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Based upon document review, interview, and policy review the facility failed to ensure care in a safe setting for one of one patients (pt.#1) and failed to ensure a physician order was obtained for use of restraints in one of five patients (pt.#1) resulting in the death of a patient. Findings include:

1. The facility failed to provide care in a safe setting to 1 of 1 patients (pt.#1) resulting in the death of a patient. See tag A-0144.

2. The facility failed to obtain a physician order for the use of restraints in one of five patients (pt.#1) resulting in denying one of one patients (pt. #1) being patient rights. See tag A-0168.

Based on document review, interview, and policy review the facility failed to provide care in a safe setting for one of one patients (pt. #1) resulting in a patient eloping from the facility in a confused and delusional state resulting in the death of a patient. Findings include:

On 4/5/2018 at 1500 a document review of the medical record of patient #1 was conducted. On 3/13/2018 at 1714, the patient (#1) arrived at the facility via transfer to the Emergency Department from an outlying hospital. The patient was noted as being a 48-year-old male transferred to the facility for treatment for vomiting, upper GI (gastrointestinal) bleed, and kidney failure. The patient's emergency record states "c/o (complaints of) bloody vomiting since last night, pt. is alcoholic, last time he had something to drink was 5pm yesterday, he started vomiting last night, stated it was bloody yesterday, black in color today, c/o weakness, no energy ...no abdominal pain...pt. was pale and cold to touch when arrived to the ED." Further documentation states the patient exhibited "anxiety, chills, depression, dizziness, fainting, headache, light headedness, weakness, and weight loss."

According to the patient's health summary for the hospital stay from 3/13/2018 - 3/24/2018 active problems list is documented as: acute blood loss anemia, alcoholic gastritis with bleeding, chronic anemia, hypernatremia (high sodium levels), hypocalcemia (low calcium levels), hypoglycemia (low capillary blood glucose levels), hypomagnesemia (low magnesium levels), metabolic encephalopathy (brain dysfunction), pneumonia, upper GI bleed, alcohol withdrawal, coffee ground emesis (vomiting), complex partial epilepsy (seizures), gastrointestinal hemorrhage, seizure disorder generalized convulsive intractable, alcohol dependence, anemia, GERD (gastrointestinal esophageal reflux disease), history of ETOH (alcohol) abuse, thrombocytopenia concurrent with and due to alcoholism.

The patient's list of diagnoses list for the hospital stay from 3/13/2018 - 3/24/2018 is documented as: acute post-hemorrhagic anemia, alcoholic gastritis with hemorrhage, chronic anemia, hypernatremia, hypocalcemia, hypoglycemia, hypomagnesemia, metabolic encephalopathy, pneumonia, upper gastrointestinal hemorrhage, acute kidney injury, acute respiratory failure with hypoxia, alcohol withdrawal delirium.

The patient was admitted to the facility on 3/13/2018 at 1714. The patient admission diagnosis was recorded at alcoholic gastritis, upper GI bleed, and acute on chronic kidney failure. The nursing assessment on 3/13/2018 at 1839 states the patient as "alert and oriented x 3", the patient's behavior was documented as "cooperative", and mood as "calm." The patient's pain level on 3/13/2018 at 1856 was documented at a score of "7" on a pain scale of 0 being no pain and 10 being extreme pain. The hourly rounding documentation of the patient's vital signs were documented as temperature 98.7 degrees Fahrenheit, pulse 118, respirations 18, oxygen saturation 99 percent, and blood pressure as 121/63. On 3/14/2018 at 0112 a critical hemoglobin lab value was documented as 6.9. On 3/14/2018 at 0533 the patient received one unit of packed red blood cells.

