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Based on interview, record review and policy review, the hospital failed to ensure that staff were trained on a periodic basis in first aid related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), for 11 staff (D, K, O, Q, T, GG, LL, TT, ZZ, HHH and PPP) of 15 staff, whose personnel files were reviewed. This failure had the potential to result in serious injury or death to patients who required restraints in the hospital. The hospital census was 242.

Findings included:

1. Review of the hospital's policy titled, "Restraints and Seclusion," dated 07/14/21, showed that all workforce members who apply restraints or provide care for patients in restraints or seclusion, including contract or agency personnel, must demonstrate competencies in application of restraints and implementation of seclusion, monitoring, assessment and providing care for a patient in restraints or seclusion, including basic first aid, initially as part of orientation and subsequently on a periodic basis. Training will include, but is not limited to, the following topics as appropriate to the patient population served: monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs and the use of first aid techniques.

Review of the hospital's restraint log showed 121 patients required violent and/or non-violent restraints for the previous six months.

Review of 11 personnel files showed no periodic restraint first aid training for the following staff since these dates:
- Staff D, Certified Nurse Assistant (CNA), 02/19/19;
- Staff K, Behavioral Health Unit (BHU) Director of Nursing (DON), no restraint first aid training;
- Staff O, BHU Mental Health Technician (MHT), 11/07/11;
- Staff Q, BHU Licensed Practical Nurse (LPN), 11/24/13;
- Staff T, Registered Nurse (RN), 01/08/19;
- Staff GG, BHU MHT, 06/19/14;
- Staff LL, RN, 09/11/12;
- Staff TT, RN, 09/27/16;
- Staff ZZ, RN, 06/02/13;
- Staff HHH, RN, 07/10/19; and
- Staff PPP, Corporate Chief Nursing Officer (CNO), 08/21/11.

During an interview on 09/23/21 at 10:45 AM, Staff QQQ, Corporate Clinical Education and Research Director, stated that all nursing staff received restraint first aid training when hired during orientation. The staff included in restraint first aid training were RNs, LPNs and Unlicensed Assistive Personnel. Nursing staff did not receive annual or periodic restraint first aid retraining.

During an interview on 09/23/21 at 11:55 AM, Staff PPP, Corporate Chief Nursing Officer, stated that she was aware that nursing staff received restraint first aid training only once, when they were hired.

Based on interview, record review and policy review, the hospital failed to assess elopement (when a patient makes an unauthorized departure) risk and implement elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury) for one current patient (#8) and one discharged patient (#17), to prevent them from leaving the hospital unsupervised. The hospital also failed to follow physicians' orders for 1:1 observation for two current patients (#59 & #62) and four discharged patients (#60, #61, #63 and #64), when nursing staff used one staff member to observe two at risk patients at the same time. These failures had the potential to affect the safety of all patients who were at risk for elopement or harm.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census 262.

Based on interview, record review and policy review, the hospital failed to assess elopement (when a patient makes an unauthorized departure) risk and implement elopement precautions (EP, interventions to prevent someone from leaving who may be at risk for self-harm or injury) for one current patient (#8) and one discharged patient (#17), to prevent them from leaving the hospital unsupervised. The hospital also failed to follow physicians' orders for 1:1 observation for two current patients (#59 & #62) and four discharged patients (#60, #61, #63 and #64), when nursing staff used one staff member to observe two at risk patients at the same time. These failures had the potential to affect the safety of all patients who were at risk for elopement or harm. The hospital census was 262.

Findings included:

1. Review of the hospital's policy titled, "Elopement and Elopement Precautions," revised 08/14/21, showed the following:
- Staff would assess the patient for elopement risk at admission and document findings in the initial triage or admission database.
- Patients who had a legal guardian were considered an elopement risk and would receive a green wristband, and staff would immediately protect them by using enhanced patient safety measures (EPSM).
- EPSM's included a green wrist band being placed on the patient, staff were to orient and reorient the patient, evaluate the patient for falls, place the patient in a room as close to the nursing station as possible and perform frequent checks.
- Nursing staff were to sit with the patient at the bedside for the entire shift when EPSM's had failed.

