HospitalInspections.org

Based on medical record review, staff interviews, review of the facility internal investigation and review of facility policies and procedures, the facility failed to provide the necessary oversight to ensure a safe setting for one patient (#8) of one patient escorted by the non-custodial parent out of the facility and not found for seven hours. This patient had been removed from her parents into protective custody, by the Illinois Department of Children and Family Services (DCFS). A visitation plan was issued by DCFS instructing facility staff that the non-custodial parents were restricted to visits from 8:00 AM to 8:00 PM and could not leave the floor with the patient. The facility delayed communicating and/or implementing the visitation plan restrictions to facility staff in order to ensure the safety of the patient.

The severity of the systemic practice resulted in the facility being out of compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights and resulted in the facility's failure to provide a safe environment for this patient and potentially any patients requiring protective oversight. The hospital total census was 411 and 148 at Cardinal Glennon Campus.

Refer to A144 for findings.

Based on medical record review, staff interviews, review of the facility internal investigation and review of facility policies and procedures, this facility failed to provide the necessary oversight to ensure a safe setting for one patient (#8) of one patient. This patient had been removed from her parents into protective custody, by the Illinois Department of Children and Family Services (DCFS). A visitation plan was issued by DCFS instructing facility staff that the non-custodial parents were restricted to visits from 8:00 AM to 8:00 PM and could not leave the floor with the patient. There was a delay in communicating and/or implementing the visitation plan restrictions to facility staff. This resulted in the facility failure to provide a safe environment for this patient (who was escorted by the non-custodial parent out of the facility and found seven hours later) and potentially any patients requiring protective oversight. The facility's census was 411 and 148 for Cardinal Glennon campus.

Findings included:

1. Review of the facility policy titled, "Child Protection" dated reviewed/revised on 4/10, showed the purpose was for determination, protection and prevention. Nursing responsibility included that patients should be monitored closely to decrease the possibility of family leaving AMA (against medical advice). Visitation and departure from the patient care area may be restricted by Child Protective Services. Social Services responsibility included documenting plan for patients and any restrictions on visitation or patient movement about the hospital. The Social Worker will also ensure that pertinent court documents regarding change of custody are placed in the patient chart and will provide documentation of caregiver/residence to which patient is to be discharged when medically cleared.

Review on 02/15/12 at 2:15 PM of a copy of the facility's written Patient Rights and Responsibilities given to patient's and/or their representatives on admission, showed that as our patient, we have the responsibility to respect, protect and promote your rights to include: Receive protective oversight while a patient in the hospital.

2. Review of Patient #8's Emergency Department (ED) Transfer Summary Report showed the patient was transferred by Emergency Medical Services (EMS) from an Illinois hospital to the facility on 02/06/12 at 8:11 PM. The ED Summary Report showed the following information:
- Nursing report and history: Patient was taken into protective custody by DCFS and taken emergently to an Illinois hospital ED with an elevated blood pressure (is the pressure exerted by circulating blood upon the walls of vessels) of 179/106 (normal range is approximately 90-120/60-80). Patient was given Clonadine (medication to treat high blood pressure) 0.1 mg (milligrams) and transferred by ambulance to this facility. Patient arrived awake and alert;
- Medical Decision Making: 14 year old adolescent status post renal (kidney) transplant, to be admitted for high blood pressure control and care of her rising creatinine (a laboratory test to measure the kidney's ability to filter, in which a high level would show renal dysfunction) level. Patient is in the custody of the state. Family cannot remove patient from the hospital.

3. Record review of the patient's medical record showed the following information:
- On 02/06/12 at 10:32 PM, the Pediatric Attending Admission Note showed history of illness included status post renal transplant on 06/08/10. The patient was hospitalized from 01/03/12 to 01/12/12 for removal of a large cystic mass originating at her native right kidney and cellular rejection. She received 3 days of IV (intravenous, administered into a blood vein) Solumedrol (steroid medication) as treatment for her rejection and left several days later AMA. She was seen for a follow-up on 02/03/12 at which time her creatinine was elevated at 3.15 (normal range for children is 0.2 -1.0 and adult females 0.6 - 1.1) and Tacrolimus (an immunosuppressive drug to help prevent rejection of organ transplants) level was to be assessed and/or adjusted. She returned today at which time her creatinine was higher at 3.8. They (the daughter and mother) were asked to agree to admission to evaluate the worsening renal function and her mother refused and left with the child.

