HospitalInspections.org

Hospital A

Based on medical record review, review of facility policy, interview and observation, the facility failed to protect and/or promote patient rights and prevent neglect for a patient with identified suicidal ideation and plan (#5) of five sampled patients, resulting in elopement. The facility's failure placed patient #5 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause injury, harm, impairment, or death to a patient).

An exit conference was conducted with two Chief Clinical Officers, a corporate Vice President of Emergency Department Operations, and the Regional Chief Nursing Officer on May 13, 2011, at 3:08 p.m., in an administrative conference room. The facility was informed of an Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) at CFR Part 482.13 Patient Rights (Condition).

The findings included:

Patient #5 presented to the facility's Emergency Room (ER) on April 13, 2011, at 2:56 p.m. Medical record review of an Emergency Department (ED) Sign-In sheet dated April 13, 2011, at 2:56 p.m., revealed, "...Complaint: Just want to kill myself...Came Alone."

Medical record review of a Triage form dated April 13, 2011, at 3:00 p.m., revealed, "...Chief Complaint...Suicidal/Hallucinations...Threats of harm to self Yes...past suicidal/homicidal attempts (?) Yes...Current Suicidal/homicidal ideation (Y) Yes...Do you have a plan (?) Yes If yes (what is the plan): jump off bridge..."

Medical record review of an Emergency Department nurse's note dated April 13, 2011, at 3:00 p.m., revealed, "pivoted per FNP (Family Nurse Practitioner #1)."

Interview with ED Clinical Leader #1 on May 6, 2011, at 12:44 p.m., in a conference room, revealed FNP #1 "pivoted" and escorted patient #5 to Room 21 on April 13, 2011. Continued interview revealed ED Clinical Leader #1 attempted to explain the process of "pivoting", and the facility had no written procedure regarding the "pivoting" process. Continued interview revealed Registered Nurse (RN) #1 was assigned to Room 21 on April 13, 2011.

Medical record review of an Emergency Provider Record dated April 13, 2011, and signed by FNP #1 revealed, "...1502 (3:02 p.m.) brief history: Suicidal ideation...Expected Disposition of Patient...Transfer pending results..."

Medical record review of an Emergency Department Physician Order Sheet signed by FNP #1 and dated April 13, 2011, at 3:02 p.m., revealed, "...Involuntary Hold for Safety..."

Medical record review of an ED nurse's note dated April 13, 2011, at 3:15 p.m., revealed, "to room 21 (in the emergency room), states feels better." Medical record review of an ED nurse's note dated April 13, 2011, at 3:18 p.m., revealed, "pt. (patient) not in room, security notified." Medical record review of a nurse's note dated April 13, 2011, at 3:25 p.m., revealed, "Pt not seen on...campus. KPD (Knoxville Police Department) notified."

Review of (un-numbered) facility policy dated July 13, 2010, revealed, "...Title Suicidal Patients: Admission and Care Policies...Policy: Upon...arrival in the emergency department, all patients with a primary diagnosis or primary complaint of an emotional or behavioral disorder is screened for suicide risk...In cases where a patient has clearly attempted suicide, an initial screening is not necessary because that patient is already assumed to be at high risk for self-harm. These high risk patients should be placed in a secure area or staffing adjusted to provide 1:1 (one on one) coverage...The patient is to remain in the 1:1 sitter's eyesight at ALL times. Suicidal patients in...emergency department will have 1:1 coverage at all times..."

Review of facility policy #NUR1020.000 dated October 18, 2010, revealed, "...Title Discharge...An electronic occurrence report is to be completed if the patient leaves without staff knowledge..."

Review of (un-numbered) facility policy dated March 22, 2011, revealed, "...Title Abuse...Neglect...Patients are further protected from any form of abuse, neglect...Abandonment: Desertion of a vulnerable individual by anyone who has assumed care or custody of that person...For any suspected instances of abuse, neglect...Associates will be instructed to...report...All observed or reported incidents...will be reported to the appropriate supervisor for additional assessment. The incident will be entered into the electronic incident reporting system. The Risk Manager and Administrator-on-call must be notified immediately...will immediately begin an investigation..."

Review of (un-numbered) facility policy dated March 22, 2011, revealed, "...Title Patient Rights...will include but not be limited to the patient's right to : ...Considerate and respectful care, provided in a safe environment...Be placed in protective services when considered necessary for personal safety..."

Telephone interview with RN #1 (on duty April 13, 2011, when patient #5 eloped) on May 6, 2011, at 1:30 p.m., revealed the "pivot" process consisted of a Physician's Assistant or FNP's intercept (meeting patient at the door) of a patient in the emergency room and she stated, "...(pivoting) jump starts the process (emergency room assessment and treatment)." Continued interview revealed Room 21 (of the ER) was called "the safe room," and she heard an announcement that a new patient was in Room 21 on April 13, 2011. The nurse stated, "I don't know what stage of (the) process the page (announcement) was done." Continued interview revealed two or three minutes passed from the time she heard the announcement until she went to Room 21 and she stated, "I went to the room and nobody was there...If (facility) had followed policy (Patient #5) would have had 1:1..."

Interview with an administration department receptionist on May 6, 2011, at 1:45 p.m., revealed Room 21 was monitored by camera twenty four hours daily seven days per week, and two facility employees monitored the cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.

Telephone interview with Monitor #1 (responsible for monitoring cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.) on May 6, 2011, at 2:00 p.m., revealed her duties included answering in-coming calls, and she stated, "...periodically monitor monitors (cameras) and exit gate...have four bays with sixteen cameras on (for) each bay." Continued interview revealed she was aware of the purpose of Room 21 and unaware of a patient's elopement from Room 21 on April 13, 2011, between 3:15 p.m. and 3:18 p.m., and she stated, "I know we have patients who have to be observed...have never been told I have to report if (I) see (a) patient leave...aware of 1:1 supervision (required in Room 21)."

