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The Condition of Patient Rights is not met based on observation, review of 1 of 10 medical records (Patient #1), interviews and review of Hospital policies titled: (1.) Patient Rights and (2.) Care and Management of the Patient at Risk for Suicide, because the Hospital failed to ensure Patient #1's safety when: (1.) Registered Nurses (RN) #1 and #2 failed to assign a safety monitor to view Patient #1 at all times, in accordance with Hospital policy and (2.) telemetry monitor alarms were not audible to the Medical Surgical Unit staff and Patient #1 eloped from the Hospital, unnoticed by Hospital staff.

See A-144.

Based on observation, review of 1 of 10 medical records (Patient #1), interviews and review of Hospital policies titled: (1.) Patient Rights and (2.) Care and Management of the Patient at Risk for Suicide, the Hospital failed to ensure Patient #1's safety because: (1.) Registered Nurses (RN) #1 and #2 failed to assign a safety monitor to view Patient #1 at all times, in accordance with Hospital policy and (2.) telemetry monitor alarms were not audible to the Medical Surgical Unit staff and Patient #1 eloped from the Hospital, unnoticed by Hospital staff.

Findings include:

1.) The Hospital reported to the Massachusetts Department of Public Health on 8/28/13, the Hospital treated Patient #1 for alcohol dependence and depression and Patient #1 eloped. The Hospital notified the Police and that evening, a truck hit and killed Patient #1.

2.) The Hospital policy titled, Patient Rights, dated 2/2012, indicated the patient has the right to expect reasonable safety insofar as hospital practices and environment are concerned.

3.) The Hospital policy titled, Care and Management of the Patient at Risk for Suicide, dated 9/17/09, indicated a patient determined to be at risk for suicide will have a safety monitor assigned and will be kept in view at all times.

4.) The Emergency Services Program (ESP) Adult Comprehensive Assessment Form, dated 8/24/13 and written by Social Worker (SW) #1, indicated Patient #1's friend reported Patient #1 made a suicidal statement today, to jump in front of a train and SW #1 evaluated Patient #1 at moderate risk for harm.

5.) The Application for an Authorization of Temporary Involuntary Hospitalization, (commonly referred to as a Section 12, from Massachusetts General Law) form, dated 8/24/13 at 6:00 P.M., indicated Patient #1 was at substantial risk of physical harm to the person himself/herself as manifested by evidence of threats of, or attempts at suicide or serious bodily harm. The Form indicated specific evidence including behavior and symptoms of depression and suicidal ideation. The Form also indicated RN #1 documented a telephone read back order (TORB, verbal order), from Physician #1 and RN #2 co-signed the verbal order.

Massachusetts General Law, Chapter 123, Sections 12 (a), indicated that a licensed: physician, nurse practitioner, psychologist, psychiatric nurse mental health clinical specialist or independent clinical social worker after examining a person, has reason to believe that failure to hospitalize such person would create a likelihood of serious harm by reason of mental illness may restrain or authorize the restraint of such person and apply for the hospitalization of the person for a 3-day period at a public facility or at a private facility authorized for such purposes by the department.

Refer to TAG 0395, RN supervision of Nursing Care regarding the Section 12.

The Surveyor interviewed SW #1, on 9/3/13 at 8:20 A.M. SW #1 said she was of the impression Patient #1's friend was a credible reporter and she evaluated Patient #1 at moderate risk for harm.

The Surveyor interviewed RN #1 on 8/29/13 at 2:00 P.M. RN #1 said SW #1 told her Patient #1 was at risk for harming himself/herself. RN #1 said she did not assign a safety monitor to view Patient #1 at all times because Patient #1 was not at risk for a fall and Patient #1's alcohol withdrawal scores were low enough to not warrant a safety monitor assigned in view him/her at all times.

The Surveyor interviewed RN #2 on 8/29/13 at 1:20 P.M. RN #2 said her nursing assessment was Patient was not a suicide risk and did not require a safety monitor assigned to view him/her at all times. RN #2 said Patient #1 was too sick on Saturday (8/24/13) to elope. RN #2 said she never thought Patient #1 would elope or she would have obtained a Physician's order for a safety monitor to view him/her at all times.

The Surveyor observed on 8/29/13 at 1:20 P.M. RNs #1's and #2's signatures on the Section 12 Form indicating they knew Patient #1 was at risk for self harm and they did not arrange for a safety monitor to view Patient #1 at all times.

