HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to:
- Follow its policy and procedures to ensure that four current patients (#6, #75, #76 and #77) of seven patients, who were classified as an elopement (when a patient makes an intentional, unauthorized departure from a medical facility) risk, were monitored to prevent elopement;
- Follow its policy and procedures to prevent two discharged patients (#50 and #72) of two patients from elopement from the Emergency Department (ED); and
- Follow its policy and procedures to prevent one discharged patient (#71) of one patient from elopement from an inpatient unit.
These failures had the potential to lead to an unsafe environment for all patients who were at risk for elopement. The hospital census was 214.

Findings included:

1. Review of the hospital's policy titled, "Elopement," dated 10/2021, showed:
- This procedure is intended to address the care of patients who has been identified as a risk for elopement.
- Elopement assessments can include information from family, the caregiver and/or previous history; and observation of behaviors or statements such as wandering, verbal expressions of wanting to leave, overly engaging or manipulative, and failure to follow directions.
- Patients at risk for elopement would have their clothing, shoes and outerwear removed, wear an orange and white checkered wrist band, would wear paper scrubs and move closer to nurses' station when possible.
- Document an appropriate elopement/safety screening completed in the ED at triage, at admission and what elopement precautions were put in place.
- The need for a sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) for constant observation would be determined on an individual basis by utilizing the "sitter tool" (sitter assessment tool).

Although requested, the hospital failed to provide a policy that defined elopement risk levels.

Review of the hospital's policy titled, "Sitter Use," dated 06/2016, showed:
- The policy established criteria for the initiation, maintenance, and discontinuation of sitter use for patients.
- Once specific sitter needs were identified, by use of the "Sitter Assessment Tool" by the Registered Nurse (RN), nursing leadership would be notified to review of the patient's criteria for a sitter. This would then be reviewed every shift thereafter.
- The manager or assistant manager would be responsible for reviewing the need to initiate, maintain or discontinue a sitter every shift.
- There are two types of sitters: a Behavioral Sitter would provide direct observation of patients demonstrating a high elopement risk, impulsive behaviors and possible suicidal (any action that could cause one's own death) or homicidal (thoughts or attempts to cause another's death) behaviors. Patients with a behavioral sitter must be observed at all times. A Safety Sitter would provide direct observation of patients at risk to harm themselves such as high fall risk, pulling at tubes, bandages or medical equipment as needed.

Review of the hospital's undated document titled, "Sitter Assessment Tool," showed:
- An assessment tool is used to assist in determining if ordering a patient sitter was appropriate.
- The assessment tool is a point based system using patient history and current behaviors as criteria.
- If a patient scores above a seven on the tool then it equals "sitter appropriate."
- The assessment tool is completed by a nurse, and reviewed for evaluation of request for a patient sitter.
- The Manager/Director/House Supervisor would then determine if a sitter was appropriate.

Observation on 07/25/22 at 2:50 PM, on the Medical Unit, in Patient #6's room showed that he was yelling, confused, and attempting to dial random phone numbers on his hospital phone. He was unsupervised and his room was located directly next to the stairwell exit. At 3:00 PM, a Patient Care Technician (PCT) entered the room and stated that she would be his one to one sitter (1:1, continuous visual contact with close physical proximity) until 7:00 PM that evening.

Record review of Patient #6 showed he was admitted on 07/19/22. He had a history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly). He was assessed as an elopement risk due to confusion. Every shift he was marked as having a behavioral sitter. Sitter observation sheets showed no documented 1:1 observations from 07/19/22 through 07/21/22. On 07/22/22, 1:1 flowsheets showed he had a sitter for eight of the 24 hours. On 07/23/22, 1:1 flowsheets showed he had a sitter for 17 of the 24 hours. On 07/25/22, 1:1 flowsheets showed he had a sitter for 14 of the 24 hours. On 07/26/22, 1:1 flowsheets showed he had a sitter for seven of the 19 hours prior to his discharge.