On 3/14/2018 at 1051 a past medical history was documented on the patient. The patient's past medical history was documented as: hypertension, liver disease, memory impairment, renal disease, seizure disorder, alcoholism, alcoholic pancreatitis, alcoholic seizures and seizures as a child, as esophageal stricture and reflux esophagitis/erosions, CRUSH ALL PILLS, alcoholic dementia, thrombocytopenia, C-diff (clostridium difficle) colitis 2016, hypoglycemia, sinus problems. Further documentation included past psychological/social history which included anxiety, bipolar, and depression. Additional psychological history states the patient lives with his mother. He uses no assistive devices. He does not drive, he gets to appts by mother or sister, mother manages his medications. The patient's social history included past alcohol use as abuse, daily, heavy, and patient states he drinks a pint of liquor-vodka daily ...pt. last drank on 3/12/2018. The patient reported no drug use. On 3/13/2018 at 1054 the admission data documented the patient's communication as a mild impairment for comprehension ability and the patient's ability to follow directions as fair. The patient was also documented as stating he did have advance directives and advance directives were on file as of 3/14/2018. The patient's durable power of attorney was listed as the patient's mother. The patient's fall risk score on 3/14/2018 at 1057 was documented as 35 (moderate risk). The documentation for nursing interventions related to the patient's alcohol abuse identified the patient as verbalizing inaccurate information, requests for information, inaccurate task performance, and denying the need to learn. A CIWA (Clinical Institute Withdrawal Assessment for Alcohol) scale was initiated on 3/14/2018 at 1057. On 3/14/2018 at 1259 a surgical consult was ordered. The patient was scheduled for an EGD (esophagogastroduodenoscopy) procedure for 3/15/2018. On 3/14/2018 at 1600 the nursing assessment documented the patient as having a productive intermittent cough, abdominal pain, nausea, blood in stool and swallowing impairment. The patient's vital signs were documented on 3/15/2018 at 1600 as temperature 97.9 degrees Fahrenheit, pulse rate 80, pulse oximetry 98 percent, respiratory rate 16, and a blood pressure of 180/90. The patient's fall risk score on 3/15/2018 at 1855 was documented as 60 (high risk for falls). The patient was moved from the ED on 3/14/2018 at 1622 to the general medical floor.

On 3/14/2018 at 1925 the patient's CIWA scale assessment was documented as presence of intermittent nausea/dry heaves and mild anxiety. The patient's CIWA scale score was recorded at 5. The nursing assessment on 3/14/2018 at 2000 documents the patient as having a productive cough with the patient stating what is brought up is coming from his stomach and not his lungs. The patient is documented as stating he experienced abdominal pain due to coughing and the emesis was clear.

The patient was assessed using the CIWA scale on 3/15/2018 at 0235 and a score of 0 was documented. The patient's neurological assessment on 3/15/2018 at 0235 documents the patient as being alert and oriented x 3 with no known deficits. On 3/15/2018 at 0340 the patient's weights was documented at 40.5 kilograms. On 3/15/2018 at 0755 the patient's CIWA scale score was 7 with documentation of intermittent nausea/dry heaves, mild anxiety, agitation as slight increase in activity, and tactile disturbances listed as very mild itch/numbness/burning. On 3/15/2018 at 0945 a pre-operative checklist was documented. The pre-operative documentation states the patient "does not have advance directive" and advanced directive on file as "no." On 3/15/2018 at 1936 the patient's CIWA scale score was 7 with documentation of intermittent nausea/dry heaves, mild anxiety, agitation as slight increase in activity, and tactile disturbances listed as very mild itch/numbness/burning. On 3/15/2018 at 2000 the patient's neurological assessment states the patient was anxious.

