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Based on interview and record review the hospital failed to provide care in a safe setting for 2 of 17 Patients (Patient #12, Patient #13).

Findings Include
Patient #12 was left outside after an outside break occurred. The staff returned to the unit walking in front of the line instead of the rear. The patient scaled the fence and side of the building to get onto the roof. The staff was reprimanded. The staff immediately completed a head count and realized Patient #12 was still outside. The staff called for coverage of the patients in the unit. He then exited the building to and informed Patient #12 to come down and climbed down.

Patient #13 was identified as isolative, withdrawn and difficult to engage, showing signs of paranoia and psychosis. Patient #13's diagnosis and care plan included diabetes to be treated with sliding scale insulin protocol; hypertension-prescribed medication and daily monitoring; Hyperlipidemia - prescribed labs were ordered; Coronary Artery Disease treated with ASA, and Anxiety to be treated per psych protocol. She actively participated in program activities. Patient #13's daughter participated in collateral calls with staff for discharge. On 09/18/19 Patient #13 was assessed by the nurse and determined that Patient #13 was not stable. The doctor ordered the patient be sent out to Charlton Methodist Hospital. Patient #13 was diagnosed with pneumonia and a mild stroke and was returned back to Hickory Trail Hospital within 4-5 hours. Patient #13 was placed on antibiotics prescribed by the emergency room doctor and was later seen by the Hickory Trail Nurse Practitioner that evening where the antibiotics were changed from Levaquin to Cipro (Facility Formulary). On 09/19/19 during the 0245 Patient rounds Patient #13 was noted to be unresponsive and emergency care was administered. Patient #13 was transferred and was pronounced dead at 0511, at Charlton Methodist ER. Throughout the course of treatment, Patient #13 remained on every 15-minute patient observations. The patient was placed on antibiotics for newly diagnosed pneumonia and aspirin for newly diagnosed mild strokes. The patient was accepted back into the facility without doctor Doc clearance, based on ER Diagnosis patient should have been admitted into acute care setting.

Policies:

The hospital Purpose/Philosophy of Nursing Department dated 05/2019 reflected, "The purpose of the nursing department is to provide quality nursing services and to assure comprehensive patient care services through cooperation and collaborating with the multidisciplinary team. The nursing staff is committed to assisting the patient in achieving his/her optimal level of physical and mental wellness."

The hospital Patient's Rights Policy dated 10/2018 reflected, "It is the policy of this hospital to ensure that all patients receive a copy of the Bill of Rights form as well as an oral explanation of those rights both in their primary language and in simple non-technical terms. We will strive to abide by and respect all patient rights without regard to race, religion, creed ethnicity, gender age, sexual orientation, or handicap. Hickory Trail Hospital shall support and protect the fundamental human, civil constitutional and statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times."

The hospital Fifteen Minute Checks Policy dated 05/2019 reflected, "To ensure adequate monitoring and maintenance of a safe and therapeutic environment by visually observing and documenting each patient's location and behavior and checking the environmental condition of the unit."