HospitalInspections.org

Based on document review, video surveillance review, and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13 Patient Rights.

Findings include:

1. The hospital failed to ensure appropriate supervision and monitoring was maintained to prevent a psychiatric patient from eloping. See A-144.

The Immediate Jeopardy (IJ) began on 10/28/2023 due to the hospital's failure to ensure appropriate supervision and measures were in place for a patient on elopement precautions. Subsequently, a patient eloped from the hospital's psychiatric unit. The IJ was identified on 11/14/2023, at 42 CFR 482.13, Patient Rights. The IJ was announced on 11/14/2023, during a meeting with the Vice President of Operations, Chief Nursing Officer, Director of Nursing, Director of Nursing, Emergency Department/ED, and the ED Manager. The IJ was not removed by the survey exit date of 11/14/2023.

Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #13 and Pt. #14) grievances reviewed, the hospital failed to provide a written response within seven days following receipt of the grievances.

Findings include:

1. On 11/09/2023, the hospital's policy titled, "Resolution of Patient Complaints" (8/2023) was reviewed and included, "... Definitions...2. Patient Grievance: A grievance is a formal or informal written or verbal complaint that is made to the Hospital by a patient, or the patient's representative, regarding the patient's care (when not able to be resolved when presented to staff)... Procedure... 4. Process for Handling Grievances... e. Communication with Patient or Representative. The management staff member who received the grievance provides a written response to the patient or representative according to the following guidelines... 2. The average timeframe of seven calendar days..."

2. On 11/09/2023, the hospital's grievance log from 8/01/2023 through 11/09/023 was reviewed. The log included the following:

- On 9/7/2023, the hospital received a grievance from Pt. #13's representative regarding issue with care coordination between clinicians and staff. The grievance was not resolved at the time the grievance was received. The hospital sent a written response to Pt. #13 on 9/15/2023 (eight days following receipt of the grievance).

- On 8/22/2023, the hospital received a grievance from Pt. #14 regarding discharge planning. The grievance was not resolved at the time of the grievance received.. The hospital sent a written response to Pt. #14 on 9/20/2023 (twenty-nine days following receipt of the grievance).

3. On 11/09/2023 at approximately 12:00 PM, findings were discussed with E #10 (Patient Advocacy Manager). E #10 stated that the written response should have been sent within seven days following receipt of the grievance.

Based on document review, video surveillance and interview, it was determined that for 1 of 4 patients (Pt. #2) on elopement precautions, the hospital failed to ensure appropriate supervision and monitoring was maintained to prevent a psychiatric patient from eloping.

Findings include:

1. The hospital's policy titled, "Psychiatric Precautions and Observation Levels - Psychiatric Inpatient Program" (7/2023) included, "Purpose: To maintain safety for patients and staff. Definition ... Dayroom/Hallway monitoring: Dayroom/hallway is kept within visual observation. Staff monitor the behavior of patients who are present in the day room and hallways. Staff observe for any change in patient's behavior that indicates the escalation, or a safety concern then immediate intervention is performed based on the clinical needs of the patient ... Elopement Precautions is indicated for patients who may be at risk of leaving the unit ... Procedure ... Elopement Precautions. Nursing staff redirect patients away from exit door. Nursing staff check door(s) to make certain doors are locked ... Observe patient's activity around the clock at fifteen (15) minute intervals or more frequently ..."

2. On 11/08/2023, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 10/24/2023 with a diagnosis of schizophrenia (type of mental health condition). The clinical record included:

- On 10/24/2023 at 10:56 PM, MD #6's (Physician) ordered elopement, assault, and suicide precautions that included every 15-minute monitoring for Pt. #1's safety. All three orders remained active during Pt. #1's hospitalization (10/24/2023 through 10/28/2023).

- On 10/24/2023 at 11:24 PM, a registered nurse's note included, "...Problem: Risk for Violence ...Suicidal Ideation ...as evidenced by: recurrent or ongoing suicidal ideation... Per ER (Emergency Room) notes, (Pt. #2) admitted for suicidal thoughts ... (Pt. #2's) behavior is unpredictable..."

-On 10/25/2023 at 11:17 AM, a physician's note included, "... (Pt. #2) was a danger to others as well as self ... re-admitted for safety, stabilization, treatment ...Readmit to the closed psychiatric unit with close observation ..."

- Between 10/25/2023 and 10/28/2023, the nursing behavioral flowsheets indicated that Pt. #2's thought process and behaviors included hallucinations, paranoia, impaired judgement, pacing, restless, and voicing verbal threats.