Review of the hospital's undated document titled, "ED Triage Form," showed that part of the nurse triage general information/safety screening included an elopement risk screening. Nursing staff were to mark the applicable elopement risks and then select the appropriate interventions to put into place to prevent the elopement. Elopement risk screening options included: had a history of previous elopement or elopement risk, was pacing or wandering, was having hallucinations or delusions, lacked mental capacity, had confusion, had a legal guardian and N/A. The elopement risk safety measure (also known as EP) to be implemented included orienting the patient to the environment, evaluating the patient for fall risk, placing the patient in a room close to the nurses station, placing the patient on a 1:1, and placing a green arm band on the patient.

Review of Patient #8's medical record showed the following:
- He was a 58 year old male who was brought into the Emergency Department (ED) on 09/02/21, for altered mental status.
- His past medical history included substance abuse (misuse of alcohol and/or drugs), agitation, altered mental status and metabolic encephalopathy (a problem in the brain that can lead to personality changes).
- On 09/03/21 at 1:31 PM, ED triage nursing documentation showed "N/A" was selected on his elopement risk screening, and no elopement safety measures were put into place.
- Nursing documentation from 09/04/21 through 09/19/21 showed that Patient #8 had altered mental capacity.
- On 09/17/21 at 7:59 PM, physician documentation showed that Patient #8 was agitated and confused.
- On 09/18/21 at 8:33 PM, physician documentation showed that Patient #8 was agitated, aggressive and combative the previous night. Patient #8 had threatened harm to nursing staff. Patient #8's roommate reported that Patient #8 threatened to beat him up. Medication was ordered for agitation. No EP were put into place.
- On 09/19/21 at 6:28 PM, nursing documentation showed Patient #8 was no longer in his room and was last seen around 5:30 PM. A Central Monitoring Technician (CMT) found the patient at the bus stop in front of the hospital, and the patient was returned to the hospital. He still had his telemetry (remote observation of a person's heart rhythm, using signals and are transmitted from the patient to a computer screen) equipment on, and his intravenous (IV, in the vein) catheter in.
- There were no psychosocial (relating to the interrelation between social factors and individual thought and behavior) assessments completed prior to the patient's elopement on 09/19/21, but all assessment documented after showed that Patient #8 had poor insight and judgement.
- Staff continued to document "N/A" for the patient's elopement risk on 09/21/21 and 09/22/21, after the patient had eloped.

Review of the hospitals document titled, "Event Report," dated 09/19/21, showed that Patient #8 was found at the bus stop with slurred speech and walked unsteadily. He was returned to the hospital. The event report recommendations for improvement included placing elopement orders for patients as appropriate.

There was no education provided to staff following this event.

2. Review of the hospital's policy titled, "Guardianship," revised 02/16/21, showed that a guardian was someone appointed by the court to have the care and custody of a minor or of an incapacitated person. An incapacitated person was defined as one who was unable by reason of any physical, mental, or cognitive condition and lacked capacity to meet essential requirements for food, clothing, shelter, safety or other care, such that serious physical injury, illness or disease was likely to occur.

Review of Patient #17's medical record showed the following:
- He was a 68 year old male who was brought to the ED by EMS on 07/16/21 for aggressive behavior, following an altercation at his nursing home where he punched another resident in the face.
- The patient's demographic information from the nursing home where he resided was scanned into the medical record with a patient label dated 07/16/21, and included the name, address and phone number of his guardian.
- He had a past medical history of schizoaffective disorder (mental health disorder where a person may experience hearing voices that are not real).
- On 07/16/21 at 9:57 PM, nursing documentation showed "N/A" was selected on the elopement risk screening assessment, and no EP were selected.
- On 07/16/21 at 11:52 PM, the ED physician documentation showed that he spoke with staff from the nursing home and was informed that the patient had a guardian.
- There were no physician orders for EP in the patient's medical record.
- On 07/17/21 at 1:55 AM, nursing documentation showed that she was preparing to discharge the patient, when she found he was missing from the room. She informed the physician of the patient's early departure. The physician told her that the patient could not leave unsupervised because he had a guardian. She was not aware the patient had a guardian, and EP had never been ordered for the patient.
- On 07/17/21 at 5:56 PM, nursing documentation showed that the patient was returned to the ED by EMS, after he was found by bystanders and called 911. His elopement risk assessment on return indicated that he had hallucinations or delusions, lacked capacity, and had a legal guardian.