On 3/16/2018 at 0000 documentation for the physical assessment states "pt. AOx3 (alert and oriented) with periods of confusion and apprehension continues to pull at telemetry, and tries to get out of bed frequently without assist ...increased risk for falls r/t periods of confusion, impulsive behavior and apprehension. On 3/16/2018 at 0140 the patient's record further continued to document the patient as not having advanced directives. On 3/16/2018 at 0430 restraint initiation was documented. Restraints were documented as being initiated for medical indications. The rational for restraint initiation was documented as patient who has been observed demonstrating safety risk, prevent interference with physical treatment or devices, and support medical healing. The patient was documented as endangering self ...physician notified. The patient's CIWA scale score on 3/16/2018 at 0439 was recorded as 16 documentation of moderate anxiety, thrashing about, and disoriented to place / person. The patient was documented as having a sitter at bedside on 3/16/2018 at 1002. The patient's fall risk score was documented as 75 (high risk) on 3/16/2018 at 1123. Restraint use continued to be documented on 3/16/2018 at 1123. The patient's neurological status on 3/16/2018 at 1124 documents the patient as being alert to self and verbal response as confused. Restraint use continued at 3/16/2018 at 1422. Documentation of patient's neurological status on 3/16/2018 at 1859 stated alert to self, confused verbal response, comprehension ability as unable to comprehend. The patient's fall risk assessment score on 3/16/2018 at 1859 was documented as 95. The patient was documented as having a hypoglycemic (low blood sugar) event on 3/16/2018 at 1902 with observations of shaking. A capillary blood glucose value was not recorded. The patient's CIWA scale score on 3/16/2018 at 0439 was recorded as 25 with documentation of the patient exhibiting frequent nausea/heaves/vomiting, moderate muscle tremors - arms extended, moderate anxiety, moderate agitation - fidgeting/restless, palms moist, disoriented to date, mild tactile disturbances - mild itch/numbness/burning, very mild auditory disturbances, and very mild visual disturbances. On 3/16/2018 at 1953 a notification was made to staff GG, the hospitalist on call to inform the physician of the patient's pulse oximetry of 79 percent requiring an increase in the patient's oxygen requirement. Restraint use continued on 3/16/2018 at 2000. The patient's neurological assessment on 3/16/2018 at 2000 was documented as anxious, restless, confused, impulsive, and resistant to care. The patient's speech pattern was described as unclear. The patient was documented as having labored breathing with a respiratory rate of 40. The patient was also documented as being incontinent of both bowel and bladder function. The patient subsequently was intubated on 3/16/2018 at 2053. On 3/16/2018 at 2325 the patient is documented as being in the ICU. The patient's vital signs were documented as temperature 102.3 degrees Fahrenheit, pulse rate of 64, respiratory rate of 32, pulse oximetry of 86 (on a non-rebreather at 15 liters), and a blood pressure of 102/64. On 3/17/2018 at 0058 the patient's vital signs were recorded as pulse rate 71, respiratory rate 26, pulse oximetry 94 percent (on a non-rebreather at 15 liters) and a blood pressure of 186/98.

The patient remained in the ICU from 3/16/2018 until 3/21/2018 when he was transferred to the general medical/surgical floor.

On 3/21/2018 at 0813 the physical assessment for patient #1 documentation states the patient's verbal response as being confused and his neurological assessment as not being within normal limits. The patient's memory description is documented as recent impaired, remote impaired. Speech pattern as inappropriate and delayed. Patient behavior as impulsive. On 3/21/2018 at 0813 the patient's fall risk score was documented at 60 (high risk). Additional notes to the fall risk assessment states disoriented.

On 3/21/2018 at 1430 an occupational therapy (OT) evaluation was documented. Documentation for the patient's assessment for activities of daily living were documented as follows: bathing ability - moderate assist, upper body dressing ability - supervision, lower body dressing ability - moderate assist, grooming ability - supervision, toileting ability - total assist, and toilet transfer ability - moderate assist. An Adult Daily Living assessment comment states "client present with supervision to moderate physical assist ...client pending swallow evaluation, but willing to work with OT at this time ...client is unstable when attempting to ambulate or transfer ...client cognitively is limited, but able to follow directions and manage rudimentary tasks, executive decision making is limited at this time ...anticipate home with 24/7 upon DC (discharge)." Comprehension ability was documented as mild impairment, speech pattern was documented as clear, inappropriate, and delayed. Cognitive ability is documented as attention to task - fair, problem solving - limited, safety judgement - limited, and orientation to person and place.

On 3/21/2018 at 1719 the patient's physical assessment was documented as verbal response confused. The patient's speech pattern was documented as clear, inappropriate and delayed. The patient's strength was documented at mild weakness in both upper and lower extremities bilaterally. The patient was documented as incontinent.