During interviews on 07/25/22 at 3:20 PM and 07/26/22 at 3:15 PM, Staff DDDD, RN, stated that Patient #6 had a safety sitter and that constant supervision was not required. She stated that safety sitters were assigned if a sitter was available. Behavioral sitters were a priority and were assigned first. If a patient care technician (PCT) was not available to fill the role of a Behavioral Sitter, staff on the unit would have to fill that role "no matter what".

Review of patients on elopement precautions, provided by the hospital, showed that Patient #75, #76 and #77 were identified as elopement risks however, the hospital was unable to provide 1:1 flowsheets showing continued patient observation for any patient.

2. Review of the hospital's document titled, "Cause Mapping," dated 01/11/22, showed Patient #50 eloped from the ED on 12/25/21. The patient had a history of schizophrenia with auditory hallucinations (hearing things that are not heard by others, imaginary) and was found at a bus stop after having eloped from a nursing home several days prior. She was brought to the ED on 12/25/21 and eloped from the ED on 12/25/21. The patient was not found until 12/27/21. Patient #50 was returned to the ED and discharged to the nursing home.

Review of the hospital's undated document titled, "Cause Mapping," showed Patient #72 eloped from the ED on 05/05/22. The patient had a history of Alzheimer's (a chronic brain disorder characterized by gradual loss of memory, decline in intellectual ability and deterioration in personality) and dementia and resided in a locked unit of a nursing home. She arrived in the ED via ambulance on 05/05/22 with active complaints of chest pain. Staff did not receive report that she was an elopement risk. The patient interrupted the report that was being giving by the paramedic. The paramedic did not report that the patient came from a locked unit. They felt she was alert and orientated since she ambulated to the ambulance on her own, she seemed appropriate. She eloped from the ED on 05/05/22 and was found five miles away. She was returned via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) to the ED several hours later and was admitted as an inpatient. The hospital identified that the elopement screening tool used in the ED was not effective and that there was no elopement screen in the triage assessment. The hospital is in the process of creating an updated elopement screening tool under the direction of the system regulatory team.

3. Review of the hospital's undated document titled, "Cause Mapping," showed Patient #71 eloped from an inpatient area on 01/07/22. The patient had a history of suicide (to cause one's own death) attempt and violence toward staff. He had been hospitalized for 28 days, awaiting placement at a residential psychiatric (relating to mental illness) facility. The patient had a guardian (a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs), was on elopement precautions, had a sitter, was in his own clothes, and had access to his personal belongings. The guardian, the patients' sister, did not want to take the patient to her home for fear of physical safety. On 01/07/22, he was walking with the sitter, as they got close to the elevator he began swinging his fists at the sitter, he entered the elevator and exited the building. He was later located at his mother's residence. He did not return to the hospital. The hospital identified their failures as the patient was assessed as low risk for elopement, the guardian permitted the patient to keep personal possessions including his clothing and phone, and the patient spoke with his mother via phone to come pick him up but this was not escalated by the sitter. The action plan included elopement precautions to be implemented for all patients with a guardian and to create a resource similar to the Ethics Committee to assist with collaborative care planning. Both of these items were marked as completed.

During an interview on 07/27/22 at 3:25 PM, Staff YY, RN, Risk Management, stated that after Patient #50's elopement the hospital educated staff the next day. They did education and found that the staff did not utilize appropriate precautions. They then focused on the lack of information from EMS that transport the patients from the nursing homes. They did change EMS questions to include history and potential for elopement (such as coming from a locked unit). They own their own ambulance system and worked with that EMS manager/director to develop the new questions. No staff education was provided after Patient #71 or #72 eloped.

During an interview on 07/28/22 at 9:00 AM, Staff JJJJ, PCT, stated that elopement risk patients would wear scrubs, have a pink and white bracelet and a bed/chair alarm. A 1:1 sitter would not always be necessary and the ED would let them know if one was. Sitter needs were dependent on whether the patient was at low or high risk elopement and the nurse would let them know that status. She could not verbalize the difference in interventions between a low risk and high risk elopement patient but knew that "high risk elopements just had to be watched more than low risk patients".

