


B. inquire about a patients advanced directives or provide the patients with information on advance directives in 3(#6, 7, and 8) of 4 (1, 3, 7, and 8) patient charts reviewed.

Refer to Tag A0132


C. 1. develop and enforce policies and processes to ensure patients, visitors, and staff remained safe during the admissions process in 1 patient care area (Admissions) out of 3 patient care areas observed.

2. a. Monitor and observe the patient to keep safe from potential harm.
b. Follow their own policy and procedures of elopement, inform the patient of her rights to readmit or discharge from the facility.
c. Physically assess the patient upon return to the facility and document assessment in 1(#1) of 3(1,6,and 8) charts reviewed.

Refer to Tag A0144


D.) provide policies and processes that protected the patient's dignity and prevented mental anguish for 1 (Patient #4) of 3 patients observed during the admission process.


Refer to Tag A0145

Based on observation, review and interviews the facility failed to;

A. 1. Allow the patient to make informed decisions, request, or refuse treatment regarding his or her care in 2(1 and 6) of 3(1,6, and 8) patient charts reviewed.
2. prevent an incapacitated individual from signing legal consents for treatment and medications in 1(#7) of 4 (1, 6, 7, and 8) patient charts reviewed.

Refer to Tag A0131


B.) inquire about a patients advanced directives or provide the patients with information on advance directives in 3(#6, 7, and 8) of 4 (1, 3, 7, and 8) patient charts reviewed.

Refer to Tag A0132


C. 1. develop and enforce policies and processes to ensure patients, visitors, and staff remained safe during the admissions process in 1 patient care area (Admissions) out of 3 patient care areas observed.

2. a. Monitor and observe the patient to keep safe from potential harm.
b. Follow their own policy and procedures of elopement, inform the patient of her rights to readmit or discharge from the facility.
c. Physically assess the patient upon return to the facility and document assessment in 1(#1) of 3(1,6,and 8) charts reviewed.

Refer to Tag A0144


D.) provide policies and processes that protected the patient's dignity and prevented mental anguish for 1 (Patient #4) of 3 patients observed during the admission process.


Refer to Tag A0145

Based on review and interviews the facility failed to;
1.) Allow the patient to make informed decisions, request, or refuse treatment regarding his or her care in 2(1 and 6) of 3(1,6, and 8) patient charts reviewed.
2.) prevent an incapacitated individual from signing legal consents for treatment and medications in 1(#7) of 4 (1, 6, 7, and 8) patient charts reviewed.

Review of #7's chart revealed he was admitted on 1-14-17. Review of the nursing Assessment notes for 1-14-17 that the assessment could not be completed due to confusion and agitation. On the page three of the assessment " Risk to Self" stated, " pt is risk to self d/t unable to answer questions regarding person, place, time, situation." Patient #7 was allowed to sign all admission consent forms including consent for treatment, patient rights, rights about Medicare, financial's, billing and advanced directives. Patient #7 was allowed to sign medication consents.

Review of #6's chart revealed the patient came into the facility on 1-17-17 on a Emergency Detention Warrant. Patient #6 was seen by the physician and a telephone physician order was written to change her from involuntary status to voluntary status on 1-18-17.

Review of the Request for Voluntary Treatment form revealed the patient signed the form at 10:00AM on 1-18-17. Review of the second page of the form revealed a statement about Consent for Treatment and Consent for Admission. Both the sections were "X" out with no patient initials.

An interview on 1-18-17 at 10:45AM was conducted with patient #6. Patient #6 was asked if she was given any information regarding the consent, why she was signing it, and what her rights were when going from a involuntary to voluntary status. Patient #6 stated, "No, she didn't explain anything to me. Just told me to sign something."

An interview was conducted with staff #24 on 1-18-17 at 11:00AM. Staff #24 was asked what information she gave patient #6 when signing a new consent form from involuntary status to voluntary. Staff #6 stated, " well, she didn't ask any questions. She was really quiet. I didn't go into a lot on that." Staff #6 was asked if she told the patient about her rights or if the patient was aware what changing that status meant. Staff #6 stated "not really. I normally tell them they are getting off the warrant and voluntarily signing in but I will go into more detail if they have questions."

Review of patient #1's chart, and interviews revealed the following;

Patient #1 was admitted to the facility on 8-25-16 as a voluntary patient. She was referred by the mental health authority where she had been receiving psychiatric care for 2 years. Patient #1 was having increased psychosis and panic attacks. Review of the Admission Psychiatric Evaluation dated 8/26/16 stated, "patient reported for the last 2 weeks she had been having daily panic attacks without any clear precipitant. She has become increasingly paranoid over the past couple of months, afraid that people are watching her continuously, hearing voices that are telling her to run away from home or else they will get her family members. She has been responding to internal stimuli and has been running away from home for many hours and her family having to look for her and search for her to bring her back home safely."