Telephone interview with FNP #1 on May 6, 2011, at 1:47 p.m., revealed, "Patients who are suicidal are put in Room 21. I do remember me and pivot nurse, or it could have been just me who walked patient (#5) to the room. As courtesy (to nurses) took (Patient #5) back to room. (Patient #5) had expressed suicidal ideation. The pivot process is (the patient) is triaged by (an) RN, as NP (FNP) I see patient from provider standpoint, order appropriate tests. I just listened to what (Patient #5) had to say. Usually nurses walk (suicidal patients) to room...don't remember leaving patient in the room. I don't have radio to communicate to nurses...We called from triage room to nurses that a patient was coming...Patient got left in (the) room unattended." Continued interview confirmed the facility's policy for 1:1 supervision for suicidal patients was not implemented for Patient #5 on April 13, 2011.

Telephone interview with Monitor #2 (responsible for monitoring cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.) on May 9, 2011, at 1:50 p.m., revealed her duties included answering calls, monitoring sixteen cameras on four bays, and she stated, "Unless (I) see something specific in Room 21 (I'm) not alarmed." Continued interview revealed she had no instructions on how to respond if she saw a patient leave Room 21, and she stated, "...don't know if they've been dc'd (discharged) or what." Continued interview revealed the camera monitoring station was located on the ground floor of the hospital and Room 21 was on lower level two of the facility, two floors below the camera monitoring station.

Observation and interview in the ER with ER Clinical Leader #1 on May 11, 2011, at 11:18 a.m., revealed the doors in Room 21 did not lock, and the distance from Room 21 to an exit door from the ER into another area of the hospital was approximately one hundred fifty feet and an exit door to the outside was approximately one hundred seventy five feet. Continued observation revealed the time to reach the exit door to the outside was less than one minute from Room 21. Observation of the camera monitoring room with the ER Clinical Leader #1 on May 11, 2011, at 11:40 a.m., revealed the cameras were monitored by two staff, and included five live camera pictures from Room 21.

Interview with ER Clinical Leader #1 on May 11, 2011, at 11:25 a.m., in an ER exam room, revealed the elopement of Patient #5 on April 13, 2011, required an electronic incident report, an electronic incident report would have brought the incident to his attention, and confirmed an electronic incident report was not completed regarding the elopement of patient #5 on April 13, 2011. Continued interview revealed no investigation into the elopement was initiated until after May 2, 2011.

Interview with the Director of Safety and Security on May 11, 2011, at 12:15 p.m., in a physician's office, revealed the facility was monitored by one hundred sixty surveillance cameras and (two) staff monitoring the cameras had assigned duties in addition to monitoring the cameras. Continued interview revealed in the event a patient on involuntary hold in Room 21 disappeared, the facility's practice was to look on the cameras to determine the patient's appearance, one officer would be dispatched to drive around/search outside, other officers would be dispatched to search inside, and he stated, "Timeframe to determine if (patient) on campus could take an hour or more to conclude patient not here..." Continued interview revealed an incident report was to be filed on completion of a campus search by security.

Interview with the Director of Safety and Security on May 11, 2011, at 12:47 p.m., revealed security had no record of any search for Patient #5 on April 13, 2011.

Observation on May 11, 2011, at 1:10 p.m., revealed the facility was located in an urban area, adjacent to a high school, and surrounded by highly trafficked streets.

Telephone interview with FNP #1 on May 6, 2011, at 1:47 p.m., revealed Patient #5 required one on one supervision and was left unattended in the facility's "safe room." Continued interview confirmed the facility failed to protect and /or promote patient rights and prevent neglect resulting in elopement for Patient #5 on April 13, 2011, placing Patient #5 in Immediate Jeopardy.

Refer to Standard A 145

C/O: #27991

21161

HOSPITAL B

Based on medical record review, review of facility policy, and interview, the facility failed to comply with one patient's (#B2) medical care decision of five patient records reviewed.

The findings included:

Patient #B2 presented to the Emergency Department via car on April 17, 2011, and was admitted under observation basis to rule out Myocardial Infarction (heart attack).

Medical record review of the History and Physical dated April 17, 2011, revealed patient #B2 experienced a sudden onset of left-sided chest pain, pressure like quality with duration of thirty minutes before spontaneous resolution of the pain. Further record review revealed the patient's pain resolved prior to arrival at the facility on April 17, 2011.

Medical record review of the Admission orders dated April 17, 2011, revealed an order for "DNR"(Do Not Resuscitate).

Medical record review revealed no Advanced Directive in the medical record.

Review of the medical record revealed after admission on April 17, 2011, the patient underwent a stress test which was "normal" and the laboratory studies and electrocardiogram were "normal" and the patient was discharged home on April 18, 2011.

Medical record review of the Discharge Summary dated April 18, 2011, revealed, "The patient is a FULL CODE."

Review of the (un-numbered) facility policy titled Advanced Directives last revised May 17, 2010, revealed, "If an individual does not have an Advance Directive, they may state their wishes verbally to the physician, chaplain, or licensed staff who will document this statement in the medical record."

Medical record review revealed no documentation the patient communicated a desire to not be resuscitated in the event of not being able to communicate for self.

Interview and electronic review of the medical record with the Clinical Leader of the 4th floor in the administrative office, on May 9, 2011, at 12:35 p.m., confirmed the facility failed to follow the Advance Directive policy in order to determine if the patient wanted to be resuscitated in the event of a code.