During an interview on 09/29/21 at 10:00 AM, Staff OOO, Registered Nurse (RN), stated the following:
- She completed Patient #17's triage assessment.
- EMS did not give her paperwork from the nursing home when they brought Patient #17 to the ED.
- She did not ask Patient #17 if he had a guardian, and she did not review his medical record to see if he had a guardian, but should have assumed he did because he came from a nursing home.
- Patient #17 paced, acted strange, and made her nervous while he was in the ED, so she checked on him frequently.
- She did not know if an elopement risk assessment was part of the triage assessment, but if it was, then she would have completed it.
- If the patient met any of the elopement risk assessment criteria, then the nurse would have been prompted to put preventative measures into place.
- She reported to Staff NNN, Doctor of Osteopathy (DO), that Patient #17 was pacing and acting strange.
- After Patient #17 eloped, she was informed by the charge nurse that all patients who had a guardian were to automatically be put on 1:1 observation. She was not aware of this policy and it was not part of her orientation.

During an interview on 09/22/21 at 1:25 PM, Staff B, Director of Emergency Services (in training), stated that all patients who presented to the ED should have an elopement risk assessment completed as part of the triage assessment.

During an interview on 09/21/20 at 2:10 PM, Staff BBB, Director of Emergency Services, stated that an elopement risk assessment included determining if the patient was pacing or wandering, had hallucinations or delusions, lacked mental capacity, was confused, or had a guardian. If they met any of these criteria, then some sort of EP should be put into place.

During an interview on 09/22/21 at 6:56 PM, Staff RRR, RN, stated the following:
- She received report that Patient #17 was from a Skilled Nursing Facility, had been in an altercation, and was ready to be discharged, but when she went to check on Patient #17, he was not in his room.
- She told the physician that the patient was missing, when the physician informed her that he could not leave unsupervised because he had a guardian.
- The nursing home paperwork paperwork given to them by EMS upon arrival, indicated that Patient #17 had a guardian.
- Staff NNN, DO, was aware that Patient #17 had a guardian, but he did not report this information to the nurses or order EP to be put into place.

During an interview on 09/22/21 at 12:00 PM, Staff NNN, DO, stated that he was Patient #17's ED physician the night he eloped from the ED. He called and spoke with nursing home staff prior to the elopement, and was made aware that the patient had a guardian. He did not report that the patient had a guardian to the nurse, and confirmed he did not order EP be put into place. It was the responsibility of the physician to find out if patients had a guardian.

The hospital failed to protect Patient #17 from eloping from the ED. Patient #17 met the criteria for elopement risk by his pacing, acting strange and having a guardian, and should have had EP put into place to prevent the patient from eloping. He left unsupervised, sometime between 1:40 AM and 1:55 AM, and was missing until around 5:56 PM.

3. Review of the hospital's document titled, "1:1 Status," revised 03/11/20, showed the following:
- Patients who are assessed to be a risk to harm themselves or others intentionally, shall be immediately protected by implementation of 1:1 status.
- Patients who exhibit behaviors or statements that demonstrate risk for intentional harm to self or others must be accompanied by and monitored by nursing staff or a 1:1 nursing designee, social worker, or provider at all times.
- The patient shall not be left alone until a provider has discontinued the 1:1 status.
- After initiation of 1:1 status, discontinuation would occur after a provider assessment and a provider order to discontinue.
- The patient with an order for a 1:1 must remain in full view of the assigned 1:1 caregiver at all times.
- The 1:1 caregiver must be situated between the patient and the door, or at the door threshold.

Review of Patient #60's medical record showed the following:
- He was a 39 year old male who presented to the ED on 09/20/21 for psychosis (a severe mental disorder causing a loss with reality), and was having auditory hallucinations (hearing imaginary things).
- On 09/20/21 at 4:21 PM, there was a physician's order for a 1:1 observation for homicidal ideation (HI, thoughts or attempts to cause another's death).
- Constant observation/1:1 observation flow records on 09/20/21 from 7:00 PM until 10:00 PM were signed by Staff UUU, Patient Care Technician (PCT).

Review of Patient #64's medical record showed the following:
- He was a 44 year old male who presented to the ED on 09/20/21 with suicidal ideation (SI, thoughts of causing one's own death), and planned to jump off of a bridge.
- On 09/20/21 at 6:43 PM, there was a physician's order for a 1:1 observation for SI.
- Constant observation/1:1 observation flow records on 09/20/21 from 7:00 PM until 10:00 PM (the same time frame as Patient #60 was observed 1:1), were signed by Staff UUU, PCT.