Review of Patient #1's physician order dated 8-25-16 revealed she was admitted with a diagnosis of Schizophrenia and placed on Observation rounds every 15 minutes and Elopement Precautions (EP). The definition of EP according to the policy and procedure "Elopement Precautions" stated, "To make every reasonable effort to prevent a patient, voluntarily or involuntarily admitted, from leaving the hospital without authorization."

Review of the physician orders dated 9-4-16 revealed the physician discontinued the Elopement Precautions.

Review of the nurses notes dated 9-7-16 at 7:55AM revealed the patient had been "tearful while talking" and stated, "her AV (auditory hallucinations) have decreased but remains tearful and states she is fearful but does not wish to discuss at this time." There was no further documentation until 7:30PM. On 9-7-16 at 7:30PM the nurse documented, "Patient is in dorm room lying in bed. She is on EP precautions and 15 minute checks and seizure precautions. Patient still responding to internal stimuli. She has been tearful at times."

Review of the nurses notes revealed a late entry note written on 9-8-16. Staff #23 (RN) documented, "Late Entry for 9-7-16. At 12:32 MHT (Mental Health Technician) informed me that she was unable to account for the patient upon returning to the unit from lunch. A thorough search of the unit and hallways were performed. Administration was informed of the elopement."

Review of the nurses notes revealed a late entry note written on 9-8-16. Staff #22 (RN) documented, "Late entry for 9-7-16 at 1545 (3:45PM) pt arrived back at hospital. Skin search and belongings search completed with no contraband found. Pt placed on SCU (adult unit) and MHT notified. Q 15 minute checks to resume at this time for safety. Order received to place pt on elopement precautions. MHT notified of new precautions. Will continue to monitor with 15 minute checks for safety."

Review of the MHT patient activity record revealed on 9-7-16 the following activities were documented at these times;

12:00PM- patient was calm and in dayroom.
12:15PM- patient was calm and outside smoking
12:30PM- patient was calm and in dining room. The entry was marked through.
12:45PM- patient was calm but the location was blank. The entry was marked through.
13:00-14:45 patient behavior was "n/a" and location stated off campus.
15:00 (3:00PM) -patient is calm and sleeping.
15:15- 16:30- patient is sleeping in bedroom.

There was a 45 minute discrepancy in time on when the patient was back to the unit. The MHT documented the patient activity at 3:00PM but the nurse stated the patient was not back on the unit until 3:45PM. There was no further nursing documentation found on the elopement or patient's condition in the chart.

Review of patient #1's chart revealed there was no medical examination from a physician upon return to the unit on 9-7-16 or labs to see if any substances were ingested during the absence from the facility.

Review of the incident reports revealed the Risk Manager filled out an incident report the following day on 9-8-16. The report had minimal information on it but stated the Physician, RN Supervisor, Administrator, Risk Manager, and Greenville Police Department were all contacted at 12:35PM on 9-7-16. It did not say who contacted these individuals. On physician response it stated, "n/a."

Review of the physician progress notes dated 9-7-16 at 22:58 (10:58PM) stated, Patient #1 "is a white female, who was admitted to Glen Oaks Hospital for sever psychosis. She is exhibiting reduction in level of anxiety this morning, but this afternoon _____ (patient name) eloped from the hospital, was brought back by Sulfur Springs Police Department after seen walking beside the road. When she arrived back at Glen Oaks Hospital, on interview, ____ (patient's name) stated, "The voices were telling me to run away, so I ran." She has been placed on elopement precautions. She is tearful and anxious, says the voices still keep bothering her."

Review of patient #1's treatment plan revealed there was no documentation of the EP precautions or the elopement. Problem #1 stated, "Alteration in Thinking. Hallucinations telling her to run away." There was no long term goals or dates documented. There was four different medication changes for Seroquel and Haldol. There was no short term or long term goals documented. No target dates noted.

Review of the patient consents revealed the patient was brought back to the facility with no warrant by the police. The patient had initially signed in as voluntary. The patient was not readmitted or asked to sign back in as a voluntary patient. There was no documentation that the patient was informed of her patient rights and if she wanted to remain as a patient or request to be discharged.

Review of the date and time when this incident happened revealed this surveyor was in the facility for another complaint visit. This surveyor and another surveyor had gone to lunch when this incident occurred on 9-7-16. The facility did not divulge to the surveyors that the patient had eloped or had returned.