Hospital A

Based on medical record review, review of facility policy, interview and observation, the facility failed to prevent neglect for a patient with identified suicidal ideation and plan (#5) of five sampled patients, resulting in elopement. The facility's failure placed Patient #5 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause injury, harm, impairment, or death to a patient).

An exit conference was conducted with two Chief Clinical Officers, a corporate Vice President of Emergency Department Operations, and the Regional Chief Nursing Officer on May 13, 2011, at 3:08 p.m., in an administrative conference room. The facility was informed of an Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) at CFR Part 482.13(c)(3) Patient Rights.

The findings included:

Patient #5 presented to the facility's Emergency Room (ER) on April 13, 2011, at 2:56 p.m. Medical record review of an Emergency Department (ED) Sign-In Sheet dated April 13, 2011, at 2:56 p.m., revealed, "...Complaint: Just want to kill myself...Came Alone."

Medical record review of a Triage form dated April 13, 2011, at 3:00 p.m., revealed, "...Chief Complaint...Suicidal/Hallucinations...Threats of harm to self Yes...past suicidal/homicidal attempts (?) Yes...Current Suicidal/homicidal ideation (Y) Yes...Do you have a plan (?) Yes If yes (what is the plan): jump off bridge..."

Medical record review of an Emergency Department nurse's note dated April 13, 2011, at 3:00 p.m., revealed, "pivoted per FNP (Family Nurse Practitioner #1)."

Medical record review of an Emergency Provider Record dated April 13, 2011, and signed by FNP #1 revealed, "...1502 (3:02 p.m.) brief history: Suicidal ideation...Expected Disposition of Patient...Transfer pending results..."

Medical record review of an Emergency Department Physician Order Sheet signed by FNP #1 and dated April 13, 2011, at 3:02 p.m., revealed, "...Involuntary Hold for Safety..."

Medical record review of an ED nurse's note dated April 13, 2011, at 3:15 p.m., revealed, "to room 21 (in the emergency room), states feels better." Medical record review of an ED nurse's note dated April 13, 2011, at 3:18 p.m., revealed, "pt. (patient) not in room, security notified." Medical record review of a nurse's note dated April 13, 2011, at 3:25 p.m., revealed, "Pt not seen on...campus. KPD (Knoxville Police Department) notified."

Review of (un-numbered) facility policy dated July 13, 2010, revealed, "...Title Suicidal Patients: Admission and Care Policies...Policy: Upon...arrival in the emergency department, all patients with a primary diagnosis or primary complaint of an emotional or behavioral disorder is screened for suicide risk...In cases where a patient has clearly attempted suicide, an initial screening is not necessary because that patient is already assumed to be at high risk for self-harm. These high risk patients should be placed in a secure area or staffing adjusted to provide 1:1 (one on one) coverage...The patient is to remain in the 1:1 sitter's eyesight at ALL times. Suicidal patients in...emergency department will have 1:1 coverage at all times..."

Review of facility policy # NUR1020.000 dated October 18, 2010, revealed, "...Title Discharge...An electronic occurrence report is to be completed if the patient leaves without staff knowledge..."

Review of (un-numbered) facility policy dated March 22, 2011, revealed, "...Title Abuse...Neglect...Patients are further protected from any form of abuse, neglect...Abandonment: Desertion of a vulnerable individual by anyone who has assumed care or custody of that person...For any suspected instances of abuse, neglect...Associates will be instructed to...report...All observed or reported incidents...will be reported to the appropriate supervisor for additional assessment. The incident will be entered into the electronic incident reporting system. The Risk Manager and Administrator-on-call must be notified immediately...will immediately begin an investigation..."

Review of (un-numbered) facility policy dated March 22, 2011, revealed, "...Title Patient Rights...will include but not be limited to the patient's right to : ...Considerate and respectful care, provided in a safe environment...Be placed in protective services when considered necessary for personal safety..."

Interview with ED Clinical Leader #1 on May 6, 2011, at 12:44 p.m., in a conference room, revealed FNP #1 "pivoted" and escorted patient #5 to Room 21 on April 13, 2011. Continued interview revealed ED Clinical Leader #1 attempted to explain the process of "pivoting", and confirmed the facility had no written procedure regarding the "pivoting" process. Continued interview revealed Registered Nurse (RN) #1 was assigned to Room 21 on April 13, 2011.

Telephone interview with RN #1 (on duty April 13, 2011, when Patient #5 eloped) on May 6, 2011, at 1:30 p.m., revealed the "pivot" process consisted of a physician's assistant or FNP's intercept (meeting patient at the door) of a patient in the emergency room and she stated, "...(pivoting) jump starts the process (emergency room assessment and treatment)." Continued interview revealed Room 21 (of the ER) was called "the safe room," and she heard an announcement that a new patient was in Room 21 on April 13, 2011. The nurse stated, "I don't know what stage of (the) process the page (announcement) was done." Continued interview revealed two or three minutes passed from the time she heard the announcement until she went to Room 21 and she stated, "I went to the room and nobody was there...If (facility) had followed policy (Patient #5) would have had 1:1..."

Interview with an administration department receptionist on May 6, 2011, at 1:45 p.m., revealed Room 21 was monitored by camera twenty four hours daily seven days per week, and two facility employees monitored the cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.

