HospitalInspections.org

Based on review of hospital policies and procedures, medical record reviews, review of incident report log, observations during tour, medical-surgical unit nursing assignment sheets and interviews with physician and staff, the hospital nursing staff failed to supervise and evaluate the nursing care for patients by; failing to prevent and document an elopement of a confused, wandering patient for 1 of 1 patients that eloped (#10); failing to provide neurological checks as ordered by a physician for 3 of 3 patients with neurological checks (#5, #4 and #10; and failing to document telemetry monitoring for 2 of 3 patients on telemetry (#7 and #10).

The findings include:

A. Review on 08/15/2017 of the hospital policy titled "Elopement-Suspected Patient" effective date 06/19/2014 revealed "...Policy: This policy describes the process to be implemented when it is suspected that a patient is missing from the Medical/Surgical Unit... Procedural Guidelines... When it is discovered that a patient is missing or lost the following procedure shall occur: The Unit Staff will: *Conduct a unit search and a patient count. *An overhead page announcement will be made for the patient to return to the unit. The Charge Nurse will: *Notify security and provides a physical description of the patient and the clothes they were last seen wearing. *Notify the patient's attending physician and or the physician on call. *Notify the Director or House Supervisor/Relief Supervisor. *Notify the family as appropriate. *Fill out an occurrence report. ...Upon Return to the Unit: *Nursing staff will assess and document the status of the patient. *Verify the completion of an occurrence report. *Physician will assess the patient's condition and document the same."

Review on 08/15/2017 of the hospital policy titled "Guidelines for the Safety Attendant" effective 08/21/2015 revealed "...Policy: The attendant is to assist in providing for the care, welfare, safety and security of the patients... Procedural Guidelines: 1...c. ...v. Medical conditions whereby patient is pulling at necessary lines...3. Attendant is responsible for the following: ...d. Observation of the patient continuously...g. Documentation on the special observation record...i. Notifying the patient's nurse and security of the following: i. Patient attempts to leave the unit...j. Notifying the patient's nurse of scheduled break or meal...5. Documentation a. Attendant is to document every 15 minutes on the special observation record..."

Review on 08/15/2017 of the medical record for Patient #10 revealed a 62-year-old female admitted to the Medical-Surgical Unit on 06/21/2017 at 1831 with a diagnosis of Altered Mental Status with increased confusion. Medical record review revealed Patient #10 arrived to Room 134 on the Medical-Surgical Unit at 2105. Review of the Physician History and Physical report dated 06/21/2017 at 1838 revealed "Chief Complaint Change in mental status-with increased confusion. ...past medical history of cirrhosis and dementia...Neurological Comment Awake but disoriented to time and place...Assessment and Plan Comment 1. Acute metabolic encephalopathy (brain disease, damage or malfunction) due to renal failure and hyperammonenemia (elevated ammonia level).-IV (intravenous) fluids, neuro check, Lactulose. 2. Acute kidney injury most likely prerenal from dehydration..." Review of Physician's Orders dated 06/21/2017 at 1831 revealed "Admit to Inpatient Status to Floor-Med/Surg *** On TELEMETRY *** Reason for Telemetry: Risk for arrhythmia...Vital Signs Q4H (every 4 hours)...Neurological Checks Q4H (every 4 hours)...IVF (intravenous fluids): for hydration....Sodium Chloride (Normal Saline) 0.45% (100 mL [milliliters] bag) intravenous @ 100 mL/hr (milliters per hour)..." Further review of physician's orders revealed "Activity Level Q12H (every 12 hours)...BEDREST" written on 06/21/2017 at 2100. Review of physician's orders dated 06/22/2017 at 0125 revealed a verbal order "for Ativan 0.5 milligrams intravenously now" with no documented reason for now dose. Further review of physician's orders revealed Ativan 0.5 milligram intramuscular every 6 hours as needed for restlessness/agitation was ordered on 06/21/2017 at 2248 and Ativan 1 milligram intramuscular every 4 hours as needed for restlessness/agitation was ordered on 06/22/2017 at 1319. Review of a physician's progress note dated 06/22/2017 at 0819 revealed "Subjective...Patient continued to be confused this morning. Up ambulated in the hall....Due to confusion patient continues to take out her IV, though she's not received an adequate rehydration. I have talked to the staff about encouraging her to take by mouth liquids. She will only take small amounts. I spoke to her granddaughter at her bedside with my concerns...Neurological Comment Awake but disoriented to time and place. Seems anxious and pulls out her IV's. Neurological Details Mental Status Glasgow Coma Scale Best Eye Response Spontaneous (4), Best Verbal Response Appropriate/Oriented (5), Best Motor Response Obeys Commands (6), Glasgow Coma Scale Total 15; Level of Consciousness Alert, Orientation Disoriented to Time." Review of Discharge Summary dated 06/23/2017 at 0939 revealed Patient #10 was discharged to an Assisted Living Facility. Review of the Discharge Planning Note dated 06/23/2017 at 1218 revealed "...Patients discharge was held yesterday due to her BUN and creatinine (renal lab values) being elevated..." Further review of the medical record revealed no available documentation by a physician of Patient #10's elopement and no documentation of an assessment by the physician following the elopement.

