HospitalInspections.org

.
Based on medical record review, document review, observations and interview, in twelve (12) of twenty-one (21) medical records reviewed, the facility failed to maintain a safe environment for patients.

Specifically, the facility failed to ensure:
1.
(a) placing one nurse to one patient at the bedside when patients have a physician order for 1:1 continuous observation
(b) documentation of patient monitoring Q15 (every fifteen minutes) as per the hospitals (1:1) observation policy
2.
a) assessments of all patients to identify whether they met criteria as having a high risk for elopement
b) implement an effective response to conduct a search and rescue of a patient who was later found deceased inside of the facility as per the patient Elopement policy (Patient #1).
c) escalation to chain of command prior to calling off a search for a patient who was later found deceased inside the facility.

These findings were identified for Patient #s 1, 2, 3, 5, 6, 7, 16, 17, 18, 19, 20 and 21.

This failure placed all patients at risk for harm.

Findings include:

1-a) Review of documents, including the Nurse shift assignments dated 9/4/20 and 9/5/20, observations of video surveillance and interviews identified patients who were admitted with history of mental/cognitive impairment and were at risk of self-injury. The providers ordered these patients to be on one to one continuous observation by placing one nurse to one patient at an arm's length away next to the bedside, which did not occur. (Patient's #1, #2 and #3.)

1-b) Review of the medical records lacked documentation of patient monitoring Q15 (every fifteen minutes) as per the (1:1) observation policy (Patients #1, 2, 3, 5, 6, and #7).

2-a) Review of the medical records and interviews with staff identified that not all patients with high risk for elopement including mental impairment, were assessed to identify their risk for elopement (Patients #1, 16, 17, 18, 19, 20 and 21).

2-b) Review of the incident/occurrence reports and interviews identified an ineffective response to the patient elopement policy to conduct a search and rescue of a patient who was later found deceased inside of the facility (Patient #1).

2-c) Interviews and review of documents showed hospital police did not escalate up through the chain of command prior to calling off a search for a patient who was later found deceased inside the facility (Patient #1).

This failure placed all patients at risk for harm.

See Tag A 144.

Based on medical record review, document review, observations and interview, in twelve (12) of twenty-one (21) medical records reviewed, the facility failed to maintain a safe environment for patients. Specifically, the facility failed to ensure:

1-
(a) placing one nurse to one patient at the bedside when patients have a physician order for 1:1 continuous observation in three (3) of three (3) patients (Patients #1, 2, 3)
(b) documentation of patient monitoring Q15 (every fifteen minutes) as per the hospitals (1:1) observation policy in six (6) of eight (8) patients (Patients #1,2,3,5,6,7)

2-
(a) assessments of all patients to identify whether they met criteria as having a high risk for elopement in seven (7) of twenty-one (21) patients (Patients #1, 16, 17, 18, 19, 20 and 21)
(b) implement an effective response to conduct a search and rescue of a patient who was later found deceased inside of the facility as per the patient Elopement policy (Patient #1)

These findings were identified for Patient #s 1, 2, 3, 5, 6, 7, 16, 17, 18, 19, 20 and 21.

Findings include:

(1a)
The facility policy and procedure (P&P) titled, " ONE TO ONE (1:1)/CONSTANT OBSERVATION: Last reviewed 8/2019 stated, "1:1 Observation - is defined as continuous or uninterrupted observation by a staff member from not more than one arm's length ...1:1 or constant observation requires a provider /LIP order, renewable every 24 hours ...The nursing staff member assigned must have no other assignments and must remain with the patient until relieved. This includes, breaks, meals and change of shift .... The Ancillary Staff (PCA) never leaves the patient alone or unattended at any time ...always maintains view ...be vigilant, face and look at the patient... This includes when patient is in the toilet, shower, or with visitors .... The staff member who is assigned to monitor, documents observation on the monitoring form every fifteen minutes ..."