On 4/5/2018 at 1400 an interview occurred with staff BB, the manager of security. Staff BB provided video of patient #1 eloping the hospital on 3/24/2018 at 1728. Staff BB was asked if he had been notified of the patient eloping the facility. Staff BB stated "yes ...I received a call on 3/24/2018 to let me know that the facility had a patient leave the facility." Staff BB was then asked if he knew what time he had been contacted. Staff BB stated, "I cannot recall ...I just remember it was on that Saturday when the patient eloped." Staff BB was then asked if he was aware of the patient having exit seeking behavior. Staff BB stated "yes ...We (security) had been called the day before (3/23/2018) to deal with the patient. We had actually had a "Mr. Strong" called on the patient." Staff BB submitted a document of the "Mr. Strong" event for review. According to the document summary of events dated 3/23/2018 at 1437, it states: "Upon arrival of security officer, (patient #1) and staff were standing in the hall. (STAFF M) and (STAFF FF) were trying to get (patient #1) to go back to his room. (Patient #1) did not want to stay in hospital any longer. (STAFF M) was able to talk (Patient #1) back to his room to talk about what's going on. (Patient #1) agreed to stay in room until doctor comes to talk to him.
Security was cleared by (STAFF FF) but would like frequent rounds."

Staff BB was then asked what would be considered a "Mr. Strong" event. Staff BB explained 'Mr. Strong' is a term used when a patient becomes out of control or exhibits behaviors that require security to become involved such as violence, belligerence, or unacceptable behaviors. Staff BB was then asked what behaviors the patient exhibited that required a 'Mr. Strong' event to be called on 3/23/2018. Staff BB stated the patient refused to stay in his room and wanted to go home. Staff BB was then asked what measures were put into place from security to ensure the patient would stay at the facility until being discharged. Staff BB stated there was an increased presence of security on the floor with increased rounding so that the patient would be aware someone was watching him intermittently. Staff BB was then asked to provide documentation from security for the elopement event. Staff BB stated no documentation was able to be obtained for the elopement other than video surveillance. Staff BB was then asked to produce a log of that day for security events. Staff BB was then asked if he was aware that the power of attorney (POA) had presented to the facility on the evening of 3/24/2018 to ask to view the video of patient #1 leaving the facility to determine the direction that the patient had left. Staff BB responded "No." Staff BB was then asked if he was aware that the POA had been told it would take a subpoena to look at the video. Staff BB stated, "I wasn't aware of the request, but it would take a court order for someone to view the video for security to assist the POA." Staff BB was then asked if security had contacted the local authorities promptly to alert them of a confused patient eloping. Staff BB stated, "that was to be handled by nursing staff."

On 4/5/2018 at 1435 an interview occurred with staff M, the patient liaison for the facility. Staff M was queried regarding the "Mr. Strong" event on 3/23/2018. Staff M stated, "I went to the floor when a "Mr. Strong" was called for patient #1. I was able to talk with the patient and the patient stated he just wanted to leave. The patient did not understand why he was being held for discharge. I explained to him that his sister had stated he was unable to return to live with his parents. The patient then stated, "my sister just wants to control me ...she wants to control me and my money." Staff M stated the patient was agreeable and seemed calm by the time the event ended. Staff M stated the patient agreed to stay in his room.

On 4/5/2018 at 1615 an interview occurred with staff O, a hospital security officer present on 3/24/2018. Staff O was asked to explain the events of 3/24/2018 and when he was made aware of patient #1 being reported as missing. Staff O stated that his shift started on 3/24/2018 at 1600. He further stated that he had been made aware during shift change report of a patient (pt.#1) located on the fifth floor being described as exit seeking. Staff O stated that during shift change report that staff had been called to a "Mr. Strong" event the previous day regarding patient #1 wandering. Staff O further stated that security had been asked to make more frequent rounds on the unit to have a presence on the unit to deter the patient from wandering. Staff O was then asked when he first became aware of the patient missing from the unit. Staff O stated it was approximately 1820 when he received a call from the security base operation that a patient had been reported as missing. Staff O was then asked if he had a description of the patient. Staff O stated, "we were told the patient was wearing a tan jacket, had brownish colored hair, and weighed approximately 150 pounds." Staff O stated a sweep of the facility occurred with himself and his co-worker. Staff O stated they looked for the patient until approximately 1850 and then was called to the ED to address another issue with another patient. Staff O was asked if any documentation was completed for the event. Staff O replied "no, not that I'm aware of." Staff O was asked if the local authorities were made aware of a patient eloping from the hospital. Staff O responded, "I know someone called the police department, but I think it was the unit nurse who placed the report."