An interview was conducted on 1-18-17 with staff #23 (RN), concerning the elopement of patient #1, on 9-7-16. Staff #23 stated she remembered the incident but it was long time ago. Staff #23 reported that the patient had gone to lunch with the group and a MHT. The MHT came back to the unit after lunch and stated she could not find patient #1. She was not sure when the patient had come up missing. Staff #23 reported that she started checking the building and alerted the DPN (Director of Psychiatric Nursing.) Staff #23 stated she didn't know who called the police. The facility was searched and the physician was notified. Staff #23 reported the patient had hitched hiked to Sulfur Springs about 30 miles from the facility. Staff #23 reported the police stated the driver felt patient #1 was acting strange and they pulled over and made patient #1 get out of the vehicle. The driver then called the police. The Sulfur Springs Police found her wondering down Interstate 30. Patient #1 was brought back to the facility and searched on the unit for contraband. Staff #23 reported that she did not readmit patient #1 to the facility. Staff #23 confirmed that nothing changed in the chart and patient #1 continued on with the same paperwork and was considered voluntary. Staff #23 was not sure if patient #1 was asked if she wanted to be there or discharged from the facility.

An interview with the Administrator, Interim Director of Psychiatric Nursing (IDPN), and Risk Manager on 1-18-17 concerning the elopement of patient #1. Administrator acknowledged that the patient did elope out the front door while going to the cafeteria. Administrator reported patient #1 had left out the front door with no one noticing her. Administrator confirmed patient #1 was reported missing to the police and was brought across county lines, from Hopkins County to Hunt County, without a warrant. The Risk Manager stated that she wrote the incident report and was working with the past DPN on the incident.

The Administrator stated the MHT had pre-charted on patient #1's activity and location. The MHT was terminated that day. The Administrator confirmed patient #1 was not discharged or readmitted as a voluntary patient. Patient #1 was brought back to the facility on the same consents and paperwork upon the initial admission. The Administrator and Risk Manager both confirmed there was no documentation that patient #1 was asked if she wanted to come back to the facility or discharge. The Administrator was asked why the surveyors were not informed of the elopement and she stated, "I didn't think that was reportable."

The Administrator and Risk Manager confirmed that the facility had not followed its elopement policy. There had been no education to the employees on elopements or how to handle a patient brought back from an elopement to the facility after the incident on 9-7-17. The Administrator and Risk Manager confirmed there was no documented physical assessment by the nurse or a medical clearance by a physician upon patient #1 returning to the facility.

Based on review of charts and interviews the facility failed to inquire about a patients advanced directives or provide the patients with information on advance directives in 3(#6, 7, and 8) of 4 (1, 3, 7, and 8) patient charts reviewed.

Review of patient #6's chart revealed the patient consent for treatment and conditions of admissions signed on 1-18-17 was blank concerning advanced directives. There was no further information that was addressed with the patient. Staff #3 confirmed the findings.

Review of patient #8's chart revealed the patient consent for treatment and conditions of admissions signed on 1-9-17 was blank concerning advanced directives. There was no further information that was addressed with the patient. Staff #3 confirmed the findings.

Review of patient #7's chart revealed the patient consent for treatment and conditions of admissions signed on 1-17-17 was blank concerning advanced directives. There was no further information that was addressed with the patient. Staff #3 confirmed the findings.

Based on observation, interview, and review of records, the facility failed to:

A. develop and enforce policies and processes to ensure patients, visitors, and staff remained safe during the admissions process in 1 patient care area (Admissions) out of 3 patient care areas observed.

B.
1.) Monitor and observe the patient to keep safe from potential harm.
2.) Follow their own policy and procedures of elopement, inform the patient of her rights to readmit or discharge from the facility.
3.) Physically assess the patient upon return to the facility and document assessment in 1(#1) of 3(1,6,and 8) charts reviewed.

Findings were as follows:

A. On 1-18-2017 at approximately 10:00 AM, a tour and observation of admissions was conducted with Staff #11, #19, #20, and #21 present.

Upon entering the admission area, there were 3 people in the lobby.

Patient #3 was a 15 year old female with her mother. She was in the process of being sent to another hospital for medical treatment rather than being admitted. An ambulance was in route. Staff #19 was working on the necessary paperwork in an office at the back of admissions. This office had two large windows that allowed the lobby to be viewed by staff in the office.

Patient #4 was an adult female that had been screened for admission and was waiting on the admission paperwork to be processed by Staff #20. Patient #4 was sitting with her back to the office where Staff #19 was working. Patient #4 appeared to have been crying, with red eyes and a tissue wiping her face.