The Hospital did not have a policy or procedure for patients placed on a Section 12.

The Hospital failed to have an organized nursing service, that implemented 6 of 6 polices and procedures for 1 of 10 patients reviewed (Patient #1), in a total sample of 10. The 6 Hospital policies reviewed were titled:
(a.) Care and Management of the Patient at Risk for Suicide,
(b.) Patient Reassessment, Care Planning and Documentation,
(c.) Social Work High Risk Screen,
(d.) Management of Physician Orders,
(e.) Chain of Command and
(f.) Hand-Off Communication.

Failure to implement the policies and procedures resulted in Patient #1 not being supervised/monitored appropriately. Patient #1 eloped from the hospital, unnoticed and was later hit by a car and killed.

Refer to A-392, A-395 and A-396.

Based on review of 1 of 10 medical records (Patient #1), interviews, and the 4 Hospital policies titled:
(1.) Patient Reassessment, Care Planning & Documentation and Care & Management of the Patient at Risk for Suicide,
(2.) Chain of Command,
(3.) Social Work High Risk Screen and
(4.) Hand-Off Communication, the Hospital failed to ensure Patient #1's safety needs and ongoing assessment of safety needs was met.

Findings include:

A.) RN's #1 and #2 failed to arrange a safety monitor to view Patient #1 at all times, according to 2 Hospital policies, Care and Management of the Patient at Risk for Suicide and Chain of Command, after Social Worker (SW) #1 evaluated Patient #1 to be at risk of self harm.

The Surveyor interviewed SW #1, on 9/3/13 at 8:20 A.M. SW #1 said a friend of Patient #1 reported he/she wanted to throw himself/herself in front of a train.

The Surveyor interviewed RN #1, on 8/29/13 at 2:00 P.M. RN #1 said she admitted Patient #1 to the Medical Surgical Unit (MSU) and SW #1 told her Patient #1 should be placed on a Section 12 because she (SW #1) evaluated Patient #1 was at risk for harming himself/herself. RN #1 said she did not assign a safety monitor to view Patient #1 at all times because Patient #1 was not at risk to harm him/her from a fall and Patient #1's alcohol withdrawal scores were not high enough to warrant a safety monitor to view him/her at all times.

The Surveyor interviewed RN #2, on 8/29/13 at 1:20 P.M. RN #2 said she was the Charge Nurse the evening of 8/24/13. RN #2 said she did not assign Patient #1 a safety monitor to view him/her at all times because, her nursing assessment was, Patient #1 was not a suicide risk and did not require a safety monitor to view him/her at all times.

The Surveyor observed on 8/29/13 at 1:20 P.M. RNs #1's and #2's signatures on the Section 12 Form indicating they knew Patient #1 was at risk for self harm and they did not arrange for a safety monitor to view Patient #1 at all times.

B.) RN's #1 and #2 failed to communicate, according to the Hospital policy, Chain of Command, with the Nursing Supervisor and the appropriate covering Physician about executing Patient #1's Section 12 (emergency restraint and hospitalization of persons posing serious risk because of mental illness) when they were uncertain how to execute the Section 12.

The Hospital policy titled Chain of Command, dated 2/2013, indicated the purpose of the policy was to provide the nursing staff with the chain of command to assist in conflict resolution in the management of patients. The algorithm included in the policy demonstrated the communication chain of command flowed from the Staff Nurse communicating with Charge Nurse, who communicated with the Nurse Director or Nurse Supervisor, who would communicate with the Chief Nurse Officer or Hospital Administrator. The algorithm also demonstrated that the communication chain of command flowed from the Staff Nurse to the physician and communication flowed from the Charge Nurse to the physician.

RN #1 said that she had never have placed a patient on a Section 12 before and it was better to have the Charge Nurse co-sign the Section 12. RN #1 said that she had not attended education on Section 12's and did not consult with the Nursing Supervisor or refer to a Hospital Policy. RN #1 said she did not know how to do differently than what she had done.

The Hospital did not have a policy or procedure for patients placed on a Section 12.

RN #2 said she co-signed Patient #1's verbal order for the Section 12 with RN #1 because she was the Charge Nurse and Social Worker #1 needed the Section 12. RN #2 said co-signing the Section 12 was similar to the process of a do-not-resuscitate order (DNR) that required two signatures and because the Section 12 was a protective order, where Patient #1 could not leave the Hospital. RN #2 said that a verbal order for a Section 12 was not typical procedure.