Telephone interview with Monitor #1 (responsible for monitoring cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.) on May 6, 2011, at 2:00 p.m., revealed her duties included answering in-coming calls, and she stated, "...periodically monitor monitors (cameras) and exit gate...have four bays with sixteen cameras on (for) each bay." Continued interview revealed she was aware of the purpose of Room 21 and unaware of a patient's elopement from Room 21 on April 13, 2011, between 3:15 p.m. and 3:18 p.m., and she stated, "I know we have patients who have to be observed...have never been told I have to report if (I) see (a) patient leave...aware of 1:1 supervision (required in Room 21)."

Telephone interview with FNP #1 on May 6, 2011, at 1:47 p.m., revealed, "Patients who are suicidal are put in Room 21. I do remember me and pivot nurse, or it could have been just me who walked Patient (#5) to the room. As courtesy (to nurses) took (Patient #5) back to room. (Patient #5) had expressed suicidal ideation. The pivot process is (the patient) is triaged by (an) RN, as NP (FNP) I see patient from provider standpoint, order appropriate tests. I just listened to what (Patient #5) had to say. Usually nurses walk (suicidal patients) to room...don't remember leaving patient in the room. I don't have radio to communicate to nurses...We called from triage room to nurses that a patient was coming...Patient got left in (the) room unattended." Continued interview confirmed the facility's policy for 1:1 supervision for suicidal patients was not implemented for Patient #5 on April 13, 2011.

Telephone interview with Monitor #2 (responsible for monitoring cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.) on May 9, 2011, at 1:50 p.m., revealed her duties included answering calls, monitoring sixteen cameras on four bays, and she stated, "Unless (I) see something specific in Room 21 (I'm) not alarmed." Continued interview revealed she had no instructions on how to respond if she saw a patient leave Room 21, and she stated, "...don't know if they've been dc'd (discharged) or what." Continued interview revealed the camera monitoring station was located on the ground floor of the hospital and Room 21 was on lower level two of the facility, two floors below the camera monitoring station.

Observation and interview in the ER with ER Clinical Leader #1 on May 11, 2011, at 11:18 a.m., revealed the doors in Room 21 did not lock, and the distance from Room 21 to an exit door from the ER into another area of the hospital was approximately one hundred fifty feet and an exit door to the outside was approximately one hundred seventy five feet. Continued observation revealed the time to reach the exit door to the outside was less than one minute from Room 21. Observation of the camera monitoring room with the ER Clinical Leader #1 on May 11, 2011, at 11:40 a.m., revealed the cameras were monitored by two staff, and included five live pictures from Room 21.

Interview with ER Clinical Leader #1 on May 11, 2011, at 11:25 a.m., in an ER exam room, revealed the elopement of Patient #5 on April 13, 2011, required an electronic incident report, an electronic incident report would have brought the incident to his attention, and an electronic incident report was not completed regarding the elopement of Patient #5 on April 13, 2011. Continued interview revealed no investigation into the elopement was initiated until after May 2, 2011.

Interview with the Director of Safety and Security on May 11, 2011, at 12:15 p.m., in a physician's office, revealed the facility was monitored by one hundred sixty surveillance cameras and (two) staff monitoring the cameras had other duties in addition to monitoring the cameras. Continued interview revealed in the event a patient on involuntary hold in Room 21 disappeared, the facility's practice was to look on the cameras to determine the patient's appearance, one officer would be dispatched to drive around/search outside, other officers would be dispatched to search inside, and he stated, "Timeframe to determine if (patient) on campus could take an hour or more to conclude patient not here..." Continued interview revealed an incident report was to be filed on completion of a campus search by security.

Interview with the Director of Safety and Security on May 11, 2011, at 12:47 p.m., revealed security had no record of any search for Patient #5 on April 13, 2011.

Observation on May 11, 2011, at 1:10 p.m., revealed the facility was located in an urban area, adjacent to a high school, and surrounded by highly trafficked streets.

Telephone interview with FNP #1 on May 6, 2011, at 1:47 p.m., revealed Patient #5 required one on one supervision and was left unattended in the facility's "safe room" and confirmed the facility failed to prevent neglect resulting in elopement for Patient #5 on April 13, 2011, placing Patient #5 in Immediate Jeopardy.

C/O: #27991

Hospital B

Based on medical record review, review of The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, review of facility policy and interview, the facility failed to ensure the nursing staff assessed the health status/condition of one patient (#B1) with elevated blood pressure and symptoms of pain; failed to notify the physician of continued elevated blood pressure; and failed to assess pain and the patient's response to medication for one patient (#B1) of five patients reviewed.

The findings included:

Medical record review of the Triage Note for patient #B1 dated April 18, 2011, at 12:19 p.m., revealed the vital signs included Blood Pressure (BP) of 189/120; Pulse 102; Respirations of 20 breaths per minute; and respiratory rate and oxygen saturation within normal limits. Continued review revealed the patient denied any past medical history (including High Blood Pressure/Hypertension), and took no prescribed medications at home for any medical condition.

Review of The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (a professional medical reference utilized by the facility) revealed a normal blood pressure was "less than 120/80. " The normal range for an adult's pulse was 60 - 100 beats per minute.

Medical record review of the Emergency Department (ED) Nursing Notes dated April 18, 2011, revealed the following BPs and times: 12:54 p.m. - 184/126; 1:02 p.m. - 193/115; 1:30 p.m. - 174/91; 2:08 p.m. - 182/100; 3:00 p.m. - 201/84.

Medical record review revealed the patient was administered oxygen therapy at 12:40 p.m.; a Nitroglycerin tablet (for chest pain) 0.4 milligrams (mg) sublingual (under the tongue) at 12:43 p.m., Labetolol (anti-hypertensive) 10 mg intravenously at 1:02 p.m.; Tylenol 650 mg at 3:25 p.m., and Lopressor (anti-hypertensive) 25 mg tablet orally at 3:35 p.m.

