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Tag No.: A0115
Based on medical record review and staff interview, it was determined the hospital failed to ensure patients' rights were protected and promoted. This resulted in care not being provided in a safe setting and had the potential to affect all patients receiving care at the hospital. Findings include:
1. Refer to A 144, as it relates to the failure of the hospital to ensure care was provided in a safe setting.
The cumulative effects of these systemic practices seriously impeded the ability of the hospital to protect and promote patient rights, and provide care in a safe setting.
Tag No.: A0144
Based on medical record review and staff interview, it was determined the hospital failed to ensure care was provided in a safe setting. This directly impacted the safety of 1 of 3 patients (Patient #5) who left the hospital AMA and whose records were reviewed. This resulted in a patient found by EMS wandering in the snow after signing himself out of the hospital AMA and unable to care himself. Additionally, this resulted in incomplete patient care, missed clinical interventions, and had the potential to affect all patients receiving care at the hospital. Findings include:
Patient #5 was a 79 year old male who was seen in the ED on 12/22/19, with a presenting diagnosis of abdominal pain. Additional diagnoses included dementia, Alzheimer's Disease, and behavioral issues. Patient #5 had battered an employee of the assisted living facility he resided in and was dropped off at the ED. He was placed in the hospital on observation status from 12/22/19 to 1/13/20; 23 days. He signed himself out of the hospital AMA to his home alone on 1/13/20.
Patient #5 signed himself out of the hospital AMA and returned to his home alone despite being documented as gravely disabled and unsafe to do so. Patient #5's medical record included several entries which documented his compromised mental state, inability to be safe at home, and missed interventions. Examples include:
1. Patient #5's medical record included an "EMERGENCY DEPARTMENT NOTE," dated 12/22/19, signed by the ED PA, which stated:
- "During his stay in the ER the patient has been roaming the hallways at one time stated that he is being held against his will. I discussed this with the attending emergency room physician and do believe that the patient is gravely disabled and lacks the capacity to make his own decisions."
- "At this point the patient needs to have further evaluation or to test his capacity for understanding. He is gravely disabled and not safe for discharge to home."
A capacity exam was not done for Patient #5.
2. Patient #5's medical record included an "EMERGENCY NOTE ADDENDUM," dated 12/22/19, signed by the ED physician, which stated:
- "The patient's home is not livable per multiple first responders who have been to that house."
- "I question whether or not this patient has capacity for decision making. He frequently walks around with his colostomy open and draining all over the place. There is [sic] multiple documented other social issues as well as multiple issues regarding safety to himself and others with this patient. I do not feel that this patient has capacity to live and take care of himself within the community without significant support. We cannot find any family members to discharge him with and he is not okay to be discharged to the street by himself. Also I do not feel he has capacity for decision making as mentioned."
- "Plan is to also get capacity exam on this patient."
A capacity exam was not done for Patient #5.
3. Patient #5's medical record included an "SS Social Worker Note," dated 12/23/19, signed by a CM, which stated "The pt known to this worker from frequent admits. The pt has been diagnosed with dementia, with the inability to reside alone, and has a history of behavior issues at times. The pt does have a home, but this is not livable, per family."
4. Patient #5's medical record included an "SS Social Worker Note," dated 12/30/19, signed by a CM, which stated, "Spoke with [Washington State APS worker], and spoke with her regarding the pt. She did fax this worker a statement from the pt's PA (VA Clinic) [name], stating that the pt is unable to make his own decisions due to dementia and that he does not have the ability to reside alone and care for himself."
5. Patient #5's medical record included a physician order, dated 1/02/20, signed by a hospitalist, which stated, "Psych Eval...Consultation for Medication Recommendations...Triggers consultation by psychiatrist for help with diagnosis and medication recommendations...Provider should call to speak with psychiatrist...Appropriate for patients that have psychiatric conditions complicating their medical care."
A psych evaluation was not done for Patient #5.
6. Patient #5's medical record included a "HOSPITALIST PROGRESS NOTE," dated 1/10/20, signed by his attending physician, which stated, "He still does not seem that he would be reliable for going home alone."
7. Patient #5's medical record included a "HOSPITALIST PROGRESS NOTE," dated 1/11/20, signed by his attending physician, which stated, "Patient wanted to talk about leaving to go home. He says he will be okay. I told him that is not okay. He needs to stay."
8. Patient #5's medical record included a nursing note, dated 1/13/20, signed by an RN, which stated, "PATIENT BECAME INCREASINGLY AGITATED, REQUESTED TO LEAVE HOSPITAL, WHEN ASKED TO SIT AND TALK, PATIENT BECAME MORE AGITATED AND BEGAN CURSING AND THREATENING STAFF. BOTH THE DOCTOR [attending physician] AND CASE MANAGER WERE CALLED AND NOTIFIED. IT WAS DECIDED THAT THE PATIENT WOULD LEAVE AGAINST MEDICAL ADVICE. A TAXI WAS CALLED FOR THE PATIENT AND THE PATIENT IS WAITING PATIENTLY FOR THE ARRIVAL OF THE TAXI AT THIS TIME."