Review of Patient #1's MR identified the following information:
Patient #1 presented on 8/11/20 for Voluntary admission into inpatient Psychiatry. Chief complaint was suicidal ideation with history of paranoid schizophrenia and OCD (Obsessive Compulsive Disease). The patient was positive for auditory hallucinations, paranoid ideation, and thought broadcasting (a symptom of schizophrenia that is a delusion the person has that external entities are inserting thoughts into their minds).
During the hospitalization the patient was treated with psychotropic medications, and despite the dose titrated up to the maximum allowable dosage he remained overtly psychotic.
The Psychiatrist instructed the Nursing Staff to monitor the patient on Q15 minute observations for safety. Nursing Staff documented Q15 checks from 8-11-2020 through to 8-26-20.
The patient was compliant with treatment and activities, and the Broset Violence Scale was consistently scored as a low risk for aggression. The patient had no episodes of restraints or seclusion from 8-11-2020 to 9/2/20.

The Psychiatrist downgraded the monitoring to Q30 minute observation on 8-26, 8-27, 8-28, 8-29, 8-30, 8-31.

The Patient received his first ECT treatment on 8-31-20. On 9-1-20 at 6:58 PM the Nurse noted, "the patient is with transient confusion this afternoon. Serum Sodium was 128 this morning and repeat blood draw in the afternoon trended up to 131 (normal range levels are 135 to 145 mEq/L)."

On 9-2-20 at 6:10 AM, the Nurse documented, "grossly disorganized this tour. Standing staring at the Nurses Station at 11:00 PM on 9/1/20 with blood on his lips, he said he bit his lips. The patient became very aggressive and combative and required, seclusion and restraints and medication for seven hours through the night."

The Nurse noted at 6:23 PM, "the patient was in wrist and ankle restraint until 8:20 AM, once released he was placed on a 1:1, he attempted to attack the staff doing the 1:1 observation and was placed in Seclusion at 9:15 AM and medicated.

The patient was released at 10:15 AM from Seclusion and was calm until noon when he attacked a staff member. The 1:1 was maintained and he was medicated again."

The Physician noted on 9/2/20 at 6:15 PM, the patient is for transfer to medicine for evaluation and treatment of delirium, possible pneumonia and possible ileus. The labs show low sodium and elevated white blood count.

On 9/2/20 at 9:10 PM the patient was transferred from Psychiatry to Medicine into Room 16 East- 33 and was placed on elopement precautions and a 1:1 continuous observation by physician order. The physician renewed the 1:1 order on 9/3/20 and 9/4/20. However, the patient was not maintained on a 1:1 on 9/4/20 or 9/5/20.

Review of Nursing Assignment Sheet dated 9/4/20 7AM to 7PM, a PCA was assigned to do Close Observations with the four patients in Room 16E-33.

The Nursing Assignment Sheet dated 9/4/20 from 7PM until 7AM on 9/5/20, a PCA was assigned to Close Observation with three patients in room 16E-33 (3:1).
(however, two of those three patients were on 1:1 continuous observation as per physician orders).
Another PCA was assigned to the fourth patient housed in room 16E-33, that patient was on a 1:1.
Both PCA's were relieved for break at 6PM to 7PM by another PCA.

Per interview of Staff D (Registered Nurse (RN) 16 East) on 9/18/20 at 12:03 PM, Staff D stated, "I was on break when the patient eloped, when I came back at 5:30 AM Staff E, who was the PCA (Patient Care Associate) assigned to watch him told me that he ran away and she chased him but he had left the unit. The PCA was watching two patients who were both on 1:1 so it was a 2 to 1 watch. The patient had left the unit and the search was still ongoing at 5:30 AM. My shift ended at 7 AM and he still wasn't located when I left for the day."

Per interview of Staff E (Patient Care Associate (PCA) 16 East) on 9/18/20 at 12:15 PM, Staff E stated, "I was the PCA (Patient Care associate) assigned to watch three of the four patients who were in Room 33 that night. There was another PCA watching the fourth patient. Two of patients were both on Close Supervision Watch and the third wasn't on any special watch ...he was just a regular patient. The patient (Patient #1) who ran away wasn't a 1:1. The Charge Nurse (Staff F) gave me my assignment and she didn't tell me anything about doing a 1:1. I didn't do the q15 checks on the Rover (document every 15 minutes) because he wasn't on a 1:1." "...the patient got up and asked to use the bathroom. But he didn ' t want to use the one in the room, so I let him use another bathroom then when he was done with that, he wanted to use a phone to make a phone call... While I was talking with him, he ran out of the room and I screamed. I chased after him, but he ran through 16 East to the South then to the West and then to the North. All the Nurses came and ran after him, but he ran down the stairs, so a Nurse took the stairs after him. That Nurse ended up all the way down near the parking lot (the Stair way ends on the first floor and the exit door opens into a Fire Line next to a busy highway). We couldn't find him. The CMT (Crisis Management Team) was called too. No one found him when I went home at 8 AM."