Medical record review of the Emergency Provider Record dated April 18, 2011, revealed the physician's clinical impression of the patient's condition was Acute (sudden onset) Chest Pain and Hypertensive Urgency.

Medical record review revealed the patient was admitted to the hospital and the admission History and Physical dated April 18, 2011, at 2:45 p.m., revealed the patient's assessment and plan included, "Chest Pain ...some risk factors...uncontrolled blood pressure...Also with the chest pain...has had some EKG (electrocardiogram) changes significant for Ischemia (reduced blood flow with resultant damage/dysfunction of organ)..."

Medical record review of the Admission Physician Orders dated April 18, 2011, at 2:08 p.m., revealed an order for Hydrochlorothiazide (HCTZ) (anti-hypertensive) 25 mg by mouth once daily. Continued review revealed an order for Lopressor (anti-hypertensive) 25 mg by mouth one time, and review of the Emergency Department Record revealed Lopressor was administered at 3:25 p.m.

Medical record review of the Nurse's Notes dated April 18, 2011, revealed patient #B1 arrived to a medical/surgical nursing unit at 4:09 p.m. Medical record review revealed the following elevated blood pressures and times:

April 18, 2011, at 4:09 p.m. - 183/108; at 8:23 p.m. - 173/105;

April 19, 2011, at 12:03 a.m. - 162/101; at 5:04 a.m. - 154/106; 9:43 a.m. -190/115; 1:17 p.m. - 187/121; 2:25 p.m. - 197/120; 4:02 p.m. - 185/119.

Medical record review of the Certified Nursing Assistant (CNA) documentation dated April 18, 2011, revealed a nurse was notified of the elevated blood pressures at 4:09 p.m. and 8:23 p.m. Medical record of the CNA documentation dated April 19, 2011, revealed a nurse was notified of the elevated blood pressures at 9:43 a.m. and 1:17 p.m.


Medical record review revealed no documentation the physician was notified of the elevated blood pressures. Medical record review revealed no assessment of the patient's status with the elevated blood pressures (associated symptoms such as chest pain, shortness of breath, headache).

Medical record review of a Nurse's Note dated April 19, 2011, at 3:30 a.m., revealed, "...(patient) grimacing."

Medical record review revealed no documentation of the assessment of the pain's location, quality, severity, duration and/or use of the pain scale. Medical record review revealed patient #B1 was administered a narcotic pain medication at 3:30 a.m. Continued review revealed no documentation of the location, severity, or quality of the pain.

Review of the (un-numbered) facility policy titled Pain Assessment and Management revised October 8, 2010, revealed, "Patients are assessed for comfort in an ongoing manner...The pain scale will be used and documented with each subjective pain assessment."

Medical record review of a physician's order dated April 19, 2011, at 4:00 p.m., revealed a one-time order for Clonidine (anti-hypertensive) 0.1 mg to be administered by mouth. (Onset time of effect of Clonidine tablet is thirty to sixty minutes.)

Medical record review revealed patient #B1 was discharged from the facility on April 19, 2011.

Medical record review of the Discharge Summary dated April 19, 2011, at 4:08 p.m., revealed, "Significant Findings at Discharge...Blood Pressure 185/119...Blood pressure recheck is pending."

Medical record review of the Medication Administration Record dated April 19, 2011, revealed the Clonidine was administered at 4:09 p.m.; no further assessment of the vital signs or recheck of the blood pressure was documented prior to discharge.

Interview with the Clinical Leader of the fourth floor on May 9, 2011, at 2:10 p.m., confirmed the medical record did not contain documentation regarding assessment of the patient for symptoms related to elevated blood pressure, attempt to obtain parameters for blood pressure, or notification of the physician regarding the patient's elevated blood pressure from admission to the floor on April 18, 2011, at 4:09 p.m. until April 19, 2011, at 1:17 p.m., a period of more than twenty-one hours.

Interview with a Registered Nurse (RN #4) on May 10, 2011, at 2:10 p.m., on the fourth floor, revealed, "The doctors usually write an order for PRN (as needed) medication for blood pressure...If they did not we call them, tell them the BP is high and get an order for medication with parameters...The typical parameters...they usually like the BP less than 160/90..."

Interview with the Nurse Practitioner (NP) #1 on May 10, 2011, at 1:20 p.m., in the conference room, revealed the NP had no knowledge of a blood pressure obtained after Clonidine was administered at 4:09 p.m. Continued interview revealed the facility used The Joint National Committee as a reference, it was the resource used by NP #1 to manage high blood pressure, and NP #1 stated, "...I would never discharge someone with a blood pressure like that."

Interview with the Clinical Leader on May 9, 2011, at 2:10 p.m., confirmed the facility failed to assess the health status/condition of a patient with elevated blood pressure and symptoms of pain, failed to notify the physician of continued elevated blood pressure; and failed to assess the patient's response to medication.

C/O: #27998

Hospital A

Based on medical record review, review of facility policy and interview, the facility failed to maintain a complete medical record for one Patient (#3) of five sampled patients.

The findings included:

Medical record review on May 6, 2011, revealed Patient #3 presented to the Emergency Room on April 13, 2011, at 11:05 a.m. Medical record review on May 6, 2011, of a triage form dated April 13, 2011, at 11:06 a.m., revealed, "...Chief complaint...Brought from pain clinic for suicidal ideation, depression...Arrival mode Ambulance...Threats of harm to self (?)Yes..."