- On 02/07/12 at 11:18 AM the Social Worker Progress Note showed that Staff J (Social Worker) contacted Staff L (DCFS Caseworker) and was informed that they (DCFS) had temporary custody, anticipated that custody would be extended and at discharge the patient would not be returned to her mother's care. Staff L verbally informed Staff J that mother would be allowed to visit, but could not interfere with the patient's medical care.
The progress note showed that Staff J returned the patient's mother's phone call to discuss her upcoming plan to visit. The mother stated that she would be coming to the hospital later today to take the patient home and stated that she would not allow the patient to live at the hospital.
Staff J contacted Staff L by telephone and based on the mother's threats to remove the patient from the hospital, Staff L verbally informed Staff J that the mother could not speak, visit or have access to any of the patient's medical records. Staff J documented that she notified guest services, the bedside nurse, the RN transplant coordinator and the physician of the verbal restriction placed on the mother.
Note: Staff J documented in the progress note that the mother was restricted from visiting the patient at the hospital, if she attempted to visit, she was to be asked to leave and security notified if she refused to leave. She also documented that there were no restrictions of the patient's father having contact or obtaining medical information from staff caring for the patient.

- On 02/07/12 at 4:09 PM the Social Worker Progress Note showed that Staff L called Staff J and reported that the patient's mother was currently in the process of trying to transfer the patient's care to a Wisconsin hospital.

- On 02/07/12 at 8:23 PM, the Pediatric Resident Daily Progress Note showed that the patient was somewhat upset and uncooperative when interviewed. Had poor oral intake and started on IV fluids.

- On 02/08/12 at 3:18 PM, the Pediatric Resident Daily Progress Note showed that psychology service had been consulted as "patient's going through major medical and psychosocial stressors and evidently endorses depressed mood".

- On 02/08/12 at 3:58 PM, the Social Worker Progress Note showed that Staff L informed her by telephone that the court had extended custody of the patient and they would now allow the mother to contact, visit and have access to the patient's medical information. The note showed that "mother is not allowed to interfere with {the patient's} medical care or escort {the patient} off the floor and {the patient} cannot be discharged to either parent without DCFS approval.

- On 02/08/12 at 8:37 PM, the Pediatric Nephrology Attending Daily Progress Note showed worsened renal function with creatinine elevated at 3.94 and rejection a possibility. The plan was to continue IV hydration, repeat creatinine lab in AM and schedule renal biopsy for 02/10/12.

- On 02/09/12 at 2:06 PM, the Social Worker Progress Note showed that the patient's mother and father were planning to visit. Staff J called DCFS and was verbally informed that the mother would need to be supervised by DCFS staff or their representative for all visits. Staff J documented, "mother cannot visit without DFS supervision. There are no restrictions on father visiting".

- On 02/10/12 at 8:48 AM, the Social Worker Progress Note showed that it was anticipated that the patient's mother would be coming to the facility today for the patient's scheduled biopsy. Staff J documented that DCFS verbally notified her by telephone that the patient's mother was now allowed to visit without supervision. Staff J documented that the parents were restricted from making any medical decisions for the patient or from taking her off the floor. She also documented that the physician and bedside RN were notified of current visitation plan.

- On 02/10/12 at 2:13 PM, the Pediatric Nephrology Attending Daily Progress Note showed that the patient underwent a renal biopsy. The documentation showed that the physician spoke with the patient's mother by phone about the biopsy results of cellular rejection but no vascular rejection; and the plan to repeat creatinine lab tomorrow after 3rd dose of steroids, and to continue IV hydration.