C.) RN's on the Medical Surgical Unit (MSU) failed to:
(1.) communicate correct and pertinent data, facts and knowledge about Patient #1's risk for self harm, according to the Hospital policy, Hand-Off Communication,
(2.) communicate correct and pertinent data, facts and knowledge about Patient #1's Section 12 status (active or expired) or know a Section 12 was active for 3 days, according to Massachusetts General Law,
(3.) communicate correct and pertinent data, facts and knowledge about physicians discharge plan for Patient #1 (discharge to home or transfer for psychiatric hospitalization) and
(4) communicate correct and pertinent data, facts and knowledge about the status Patient #1 left the Hospital [against medical advice (AMA) or eloped].

The Hospital policy titled, Hand-Off Communication, dated 12/12, indicated communication was to provide correct and pertinent data, facts and knowledge about a patient's care, treatment and services, current condition and any recent or anticipated changes. The policy also indicated that staff providing direct patient care and support services are responsible for ensuring that information is exchanged correctly and quickly to facilitate timely response related to patient care delivery. This type of "hand-off " communication involves information exchanged between nursing personnel, nursing personnel and medical staff.

The Hospital Disposition Form, dated 8/24/13 at 5:15 P.M. and The Emergency Services Program (ESP) Adult Comprehensive Assessment Form, dated 8/24/13 (time not documented) and documented by SW #1, indicated Patient #1 had a history of dangerous impulsivity (a tendency to act quickly without thinking about the consequences of his/her actions and was moderate risk for self harm.

The Surveyor interviewed RN #1, on 8/29/13 at 2:00 P.M. RN #1 said she did not receive any information during hand-off about Patient #1 having suicidal thoughts.

The Surveyor interviewed RN #2, on 8/29/13 at 1:20 P.M. RN #2 said she was the Charge Nurse the evening of 8/24/13. RN #2 said that if she did know about Patient #1's suicide risk she would have notified the Nurse Supervisor.

The Surveyor interviewed RN #3, on 9/5/13 at 8:15 A.M. RN #3 said she did not receive in shift hand-off that Patient #3 was on a Section 12. RN #3 said she would definitely remember if the previous shift nurse told her, Patient #1 was on a Section 12.

The Nursing Note, dated 8/26/13 at 11:26 and documented by RN #4, indicated that Patient #1 wanted to go home, did not want to go to a treatment program and was going to sign out of the Hospital AMA if a doctor did not discharge him/her. The Nursing Note indicated that Doctor #2 said Patient #1 could not sign out of the Hospital AMA because he/she was on a Section 12. The Nursing Notes indicated RN #4 informed the Charge Nurse (RN #5).

The Surveyor interviewed RN #4, on 8/29/13 at 7:50 A.M. RN #4 said she did not receive the information that Patient #1 had a psychiatric history or that Patient #1 was on a Section 12, in her shift report the morning of 8/26/13 (the day Patient #1 eloped). RN #4 said Doctor #2 said Patient #1 could not leave AMA because he/she is awaiting placement to a psychiatric hospital and is on a Section 12. RN #4 said this was the first time that she heard that Patient #1 was on a Section 12 and she viewed the Section 12 Form in Patient #1's medical record. RN #4 said Doctor #1 signed the Section 12 Form on 8/24/13 and the date was now 8/26/13. RN #4 said the Section 12 Form had expired because Section 12's were active for 24 hours. RN #4 said she informed Physician #2 and the Charge Nurse that Section 12 for Patient #1 was expired. RN #4 said Doctor #2 told her that he does not sign the Section 12; the Department of Children and Families (DCF) signs the Section 12 Forms. RN #4 said she progressed with Patient #1's nursing care and Patient #1 was not on a Section 12 because it had expired and because DCF was scheduled to evaluate Patient #1 at 3:00 P.M. on 8/26/13. RN #4 said she informed the Charge Nurse (Nurse Educator #1 covering for the Charge Nurse, RN #5), Physician #2 and Nurse Educator #1 informed Nurse Director #1 and the Case Manager that Patient #1 had left the Hospital AMA.

The Surveyor interviewed RN #5 (Charge Nurse on 8/26/13), on 9/3/13 at 3:00 P.M. RN #5 said that she did not know that Patient #1 told a friend that she planned to throw himself/herself in front of a train and would expect to receive this information from the night nurse during change of shift report (hand-off). RN #5 said Patient #1's Section 12 had expired. RN #5 said sometimes staff has told her a patient was on a Section 12 and the Section 12 Form was not in the patient's medical record. RN #4 said Section 12's were active for 24 hours.