Review on 08/15/2017 of the nursing assessment notes revealed documentation by the nursing assistants of Patient #10's "Activity" on 06/21/2017 at 2200; on 06/22/2017 at 0000 and 0200 "Ambulate With Assistance"; on 06/22.2017 at 0400 and 0608 "Ambulate With Assistance, Ambulate Without Assistance"; on 0622/2017 at 0720 "Ambulate Without Assistance, Sit at Edge of Bed"; on 06/22/2017 at 0800 and 1159 "Ambulate Without Assistance"; on 06/22/2017 at 1500 and 1637 "Ambulate Without Assistance, OOB (out of bed) to Chair"; on 06/22/2017 at 1700 "Ambulate Without Assistance"; on 06/22/2017 at 2117 "N/A"; and on 06/23/2017 at 0045 "Ambulate With Assistance". Review of the nursing narrative notes revealed the following documentation: on 06/21/2017 at 2105 "pt arrived to med-surg room 134...; on 06/21/2017 at 2126 "...wrapped coban around pt's IV so she would not pull IV out"; on 06/21/2017 at 2200 "pt up walking around in room. pt pulled out iv and took telemetry off"; on 06/21/2017 at 2312 "pt has dementia unable to assess due to mental condition. all information received from daughter...; on 06/21/2017 at 2329 "...pt has dementia oriented to self only. pt keeps repeating I don't understand why you guys are holding me here"; on 06/22/2017 at 0020 "24g (intravenous catheter) inserted in rt (right) wrist...Daughter at bedside"; on 06/22/2017 at 0030 "pt sitting up on side of bed. daughter at bedside. daughter request something to help mother rest. MD (physician) notified"; on 06/22/2017 at 0204 "gave iv ativan 0.5 mg as ordered for agitation"; on 06/22/2017 at 0400 "pt pulled out 2nd iv. pt pulled off telemetry. pt sitting on side of bed refusing care."; on 06/22/2017 at 0507 "went in and attempted to give ativan po (by mouth). pt refused all meds. pt sitting on side of the bed repeating over and over I want to go home. pt refuses all care."; on 06/22/2017 at 0712 "pt is confused. only oriented to self. pt continues to pull out iv's and take off telemetry. pt has telemetry pads on shirt. pt comes out into the hallway with bags in her hand"; on 06/22/2017 at 0730 "Pt has been up roaming hallway and had had to be guided back to room several times. Pt agreed to take po ativan and other meds."; on 06/22/2017 at 0743 "Ativan 1 mg po given...Assisted pt to lie down in bed and place covers on her. Bed in low position and call light within reach."; on 06/22/2017 at 0843 "Pt in room and resting quietly in chair...Daughter at chairside. Call light within reach."; on 06/22/2017 at 0945 "Pt continues wandering out into hallway. Daughter is here for a few minutes then she goes out of building and returns later. Reguided pt back to room and oriented to surroundings."; on 06/22/2017 at 1145 "Pt in room at this time...Call light within reach."; on 06/22/2017 at 1345 "Daughter was called via telephone at 1215 and asked to come back to hospital to sit with mother due to her wandering and opening exit doors and setting off alarms. Daughter was sitting in room and pt was standing outside of room 134 at door with her clothes folded and in her arms. There were 2 nurses and couple of nursing assistants at the desk and all staff was busy with discharges, etc and pt disappeared. Pt was found outside of building and was escorted back to med surg."; on 06/22/2017 at 1500 "Medicated pt with ativan 1 mg im (intramuscular) lt (left) deltoid for agitation."; on 06/22/2017 at 1600 "Granddaughter in room at this time. Pt sitting in chair resting quietly."; on 06/22/2017 at 1745 "Pt continues to get up and wander in hallway at intervals..."; on 06/22/2017 at 1850 "...pt is confused, pt does like to wander in the halls, call bell within reach of pt."; and on 06/22/2017 at 2001 "pt is alert, pt is confused at times,...pt has no IV access, reports to this nurse pt has pulled out two IV's, physician aware, pt has moderate push/pull to upper and lower extremities,...pt refuses to wear her telemetry box." Further review of nursing narrative notes from 06/22/2017 at 2034 through discharge note on 06/23/2107 at 1310 revealed no further documentation of Patient #10 wandering in the hallway. Review of the medical record revealed Patient #10 was moved from Room 134 to Room 156 on 06/22/2017 at 1921. Review of the medical record from 06/21/2017 through 06/23/2017 revealed no available documentation of an order for a safety attendant (sitter), no nursing documentation of a sitter assigned to the patient and no documentation by a sitter of every 15 minutes observations.