Patient #2 was an adult male in handcuffs that had just been escorted in by two police officers and Staff #21. Staff #11 stated she would have to leave the area because she knew the patient and it was a conflict of interest for her to stay.

Staff #21 stated the patient was from the local Mental Health and Mental Retardation (MHMR) facility. Staff #21 stated the MHMR staff became concerned about his increased level of agitation and responding to internal stimuli. Patient #2 was observed to have rapid and jerking body movements and mumbling as if talking to someone. Staff #20 used a metal detecting wand to scan Patient #2 for possible weapons. The patient was found to have a lighter in his pocket that was removed by one of the police officers present. The patient was found to have a belt with a metal belt buckle. This was not removed from the patient. The police then removed the handcuffs. The police remained present while completing their paperwork. Staff # 20 attempted to interview the patient with limited responses from the patient. Staff #20 told Staff #21 that she believed the patient had been admitted previously. She stated she was going to go to medical records department to pick up his chart from that admission in order to review medical information she was unable to obtain from the patient.

After Staff #20 had departed the locked admissions area, Staff #21 departed the locked admissions area to escort the police out of the building. Nobody was observed to advise Staff #19 that she was being left alone with the 3 females in the lobby and a potentially aggressive male patient in an interview room that could not be observed from the windows in the back office. In addition, the male patient had been left with a belt that had a metal belt buckle. This could have been used as a weapon or ligature to harm himself or the other females that had been left in the lobby.
As soon as Staff #21 had exited the locked admissions area, Patient #2 came out of his interview room and began pacing around the females in the lobby. Staff #19 continued to process Patient # 3's paperwork for transport to the hospital. Staff #19 did not come out of the office to check on the patients and family member in the lobby. Staff #20 returned approximately 3 to 5 minutes later and redirected Patient #2 back to the interview room.

Interview with Staff #11, #19, and #20 was conducted. Staff #11 confirmed that Patient #2 should not have been left unsupervised with his belt. Staff #19 confirmed that she did not know everyone had left the lobby and Patient #2 was left in her care with a belt. Staff #20 stated she was the first to leave and did not know the police and Staff #21 were going to leave. When asked, Staff #11, #19, and #20 did not describe a standard handoff procedure for patients between admission staff.

Telephone interview of weekend and overnight staff was conducted. Staff #8 and Staff #22 confirmed that only one person is scheduled for admissions on weekend and overnight. They confirmed that they are the only staff at the front of the building during this time. They confirmed the only security during the admissions process are cameras allowing the staff in the back of the building to observe the lobby of admissions. However, if there were an incident, there are 3 locked doors between the patient units at the back of the building and admissions at the front of the building. Both confirmed that they are often alone with one or more admissions. Staff #8 stated that the majority of admissions on weekend and nights are brought in by the police as involuntary admissions. Staff #22 stated that admission staff rely on their "Handle with Care" training to de-escalate situations while alone. Staff #8 stated that, if it is possible, extra staff is requested to come to the front. Staff #8 stated this isn't always possible due to short staffing. When asked why the House Supervisor does not help, Staff #8 stated the House Supervisor on weekends and nights is usually a registered nurse assigned to a unit, who can't leave the unit.

Review of Glen Oaks Hospital Risk Management Policy and Procedures, Title: Suicidal and Homicidal Special Precautions, Policy Number: RM044, Review Date 01/2016 was completed. The policy is as follows:

"POLICY: Patients demonstrating ideation, impulses or behavior indicating that they are at high risk of danger to themselves of (sic) others should be managed in such a way as to minimize the threat of injury of (sic) harm."

PURPOSE:

To establish procedures which support the following:
1. Guidelines for the assessment and diagnosis of suicidality, and/or homicidality at the time of assessment and throughout hospitalization.
2. Appropriate protection and treatment for patients and others at risk.

PROCDURES:

1. A comprehensive evaluation for the following should be performed and documented on all individuals assessed by the admissions staff:
1.1 Current risk to self/others;
1.2 History of suicidal/homicidal ideation/behaviors;
1.3 Accuracy of reports and history of risk;
1.4 Suicide/homicide risk factors

2. Admissions staff should contact the physician for individuals assessed to be at risk for harm to self/others. The physician should utilize the information from the needs assessment evaluation of risk to self/others to determine the appropriate level of care.

3. During the admission process, the patient and their belongings should be checked for items that could be used for self injury or injury to others."

The policy did not address the risks and management of patients in the admission area befor admission staff had completed an assessment to determine if the patient is a risk to self or others. The policy did not address the monitoring of patients in the admission area before the completion of an assessment when multiple admission patients are present and level of patient risk is unknown.