On 4/5/2018 at 1640 an interview was conducted with staff Q, a hospital security officer at the facility. Staff Q was queried about the elopement of patient #1 on 3/24/2018. Staff Q stated he was in the basement at the security base of operations taking calls and viewing video. Staff Q was then asked when he was alerted a patient (pt.#1) was missing. Staff Q stated that he was made aware of the patient missing by nursing staff at approximately 1820 on 3/24/2018. Staff Q was then asked how the security department proceeded to locate the patient. Staff Q stated two security officers were notified and conducted a search of the premises. Staff Q stated the officers searched for the patient from 1820 to approximately 1855. Staff Q was then asked what description was provided by nursing staff to conduct the search. Staff Q explained he had received a description of the patient being 5'6" in height, approximately 150 pounds, wearing a tan jacket and blue jeans. He added that the patient's hair color was described as a grayish brown. Staff Q was asked that in retrospect had the description of the patient been accurate. Staff Q responded "no ...actually he had on a blue jacket, sweat pants, and had red hair." Staff Q was then asked if nursing staff was asked to come down to the security home base located in the basement to view video. Staff Q responded "no."

On 4/5/2018 at 1700 an interview was conducted with staff P, a hospital security officer at the facility. Staff P was queried if she was on duty on 3/24/2018 when patient #1 was reported as missing. Staff P responded "Yes, I worked from 1600 to 2400 on 3/24/2018." Staff P was then asked what time she was made aware that a patient had been reported as missing to the security staff. Staff P stated she became aware of the patient missing at approximately 1820. Staff P stated that she and staff O were alerted by security home base that a patient (pt.#1) had been reported as missing. Staff P was then asked what efforts were made to locate the patient. Staff P responded, "We searched the entire facility until about 1855 when we were called to go to the ED for another issue." Staff P was then asked what patient description was given for her to look for the patient. Staff P stated, "We were told that the patient had on a tan jacket and jeans, brownish colored hair, and was about 5'6" in height weighing about 150 lbs." Staff P then stated that she had removed a patient from the west entrance at approximately 1800 but it was later confirmed it was not the patient that eloped. Staff P was then queried if she knew if the local authorities were notified. Staff P stated "No."

On 4/6/2018 at 1400, a log for security events on 3/23/2018 and 3/24/2018 was made available for review. The log for 3/23/2018 indicated security involvement with patient #1 at 1419 and 1420 for a "Mr. Strong". The log for 3/24/2018 indicated security involvement with patient #1 at 0822 "(STAFF T) request security to 560-2 to talk to patient who is non-compliant" cleared at 0840, and at 0910 "request security to 560-2" cleared at 0929. No documentation in the log of 3/24/2018 was able to be in reference to staff M reporting patient #1 eloping from the facility. No documentation in the log of 3/24/2018 was located reference to security attempts to locate patient #1.

On 4/6/2018 at 0730 an interview occurred with staff L a nurse aid that cared for the patient on 3/23/2018 from 1830 to 0630 on 3/24/2018. Staff L was asked if during the time she cared for the patient was the patient noted as being exit seeking. Staff L responded, "Well yes ...the patient (pt.#1) was found in another patient's bathroom in the oncology unit ...the patient was also found wandering on the floor several times." Staff L was asked if the patient seemed confused when he was found in another patient bathroom. Staff L stated the patient did not grasp that using another bathroom than the one in his room was inappropriate. Staff L was asked if a sitter was requested for the patient. Staff L stated, "No ...we generally do not ask for a sitter because if we (staff) can manage the patient without a sitter then an aid is not taken off the floor." Staff L stated that a bed alarm had been used with the patient where he could be assisted to the restroom. Staff L further stated, "because we (staff) knew that the patient was wandering we closed the doors on the unit where we could monitor every time the doors opened." Staff L was then asked if the doors were locked or just closed. Staff L responded, "The doors cannot be locked ...just closed." Staff L was then asked if the patient had been identified as missing when she arrived for her shift on 3/24/2018. Staff L stated she always arrives for work at around 1800 and the patient was not noticed as missing until after she arrived.