During an interview on 07/28/22 at 9:00 AM, Staff FFFF, RN, stated that she was not sure who could order elopement precautions. She thought that a patient would be placed in paper scrubs, but was not sure if they would have a sitter or not, it would depend on staffing.

During an interview on 07/28/22 at 9:15 AM, Staff EEEE, RN, stated that a patient on elopement precautions would not always have a sitter.

During an interview on 07/28/22 at 9:20 AM, Staff DDDD, RN, stated that she would have to ask the charge nurse when she would need to assess a patient for elopement risk; and it would depend on the nurse's judgement and the elopement score as to when a patient would have a sitter. All sitters do the same thing, they are just in a patient's room.

During an interview on 07/28/22 at 9:20 AM, Staff KKKK, RN, stated that some elopement patients were at a higher risk than others. Patients would be assigned a sitter if necessary and they would be placed in a room close to the nurse's station. Sitter paperwork was filled out each shift and if the score was high enough the paperwork would go to the nursing office, who staffs the hospital, and they would decide sitter necessity. If they didn't have staff who could sit with the patient they would notify the Charge RN and staff would have to be pulled from the floor to fill that sitter need.

During an interview on 07/28/22 at 9:45 AM, Staff LLLL, Patient Care Manager, stated that when a patient were admitted to a unit that ED staff would "usually" tell them what the patient's behaviors had been. The Elopement Risk Assessment was to be used to reassess for any change in status. The assessment would tell the RN if the patient was at high risk for elopement. If a patient scored higher than a seven on the Sitter Assessment Tool it would be recommended that they have a sitter. The tool went to the nursing office who staffed sitters. If they were unable to staff a sitter they "generally pulled staff from the floor". Suicidal/homicidal patients took priority and automatically received a sitter. Elopement risk patients were the next priority. Safety Sitters were least prioritized. Safety Sitters could be used intermittently and Behavioral Sitters were required for safety.

During an interview on 08/02/22 at 2:00 PM, Staff Z, Chief Nursing Executive (CNE), stated that safety sitters were for patients who pulled at lines or tubes, impulsively climbed out of bed or were a high fall risk. Behavioral sitters would be used for suicidal or violent patients and patients that were an elopement risk depending on their screening. Ultimately, the use of a sitter would be determined by unit leadership based on the patient's present state and diagnosis.




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Based on observation, interview, record review and policy review, the hospital failed to ensure staff followed infection prevention policies for:
- 12 patients (#43, #49, #56, #57, #58, #59, #60, #61, #66, #67, #68, and #70) of 35 patients observed when staff did not follow the hand hygiene policy during patient care;
- Labeling of intravenous (IV, in the vein) sites for eight patients (#5, #6, #10, #13, #36, #37, #44, and #56) of 26 current patients;
- Maintaining clean equipment used during patient care for Patients #56, #57, #58, #61, #62, and #67;
- Maintaining a clean work space during patient care for Patients #40, #43, #59, #68, and #70; and
- Labeling control solutions (four of four vials) used during patient care.

The hospital census was 214.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety.

Based on observation, interview, record review and policy review, the hospital failed to ensure staff followed infection prevention policies for:
- 12 patients (#43, #49, #56, #57, #58, #59, #60, #61, #66, #67, #68, and #70) of 35 patients observed when staff did not follow the hand hygiene policy during patient care;
- Labeling of intravenous (IV, in the vein) sites for eight patients (#5, #6, #10, #13, #36, #37, #44, and #56) of 26 current patients;
- Maintaining clean equipment used during patient care for Patients #56, #57, #58, #61, #62, and #67;
- Maintaining a clean work space during patient care for Patients #40, #43, #59, #68, and #70; and
- Labeling control solutions (four of four vials) used during patient care.

The severity and cumulative effects of these systemic practices resulted in the hospital's non-compliance with 42 CFR 482.42 Condition of Participation: Infection Prevent and Control and Antibiotic Stewardship Programs and resulted in the hospital's failure to ensure quality health care and safety.

