HospitalInspections.org

41728


Based on record review and staff interviews, it has been determined that the facility failed to provide care in a safe setting, relative to levels of observation for 1 of 1 patient reviewed (Patient ID # 1).
Findings are as follows:

The Hospital's policy, Categories of Observation, effective 2/27/2019, states, in part:
" Explanation of Categories of Observation:
...3) 5- or 15-Minute Observations stipulate that an assigned staff member visually observes the patient regularly at the ordered interval. The patient's location on the unit may be restricted as necessary to accomplish the observation. The patient may not leave the unit unaccompanied on 5- or 15-minute observations...."

Record review revealed Patient ID #1 was admitted to the hospital (Hospital A) on 10/29/2019 with a diagnosis including, but not limited to, depression, anxiety and an attempted suicide earlier in the day.

Review of the Physician's orders dated 10/29/2019 included an order for 5-minute patient observations with unit restrictions.

Further record review revealed that on 11/5/2019, the patient, accompanied by a Mental Health Worker (MHW), was transported to another hospital (Hospital B) for an outpatient CT Scan to rule out dementia.

Surveyor interview with Staff A on 11/7/2019 at 1:50 PM revealed that after the patient was brought to the CT Scan room, Staff A went to the hospital cafeteria to get a drink. Upon return to the waiting room, Staff A stated that he waited for the patient to come out to the waiting area. He then went to the desk to inquire as to how much longer the patient would be and was told there were no patients left in the department. He immediately notified the security officer and went to the parking lot area in search of the patient and could not locate him/her. Subsequently, he notified his supervisor and Hospital B's security command center.

On 11/7/2019 at 12:49 PM, during an interview with the manager of security for Hospital B, he revealed the patient entered the CT Scan room at 4:10 PM. He then produced security camera evidence that the MHW, Staff A, walked to the cafeteria at 4:13 PM, the patient left the building at 4:18 PM, and Staff A returned to the waiting area at 4:20 PM.
Upon knowledge of this event, the Security Manager revealed they notified the police. Police and security officers searched Hospital B's building and grounds twice that night and were unable to locate the missing patient. A Silver Alert was put in place; subsequently the patient was found in the woods behind Hospital B at 1:38 PM the following afternoon.

On 11/7/2019 at 12:50 PM, during an interview with the Chief Nursing officer for Hospital A, he stated it is his expectation that while on transport with a patient who has physician orders for 5-minute checks, the MHW will always be within the sight of the patient.

The facility failed to provide care in a safe setting relative to levels of observation resulting in the patient being alone and outside overnight. Upon return to Hospital A on 11/6/2019 at 7:26 PM, the patient was evaluated and involuntarily admitted for further treatment of significant cognitive impairment, hopelessness, prominent psychotic symptoms and active suicidal ideation.