Review on 08/15/2017 of the hospital's incident report log revealed no available documentation of a patient elopement on 06/22/2017.

Observations during tour of the Medical-Surgical Unit on 08/16/2017 at 0900 revealed the Medical-Surgical unit was located on the ground floor with a North and South Entrance Exit door with audible alarms on the Room 134 hall where Patient #10 was assigned. Observations revealed Room 134 was located near the nursing station with no direct view from the charge nurse or unit secretary desk. Further observation revealed Patient #10 would have had to walk past the nursing station down a long hallway (approximately 50 feet-with a direct view from the charge nurse and unit secretary desk) to access the hallway to the front lobby door. Observations revealed a gift shop staffed during the daytime by volunteers in the front lobby. Observations during tour revealed Room 156 (room where Patient #10 was moved after elopement) was located directly across from the nurse's station and was in direct view of the charge nurse and unit secretary.

Review of the Medical-Surgical Nursing Assignment Sheets for the 7am - 7pm shift on 06/22/2017 revealed there were three (3) Registered Nurses, three (3) Nursing Assistants (1 of the nursing assistants was on orientation), and one (1) unit secretary/nursing assistant with a census of twelve (12) patients. Further review of nursing assignment sheet revealed there were 5 discharges during the 7am - 7pm shift.

Interview on 08/16/2017 at 0905 with Registered Nurse (RN) #1 revealed she was the primary nurse for Patient #10 on 06/22/2017. Interview revealed she recalled Patient #10. Interview revealed Patient #10's daughter would sit with her intermittently and then leave. Interview revealed the patient wandered more when her daughter was out of the hospital. Interview revealed the patient did open the exit doors at the end of the South hallway a couple of times, causing the alarms to activate. Interview revealed the patient never made it outside before nursing staff would redirect her. Interview revealed at the time the daughter was in the room visiting with patient when she eloped. Interview revealed "I was on the phone calling report and recall her (patient) standing outside her door (room 134) in street clothes with other clothes in her arms." Interview revealed "When I got off the phone, I looked up and saw she was gone. I did not see her in the immediate surroundings. I started to her room, daughter came out and asked where her mother was. I walked down to the end of the back hall where she had gone previously and came back down the front hall. By the time I got back to the nurse's station, the daughter and a nursing assistant were walking down the main hallway back to the unit. I was told she was found outside the door, but not sure which door. I assisted her back to her room, assessed her and named physician (MD #7) ordered Ativan. I did not see her leave the unit. I am not sure who notified the physician. I gave Ativan to the patient." Interview revealed she thought the nursing assistant orientee had been assigned to sit with the patient. Interview revealed "I did not complete an incident report." Interview revealed an incident report should have been completed per hospital policy.