Findings included:

1. Review of the hospital's policy titled, "Hand Hygiene (HH)-Infection Prevention," dated 08/25/21, directed staff to follow the Five Moments of HH:
- Before touching a patient;
- Before clean or aseptic (process that is maintained free of germs or bacteria) procedures;
- After body fluid exposure risk;
- After touching a patient; and
- After touching patient surroundings.

Review of undated hospital education titled, "Infection Prevention," showed that:
- HH is the most important action to prevent the transfer of germs.
- Gloves are not a substitute for HH, and every time they are removed, HH should be performed.
- There are five moments for hand hygiene, before touching the patient or their environment, before a clean or aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings.

Review of the hospital's undated document titled, "Christian Hospital Infection Prevention Plan 2022," identified HH as the most important measure for the prevention of disease transmission and that all staff should follow the Five Moments of HH.

Observation on 07/27/22 at 10:20 AM, showed Staff AAA, RN, failed to perform HH and glove changes when she touched the trash can and removed the sutures from Patient #43's central line site.

Observation on 07/27/22 at 10:45 AM, showed Staff LLL, RN, failed to perform HH prior to putting on gloves and after removing gloves, while caring for Patient #49.

Observation on 07/27/22 at 10:45 AM, showed Staff LLL, RN, reached under the isolation gown with contaminated gloves to remove a personal pen, write on Patient #49's dressing, returned the pen under the isolation gown after use, and failed to perform HH after removing gloves.

Observation on 07/28/22 at 8:50 AM, showed Staff BBBB, RN, touched the trash can and then touched Patient #56 to remove the urinary catheter, and failed to change gloves or perform HH.

Observation on 07/28/22 at 8:45 AM, Staff BBBB, RN, failed to perform HH prior to putting on gloves and after removing gloves, while caring for Patient #56.

Observation on 07/28/22 at 9:05 AM, showed Staff CCCC, RN, failed to perform HH prior to putting on gloves and after removing gloves, while caring for Patient #57.

Observation on 07/28/22 at 9:20 AM, showed Staff DDDD, Agency RN, failed to perform HH after removing gloves, while caring for Patient #58.

Observation on 07/28/22 at 9:00 AM, showed Staff FFFF, RN, failed to perform HH while caring for Patient #59 when she continued to wear the same pair of gloves to remove and re-apply a dermal patch and to hand the patient his medications along with his water container, after having touched multiple inanimate objects within the patient's room.

Observation on 07/28/22 at 9:35 AM, showed Staff GGGG, RN, failed to perform HH and glove changes when she continued to wear the same pair of gloves to remove and re-apply a dermal patch, hand Patient #60 his medications, and to assist him with his water container, after having touched multiple inanimate objects within the room.

Observation on 07/28/22 at 9:15 AM, showed Staff EEEE, RN, failed to perform HH and glove changes when she continued to wear the same pair of gloves while she:
- Scanned Patient #61's identification bracelet;
- Opened the Workstation on Wheels (WOW) drawer;
- Opened the patient's medication packages;
- Flushed the patient's IV catheter;
- Opened a betadine pad to cleanse Patient #61's pacemaker (small device that's placed in the chest or abdomen to help control abnormal heart rhythm) incision site; and
- Removed gloves, without performing HH.

Observation on 08/01/22 at 12:00 PM, showed Staff NNN, RN, failed to perform HH while caring for Patient #66.

Observation on 08/01/22 at 11:50 AM, showed Staff GGGG, RN, touched Patient #67's recliner handle to lower the patient's legs, then proceeded to stick the patient with a needle; Staff GGGG failed to perform HH or change gloves at that time.

Observation on 08/01/22 at 11:25 PM, showed Staff TTTT, RN, failed to perform HH and change gloves prior to administering crushed medications to Patient #68.

Observation on 08/01/22 at 11:05 AM, showed Staff RRRR, Respiratory Therapist (RT), failed to remove the contaminated exam gloves used during set up or to perform HH prior to applying sterile gloves over her exam gloves. When applying the sterile gloves she touched the exterior sterile surface of the glove on three separate attempts. She then proceeded to perform in-line suctioning (to remove thick mucus and secretions from the airway, that a person is not able to clear by coughing) of Patient #68 wearing two pairs of gloves.