- On 02/10/12 at 2:33 PM the Social Worker Progress Note showed that Staff J met with both parents in the patient's room to discuss the visitation plan from DCFS. They both requested and were given a copy of the plan and verbalized anger regarding DCFS involvement and their authority to restrict visiting. Staff J documented in the progress note that the patient's father reportedly spent the night last night (02/09/12) in the patient's room, prior to this worker receiving the visiting plan from DCFS.

Note: DCFS faxed the written instructions on 02/09/12 at 4:07 PM, to Staff J's facility office fax machine of the patient's visiting plan for mother and father, to include length of visit 8 AM - 8 PM; and their visits must end if they begin to interfere with the patient's medical care, they cannot consent to any medical care, nor can they leave the floor with the patient. Staff J did not find the fax until the next day, after the father had spent the night.

- On 02/12/12 (no time noted of encounter), the Pediatric Nephrology Attending Daily Progress Note showed the physician contacted the patient's mother by telephone to discuss improvement in renal function and the need for additional therapy. The physician documented that the father arrived here early afternoon. After the patient received her afternoon medications, the nurse stepped out of room and the father took the patient out of the hospital and their whereabouts were unknown. The patient was "at major risk for health injury due to worsening of kidney rejection and severe hypertension without medical care". The police and DCFS notified and alerts issued.

- On 02/12/12 at 2:00 PM, the Nurses Progress Note showed that the patient requested to walk with her father. The Nurse documented that she told the patient that she needed to stay on the floor. The patient requested her IV be unhooked, but the nurse informed her that it needed to remain running with IV fluids. The nurse left the patient's room, walked down the hallway and five minutes later, the patient was gone from her room. The nurse searched the floor, notified the charge nurse and security.

4. Review on 02/14/12 at 3:00 PM of the facility internal investigation showed the following event information:
- On 02/12/12 at 1:35 PM - 1:40 PM, patient requested to take a walk with dad. Nurse advised it was OK, if they stay on floor, and refuses to discontinue IV per patient request;
- At 1:50 PM, nurse walked by patient's room, door was open (uncommon for this patient) and patient was not in room. Nurse swept the unit and walked to nearby unit, and staff there indicated the patient went to the cafeteria with dad;
- At 1:51 PM - 1:53 PM, based on video surveillance, young girl and man ("pair") seen in 1st floor lobby standing by wall. Appeared man was taking out the young girl's IV and then the pair left via the stairs to the ground floor lobby;
- At 1:53 PM, Nursing Supervisor was walking up stairs from ground level and passed the pair walking down stairs. Supervisor walked through vestibule and visualized a lone IV pole with IV bag and tubing hanging. She turned to go back to see if it was possibly the young girl's. She followed the pair and called security. She also called 3 South Unit to see if they had a patient missing and was told "yes";
- At 1:53 - 1:54 PM, Security walked out of the ED security office and the pair walked out the ED exit door at the same time. Security saw Nursing Supervisor and they both walked outside and saw the pair about 20 feet away {walking to parking garage}. Supervisor yelled and asked the pair if she was a patient and had they been discharged. The man answered, "yes (patient)" and "no (not discharged) and we are going to {another hospital}". Supervisor called 3 South Unit and was informed that the patient was in custody of the State;
- At 1:55 PM, Security and Supervisor walked to parking garage exit and saw a man driving quickly out of garage, the young lady was not visible inside the vehicle. The license plate was noted and they called 911;
- At 4:17 PM, alert issued by police;
- At 11:00 PM, patient was located and receiving care at a Milwaukee hospital.

5. During an interview on 02/15/12 at approximately 10:00 AM, Staff M, Security Team Leader stated that security did not have the prior knowledge of DCFS custody regarding this patient. Staff M stated that when the nursing supervisor walked to the top of the stairs and saw the lone IV pole, she was suspicious and turned around to follow a young girl and man walking down the stairs towards the ED, but was not certain at that point, the girl was a patient. The supervisor called security stationed at the ED and they followed them, but they were already out of the building headed towards the parking garage. Staff M stated that security could detain patients but not without an authorized reason, such as court order or DCFS custody, and in this case, was not informed in time to stop them.

