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Based on record review, document review, and staff interview, it was determined the facility failed to follow policies and procedures by not following a physician order for a patient to receive Close Constant Observation (CCO) monitoring, in one (1) out of ten (10) patients (patient #1). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #1. On 08/19/22 at 6:41 p.m., it was noted the patient eloped from the facility. An "Elopement Report" was completed, and elopement procedures ensued. On 08/19/22 at 7:07 p.m., an order was placed by Nurse Practitioner (NP) #1 which stated, "If patient returns to the facility, [patient #1] will be a CCO for safety." The patient was apprehended by law enforcement and returned to the facility. The "Safety Check" documentation noted the patient returned by 8:15 p.m., and fifteen (15) minute safety checks resumed. No CCO documentation was noted. NP #1 assessed the patient on 08/20/22 at 12:49 a.m. On 08/20/22 at 8:46 a.m., a note by Physician Assistant #1 stated, "Patient has not had any behaviors overnight. [Patient #1] CCO order will be discontinued and [patient #1] will be on routine 15 (fifteen) minute checks. RN [Registered Nurse] to contact provider with any changes in patient's condition."

A review was conducted of policy titled "Non-suicidal Levels of Observation," last revised 08/26/22. The policy states in part: "Procedures: 1. Close Constant Observation (CCO-Within view with no barriers or as the order by clinical needs) ... D. A patient on this level of observation must always be in view of the staff member assigned to the observation or as directed by the on-call/attending provider's order ..."

A telephone interview was conducted with RN #2 on 09/07/22 at 11:44 a.m. Regarding patient #1, RN #2 stated in part, "I got the call that the patient had returned and that they were bringing [patient #1] to the back door. We got [patient #1] and [patient #1] came in the back door. I called the nurse practitioner on-call [NP #1] and I told [NP #1] I was putting in a note. I did not know there was an order for a CCO."

An interview was conducted with the Chief Executive Officer (CEO) on 09/07/22 at 3:13 p.m. When asked about the CCO order on 08/19/22 when patient #1 was returned after the elopement, the CEO stated, "The order prints on unit N2 [Nancy Two] since there is no printer on unit N3 [Nancy Three]. No one shared the order with N3 staff. No one on N3 saw the order."

An interview was conducted with the Quality Patient Safety Specialist (QPSS) on 09/08/22 at 8:30 a.m. When asked about the CCO order being missed, the QPSS stated, "When we found out about the order, we had difficulty getting the order to populate in the electronic medical record to be seen. We had to try several times to get it to show up. It may not have been visible to the RN."