On 4/6/2018 at 0810 an interview was conducted with staff U, the physician's assistant who conducted a neurological exam on patient #1 on 3/23/2018. Staff U was asked if the patient had any cognitive issues that he could identify. Staff U stated, "the patient was sitting up in bed and was able to answer questions ...I would say he was at his baseline." Staff U further stated, "the patient wanted to leave the hospital and stated, 'I just want to get out of here'." Staff U stated the patients CT (computed tomography) scan was normal.

On 4/6/2018 at 0825 an interview was conducted with staff EE, the social worker assigned to patient #1. Staff EE was queried how it was determined the patient was going to be discharged to a rehabilitation facility. Staff EE stated, "I did not meet personally with the patient. I was made aware by staff FF, the nurse caring for the patient on 3/23/2018 that the patient was ready for discharge but there were concerns of the patient being confused." Staff EE further stated "I tried to contact the patient's mother (listed as POA) and was unsuccessful because the number we had on file was incorrect ...I finally reached the patient's sister and she stated that the patient would not be able to return home. The patient lived with his elderly parents who according to the sister were unable to further take care of the patient due to their own health. The sister asked that I seek placement for the patient at one of two rehabilitation / long-term care facilities. The sister also stated that she had spoken with the rounding hospitalist (staff S) and he agreed that the patient would be appropriate for rehabilitation / long-term care placement." Staff EE stated the patient was accepted for rehabilitation / long-term care placement by one of the two facilities with discharge tentatively scheduled for 3/26/2018.

On 4/6/2018 at 0910 an interview was conducted with staff M, the nurse assigned to the care of the patient on 3/24/2018 from 0630 - 1900. Staff M was queried to explain the events of the day leading up to the discovery of the patient being missing. Staff M stated that she was the charge nurse for the 5th floor on 3/24/2018 and was providing care to six patients. Staff M stated that patient #1 had exhibited wandering and exit seeking behavior starting at around 0900 on that day. Staff M stated that security was called to come to the floor and the administrative charge (staff CC) was also called. Staff M stated security was called to the floor three times during the morning of 3/24/2018. Staff M stated that the patient was in his own clothing all day as he had refused to wear a hospital gown but was noted as being cooperative. Staff M described the patient as agitated and that the patient repeatedly stated he just wanted to leave. Staff M stated the patient was agitated with the number of visitors that were in the room as the patient located in bed 1 had visitors throughout the morning. Staff M stated the rounding physician had met with the patient in the oncology unit waiting area (located on the 5th floor) and told staff the patient could stay in the waiting area. Staff M stated the physician also stated that the patient had agreed not to wander off the unit and felt the patient would uphold his agreement to stay on the floor. Staff M was then queried where the oncology waiting area was on the floor. Staff M stated it was directly to the right of the entrance. Staff M was then asked if the location of the oncology waiting area was closer to the exit where elevators were located. Staff M stated "Yes ...but the patient had agreed with the physician that he would stay in that waiting area." Staff M was queried about the last time she physically interacted with the patient. Staff M stated, "I administered pain medication to the patient at 1730." Staff M was then queried when was she first aware that the patient was missing. Staff M stated, "around 1820 we (staff) discovered he wasn't in the waiting area ...we began to search for him immediately." Staff M was then asked what procedure she followed to help locate the patient. Staff M stated "I contacted the administrative charge and security...I called all the floors and the ED as well." Staff M further stated that at approximately 1925 a call was placed to the patient's POA and the local authorities. Staff M was asked if the facility had a protocol or policy that she was aware of in the case of a missing or eloped patient. Staff M stated "I knew we needed to inform administrative charge and the manager on call ...I'm not aware of any policy that outlines what we are to do in a case like this ..." Staff M was then queried if she was asked by security to view video surveillance in order to identify if the patient had left the facility. Staff M stated "no." Staff M stated "the patient had a bag of belongings that he left in his room ...I wasn't sure at first if he had left the facility...I wasn't aware he was under legal guardianship ...All I knew was that we were keeping him until Monday for him to go to (FACILITY XXX)." Staff M was asked how long it was from the time she became aware of the patient missing to notifying the local authorities. Staff M replied, "about an hour." Staff M was asked what further actions were taken prior to her leaving her shift. Staff M stated an incident report was completed.