6. During an interview on 02/15/12 at 10:16 AM, Staff J, Social Worker stated that in January 2011, the patient had a fluid filled mass on her native kidney removed and several days later, stated that she was leaving no matter what. Staff J stated that the patient was just tired of being here and insisted on leaving (left AMA with mother). When questioned about her recent communication with DCFS, Staff J stated that most was by telephone. Staff J stated that DCFS faxed the visiting plan on 02/09/12 to her office fax but she did not did see it until the following morning on 02/10/12. She confirmed that the visiting plan instructed the facility that the parents' visitation was from 8:00 AM - 8:00 PM and they were not to leave the floor with the patient. She also confirmed that the father had spent the night of 02/09/12 in the patient's room. Staff J stated the communication with DCFS was mostly by phone instead of in writing and there were numerous changes regarding the mother's supervision requirements. Staff J stated that she should have obtained the communication from DCFS in writing so that the changes would not be so confusing for staff to follow. Staff J stated that she communicated DCFS instructions to 3 South Unit staff verbally and documented in her progress notes, but did not have a system to inform staff working other units such as TCU (Transitional Care Unit). Staff J stated as far as she could remember, she had not informed TCU, other units or the nursing house supervisor of the parents' visitation restrictions for this patient. Staff J stated that they had not received a written copy of DCFS temporary custody, and had not received a copy of the extended custody until the Police Department faxed it to the facility following the incident. Note: the fax was dated 02/13/12 at 3:06 PM. When questioned, Staff J stated that she should have followed up and insisted that DCFS send a copy of the legal custody document immediately in order to ensure it was completed as stated.

7. During an interview on 02/15/12 at 2:15 PM, Staff B, Team Leader of Quality/Risk Management and Safety stated that the facility did not have a policy and procedure regarding DCFS custody and/or visitation restriction procedures. Staff B also stated that they did not have a policy and procedure regarding informing other units, managers and/or security regarding DCFS custody and/or visitation restriction procedures.

8. During an interview on 02/16/12 at 9:00 AM, Staff P, Physician stated that he had been involved with the patient and family for several years. Staff P stated that one of his physician partner's had made the decision to file the affidavit to DCFS based on the high creatinine level of 3.8, which showed a cleaning formula (the ability for the kidney to act as a filter) of approximately 20% kidney function. He stated, "we did not feel it would get better on its' own". On 02/12/12, the level was some improved at 3.1 with a cleaning function about 27%. Staff P stated they were still in the process of monitoring and adjusting her medications and as long as she went to another medical facility, should not have been harmed, but not knowing for sure, was a risk.

9. During interviews on 02/16/12 at 10:45 AM, Staff N and Staff O, Registered Nurses working on TCU both stated that they were very familiar with the patient from numerous prior visits. They both stated that on 02/12/12, they were walking to the medication room together when they saw the patient walking down the hall from 3 South towards the elevator. They spoke to her, as usual, and Staff N stated that she noticed a man sticking his head out the elevator calling for the patient to follow. Staff N stated, "I thought they were going to the cafeteria, whoever she was with mentioned something about a cheeseburger". Staff N stated that a little time later, three nurses from the 3 South Unit came running down the hall to TCU (Note: TCU unit is located on the 3rd floor approximately 264 feet down hallway from 3 South Unit) asking if they had seen the patient. Staff N and Staff O both stated they were not aware that the patient was in DCFS custody and had not been informed that she could not leave the floor. Staff O stated that there was no system in place to alert other facility staff on the floor, other than those working on the specific unit, of DCFS custody and/or visitation plan requirements.

10. During an interview on 02/16/12 at 12:15 PM, Staff Q, Nursing House Supervisor stated that at the time of the event, she had just walked down the vestibule area and when she came back up the steps, noticed the IV pole that was not there just a few minutes prior. She stated that she noticed a girl and man walking down the stairs, but did not know who they were and did not know they should not be leaving the hospital. She stated, "I just knew the lone IV pole was not there a few minutes prior". When questioned, Staff Q stated that it would be very difficult to inform hospital wide staff of the patient's individual plan, but they need to provide closer supervision of patients who have restrictions.