Interview on 08/16/2017 at 0925 with Unit Secretary #8 revealed she recalled Patient #10. Interview revealed "I was on the phone making an appointment for another patient. I remember we had a new CNA (certified nursing assistant #2) Name. I remember the charge nurse asked Name (CNA #2) to go sit with the patient. He (CNA #2) came back up to the charge nurse desk just a short time later, slapped his hand on the desk a few times and asked the charge nurse if he could go to lunch. I turned and saw another CNA #9 and RN #1 (primary nurse) standing outside the patient's room door. I turned back around and continued my phone call. I was still on the phone, when I heard Name (CNA #2) tell someone the patient was outside the hospital door. CNA #2 said she was coming back now. I looked up and saw CNA #3 and patient's daughter coming up the main hallway from outside with the patient." Interview revealed CNA #9 was in the break room eating lunch when CNA #2 returned with his lunch and they were both in the break room at the same time. Interview revealed "I did not see her walk past the nursing desk to leave."

Interview on 08/16/2017 at 0955 with CNA #3 revealed she recalled Patient #10. Interview revealed it took all three CNAs to look after Patient #10. Interview revealed Patient #10 attempted several different times to go out the South hall exit door. Interview revealed she recalled the alarm activating one time during her shift. Interview revealed the daughter was visiting with the patient when she left the unit. Interview revealed the daughter came to the nurse's station and said she had received a phone call reporting that her mother was behind the hospital. Interview revealed the daughter and I went outside and found Patient #10 near the hospital sign located on the corner near US701 and the street where the Emergency Department is located in a hospital gown with her personal clothes folded in her arms. Interview revealed the patient told the daughter she wanted to go home. The daughter encouraged the patient to return to her room. Interview revealed the daughter took the patient into her room and closed the door. Interview revealed "I did not see the patient leave the unit." Interview revealed the next time the daughter left the unit, CNA #9 went in and sat with the patient. Interview revealed she sat with the patient while CNA #9 obtained 4 O'clock vital signs. Interview revealed she was relieved by a family member. Interview revealed she did not document any observations while she sat with the patient. Interview revealed she discussed with RN #6 the need to move the patient to a different room. Interview revealed the patient was moved to Room 156 right before change of shift. Interview revealed there were no further issues with the patient after she was returned to her room.

Interview on 08/16/2017 at 1130 with the Medical-Surgical Nurse Manager revealed she was notified of the incident on 06/23/2017 by the patient representative. Interview revealed she spoke with the staff involved. Interview revealed she spoke with the patient's daughter and apologized for the staff calling her to sit with her mother. Interview revealed the expectation is for staff to take care of the patients. Interview revealed she did not complete an incident report. Interview revealed she did not document any conversations she had related to the elopement incident for Patient #10. Interview revealed the unit was fully staffed on 06/22/2017 with 3 nurses, 2 CNA's, 1 unit secretary and one CNA on orientation.

Interview on 08/16/2017 with MD #7 revealed she remembered receiving a call about the patient pulling out her IV's. Interview revealed she did not recall changing any orders. Interview revealed she told the staff to contact the family to stay with patient. Interview revealed she talked with the unit staff at the nurse's station about the family coming in to sit with the patient. Interview revealed she did not order a hospital sitter as she though the family would be a better influence with her dementia. Interview revealed the CNA's were watching the patient. Interview revealed she did not recall any orders to discontinue the telemetry monitor or the Intravenous fluids. Interview revealed she did not recall receiving a call about Patient #10's elopement.