On 4/6/2018 at 0940 an interview was conducted with staff S, the rounding hospitalist on 3/23/2018. Staff S was queried about the patient's cognitive state. Staff S stated, "He was appropriate at times but did have some confusion. I asked the patient where he was at and although he knew he was in the hospital he had stated that he was in a dorm ...He had stated that he was going to quit drinking." Staff S was asked what prompted the patient's discharge status to be changed from going home to being placed in a rehabilitation / long-term care facility. Staff S stated that a conversation had taken place with the patient's sister and the sister had stated the patient was unable to return to his parents' home due to the parents age and medical issues. Staff S stated that he agreed with the sister and that the discharge home was changed to discharge to a rehabilitation / long-term care facility. Staff S also stated that he ordered a neurological consult on 3/23/2018.

On 4/6/2018 at 0955 an interview was conducted with staff V, the nurse aid assigned to the patient on 3/24/2018 from 0630 - 1900. Staff V was asked if she remembered caring for the patient (pt. #1). Staff V stated, "I was the only nurse aid on the floor that day ...I do not remember him trying to leave but I did get his vital signs in the oncology waiting room area." Staff V was asked if hourly rounding was documented on patients. Staff V stated, "We (staff) use a white board to document hourly rounding." Staff V was then queried if hourly documentation was documented in the electronic medical record. Staff V replied, "We (staff) only use the white board for hourly documentation of rounding ...there is not an area we (staff) document on the computer." Staff V further stated, "the main doors were closed on the unit to discourage the patient from leaving." Staff V was queried if the doors were locked. Staff V replied, "No ...the doors cannot be locked."

On 4/6/2018 at 1038 an interview was conducted with staff W, the nurse assigned to the care of the patient on 3/23/2018 from 1830 - 0700. Staff V was asked if the patient (pt. #1) was confused during the time she cared for him. Staff V stated, "the patient was pleasant and cooperative but did have some confusion during the time she provided care." Staff V was asked if it was necessary to have security present during her shift due to the patient wandering. Staff V stated security was not necessary. Staff V further stated that the patient had changed from his hospital gown into his street clothes during her shift but that the patient seemed more comfortable in his own clothes.

On 4/6/2018 at 1130 an interview was conducted with staff Y, the risk manager for the facility. Staff Y was queried as to when she was made aware that the patient had eloped from the facility. Staff Y stated, "The CNO (chief nursing officer) sent me a newspaper clipping on the evening of 3/25/2018 stating a patient (pt. #1) had eloped from the hospital and was found deceased." Staff Y was then queried whether a root cause analysis (RCA) was started for the sentinel event. Staff Y stated a medical record review and a timeline had been started prior to her leaving for vacation and that a conversation with the family regarding the request for the patient's medical record had taken place. Review of documentation presented for the RCA consisted of notes from the medical record only. The documentation failed to have analysis of how the patient eloped undetected, interviews with those involved, or review of policy.

On 4/6/2018 at 1230 an interview occurred with staff X, the rounding hospitalist for 3/24/2018. Staff X was asked if he recalled the patient on 3/24/2018. Staff X stated, "I saw the patient the last day he was here ...I recall the patient was bothered by his roommate and he was complaining about his sister intervening in his life." Staff X stated the patient was found located in the oncology waiting room area and nothing seemed out of the normal.