32143


B. Review of patient #1's chart, and interviews revealed the following;

Patient #1 was admitted to the facility on 8-25-16 as a voluntary patient. She was referred by the mental health authority where she had been receiving psychiatric care for 2 years. Patient #1 was having increased psychosis and panic attacks. Review of the Admission Psychiatric Evaluation dated 8/26/16 stated, "patient reported for the last 2 weeks she had been having daily panic attacks without any clear precipitant. She has become increasingly paranoid over the past couple of months, afraid that people are watching her continuously, hearing voices that are telling her to run away from home or else they will get her family members. She has been responding to internal stimuli and has been running away from home for many hours and her family having to look for her and search for her to bring her back home safely."

Review of Patient #1's physician order dated 8-25-16 revealed she was admitted with a diagnosis of Schizophrenia and placed on Observation rounds every 15 minutes and Elopement Precautions (EP). The definition of EP according to the policy and procedure "Elopement Precautions" stated, "To make every reasonable effort to prevent a patient, voluntarily or involuntarily admitted, from leaving the hospital without authorization."

Review of the physician orders dated 9-4-16 revealed the physician discontinued the Elopement Precautions.

Review of the nurses notes dated 9-7-16 at 7:55AM revealed the patient had been "tearful while talking" and stated, "her AV (auditory hallucinations) have decreased but remains tearful and states she is fearful but does not wish to discuss at this time." There was no further documentation until 7:30PM. On 9-7-16 at 7:30PM the nurse documented, "Patient is in dorm room lying in bed. She is on EP precautions and 15 minute checks and seizure precautions. Patient still responding to internal stimuli. She has been tearful at times."

Review of the nurses notes revealed a late entry note written on 9-8-16. Staff #23 (RN) documented, "Late Entry for 9-7-16. At 12:32 MHT (Mental Health Technician) informed me that she was unable to account for the patient upon returning to the unit from lunch. A thorough search of the unit and hallways were performed. Administration was informed of the elopement."

Review of the nurses notes revealed a late entry note written on 9-8-16. Staff #22 (RN) documented, "Late entry for 9-7-16 at 1545 (3:45PM) pt arrived back at hospital. Skin search and belongings search completed with no contraband found. Pt placed on SCU (adult unit) and MHT notified. Q 15 minute checks to resume at this time for safety. Order received to place pt on elopement precautions. MHT notified of new precautions. Will continue to monitor with 15 minute checks for safety."

Review of the MHT patient activity record revealed on 9-7-16 the following activities were documented at these times;

12:00PM- patient was calm and in dayroom.
12:15PM- patient was calm and outside smoking
12:30PM- patient was calm and in dining room. The entry was marked through.
12:45PM- patient was calm but the location was blank. The entry was marked through.
13:00-14:45 patient behavior was "n/a" and location stated off campus.
15:00 (3:00PM) -patient is calm and sleeping.
15:15- 16:30- patient is sleeping in bedroom.

There was a 45 minute discrepancy in time on when the patient was back to the unit. The MHT documented the patient activity at 3:00PM but the nurse stated the patient was not back on the unit until 3:45PM. There was no further nursing documentation found on the elopement or patient's condition in the chart.

Review of patient #1's chart revealed there was no medical examination from a physician upon return to the unit on 9-7-16 or labs to see if any substances were ingested during the absence from the facility.

Review of the incident reports revealed the Risk Manager filled out an incident report the following day on 9-8-16. The report had minimal information on it but stated the Physician, RN Supervisor, Administrator, Risk Manager, and Greenville Police Department were all contacted at 12:35PM on 9-7-16. It did not say who contacted these individuals. On physician response it stated, "n/a."

Review of the physician progress notes dated 9-7-16 at 22:58 (10:58PM) stated, Patient #1 "is a white female, who was admitted to Glen Oaks Hospital for sever psychosis. She is exhibiting reduction in level of anxiety this morning, but this afternoon _____ (patient name) eloped from the hospital, was brought back by Sulfur Springs Police Department after seen walking beside the road. When she arrived back at Glen Oaks Hospital, on interview, ____ (patient's name) stated, "The voices were telling me to run away, so I ran." She has been placed on elopement precautions. She is tearful and anxious, says the voices still keep bothering her."

Review of patient #1's treatment plan revealed there was no documentation of the EP precautions or the elopement. Problem #1 stated, "Alteration in Thinking. Hallucinations telling her to run away." There was no long term goals or dates documented. There was four different medication changes for Seroquel and Haldol. There was no short term or long term goals documented. No target dates noted.

Review of the patient consents revealed the patient was brought back to the facility with no warrant by the police. The patient had initially signed in as voluntary. The patient was not readmitted or asked to sign back in as a voluntary patient. There was no documentation that the patient was informed of her patient rights and if she wanted to remain as a patient or request to be discharged.