Per interview of Staff F (RN Charge Nurse for 16 East) on 9/18/20 at 12:15 PM, Staff F stated, " I gave Staff E her assignment that evening she was doing overtime when I came into work at 7 PM ...and she had already been working with the patients in room 33 ...so I kept her with the same patients. The PCA was already with the patients in room 33 so I went to her to make sure she was there ... The PCA knew the patients she was with were on Close Supervision. Close Supervision is not the same thing as 1:1 observation and they don't have to do the same documenting as a 1:1 ...so the PCA didn't need to document the Q15 minute checks ... so I left her alone to work. The patient (Patient #1) who ran away he wasn ' t an elopement risk, no one told me that he was an elopement risk when I came into work that night ...so I didn't tell the hospital police that. "


Review of Patient #2's MR identified the following information:
Patient admitted in Cardiac Arrest, with past medical history for AKI (acute kidney injury), HTN (hypertension), and OSA (obstructive sleep apnea). The patient had a complicated hospital course and required Tracheostomy for mechanical ventilation.
On 9/02/20 at 2:44 PM the Provider noted, "the patient requires 1:1 observation due to high risk of self-injury. Please station a PCA or Tech at bedside within an arm's length away for continuous observation for 24 hours." This Provider order was renewed on 9/03/20 at 8:52 AM, and again on 9/04/20 at 8:10 AM. The order was still in effect through to 9/5/20 and was not discontinued. The patient was not maintained on 1:1 on 9/4/20 or 9/5/20. Patient #2 was housed in Room 33 on 9/2/20 through to 9/5/20.


Review of Patient #3's MR identified the following information:
Patient was admitted on 8/14/20 for cognitive impairment resulting in multiple episodes of the patient running away from home and presents with running away from home. Unable to contact family members, including brother with whom patient currently resides. Mother lives in Canada and patient does not have citizenship. Brothers are difficult to reach and have expressed inability to care for patient. Admitted under 9.40 legal status for safe discharge planning. The Providers treatment plan on 8/14/20 included prescribed Psychotropic medication and the doctor noted, "the Nurses to Observe q15 minutes. Patient is a high risk for elopement. The Provider renewed the 1:1 Continuous Patient Observation (Arm Length) every day with the indication being, "Patient does not have capacity to leave and is an immediate and/or high elopement risk." The order was renewed on 9/5/20 at 1:36 AM. However, there was no documented evidence on the Nursing Assignment Sheets that the patient was maintained on 1:1 on 9/4/20 or 9/5/20. Patient #3 was housed in Room 33 on 9/2/20 through to 9/5/20.



These findings were confirmed on 9/18/20 at 11:40 AM by Staff A (Director Quality) and Staff B (Director Risk).



(1b)
Patient #1's MR identified an order for the proceeding 24 hours of 1:1 continuous patient observation on 9/2/20 at 10:58 AM, order was renewed on 9/3/20 at 2:55 PM and again on 9/4/20 at 4:07 PM. There was no documented evidence of 1:1 monitoring every fifteen minutes as per policy from 9/3/20 at 6:49 AM to 9/5/20 at 5:00AM.

Patient #2's MR identified the following information: On 9/02/20 at 2:44 PM the Provider noted, "the patient requires 1:1 observation due to high risk of self-injury. Please station a PCA or Tech at bedside within an arm's length away for continuous observation for 24 hours." This Provider order was renewed on 9/03/20 at 8:52 AM, and again on 9/04/20 at 8:10 AM. The order was still in effect through to 9/5/20 and was not discontinued. The Nurses documented on the Flowsheet titled Special Observation every fifteen minutes on 9/04/20 until 10:36 PM and then the Q15 minute documentation stopped. There was no documented evidence that the patient was monitored every fifteen minutes as per policy.

Review of Patient #3's MR identified the following information: Patient was admitted on 8/14/20 for cognitive impairment resulting in multiple episodes of the patient running away from home and presents with running away from home. Admitted under 9.40 legal status for safe discharge planning. The Providers treatment plan on 8/14/20 included prescribed Psychotropic medication and the doctor noted, "the Nurses to Observe q15 minutes. Patient is a high risk for elopement. The Provider renewed the 1:1 Continuous Patient Observation (Arm Length) every day with the indication being, "Patient does not have capacity to leave and is an immediate and/or high elopement risk."
The order was renewed on 9/5/20 at 1:36 AM. There was no documented evidence that the patient was monitored every fifteen minutes as per policy.


