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Review of 11 patient medical records and staff interviews revealed that the staff failed to document that the family and guardian of patient #1 were provided educational information needed to provide care and supervision while the patient was granted an overnight pass to visit his home.

Among patient #1's diagnoses was psychogenic polydipsia, a clinical disorder in which the patient increases fluid intake to an excess. Excessive fluid intake may cause confusion, lethargy, psychosis, seizures and/or death. Patient #1 had had multiple hospitalizations due to hyponatremia (low serum sodium level), a side effect of polydipsia. Patient #1 was supervised while an in-patient at Springfield for his excessive fluid intake and was placed on fluid restriction limiting intake to 2000 ml per day. Documentation on his most recent treatment plan (IPOC), dated 7/16/15, stated "refuses to comply with water restrictions, remains intrusive and resists redirection" and also, "The patient's fluid intake remains high despite fluid restrictions ...is frequently seen at the water fountain and requires frequent redirection".

Patient #1 was granted an overnight pass to visit a family member on 8/1/2015. The medical record indicated that the patient left the hospital on 8/1/2015 at 10:39 AM and was expected to return on 8/2/2015 at 6:00 PM. The nurse documented "education was given to both patient and family member about the conditions for the overnight visit" but failed to document what the family member was instructed to do (ex: return to hospital or call 911 if symptoms are present) if the patient should be found drinking in excess or have symptoms of excessive fluid intake. Review of the 'Multidisciplinary Patient Teaching/Learning Summary' documented education from 5/9/2015 through 7/29/2015 and listed only the patient, not the family, as receiving education about medication and treatment compliance. An interview with the psychiatrist on 10/6/2015 revealed that the medical record failed to reflect conversations with and education provided to the patient's family.

On 8/2/2015 patient #1 was returned to the hospital by his family, more than 8 hours before the scheduled time. The patient's family member stated "this was a terrible mistake." The patient was noted by nursing to be disoriented with "slow speech, and nonsensical." Minutes after returning to the hospital the patient began to seize. Staff immediately provided supportive care and 911 was called to transport the patient to an acute care facility. The patient died later that morning as a result of the excessive fluid intake.

1. Based on review of 10 open and 1 closed medical record, it was determined that 1 of the 10 open medical records (patient #6) lacked documentation regarding follow-up care following a fall.

Patient #6 was a 57 year old female who had chronic mental health concerns with treatment resistance. The patient was currently on 1:1 observation for aggressive behavior toward her peers. Her record review revealed trials of various medications with ineffective results in addressing the behavior. The patient also had multiple medical co-morbidities. Per a progress note written on 10/3/15 at 12:00 AM the patient had fallen from a standing position onto the left side of her body. The patient was assessed by the RN, and vital signs were obtained. The patient received pain medication for a pain score of 5 out of 10. An Adverse Drug Report was completed, and the somatic physician was notified of the fall. The patient did not appear to have any injuries but per the hospital protocol patients are to be seen by the somatic physician and an event report is to be completed. Review of the patient's medical record revealed that the physician completed an event report on 10/3/15 at 5:30 AM with a description of the fall and an assessment. There was only one note written by the nurse regarding the fall. No documentation of follow-up assessment by nursing or monitoring by nursing staff to ensure that no injuries resulted from the fall could be found in the patient's medical record. The hospital failed to document follow-up assessment and care provided for patient #6 after a fall as well as failed to follow their own protocol/policy procedure for assessment, care and monitoring.



2. Based on review of 11 medical records, it was determined that 1 of 11 (patient #1) records failed to have documentation that education was provided to the patient's family about symptoms and side-effects to monitor in regard to excessive fluid intake. Also, confirmed with the risk manager, there were discrepancies in staff documentation regarding the patient's behavior that validated justification for an overnight pass (LOA) being granted for 8/1/2015.

Patient #1 was granted an overnight pass to visit a family member on 8/1/2015. The medical record indicated that the patient left the hospital on 8/1/2015 at 10:39 AM and was expected to return on 8/2/2015 at 6:00 PM. The nurse documented "education was given to both patient and family member about the conditions for the overnight visit" but failed to document what the family member was instructed to do (ex: return to hospital or call 911 if symptoms are present) if the patient should be found drinking in excess or have symptoms of excessive fluid intake. Review of the 'Multidisciplinary Patient Teaching/Learning Summary' documented education from 5/9/2015 through 7/29/2015 and listed only the patient, not the family, as receiving education about medication and treatment compliance. An interview with the psychiatrist on 10/6/2015 revealed that the medical record failed to reflect conversations with and education provided to the patient's family.

Patient #1 was returned to the hospital early the next morning by the family member with symptoms of life threatening excessive fluid intake. Minutes after returning to the hospital the patient began to seize. Staff immediately provided supportive care, and 911 was called to transport the patient to an acute care facility. There was no staff documentation indicating that patient #1's family was educated that the presenting symptoms (disoriented, slow and nonsensical speech) could have been life threatening and that the family should have called 911.

More than one month prior on 7/28/2015 a Physician's Assistant (PA) noted "Patient is reported per nursing to be non-compliant, especially at day pass (2 hour passes) as monitoring cannot be done."

On 7/29/2015 the patient's Social Worker (SW) documented that the patient "does not comply with fluid restrictions." He then noted "the patient has been going on weekly day passes for 2 hours because the patient is more compliant with treatment." SW also stated in the 7/29/15 note that "the patient unrealistically feels he/she is ready for discharge and that he/she can live with family. The patient pressures the father to take him/her home. This is not a realistic option because his/her family cannot even control his/her fluid intake and smoking while on a 2 hour weekly pass."

On 7/30/2015 the patient's psychiatrist documented "the patient continues to argue with staff and continues to drink water. The father wanted to try an overnight pass. Will try an overnight pass to see if the patient can maintain fluid restriction without supervision."

Documentation failed to note why the psychiatrist felt that patient #1 would be safe without staff supervision while on a 2 hour home pass with family when he was non-compliant with nursing staff. The psychiatrist also failed to document education provided to patient #1's guardian about harmful behaviors and symptoms to monitor for while the patient was on the overnight pass (LOA).