Review of the date and time when this incident happened revealed this surveyor was in the facility for another complaint visit. This surveyor and another surveyor had gone to lunch when this incident occurred on 9-7-16. The facility did not divulge to the surveyors that the patient had eloped or had returned.

An interview was conducted on 1-18-17 with staff #23 (RN), concerning the elopement of patient #1, on 9-7-16. Staff #23 stated she remembered the incident but it was long time ago. Staff #23 reported that the patient had gone to lunch with the group and a MHT. The MHT came back to the unit after lunch and stated she could not find patient #1. She was not sure when the patient had come up missing. Staff #23 reported that she started checking the building and alerted the DPN (Director of Psychiatric Nursing.) Staff #23 stated she didn't know who called the police. The facility was searched and the physician was notified. Staff #23 reported the patient had hitched hiked to Sulfur Springs about 30 miles from the facility. Staff #23 reported the police stated the driver felt patient #1 was acting strange and they pulled over and made patient #1 get out of the vehicle. The driver then called the police. The Sulfur Springs Police found her wondering down Interstate 30. Patient #1 was brought back to the facility and searched on the unit for contraband. Staff #23 reported that she did not readmit patient #1 to the facility. Staff #23 confirmed that nothing changed in the chart and patient #1 continued on with the same paperwork and was considered voluntary. Staff #23 was not sure if patient #1 was asked if she wanted to be there or discharged from the facility.

An interview with the Administrator, Interim Director of Psychiatric Nursing (IDPN), and Risk Manager on 1-18-17 concerning the elopement of patient #1. Administrator acknowledged that the patient did elope out the front door while going to the cafeteria. Administrator reported patient #1 had left out the front door with no one noticing her. Administrator confirmed patient #1 was reported missing to the police and was brought across county lines, from Hopkins County to Hunt County, without a warrant. The Risk Manager stated that she wrote the incident report and was working with the past DPN on the incident.

The Administrator stated the MHT had pre-charted on patient #1's activity and location. The MHT was terminated that day. The Administrator confirmed patient #1 was not discharged or readmitted as a voluntary patient. Patient #1 was brought back to the facility on the same consents and paperwork upon the initial admission. The Administrator and Risk Manager both confirmed there was no documentation that patient #1 was asked if she wanted to come back to the facility or discharge. The Administrator was asked why the surveyors were not informed of the elopement and she stated, "I didn't think that was reportable."

The Administrator and Risk Manager confirmed that the facility had not followed its elopement policy. There had been no education to the employees on elopements or how to handle a patient brought back from an elopement to the facility after the incident on 9-7-17. The Administrator and Risk Manager confirmed there was no documented physical assessment by the nurse or a medical clearance by a physician upon patient #1 returning to the facility.

Based on observation, interview, and review of records, the facility neglected to provide policies and processes that protected the patient's dignity and prevented mental anguish for 1 (Patient #4) of 3 patients observed during the admission process.

Findings included:

On 1-18-2017 at approximately 10:00 AM, a tour and observation of admissions was conducted with Staff #11, #19, #20, and #21 present.

Upon entering the admission area, there were 3 people in the lobby.

Patient #3 was a 15 year old female with her mother. She was in the process of being sent to another hospital for medical treatment rather than being admitted. An ambulance was in route. Staff #19 was working on the necessary paperwork in an office at the back of admissions. This office had two large windows that allowed the lobby to be viewed by staff in the office.

Patient #4 was an adult female that had been screened for admission and was waiting on the admission paperwork to be processed by Staff #20. Patient #4 was sitting with her back to the office where Staff #19 was working. Patient #4 appeared to have been crying, with red eyes and a tissue wiping her face.

Patient #2 was an adult male in handcuffs that had just been escorted in by two police officers and Staff #21. Staff #11 stated she would have to leave the area because she knew the patient and it was a conflict of interest for her to stay.

Staff #21 stated the patient was from the local Mental Health and Mental Retardation (MHMR) facility. Staff #21 stated the MHMR staff became concerned about his increased level of agitation and responding to internal stimuli. Patient #2 was observed to have rapid and jerking body movements and mumbling as if talking to someone. Staff #20 used a metal detecting wand to scan Patient #2 for possible weapons. The patient was found to have a lighter in his pocket that was removed by one of the police officers present. The patient was found to have a belt with a metal belt buckle. This was not removed from the patient. The police then removed the handcuffs. The police remained present while completing their paperwork. Staff # 20 attempted to interview the patient with limited responses from the patient. Staff #20 told Staff #21 that she believed the patient had been admitted previously. She stated she was going to go to medical records department to pick up his chart from that admission in order to review medical information she was unable to obtain from the patient.