On 9/16/20 between 2:30 PM and 3:30PM on the Telemetry Unit observations, document review and interviews in patient care areas revealed that 3 of 5 patients (patients 5,6, and 7) on 1:1 were lacking the required Q15 documentation of monitoring as required by hospital policy.

Review of the 1:1 monitoring, for patients on the 17w unit on 9/16/20, between 2:30PM and 3:30PM, identified the following:
Patient # 5 identified an order for 1:1 observation was missing documentation of 1:1 monitoring on 9/16/20, from 1:45AM to 3:00AM, a total of one (1) hour and forty-five (45) minutes.
Patient #6 identified an order for 1:1 observation, was missing documentation of 1:1 monitoring on 9/15/20, from 3:04AM to 6:19AM, a total of three (3) hours.
Patient #7 identified an order for 1:1 observation, was missing documentation of 1:1 monitoring on 9/15/20, from 11:07AM to 3:00PM, a total of four (4) hours.

Similar findings of missing documentation of 1:1 observation monitoring was noted in the MRs for the above listed patients on varying dates and times.

These findings were confirmed in the presence of Staff N (Nursing Director of Medicine and Telemetry), at the time of this observation.

These findings were in open patient's medical records, indicating current noncompliance to the policy.

(2a)
Review of the Facility Policy titled, "ELOPEMENTS/MISSING PATIENTS: Last reviewed 1/2017" stated: To outline procedures to follow whenever a patient who is receiving treatment is missing, cannot be located, and/or the patient's whereabouts are unknown to the responsible staff and not reflected in the hospital chart ...Elopement: the patient is incapable of adequately protecting him/herself and departs the facility unsupervised and undetected. The eloped patient is at risk ...
A patient's risk factor is to be determined on admission or at any point during the hospital stay and documented in the electronic medical record and medical chart ... Special attention must be given to persons at risk as defined by the following criteria ..."Criteria to determine Risk: 1. Patient is a minor/under the age of 18 years of age. 2. Patient is considered to be a danger to self or others. 3. Patient has been legally committed. 4. Patient has a court appointed legal guardian. 5. Patient lacks cognitive ability to make relevant decisions or cognitive abilities are questionable. 6. Patient presents a health risk to the community, e.g., a serious communicable disease, infections process, or court ordered admission. 7. Presence of Hep-lock or other IV Access."

Review of Patient #1's MR documented that on 9/5/20 at 5:00AM the patient had a Physician Order for Elopement Precautions. The patient was grossly psychotic with paranoid schizophrenia and auditory hallucinations and lacked the cognitive ability to make relevant decisions. Patient #1 met three of seven of the risk factor Criteria for High Risk Elopement listed in the Policy ... (1. Patient is considered to be a danger to self or others, 2. Patient lacks cognitive ability to make relevant decisions or cognitive abilities are questionable and 3. Presence of Hep-lock or other IV Access).
The patient successfully eloped from 16 East and was found deceased at 1:18 PM in the Finance Area of the 1st Floor.

Per interview of Staff F (RN Charge Nurse for 16 East) on 9/18/20 at 12:15 PM, Staff E stated, "Patient #1, who ran away he wasn't an elopement risk, no one told me that he was an elopement risk when I came into work that night.".

Review of MR for Eloped patient #16: On 5/11/ 20, Patient#16 a 42-year-old, undomiciled patient with a history of mental illness and a communicable disease, was noted as aggressive, verbally abusive and not redirectable while on unit 16 East. Patient #16 met four of seven of the risk factor Criteria for High Risk Elopement listed in the Policy ... (1. Patient is considered to be a danger to self or others, 2. Patient presents a health risk to the community, e.g., a serious communicable disease, infections process, 3. Patient lacks cognitive ability to make relevant decisions or cognitive abilities are questionable and 4. Presence of Hep-lock or other IV Access.
Per the MR, the patient was seen walking away from the unit at 7:25AM, getting on the elevator, with a right forearm peripheral IV. Hospital police was called to search for the patient and the Head nurse and MD made aware. The ID treatment plan was reviewed and her whereabouts was unknown.