- On 10/28/2023 at 12:46 PM, the Psychiatrist's (MD #5) note indicated that Pt. #2 required inpatient hospitalization, and plan was to maintain suicide, assault, and elopement precautions. The plan also included to discharge Pt. #2 on Monday (10/30/2023).

-On 10/28/2023 at 3:05 PM, a registered nurse's progress note included, " ...at around 12:15 PM (Pt. #2) walked out when staff (E #8/ Mental Health Counselor) opened the (unit's entrance/exit door) to drop the meal cart outside (of the unit) ..." The note indicated that Pt. #2's mother called the unit to report that Pt. #2 went home.

3. On 11/9/2023 at 2:11 PM, a video surveillance of the Behavioral Health Unit/BHU, elevator outside the BHU, and the main entrance of the hospital for the timeframe that Pt. #2 eloped on 10/28/2023 was reviewed with E #1 (Director of Nursing). The video showed the following:

-At 12:11 PM, the door was propped open while E #8 pulled the meal cart off the unit.

- At 12:12 PM, E #9 (Registered Nurse/hallway and dayroom monitor) was sitting on a chair, looking at a hand-held electronic device (phone), and was not observing patients in the dayroom, hallway, or the unit entrance/exit door.

- At 12:13 PM, Pt. #2 was able to walk off the unit.

- At 12:16 PM (three minutes after Pt. #2 walked off the unit), E #8 noticed that the entrance/exit door was open.

4. On 11/09/2023 at approximately 9:20 AM, an interview with the Director of Nursing (E #1) was conducted. E #1 stated that all patients in the psychiatric unit are at risk for elopement. E #1 stated that the investigation regarding elopement of (Pt. #2), did not identify an issue with monitoring and supervision of patients. E #1 also stated that the focus was to reeducate staff about appropriate functioning and closing of the unit entrance/exit doors.

5. On 11/09/2023 at approximately 11:27 AM, an interview with Mental Health Counselor (E #8) was conducted. E #8 stated that on 10/28/2023, (E #8) failed to ensure that unit door was closed after pushing out the meal cart.

6. On 11/09/2023 at approximately 12:42 PM, an interview with the Psychiatrist (MD #5) was conducted. MD #5 stated that Pt. #2 was examined on 10/28/2023 and determined that Pt. #2 needed to continue inpatient hospitalization. MD #5 stated the plan was discussed with Pt. #2 who agreed and did not express wanting to be discharge prior to Monday (10/30/2023). MD #1 confirmed that the plan was to continue assault, suicide, and elopement precautions for Pt. #2.

7. On 11/14/2023 at approximately 9:18 AM, an interview with the Registered Nurse (E #9) was conducted. E #9 stated that on 10/28/2023, (E #9) was delegated to monitor the dayroom and hallway. E #9 stated that if taking eyes off the patients for even a second, something (e.g., patient fights, abuse) could happen. E #9 admitted constant use of hand-held work device while performing the observer role. E #9 stated that (E #9) did not observe the door being opened nor Pt. #2 exiting the unit.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #12) clinical records reviewed regarding use of violent restraints, the hospital failed to complete the required face to face evaluation within one hour after the initiation of the restraints.

Findings include:

1. On 11/08/2023, the hospital's policy titled, "Restraint Usage" (1/20221) included, "... Procedure... 2. Violent or Self-destructive Behavior Restraint Usage Description. Restraint for management of violent or self-destructive behavior can only be used in emergency situations in which... c...2. A physician or LP/licensed practitioner performs one-hour face-to-face evaluation of the patient and assesses reason restraints applied, current behavior, current medical condition, restraints risk to patient, and decision to continue or discontinue/ Physician or LP confirms in writing within one (1) hour of restraint application...""

2. On 11/09/2023, the clinical record for Pt. #12 was reviewed. On 11/05/2023, Pt. #12 was brought to the hospital's ED/emergency department due to alcohol intoxication. On 11/05/2023, Pt. #12 was placed in violent restraints (four-point restraints) from 9:37 PM through 11:07 PM (1 hour and 30 minutes). The clinical record lacked the required face to face evaluation within one hour after the initiation of the restraints.

3. On 11/09/2023 at approximately 11:00 AM, findings were discussed with E #4 (ED Manager). E #4 confirmed that Pt. #12's clinical record lacked the required face to face evaluation within one hour after the initiation of the restraints.