After Staff #20 had departed the locked admissions area, Staff #21 departed the locked admissions area to escort the police out of the building. Nobody was observed to advise Staff #19 that she was being left alone with the 3 females in the lobby and a potentially aggressive male patient in an interview room that could not be observed from the windows in the back office. In addition, the male patient had been left with a belt that had a metal belt buckle. This could have been used as a weapon or ligature to harm himself or the other females that had been left in the lobby.

As soon as Staff #21 had exited the locked admissions area, Patient #2 came out of his interview room and began pacing around the females in the lobby. Staff #19 continued to process Patient # 3's paperwork for transport to the hospital. Staff #19 did not come out of the office to check on the patients and family member in the lobby. Staff #20 returned approximately 3 to 5 minutes later and redirected Patient #2 back to the interview room.

Interview with Staff #11, #19, and #20 was conducted. Staff #11 confirmed that Patient #2 should not have been left unsupervised with his belt. Staff #19 confirmed that she did not know everyone had left the lobby and Patient #2 was left in her care with a belt. Staff #20 stated she was the first to leave and did not know the police and Staff #21 were going to leave. When asked, Staff #11, #19, and #20 did not describe a standard handoff procedure for patients between admission staff.

Staff #19 was advised that Patient #4 had appeared to be frightened by Patient #2. Staff #19 stated that she had spoken with Patient #4 prior to Patient #2's arrival and told her the staff would be watching to keep her safe. Again, Staff #19 was advised that Patient #4 had appeared to be frightened and upset. Staff #19 then went to the lobby and moved Patient #4 into a private interview room.

An interview was conducted with Patient #4 after she was moved to a private interview room. When told she had appeared frightened, the patient stated, "I was terrified. I'm already anxious. I don't know how much more I can take." When asked if Staff #19 had spoken to her about Patient #2 prior to his arrival, she stated, "No. Nobody said anything until they brought me in here." (Referring to being placed in the private interview room)

When Patient #4 was ready to go to the unit for the nursing skin assessment and contraband check, she was made to walk from the admissions area to the patient unit in her socks. It was raining outside. The patient questioned Staff #19 about having to go outside to smoke in the rain, in her socks. Staff #19 explained that Patient #4 had been wearing shoes with shoe laces when she arrived. Her shoes were taken from her while her partner had gone home to get another pair. The patient was not offered a pair of non-slip socks or any other form of footwear. The patient was told, "Maybe it will quit raining or they'll take you to a covered patio area to smoke." When Staff #19 was asked why Patient #4 wasn't given non-skid socks or alternate footwear, she replied, "Should I have given her non-skid socks?"

Once inside the exam room for the nursing skin assessment and contraband check, Staff #19 was asked to explain the search process once again. Staff #19 explained that the patient was going to have remove all clothing from her upper body and stand in full view of the nurse conducting the skin assessment and admissions person who would simultaneously check the removed clothing for contraband. Once the clothing search and skin assessment were completed, the patient could put her top clothing on. The patient would then be asked to remove all of her bottom clothing and stand naked in front of the staff from the waist down while the process was repeated for the lower half of the body and clothing. When asked if the patient had a sheet or gown to cover up with during the process, only exposing those parts of the body briefly, Staff #19 stated no. Staff #19 stated there was a screen in the room that the patient could stand behind.

Upon observation of the exam room, no sheets, towels, gowns, blankets or dirty linen carts were available to accommodate patients who were modest. There was a screen. However, Staff #19 explained that she and Staff #18 would both be behind the screen with the patient. Patient #4 expressed to Staff #19 that she found this process distressing. The process was stopped at this time by the surveyor and Nursing Staff #18 was directed to provide Patient #4 with a sheet.

When questioned, Staff #18 stated, "We give them a blanket if they're cold or ask for one." When asked how many times she has seen a patient given a blanket or something to cover up with, Staff #19 said, "Never."

Interview was conducted with Staff #1. Staff #1 stated patient dignity is maintained by the patient only have to remove full clothing from half their body at a time and by providing a screen for the patient to stand behind. When advised that everyone in the room is behind the screen and that patients still have to stand fully naked from the waist up or waist down in front of staff, Staff #1 stated, "The admission staff isn't supposed to be behind the screen." Staff #1 stated they did not have patient gowns for examination. Staff #1 stated that it was their policy to provide the patient with a blanket to cover up with. Staff #1 was advised that there were no blankets available in the exam room or a dirty hamper to place them at the end of the exam. Staff #1 was advised that Staff #18 and #19 both indicated that this practice is not routinely carried out.