On 4/6/2018 at 1240 an interview occurred with staff K, the manager on call for 3/24/2018. Staff K was asked when sh

Based on document review, interview, and policy review the facility failed to obtain a physician's order for the use of restraints in one of five patients (pt.#1) requiring medical restraints resulting in the potential loss of patient rights. Findings include:

On 4/6/2018 at 1300 a document review occurred of the medical record for patient #1. On 3/16/2018 at 0430 restraint initiation was documented. Restraints were documented as being initiated for medical indications. The rational for restraint initiation was documented as patient who has been observed demonstrating safety risk, prevent interference with physical treatment or devices, and support medical healing. The patient was documented as endangering self ...physician notified. The patient's CIWA scale score on 3/16/2018 at 0439 was recorded as 16 documentation of moderate anxiety, thrashing about, and disoriented to place / person. The patient was documented as having a sitter at bedside on 3/16/2018 at 1002. The patient's fall risk score was documented as 75 (high risk) on 3/16/2018 at 1123. Restraint use continued to be documented on 3/16/2018 at 1123. The patient's neurological status on 3/16/2018 at 1124 documents the patient as being alert to self and verbal response as confused. Restraint use continued at 3/16/2018 at 1422. Documentation of patient's neurological status on 3/16/2018 at 1859 stated alert to self, confused verbal response, comprehension ability as unable to comprehend. The patient's fall risk assessment score on 3/16/2018 at 1859 was documented as 95. The patient was documented as having a hypoglycemic (low blood sugar) event on 3/16/2018 at 1902 with observations of shaking. A capillary blood glucose value was not recorded. The patient's CIWA scale score on 3/16/2018 at 0439 was recorded as 25 with documentation of the patient exhibiting frequent nausea/heaves/vomiting, moderate muscle tremors - arms extended, moderate anxiety, moderate agitation - fidgeting/restless, palms moist, disoriented to date, mild tactile disturbances - mild itch/numbness/burning, very mild auditory disturbances, and very mild visual disturbances. On 3/16/2018 at 1953 a notification was made to staff GG, the hospitalist on call to inform the physician of the patient's pulse oximetry of 79 percent requiring an increase in the patient's oxygen requirement. Restraint use continued on 3/16/2018 at 2000. The patient's neurological assessment on 3/16/2018 at 2000 was documented as anxious, restless, confused, impulsive, and resistant to care. The patient's speech pattern was described as unclear. The patient was documented as having labored breathing with a respiratory rate of 40. The patient was also documented as being incontinent of both bowel and bladder function. The patient subsequently was intubated on 3/16/2018 at 2053. On 3/16/2018 at 2325 the patient is documented as being in the ICU. The patient's vital signs were documented as temperature 102.3 degrees Fahrenheit, pulse rate of 64, respiratory rate of 32, pulse oximetry of 86 (on a non-rebreather at 15 liters), and a blood pressure of 102/64. On 3/17/2018 at 0058 the patient's vital signs were recorded as pulse rate 71, respiratory rate 26, pulse oximetry 94 percent (on a non-rebreather at 15 liters) and a blood pressure of 186/98.

Documentation indicated the patient remained in restraints from 3/16/2018 at 0430 and remained in restraints until 3/19/2018 at 1616 when the patient was extubated.

On 4/5/2018 at 1500, a document review occurred of the facility's restraint use. A review of the restraint use log listed patient #1 as having been in restraints. No dates or times were correlated with the restraint use with patient #1. Document review of patient #1 chart orders for restraint use were unable to be located although documentation of restraints was found in the patient's medical chart from 3/16/2018 through 3/19/2018. On 4/6/2018 at 1030 staff A, director of quality and management confirmed that orders for restraint use were unable to be located.

On 4/6/2018 at 1330 a review occurred of the policy titled "Use of Restraint and Seclusion", policy number 1.2.17, dated 6/16. According to the policy under section "IV. General Restraint / Seclusion Provisions" it states, "The use of restraint must be ordered by a physician or other LIP (licensed independent practitioner) who is responsible for the care of the patient. If the attending physician did not order the restraint or seclusion, the attending physician must be consulted as soon as possible."