HospitalInspections.org

Based on policy and procedure review, medical record review and personnel interview, the registered nurse failed to supervise and evaluate the care planned for each patient related to implementation of physician orders for a continuous sitter and notification of patient's family of elopement according to policy and procedure for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy titled, "Plan for the Provision of Nursing Care" revised/reapproved 3/5/13, was reviewed on 5/16/13 at approximately 11:14 AM, and indicated on pg. 1, "It is the nurse's responsibility to provide quality patient care...Nursing has accountability and authority to identify and meet the patient's needs in cooperation with peers and other health professionals."

2. Policy titled, "Patient Companion" revised/reapproved 10/19/11, was reviewed on 5/16/13 at approximately 1:02 PM, and indicated on pg. 1 under:
A. Policy Statement section, "Situations may arise whereby a Patient Companion is required to be in constant attendance of an individual patient to provide continuous observation of an individual patient in order to monitor for patient safety."
B. Key Points section, point 3, "Shift Director will arrange a patient companion for the patient's safety based on priority and availability."

3. Policy titled, "Code Green (Missing Patient)" revised/reapproved 1/19/11, was reviewed on 5/16/13 at approximately 11:14 AM, and indicated on pg. 1, under Key Points section, point 7, "If the patient is not located in the medical center or on the grounds the Nursing Supervisor/Nurse Manager/Charge Nurse will call the patients home and/or relatives to advise them the patient has left the medical center. A request for a return call to the former patient's medical unit will be made."

4. Policy titled, "Patient Rights and Responsibilities" revised/reapproved 2/5/13, was reviewed on 5/16/13 at approximately 11:14 AM, and indicated on pg. 3, under Patient Rights section, point 5, "To receive care in a safe setting."

5. Review of closed patient medical records on 5/16/13 at approximately 11:53 AM, indicated Patient N1 was a 55-year-old who presented to the Emergency Department (ED) on 3/21/13 for change in mental status and confusion/dementia and admitted to the Ortho Surgical Oncology Unit at 1959 for further medical management. Documentation in the medical record included:

A. per History and Physical dated 3/21/13 at 2322 "admitted to [this facility] from the nursing home following a very brief stay there. The patient had been hospitalized just recently with a cellulitis of his/her left face and dental infection of his/her left mandible. Was treated with intravenous antibiotics and has had a good response to that treatment. Was transferred to facility #1 with the plan of him/her residing there until he/she had his/her dental problem fully cared for and then for him/her to be placed in some type of long-term care facility. Was transferred to the nursing home and was only there for several hours when he/she attempted to elope and, by their report, became somewhat combative following his/her confrontation on the elopement issue. The patient denies there being any problem whatsoever. He/She is not an entirely accurate historian however, and does have a history of previous anoxic brain injury which makes him/her somewhat cognitively impaired."
B. per Physician Progress Note dated 3/24/13 at 1607, "Still wants out of hospital. Left for a time last p.m. Returned by police."
C. per Physician Orders dated 3/21/13, "Sitter at bedside until discontinued."
D. lacked continuous sitter as ordered per physician.

6. Incident Reports for March, 2013 through May, 2013 were reviewed on 5/16/13 at 11:54 AM, one found related to complaint indicated:
A. an incident report was filed on 3/24/13 for a code purple/disorderly person on the same date at 2300.
B. "patient had a sitter. Right after she left, the patient left his/her room and left the hospital. He/She went to the grocery store across the street according to security. He/She was found walking back toward the hospital."
C. security, physician, and charge nurse were notified.
D. lacked notification of patient's family.

7. Personnel P9 was interviewed on 5/16/13 at approximately 12:17 PM and confirmed:
A. patient N1 was alert and oriented somewhat, but he/she was not oriented to his/her situation all the time...when the patient came back to the unit I notified the house supervisor and directed the nurse to make an incident report. We did not notify the family as required by facility policy and procedure because patient was unharmed and back safely in their room."

8. Personnel P2 was interviewed on 5/16/13 at approximately 12:56 PM and confirmed, it was indicated in conversation with the nurse caring for the patient at the time of elopement on March 23, 2013 that a sitter was not present. Physician order for a continuous sitter for this patient was not followed.