Medical record review on May 6, 2011, of an Emergency Provider Record dated April 13, 2011, at 11:23 a.m., revealed a suicide risk assessment, clinical impression, disposition, or condition at disposition had not been completed. Continued review revealed, "...chief complaint: suicidal thoughts...severity moderate...context...lost house, chronic pain mother passed away 6 weeks ago...Psych (Psychiatric)...tearful...suicidal...poor insight/poor judgement...discussed with...@ (at) (crisis intervention center) pt (patient) will sign no harm (contract or agreement the patient signs stating the patient will not inflict any self-injury or harm) & (and) f/u (follow up)@ clinic."

Medical record review on May 6, 2011, of an Emergency Department Physician Order dated April 13, 2011, at 11:24 a.m., revealed, "Physician's order form reasons for lab/x-ray: Other CI (Crisis Intervention)..." Medical record review on May 6, 2011, revealed no documentation regarding follow-up on the physician's order for Crisis Intervention dated April 13, 2011. Medical record review on May 6, 2011, revealed no documentation regarding a no harm contract.

Medical record review on May 6, 2011, of an ED nursing note dated April 13, 2011, revealed no documentation regarding the patient (the form included space for medications/procedures, vital signs, patient/family education, and disposition and/or condition at discharge).

Medical record review on May 6, 2011, of discharge instructions signed by the patient and dated April 13, 2011, revealed, "...Time released 1430 (2:30 p.m.)"

Medical record review on May 11, 2011, of faxed documentation imprinted with the date of May 11, 2011, revealed the following: a faxed authorization for treatment signed by the patient was not dated; a Multidisciplinary Assessment dated April 13, 2011, included, "...willing to contract for safety...;" and individual provisions of a no harm contract dated April 13, 2011, were initialed by the patient and the contract contained no patient signature.

Review of facility policy dated November 17, 2010, revealed, "...Title Mobile Crisis Unit Telemedicine Assessments within Hospital Setting...A copy of the Mobile Crisis Multidisciplinary Assessment will be provided to the hospital via fax so that it may be included in the patient's record..."

Interview with Emergency Room Clinical Leader #1 on May 11, 2011, at 11:50 a.m., in a physician's office, confirmed the facility failed to maintain a complete medical record for Patient #3.

Hospital B

Based on medical record review, review of The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, policy review and interview, the facility failed to re-assess the discharge needs for one (#B1) patient of five patients reviewed.

The findings included:

Patient #B1 presented to the Emergency Department (ED) on April 18, 2011, with chief complaint of chest pain, headache, and shortness of breath.

Medical record review of the Triage Note dated April 18, 2011, and timed 12:19 p.m., revealed the Triage vitals included Blood Pressure (BP) of 189/120. (The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure listed a normal blood pressure of "less than 120/80"). Continued review of the Triage Note revealed the patient denied any past medical history (including Hypertension), and took no prescribed medications.

Review of the ED Nursing Notes dated April 18, 2011, revealed the following BP and times: 12:54 p.m. - 184/126; 1:02 p.m. - 193/115; 1:30 p.m. - 174/91; 2:08 p.m. - 182/100; 3:00 p.m. - 201/84.

Medical record review of the History and Physical conducted by the Hospitalist #2 dated April 18, 2011, revealed Patient #B1 "does not check ...blood pressure."

Medical record review of the admission orders dated April 18, 2011, included an order for Case Manager to assist patient with Primary Care Physician.

Medical record review of the nurses' notes revealed patient #B1 arrived to the medical/surgical nursing unit 4th floor at 4:09 p.m. Medical record review revealed the following blood pressures and times: April 18- 183/108 at 4:09 p.m.; April 18- 173/105 at 8:23 p.m.; April 19- 162/101 at 12:03 a.m.; April 19- 154/106 at 5:04 a.m.; April 19- 190/115 at 9:43 a.m.; April 19- 187/121 at 1:17 p.m.; April 19- 197/120 at 2:25 p.m.; April 19- 185/119 at 4:02 p.m.

Medical record review of the Discharge Summary dictated April 19, 2011, and timed 4:08 p.m., revealed the patient (B1) was discharged on four new medications: Aspirin 81 milligrams (mg) daily; Hydrochlorothiazide 25 mg daily (to reduce BP); Zocor 20 mg at bedtime (to reduce lipid level); and Atenolol 25 mg twice a day (to reduce BP). Review of the summary revealed the patient "will need close monitoring of...blood pressure."

Medical record review and interview with Case Manager (CM) #1 in the administrative conference room on May 10, 2011, at 11:30 a.m., verified Patient #B1 was seen by a CM #2 on April 19, 2011, and established the patient is under the care of a PCP (Primary Care Physician) at another facility. Continued interview revealed CM was consulted and the patient was evaluated as ordered. Continued interview revealed the discharge orders were written after CM evaluated and CM was not aware the provider instructed close monitoring of the BP.

Medical record review of the Nurses' Notes revealed the functional screen and discharge planning were not performed after the discharge orders were written.

Interview in the conference room with the Chief Clinical Officer on May 10, 2011, at 12:45 p.m., confirmed the facility failed to re-assess the discharge needs of the patient.

C/O: #27998

Hospital A

Based on Facility Policy, medical record review, interview and observation, the facility failed to implement the facility's policies to meet the emergency needs for one patient (#5) with identified suicidal ideation and plan of five sampled patients, resulting in Patient #5's elopement. The facility's failure placed Patient #5 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause injury, harm, impairment, or death to a patient).

An exit conference was conducted with two Chief Clinical Officers, a corporate Vice President of Emergency Department Operations, and the Regional Chief Nursing Officer on May 13, 2011, at 3:08 p.m., in an administrative conference room. The facility was informed of an Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) at CFR Part 482.55 Emergency Services (Condition).