Observation on 08/01/22 at 2:10 PM, showed Staff MMM, RN, failed to remove her gloves or perform HH before she opened the door to the bathroom, with her dirty gloves, to dispose of the urinary catheter she had removed from Patient #70.

During an interview on 08/01/22 at 12:10 PM, Staff GGGG, RN, stated that normally HH and gloves would have been changed after the chair was touched.

During an interview on 07/27/22 at 11:05 AM, Staff Q, Quality RN, stated that staff should not reach under the isolation gown with a contaminated glove to retrieve a pen.

During an interview on 08/02/22 at 12:55 PM, Staff SSS, Infection Prevention Manager, stated that:
- All staff received training related to infection control and HH during orientation and yearly thereafter.
- Staff should follow the Five Moments of HH.
- Staff were educated not to move between the patient zone and the clean zone without performing proper HH.

2. Review of the hospital's policy titled, "Central Venous Catheter: Management and Dressing," dated 06/24/22, showed that all dressings should be dated.

Review of the hospital's policy titled, "Peripheral IV Insertion and Saline Lock (Intermittent Device)," dated 06/27/22, directed staff to apply a dressing to the insertion site and to date it.

Observation on 07/25/22 at 2:30 PM, showed no date, time, or initials on Patient 5's IV dressing.

Observation on 07/25/22 at 2:30 PM, showed no date, time, or initials on Patient 6's IV dressing.

Observation on 07/25/22 at 3:00 PM, showed no date, time, or initials on Patient #10's IV dressing.

Observation on 07/25/22 at 3:07 PM, showed no date, time, or initials on Patient #13's IV dressing.

Observation on 07/26/22 at 3:25 PM, showed no date, time, or initials on Patient #36's IV dressing.

Observation on 07/26/22 at 3:40 PM, showed no date, time, or initials on Patient #37's IV dressing.

Observation on 07/27/22 at 9:00 AM, showed no date, time, or initials on Patient #44's IV dressing.

Observation on 07/28/22 at 8:45 AM, showed no date, time, or initials on Patient #56's IV dressing.

During an interview on 7/25/22 at 3:55 PM, Staff T, Staff Educator, stated that IV dressings were to have been dated, timed and initialed at the time it was started.

3. Review of the hospital's undated protocol titled, "WOW Cleaning," showed that staff were not to go from the patient to the WOW without doing hand hygiene.

Review of undated hospital education titled, "Infection Prevention," showed that:
- The patient zone includes items such as over-bed table, side rails, night-stand, call light, phone, IV pump, ventilator, closet, chairs/furniture, and in room computer.
- HH should be done prior to touching items in the clean zone.
- The clean zone includes items such as crash carts, lab carts, supply drawers, WOWs, and glucometer supply caddies.

Observation on 07/28/22 at 8:45 AM, showed Staff BBBB, RN, had pushed her WOW into Patient #56's room to administer medications. She did not wipe down the work surface prior to entering the room, nor when she exited the room after giving medications.

Observation on 07/28/22 at 9:05 AM, showed Staff CCCC, RN, had pushed her WOW into Patient #57's room to administer medications. She did not wipe down the work surface prior to entering the room, nor when she exited the room after giving medications.

Observation on 07/28/22 at 9:20 AM, showed Staff DDDD, Agency RN, had pushed his WOW into Patient #58's room to administer medications. He did not wipe down the work surface prior to entering the room, nor when he exited the room after giving medications. He also failed to changed his gloves or perform HH after he administered a topical medication to Patient #58 and prior to returning to the WOW drawer to replace the medication.

Observation on 07/28/22 at 9:15 AM, showed Staff EEEE, RN, had pushed her WOW into Patient #61's room to administer medications. She did not wipe down the work surface prior to entering the room, nor when she exited the room after giving medications.