Staff #3 was interviewed. Staff #3 asked why the patient wasn't given non-skid sock. Staff #3 was told Staff #19's response to the same question, "Should I have given her non-skid socks?" Staff #3 asked if Patient #4 had been given non-slip socks when she had arrived on the Unit. Staff #3 was advised she had not. Patient #4 was given back her own socks to continue wearing.

Review of Glen Oaks Hospital Policy and Procedures, Title: Patients' Rights, Policy No.: SS.20 with attached Patients' Bill of Rights, revised 12/4/2014 was conducted. Basic Rights for All Patients on page [11], Item 3 was as follows:

"3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regards to personal need, and are treated with dignity and respect. This organization supports the right for each patient to personal dignity."

Based on observation, interview, and document review, hand hygiene for the control and spread of infection between patients and staff is not being effectively monitored in Admissions. 1 staff member (Staff #20) out of 4 staff members observed in the admissions area failed to remove gloves and perform proper hand hygiene after examining a patient.

Findings are as follows:

On 1-18-2017 at approximately 10:00 AM, a tour and observation of admissions was conducted with Staff #11, #19, #20, and #21 present. When Patient #2 arrived, Staff #20 put gloves on and proceeded to examine the patient for possible contraband. Upon completion of the exam, Staff #20 went to the office in the back of admissions and proceeded to look up patient information on the computer without removing her gloves. After accessing the information, Staff #20 realized she still had her gloves on; got up, removed and discarded the gloves; and used hand sanitizer from the wall dispenser to clean her hands. However, Staff #20 never wiped down the keyboard she had been using to access the patient data. Staff #11 and Staff #19 both used the keyboard after her.

Interview with Staff #20 was conducted. Staff #20 confirmed that she had forgotten to remove her gloves upon leaving the patient interview area and disposing of them. Staff #20 confirmed she did not wipe down the keyboard.

Infection control policies for controlling the spread of infection were reviewed as follows:

Review of GLEN OAKS HOSPITAL Infection Control Policy and Procedures, Title: Hand Hygiene Monitoring, Policy Number: ICA007, Review Date: 01/2016 was conducted and was as follows:

"POLICY: Glen Oaks Hospital will monitor all staff for opportunities, compliance and proper use and technique of hand hygiene before and after patient contact, before an aseptic procedure, after exposure to body fluid and after contact with patient surroundings.

PROCEDURE:

1. Department managers will be assigned to randomly monitor 10 health care workers monthly.
2. Department managers will be given a hand hygiene monitoring tool to use monthly, specifying when to do hand hygiene, what was the hand hygiene method used and was appropriate technique used.
3. Whenever a discrepancy is observed, department manager will educate health care worker.
4. At the end of each month, the monitoring tool will be submitted to the infection preventionist.
5. Infection preventionist will gather information from the monitoring tool and report to managers/directors of the result for further education of specific department.
6. Infection preventionist will have data ready to be submitted and presented to committee responsible for infection control."

Review of GLEN OAKS HOSPITAL Infection Control Policy and Procedures, Title: Hand Hygiene, Policy Number: ICA008, Review Date: 01/2016 was conducted and was as follows:

"PURPOSE:

1. Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings.
2. Hand hygiene reduces the incidence of healthcare associated infections.
3. CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of these patients die as a result of their infection.
4. More widespread use of hand hygiene products that improve adherence to recommended hand hygiene practices will promote patient safety and prevent infections."


Page 2 of 4," HAND HYGIENE INDICATIONS:
1. Hand hygiene is indicated before;
1.1.1. patient contact
1.1.2. donning gloves inserting urinary catheters or other invasive devices that don ' t require surgery
2. Hand hygiene is also indicated after;
2.1.1 contact with a patient ' s intact skin
2.1.2 contact with body fluids or excretions
2.1.3 non-intact skin or wound dressings
2.1.4 removing gloves."

Review of Glean Oaks Hospital Performance Improvement Monitor for the third quarter was completed. Information for the fourth quarter had not been compiled per Staff #2. Staff #2 stated she had been too busy to pull all of the data together in a report. The third quarter report under "Findings" showed, "Admission staff were monitored between patient assessments. No monitoring log was submitted for the quarter."

Under "Result of actions from previous quarter" was listed, "Unable to compare compliance rate for housekeeping staff, PHP/IOP, reception and admissions due to no monitoring logs submitted for the second quarter."

Per the graph provided with the monitor, no data was provided for Admissions Staff for 3rd Quarter 2015, 4th Quarter 2015, 2nd Quarter 2016, and 3rd Quarter 2016.