Additionally, pertaining to a list of 42 people from May 20th to August 30, 2020 who the Hospital identified as Elopement Patients. Review of a sample of MR's from that list identified that Patients# 17, 18, 19, 20 and 21 met one or more of the assessment criteria to qualify for Elopement Risks as per Policy, and in review of the MR's they were not identified as an elopement risk and the whereabouts of the patients remained unknown.

(2b)
Review of Video Surveillance: Observations of video recording dated 9/5/20 at 5:01 AM show Patient #1 running through the corridors of the 16 floor and then emerge through exiting into the East Stairwell and onto the 14th Floor. At 5:02 AM the patient is observed running through the hallway and is seen tripping over a wooden pallet of supplies and falls to the ground and his upper torso and head hit the ground. The patient gets up and moves into the 14th floor North Stairwell and at 5:04 AM, the patient was last seen heading down the north stairwell. MR of Patient #1 documented Provider note at 1:17 PM that the patient was found deceased in a non-clinical area of the hospital (Finance Area).

The Hospital Police incident/occurrence report dated 9/5/20 stated, "Patient #1 eloped from 16E at 5:00AM ...at 1:15 PM on 9/5/20 a Rapid Response was called to 1 North (Finance Area) ...the patient was found on the ground pulseless, cold and stiff ...the Patient was seen by the Medical Examiner's Office who reported that the patient was eating dirt and that that could be the cause of death from suffocating."

Review of the Elopement Policy states, Hospital Police Responsibilities: For " At Risk Elopements":
Immediate notification to Hospital Police will allow officers posted at hospital exits/egresses to be placed on alert for the suspected eloped patient and preventing the patient from exiting the building ...
a complete and extensive hospital wide search will be conducted. The search will continue until the patient is found or confirmed to have left the facility ...if the initial search is unsuccessful, an extensive search is to be conducted. The areas to be searched are all patient wards, all stairwells and fire stairwells, all clinics, mezzanine floor office area, lobby area - ground floor, all roof tops, Engineering Department and service buildings, boiler room area, motor room, storage areas, basement shop area, all bathrooms, Emergency Department, and Administration Buildings, and Outer perimeter.

Per interview on 9/18/20 at 10:45 AM with the doctor who performed autopsy in the Office of Chief Medical Examiners (OCME) Staff J (Medical Examiner) stated, "the patient was found on 9/5/20 at around 1PM with dirt on his face and soil was well packed into his trachea and bronchial all the way down to where it branches. The cause of death was aspiration of dirt and then asphyxiation ...we know that there was no artificial cause because resuscitation was not done on this patient."

Per interview of Staff C (Director of Hospital Police) on 9/18/20 at 1 PM, Staff C stated, "we last saw the patient on video surveillance on the 13th floor and the recorded time was 5:04 AM on 9/5/20. No one was watching the camera in real time it was done (retrospectively) on review during our investigation. At approximately 8 AM the Sargent on duty made a decision to stop the search because he assumed that the patient got out of the building. The search should have continued, and the policy wasn't followed. The officer also should have escalated the decision making up the chain of command before halting the search.

Based on document review and interview, the facility did not use data collected to identify opportunities to improve the quality of care and possible reduce the number of patient Elopements from the hospital (42 elopements hospital wide from May 20 to August 30th, 2020).


Findings include:

Review of the hospital's performance improvement data for 2020 showed no documentation that 42 Elopements dated 5/20 to 8/30/20 were reviewed and analyzed. The hospital recorded the number of Elopements each month but did not present documented evidence that this information was reviewed or analyzed to identify areas for improvement.

Example:
Review of the QA/PI Committee Acute Care Board Report to the Governing Body on July 17 2020 indicated: On 2/2/20 a 31-year-old involuntarily admitted patient who was grossly psychotic eloped from the hospital while on a secured unit and on a 1:1. The nursing staff assigned to perform the Q15 minute observations did not notice the patients absence for three hours despite that they were required to check on him every fifteen minutes.

Although this data was reviewed and addressed in the care unit (18W) where it occurred there was no evidence that a plan was developed and implemented to address the failure to decrease the facilitys hospital wide Elopement rates.

During an interview on 9/19/20 at 1:35 PM, Staff A (Director of Quality) acknowledged the findings.