Observation on 07/28/22 at 9:20 AM showed Staff HHHH, RN, pushed her cart into Patient #62's room to administer medications. During the medication administration she used an applicator to apply a gel to the patient's right foot. When finished, she placed the applicator on the WOW without cleaning it. After completion of the medication administration she did not wipe down the applicator, or the WOW, prior to exiting the room.

Observation on 08/01/22 at 12:00 PM, showed Staff NNN, RN, touched Patient #67, opened the WOW and removed a needle, stuck the patient, then proceeded and opened the WOW for a second time and removed gauze that was used on the patient.

During an interview on 08/01/22 at 12:07 PM, Staff NNN, RN, stated, "I was never told I had to change gloves 14 times when I touch things on the cart."

During an interview on 08/02/22 at 12:55 PM, Staff SSS, Infection Prevention Manager, stated that the WOWs should not enter the patient rooms and should always be cleaned between patients.

4. Although requested, the hospital failed to provide a policy specific to placing a barrier or establishing a clean work space prior to placing supplies on a surface.

Observation on 07/27/22 at 9:25 AM, showed Staff RR, RN, failed to ensure a clean work space prior to placing IV supplies on Patient #40's bed.

Observation on 07/27/22 at 10:20 AM, showed Staff AAA, RN, failed to ensure a clean work space prior to placing suture removal supplies on Patient #43's bedside table.

Observation on 07/28/22 at 9:05 AM, showed Staff UUUU, Phlebotomist (a health worker trained in drawing venous blood for testing or donation), failed to place a barrier on Patient #59's bed prior to laying her blood collection supplies down, she also failed to remove her gloves and perform HH when she exited the room, directly touching the label printer and a drawer on her cart.

Observation on 07/28/22 at 9:00 AM, showed Staff FFFF, RN, failed to ensure a clean work space prior to placing a medication on top of Patient #59's bedside table.

Observation on 08/01/22 at 2:10 PM, showed Staff MMM, RN, failed to ensure a clean work space prior to placing supplies used for a catheter removal on Patient #70's bedside table.

During an interview on 08/02/22 at 12:55 PM, Staff SSS, Infection Prevention Manager, stated that staff should always utilize clean barriers or properly clean a surface before placing supplies upon it and a patient's bed or bed linens would not be considered clean.

Review of the hospital's undated skills document titled, "Tracheostomy Tube: Care and Suctioning," directed staff to apply a towel or barrier across the patient's chest prior to providing tracheostomy care and to perform hand hygiene prior to donning sterile gloves after setting up the suction kit. There was no direction listed for performing in-line suctioning.

Observation on 08/01/22 at 11:05 AM, showed Staff RRRR, RT, failed to place a clean barrier upon Patient #68's bed prior to placing tracheostomy cleaning supplies on the bed.

During an interview on 08/02/22 at 12:55 PM, Staff SSS, Infection Prevention Manager, stated that:
- Staff should always utilize clean barriers or properly clean a surface before placing supplies upon it.
- A patient's bed or bed linens would not be considered clean.
- Staff should always utilize gloves when suctioning a patient.

5. Review of the hospital's policy titled, "Whole Blood Glucose by Medline Harmony Meter," dated 08/22/19, directed staff to date the control vial when opened and controls expire 90 days after opening.

Observation with concurrent interview on 07/27/22 at 9:40 AM in the ED, showed four glucometer control vials not labeled with an open date or expiration date. Staff CCC, ED Manager, stated that her expectation of staff was to label the date the vial was opened and the expiration date. The glucometer control vials expire 90 days after it was opened.

During an interview on 08/02/22 at 1:55 PM, Staff Z, Chief Nursing Executive, stated that:
- She would expect all IV sites to have the dressing labeled with date, time, and initials.
- Supplies used for patient care should be placed onto a clean surface, either by wiping the area down, or placing a clean barrier.
- Staff should always wear gloves when suctioning a patient's tracheostomy (trach, an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs).
- Staff should not be taking WOWs into patient rooms, and the surfaces should be cleaned between patients.
- Staff should follow the Five Moments of HH at all times, including ancillary staff, such as laboratory and radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) staff.


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