Interview on 08/16/2017 at 1555 with RN #6 revealed she was the charge nurse on the medical-surgical unit on 06/22/2017. Interview revealed she had had issues with Patient #10 wandering out of her room and into the hall and removing her telemetry monitor during her shift. Interview revealed "I called the Director about the patient wandering and asked if we could use a CNA to sit with the patient. She said yes we could, so I asked a CNA that was on orientation to sit with the patient." Interview revealed CNA #2 went into the patient's room to sit with the patient and found the patient's daughter had returned and was in the room visiting. Interview revealed "I did not ask the staff to document every 15 minutes observations on the patient since she was not an Involuntary Commitment. I was distracted with discharges and do not recall her (patient) passing by the nurse's station." Interview revealed she did not recall which staff told her the patient was gone. Interview revealed CNA #3 went out to find the patient. Interview revealed she saw CNA #3 and the patient's daughter walking back up the hall towards the nursing station with the patient about the same time she was getting ready to notify security. Interview revealed the primary nurse was responsible for completing the incident report. Interview revealed she did not complete an incident report because she thought the primary nurse had already completed. Interview revealed she contacted the Director to let her know the patient had been found outside in the parking lot, but did not notify the physician.

Interview on 08/16/2017 at 1625 with CNA #2 revealed he was orienting to the CNA role on 06/22/2017. Interview revealed he was not asked to sit with Patient #10 by the charge nurse. Interview revealed there were 3-4 staff members at the nursing station when the patient walked out. Interview revealed "I got permission from charge nurse to go to lunch and left Name (CNA #9) in the room with the patient getting vital signs. I went down the street to get lunch and found the patient wandering outside when I returned. I stopped the patient on the sidewalk near a sign in the parking lot. Name (CNA #3) was outside with the patient. I asked Name (CNA #3) if she needed assistance. I walked back in the facility, clocked back in and spoke with Name (charge nurse) and Name (primary nurse)."

B. Review on 08/16/2017 of the hospital policy titled "Guidelines for Neurological Exam by Nursing Personnel" effective date 08/11/2017 revealed "Policy: A patient's neurological status is assessed upon admission, during hospitalization as warranted, and at discharge. Documentation is completed electronically..."

1. Review on 08/15/2017 of the medical record for Patient #5 revealed an 80-year-old female admitted on 08/13/2017 at 0006 with a diagnosis of Acute Urinary Tract Infection, nausea, vomiting, hypoglycemia and dehydration. Review of the physician's orders dated 08/13/2017 at 0006 revealed an order for neurological checks every 4 hours for 30 days. Review of the nursing notes revealed documentation of a neurological check assessment on 08/13/2017 at 0429 and 2011(15 hours and 42 minutes since last assessment); on 08/14/2017 at 1928 (23 hours and 17 minutes since last assessment); and on 08/15/2017 at 1923 (23 hours and 55 minutes since last assessment). Review of nursing notes revealed no available documentation of a neurological check assessment on 08/13/2017 at 0800, 1200 and 1600; on 08/14/2017 at 0000, 0400, 0800, 1200 and 1600; on 08/15/2017 at 0000, 0400, 0800, 1200 and 1600.

Interview on 08/15/2017 at 1500 with Administrative Staff revealed nursing staff were expected to follow the physician's orders. Interview revealed the nursing staff failed to follow the physician's orders for neurological checks on Patient #5. Interview revealed the hospital nursing staff failed to follow the hospital policy. Interview confirmed the findings.

2. Review on 08/15/2017 of the medical record for Patient #4 revealed a 79-year-old female admitted on 05/28/2017 at 1729 with a diagnosis of Acute Kidney Failure and discharged home on 06/01/2017 at 1649. Review of the physician's orders dated 05/296/2017 at 0129 revealed an order for neurological checks every 4 hours for 30 days. Review of the nursing notes revealed documentation of a neurological check assessment on 05/29/2017 at 0129, 0529, 1000, 1400 and 1942; on 05/30/2017 at 0800 (14 hours and 18 minutes since last assessment), 1203, and 1609; on 05/31/2017 at 0749 (15 hours and 40 minutes since last assessment), 1201, 1610 and 2008; on 06/01/2017 at 0035, 0434, 0929 and 1329. Review of nursing notes revealed no available documentation of a neurological check assessment on 05/30/2017 at 0000, 0400 and 2000; on 05/31/2017 at 0000 and 0400.