During an interview on 09/27/21 at 7:15 PM, Staff UUU, PCT, stated the following:
- On 09/20/21 she performed 1:1 observation for both Patient #60 and Patient #64 at the same time, and the patients were not in the same room.
- She had been the sitter for more than one patient at a time who had orders for a 1:1 observation.
- She had received training "in a roundabout way" for 1:1 observation.
- Patients in restraints were the only patients who had a strict 1:1.

Review of Patient #63's medical record showed the following:
- She was a 33 year old female who presented to the ED by EMS for SI, and a plan to overdose on medications.
- On 09/21/21 at 7:46 PM, there was a physician's order for a 1:1 observation for SI.
- Constant Observation/1:1 observation flow records on 09/21/21 from 8:00 PM until 09/22/21 at 6:00 AM were signed by Staff TTT, PCT.

Review of Patient #59's medical record showed the following:
- He was a 54 year old male who presented to the ED by EMS for SI.
- On 09/21/21 at 8:31 PM, there was a physician's order for a 1:1 observation for SI.
- Constant observation/1:1 observation flow records on 09/21/21 from 8:00 PM until 09/22/21 at 6:00 AM (the same time frame as Patient #63 was observed 1:1), were signed by Staff TTT, PCT.

During an interview on 09/27/21 at 7:00 PM, Staff TTT, PCT, stated the following:
- It was normal for her to be assigned two patients at the same time who had 1:1 observation orders.
- She performed 1:1 observation for both Patient #63 and Patient #59 on 09/21/21 and 09/22/21, and the patients were not in the same room.
- She did not remember if she received training for 1:1 observations.

Review of Patient #62's medical record showed the following:
- She was a female who walked into the ED with SI. She told them her name was leg and dirt.
- On 09/21/21 at 9:27 PM, there was a physician's order for a 1:1 observation for SI.
- Constant observation/1:1 observation flow records on 09/21/21 at 9:00 PM were signed by Staff VVV, PCT.

Review of Patient #61's medical record showed the following:
- She was a 30 year old female brought to the ED by EMS for SI.
- On 09/21/21 at 9:08 PM, there was a physician's order for a 1:1 observation for SI.
- Constant observation/1:1 observation flow records on 09/21/21 at 9:00 PM (the same time frame as Patient #62 was observed 1:1), were signed by Staff VVV, PCT.

During an interview on 09/28/21 at 7:00 PM, Staff VVV, PCT, stated the following:
- The hospital considered a 1:1 and a 2:1 observation the same thing.
- If she were doing a 2:1 observation and one of the patients was hurting themselves, she would not intervene, but call for assistance.
- If she were doing a 1:1 observation and the patient was hurting themselves she would intervene to keep them safe.
- Patients who were monitored 2:1 were never placed in the same room, but usually close to one another.
- She watched Patient #62 and Patient #61 at the same time on 09/21/21, and the patients were not in the same room.
- Even if the physician ordered a 1:1 observation for SI, HI, or elopement, she would do a 2:1 observation.
- A strict 1:1 observation was only done on certain patients that staff were familiar with, who had hurt themselves in the past.
- There was a patient that came in frequently who had stabbed herself in the stomach, and she was always a strict 1:1 observation, because "staff just knew her."

During an interview on 09/23/21 at 10:07 AM, Staff A, Associate Chief Nursing Officer (CNO), and Staff BBB, Director of Emergency Services, stated that 2:1 observation was acceptable when a 1:1 was ordered by the physician, if the patients were close and the sitter could watch them both. There was no notation in the 1:1 policy, that 2:1 observation was acceptable.

During an interview on 09/22/21 at 6:56 PM, Staff RRR, RN, stated that it was not possible for one staff member to be able to safely watch two patients at the same time.

During an interview on 09/23/21 at 11:55 AM, Staff PPP, Corporate CNO, stated that they allowed 2:1 observation when a 1:1 was ordered by the physician, although it would not be appropriate to document the observation as 2:1 in the medical record. Staff PPP added that there was no option for a physician to order 2:1 observation in the electronic medical record.