The findings included:

Review of (un-numbered) facility policy dated July 13, 2010, revealed, "...Title Suicidal Patients: Admission and Care Policies...Policy: Upon...arrival in the emergency department, all patients with a primary diagnosis or primary complaint of an emotional or behavioral disorder is screened for suicide risk...In cases where a patient has clearly attempted suicide, an initial screening is not necessary because that patient is already assumed to be at high risk for self-harm. These high risk patients should be placed in a secure area or staffing adjusted to provide 1:1 coverage...The patient is to remain in the 1:1 (one on one) sitter's eyesight at ALL times. Suicidal patients in...emergency department will have 1:1 coverage at all times..."

Review of facility policy #NUR1020.000 dated October 18, 2010, revealed, "...Title Discharge...An electronic occurrence report is to be completed if the patient leaves without staff knowledge..."

Review of (un-numbered) facility policy dated March 22, 2011, revealed, "...Title Abuse...Neglect...Patients are further protected from any form of abuse, neglect...Abandonment: Desertion of a vulnerable individual by anyone who has assumed care or custody of that person...For any suspected instances of abuse, neglect...Associates will be instructed to...report...All observed or reported incidents...will be reported to the appropriate supervisor for additional assessment. The incident will be entered into the electronic incident reporting system. The Risk Manager and Administrator-on-call must be notified immediately...will immediately begin an investigation..."

Review of (un-numbered) facility policy dated March 22, 2011, revealed, "...Title Patient Rights...will include but not be limited to the patient's right to : ...Considerate and respectful care, provided in a safe environment...Be placed in protective services when considered necessary for personal safety..."

Medical record review of an Emergency Department (ED) Sign-In sheet dated April 13, 2011, at 2:56 p.m., revealed Patient #5 presented to the Emergency Room with, "...Complaint: Just want to kill myself...Came Alone."

Medical record review of a Triage form dated April 13, 2011, at 3:00 p.m., revealed, "...Chief Complaint...Suicidal/Hallucinations...Threats of harm to self (?) Yes...past suicidal/homicidal attempts (?) Yes...Current Suicidal/homicidal ideation (?) Yes...Do you have a plan (?) Yes If yes (what is the plan): jump off bridge..."

Medical record review of an Emergency Department nurse's note dated April 13, 2011, at 3:00 p.m., revealed, "pivoted per FNP (Family Nurse Practitioner #1)."

Medical record review of an Emergency Provider Record dated April 13, 2011, and signed by FNP #1 revealed, "...1502 (3:02 p.m.) brief history: Suicidal ideation...Expected Disposition of Patient...Transfer pending results..."

Medical record review of an Emergency Department Physician Order Sheet signed by FNP #1 and dated April 13, 2011, at 3:02 p.m., revealed, "...Involuntary Hold for Safety..."

Medical record review of an ED nurse's note dated April 13, 2011, at 3:15 p.m., revealed, "to room 21 (in emergency room), states feels better." Medical record review of an ED nurse's note dated April 13, 2011, at 3:18 p.m., revealed, "pt. (patient) not in room, security notified." Medical record review of a nurse's note dated April 13, 2011, at 3:25 p.m., revealed, "Pt not seen on...campus. KPD (Knoxville Police Department) notified."

Interview with ED Clinical Leader #1 on May 6, 2011, at 12:44 p.m., in a conference room, revealed FNP #1 "pivoted" and escorted Patient #5 to Room 21 on April 13, 2011. Continued interview revealed ED Clinical Leader #1 attempted to explain the process of "pivoting", and the facility had no written procedure regarding the "pivoting" process. Continued interview revealed Registered Nurse (RN) #1 was assigned to Room 21 on April 13, 2011.

Telephone interview with RN #1 (on duty April 13, 2011, when Patient #5 eloped) on May 6, 2011, at 1:30 p.m., revealed the "pivot" process consisted of a physician's assistant or FNP's intercept (meeting patient at the door) of a patient in the emergency room and she stated, "...(pivoting) jump starts the process (emergency room assessment and treatment)." Continued interview revealed Room 21 was called "the safe room," and she heard an announcement that a new patient was in Room 21 on April 13, 2011. The nurse stated, "I don't know what stage of (the) process the page (announcement) was done." Continued interview revealed two or three minutes passed from the time she heard the announcement until she went to Room 21 and she stated, "I went to the room and nobody was there...If (facility) had followed policy (Patient #5) would have had 1:1..."

Interview with an administration department receptionist on May 6, 2011, at 1:45 p.m., revealed Room 21 was monitored by camera twenty four hours daily seven days per week, and two facility employees monitored the cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.

Telephone interview with Monitor #1 (responsible for monitoring cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.) on May 6, 2011, at 2:00 p.m., revealed her duties included answering in-coming calls, and she stated, "...periodically monitor monitors (cameras) and exit gate...have four bays with sixteen cameras on (for) each bay." Continued interview revealed she was aware of the purpose of Room 21 and unaware of a patient's elopement from Room 21 on April 13, 2011, between 3:15 p.m. and 3:18 p.m.) and she stated,"I know we have patients who have to be observed...have never been told I have to report if (I) see (a) patient leave...aware of 1:1 supervision (required in Room 21)."

Telephone interview with FNP #1 on May 6, 2011, at 1:47 p.m., revealed, "Patients who are suicidal are put in Room 21. I do remember me and pivot nurse, or it could have been just me who walked Patient (#5) to the room. As courtesy (to nurses) took (Patient #5) back to room. (Patient #5) had expressed suicidal ideation. The pivot process is (the patient) is triaged by (an) RN, as NP (FNP) I see patient from provider standpoint, order appropriate tests. I just listened to what (Patient #5) had to say. Usually nurses walk (suicidal patients) to room...don't remember leaving patient in the room. I don't have radio to communicate to nurses...We called from triage room to nurses that a patient was coming...Patient got left in (the) room unattended." Continued interview confirmed the facility's policy for 1:1 supervision for suicidal patients was not implemented for Patient #5 on April 13, 2011.