Interview on 08/15/2017 at 1500 with Administrative Staff revealed nursing staff were expected to follow the physician's orders. Interview revealed the nursing staff failed to follow the physician's orders for neurological checks on Patient #4. Interview revealed the hospital nursing staff failed to follow the hospital policy. Interview confirmed the findings.

3. Review on 08/15/2017 of the medical record for Patient #10 revealed a 62-year-old female admitted on 06/21/2017 at 1831 with a diagnosis of Altered Mental Status with increased confusion and discharged to an Assisted Living Facility on 06/23/2017 at 1310. Review of the physician's orders dated 06/21/2017 at 1831 revealed an order for neurological checks every 4 hours for 30 days. Review of the nursing notes revealed documentation of a neurological check assessment on 06/21/2017 at 2326; on 06/22/2017 at 0330, 1031 (7 hours and 1 minute since last assessment), 1431, 1831 and 2122; and on 06/23/2017 at 0529 (8 hours and 7 minutes since last assessment). Review of nursing notes revealed no available documentation of a neurological check assessment on 06/22/2017 at 0730; on 06/23/2017 at 0122 and 0922.

Interview on 08/15/2017 at 1500 with Administrative Staff revealed nursing staff were expected to follow the physician's orders. Interview revealed the nursing staff failed to follow the physician's orders for neurological checks on Patient #10. Interview revealed the hospital nursing staff failed to follow the hospital policy. Interview confirmed the findings.

C. Review on 08/16/2017 of the hospital policy titled "Telemetry/Cardiac Monitoring Policy" effective date 01/20/2017 revealed "Policy: Cardiac monitoring (Telemetry) shall be initiated and continued upon the order of a LIP (Licensed Independent Practitioner). Procedural Guidelines: ...Monitoring duties: ...*Print a 6-second telemetry strip: *Upon admission * Every 4 hours....*Print rhythm strips and post them to the patient's medical record..."

1. Review on 08/16/2017 of the medical record for Patient #7 revealed a 73-year-old male admitted on 08/14/2017 at 2007 with a diagnosis of Renal Failure, weakness and dizziness and discharged on 08/15/2017 at 1625. Review of the physician's orders dated 08/13/2017 at 2155 revealed an order for "Telemetry***Reason for Telemetry: Risk for arrhythmia..." Review of the medical record from 08/14/2017 at 2007 through 08/15/2017 at 1625 revealed no available documentation by nursing staff of a 6-second telemetry strip charted on admission (08/14/2017 at 2007) and every 4 hours (08/15/2017 at 0000, 0400, 0800, 1200 and 1600).

Interview on 08/15/2017 at 1500 with Administrative staff revealed the nursing staff are expected to document a telemetry strip every 4 hours with interpretation per hospital policy. Interview revealed the nursing staff failed to follow hospital policy. Interview confirmed the findings.

2. Review on 08/15/2017 of the medical record for Patient #10 revealed a 62-year-old female admitted on 06/21/2017 at 1831 with a diagnosis of Altered Mental Status with increased confusion and discharged on 06/23/2017 at 1310. Review of the record revealed Patient #10 arrived on the Medical-Surgical unit at 2105. Review the physician's orders dated 06/21/2017 at 1831 revealed an order for "Telemetry***Reason for Telemetry: Risk for arrhythmia..." Review of the medical record from 06/21/2017 at 2105 through 06/23/2017 at 1310 revealed a 6-second telemetry strip charted on 06/21/2017 at 2115. Further review of the medical record revealed no further available documentation of a 6-second telemetry strip charted. Review of the medical record revealed no available documentation of a telemetry strip documented on 06/22/2017 from 0000 through 06/23/2017 at 1310 (time of discharge).

Interview on 08/15/2017 at 1500 with Administrative staff revealed the nursing staff are expected to document a telemetry strip every 4 hours with interpretation per hospital policy. Interview revealed the nursing staff failed to follow hospital policy. Interview confirmed the findings.

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