9. Patient #5's medical record included a Case Management note, dated 1/13/20, signed by a CM, which stated, "Called to [medical floor] that pt is demanding to leave AMA. Discussed with CFO and RM and decision to allow him to leave AMA. Charge RN advised to let attending MD know. Pt states he has no concerns that his home has food and utilities."
10. Patient #5's medical record included a "LEAVING MEDICAL CENTER AGAINST ADVICE" form, dated 1/13/20. The form was signed by Patient #5.
11. Patient #5's medical record included a discharge summary, dated 1/13/20, signed by the attending physician, which stated, "Patient has history of unpredictable and violent activities. Attempt was made replacement [sic]. These were all unsuccessful. At time of discharge patient went AMA."
Patient #5 did not receive a capacity exam, a psych evaluation, and was able to sign himself out of the hospital AMA to his home alone on 1/13/20. Patient #5 was found wandering in the snow with his colostomy apparatus detached and hanging on 1/14/20, and brought to a different acute care facility for evaluation by EMS.
The CFO was interviewed on 3/04/20, beginning at 8:18 AM, and Patient #5's medical record was reviewed in his presence. He stated he was familiar with Patient #5, but did not make the decision to discharge him, as that was up to the clinical team.
The Director of Case Management was interviewed on 3/04/20, beginning at 8:23 AM, and Patient #5's medical record was reviewed in her presence. She confirmed a psych evaluation was not done for Patient #5. The Director of Case Management stated a quality review and/or RCA of Patient #5's hospitalization had not been done. She stated Patient #5 went home with caregivers, but confirmed this was not documented in his medical record.
The CNO was interviewed on 3/04/20, beginning at 9:48 AM, and Patient #5's medical record was reviewed in his presence. He stated Patient #5 had a 1-to-1 sitter for the duration of his stay in observation status, from 12/22/19 to 1/13/20, due to "elopement risk and confusion." The CNO confirmed Patient #5's ability to sign himself out AMA, given his documented confusion, safety concerns, mental condition, and home environment, was not documented. He confirmed Patient #5's ordered psych evaluation was not done. When asked why Patient #5's psych evaluation was not done, the CNO stated he did not know.
A CNA who cared for Patient #5 during his admission was interviewed on 3/04/20, beginning at 11:01 AM. When asked why Patient #5 had a 1-to-1 sitter, she stated he was a "flight risk and aggressive." Additionally, the CNA stated Patient #5 was "often confused" and would state, "Where am I?" She stated Patient #5 had to be reoriented frequently.
A second CNA who cared for Patient #5 during his admission was interviewed on 3/04/20, beginning at 11:07 AM. When asked why Patient #5 had a 1-to-1 sitter, she stated he was "combative" and "would repeat and ask the same questions often."
Patient #5's attending physician was interviewed on 3/04/20, beginning at 11:16 AM. She stated Patient #5 would frequently ask to go home to which she stated it was, "not a good idea." The attending physician stated Patient #5 had a history of not being safe. She stated she did not evaluate his mental condition "due to what others were saying." The attending physician stated she was unaware Patient #5 signed himself out of the hospital AMA and stated they did not have a reason to keep him.
The RN who was assigned to Patient #5 when he signed himself out of the hospital AMA was interviewed on 3/04/20, beginning at 11:27 AM. He stated he believed he informed Patient #5's attending physician prior to having him sign AMA paperwork. The RN stated Patient #5 left the hospital AMA to his home alone and refused assistance, therapy, or home health. He stated Patient #5 had a 1-to-1 sitter due to "falls and wandering into other patients' rooms."
The ED PA was interviewed on 3/04/20, beginning at 12:59 PM, and Patient #5's ED record was reviewed in his presence. He stated Patient #5 could not make his own decisions and was gravely disabled.
The ED physician was interviewed on 3/04/20, beginning at 1:05 PM, and Patient #5's ED record was reviewed in his presence. He stated Patient #5 needed a competency evaluation [capacity exam]. When asked if Patient #5 had psychological components in addition to his medical presentations, the ED physician stated, "I'm not a psychologist, but I'd say yes."
The CNO was interviewed a second time on 3/04/20, beginning at 1:48 PM, and Patient #5's medical record was reviewed in his presence. When asked why a capacity exam was not initiated and executed by a DE, the CNO stated the DE had previously explained they would not perform one for Patient #5 due to his diagnosis of dementia without a psych component. The CNO confirmed this conversation with the DE was not referenced in Patient #5's medical record. Additionally, the CNO confirmed a capacity exam was not performed for Patient #5.
The hospital failed to ensure Patient #5's care was provided in a safe setting.