Telephone interview with Monitor #2 (responsible for monitoring cameras on April 13, 2011, between 3:00 p.m. and 3:30 p.m.) on May 9, 2011, at 1:50 p.m., revealed her duties included answering calls, monitoring sixteen cameras on four bays, and she stated, "Unless (I) see something specific in Room 21 (I'm) not alarmed." Continued interview revealed she had no instructions on how to respond if she saw a patient leave Room 21, and she stated, "...don't know if they've been dc'd (discharged) or what." Continued interview revealed the camera monitoring station was located on the ground floor of the hospital and Room 21 was on lower level two of the facility, two floors below the camera monitoring station.

Observation and interview in the ER with ER Clinical Leader #1 on May 11, 2011, at 11:18 a.m., revealed the doors in Room 21 did not lock, and the distance from Room 21 to an exit door from the ER into another area of the hospital was approximately one hundred fifty feet and an exit door to the outside was approximately one hundred seventy five feet. Continued observation revealed the time to reach the exit door to the outside was less than one minute from Room 21. Observation of the camera monitoring room with ER Clinical Leader #1 on May 11, 2011, at 11:40 a.m., revealed the cameras were monitored by two staff, and included five live camera pictures from Room 21.

Interview with ER Clinical Leader #1 on May 11, 2011, at 11:25 a.m., in an ER examination room, revealed the elopement of Patient # 5 on April 13, 2011, required an electronic incident report, an electronic incident report would have brought the incident to his attention, and confirmed an electronic incident report was not completed regarding the elopement of Patient #5 on April 13, 2011. Continued interview revealed no investigation into the elopement was initiated until after May 2, 2011.

Interview with the Director of Safety and Security on May 11, 2011, at 12:15 p.m., in a physician's office, revealed the facility was monitored by one hundred sixty surveillance cameras and (two) staff monitoring the cameras had other duties in addition to monitoring the cameras. Continued interview revealed in the event a patient on involuntary hold in Room 21 disappeared, the facility's practice was to look on the cameras to determine the patient's appearance, one officer would be dispatched to drive around/search outside, other officers would be dispatched to search inside, and he stated, "Timeframe to determine if (patient) on campus could take an hour or more to conclude patient not here..." Continued interview revealed an incident report was to be filed on completion of a campus search by security.

Interview with the Director of Safety and Security on May 11, 2011, at 12:47 p.m., confirmed security had no record of any search for Patient #5 on April 13, 2011.

Observation on May 11, 2011, at 1:10 p.m., revealed the facility was located in an urban area, adjacent to a high school, and surrounded by highly trafficked streets.

Telephone interview with the Medical Director of the Emergency Department (M.D. #1) (on duty April 13, 2011) on May 13, 2011, at 1:20 p.m., revealed he was unaware Patient #5 had eloped on April 13, 2011.

Interview with the Medical Director (M.D. #2) of the group of emergency room physicians contracted by the facility for emergency room services on May 13, 2011, at 11:40 a.m., revealed he supervised M.D. #1, and M.D. #2 was unaware Patient #5 had eloped on April 13, 2011. Continued interview confirmed the facility failed to meet the emergency needs of Patient #5 in accordance with accepted standards of practice, on April 13, 2011, resulting in elopement for Patient #5 and placing Patient #5 in Immediate Jeopardy.

C/O: #27991

HOSPITAL B
Based on medical record review, facility policy review, and interview, the facility failed to follow the facility's triage policy for one (#B3) patient who presented to the Emergency Department with Chest Pain of five records reviewed.

The findings included:

Review of the (un-numbered) facility Triage Policy revised November 2010, revealed the purpose of the policy was to "Provide a standardized process for initial assessment where by patients presenting to the ED (Emergency Department) are treated in order of priority based on acuity with the most serious illness and injuries being treated first. Utilizing the Emergency Severity Index 5-Level triage system performs this process ...Level II Presentation: High risk situations (examples include: chest pain ...) When Level II condition is identified the patient is taken directly to a room and seen as soon as possible."

Medical record review revealed Patient #B3 presented to the ED on April 17, 2011, at 9:15 p.m. via ambulance with complaint of Chest Pain located in the substernal area which radiated to the left chest. Review of the Triage note dated April 17, 2011, revealed the patient experienced chest pain for three hours and vomited prior to coming to the ED.

Review of the Triage Vitals record revealed the space designated for 'Triage Vitals' (Blood Pressure, Pulse, Respirations, Temperature, and Oxygen Saturation) was blank. Review of the record revealed pain was marked as a level '2' (mild and bearable) and there was no documentation of an evaluation of the pain characteristics for duration, location, severity, and associated symptoms.

Review of the Emergency Department Nursing Notes revealed Patient #B3 was taken directly to a treatment room and vital signs were evaluated at 11:30 p.m.(two hours and 15 minutes after arrival to the ED).

Medical record review of the History and Physical revealed Patient #B3 was admitted to the hospital for Atypical Chest Pain.

Interview with Registered Nurse #6, the Charge Nurse of the ED, on May 10, 2011, at 3:15 p.m., in the administrative room, verified Patient #B3 presented to the ED with symptoms which met criteria of Level II triage and confirmed the facility failed to evaluate pain and vital signs within two hours of arrival to the ED.