The Surveyor interviewed Dr. #2, (Patient #1's doctor), on 8/30/13 at 1:33 P.M. Dr. #2 said a nurse told him, the morning of 8/26/13, that Patient #1 had left the Hospital AMA. Dr. #2 said his response was that Patient #1 could not leave the Hospital AMA because he/she was on a Section 12. Dr. #2 said he told Patient #1, before 12:00 P.M. (approximately) on 8/26/13, that he/she could not leave the Hospital because he/she was on a Section 12 and required psychiatric hospitalization and treatment.

The Physician Progress Note, dated 8/26/13 at 1:15 P.M. indicated that Physician #2 examined Patient #1 and Patient #1 said he/she was feeling well, was not depressed and did not have suicidal thoughts. The Physician Progress Note indicated that Patient #1 was stable, did not demonstrate alcohol withdrawal symptoms and was awaiting placement at a psychiatric hospital.

The Surveyor interviewed Nurse Director #1 on 8/28/13 at 2:45 P.M. and 8/29/13 at 10:00 A.M. Nurse Director #1 said on Monday (8/26/13) she received a message from Nurse Educator #1 that Patient #1 left the Hospital AMA. Nurse Director #1 said did not know or suspected Patient #1 would elope from the Hospital and did not know he/she had a psychiatric history. Nurse Director #1 said the next day, Tuesday 8/27/13, a social worker told her Patient #1 had eloped from the Hospital and was on a Section 12. Nurse Director #1 said the Hospital does not place patients on Section 12's on this Medical Surgical Unit. Nurse Director #1 said she talked to Nurse Educator #1 who told her that Patient #1 was discussed during the morning patient care meeting and he/she was not on a Section 12 because the Section 12 had expired, therefore Patient #1 left the Hospital AMA and did not elope.

The Surveyor interviewed the Chief Nurse Officer (CNO), on 8/29/13 at 10:15 A.M. The CNO said the Hospital was treating Patient #1 for alcohol intoxication and depression and Patient #1 had not expressed suicidal thoughts. The CNO said that the Department of Children and Families (DCF) identified Patient #1's suicidal thoughts through discussion with Patient #1's friend. The CNO said that the Hospital thought staff initiated the Section 12 because Patient #1 required psychiatric hospitalization and not because Patient #1 intended to hurt himself/herself.

The Surveyor interviewed SW #3 and the Care Coordinator Nurse Director, on 8/30/13 at 12:20 P.M. SW # 3 said DCF scheduled a SW to evaluate Patient #1 and re-evaluate the need for the Section 12, at 3:00 P.M. on 8/26/13.

The Surveyor interviewed the Nurse Supervisor, on 9/3/13 at 3:04 P.M. The Nurse Supervisor said she does not expect the MSU Charge Nurse report, to her, all patients on a Section 12.

The Social Work Assessment Notes, dated 8/26/13 at 11:50 A.M., indicated an active inpatient psychiatric bed-search was ongoing by the DCF Emergency Services Team; DCF updated the Section 12 and placed it in Patient #1's medical record. The SW Notes indicated the nurses stated that Patient #1 wanted to leave, noting that he/she is not able to leave based on the Section 12, noting she was at risk for self-harm.

The Surveyor interviewed SW #2, on 8/30/13 at 12:15 P.M. The SW said Patient #1 was on a Section 12 and the Section 12 was active for 24 hours.

The Surveyor interviewed the Case Manager, on 9/3/13 at 9:45 A.M. The Case Manager said the meeting members definitely report, in the morning patient care meetings, if a patient was on a Section 12 and did not remember if the members discussed Patient #1's Section 12.

The Social Work Assessment Notes, dated 8/27/13 at 8:00 A.M., indicated the SW spoke with DCF staff and nurses on Patient #1's patient care unit, at the Hospital, at 4:00 P.M. yesterday (8/26/13) advising them that Patient #1 had eloped prior to DCF's scheduled 3:00 P.M. re-assessment of Patient #1 for involuntary inpatient psychiatric placement. The SW clarified with the DCF Clinician on site, SW Supervisor and physician via phone that an active Section 12 was in place. DCF contacted by SW Supervisor to request they notify police of the elopement and to follow up in the community for safety and reassessment by DCF.

The Hospital did not provide for review a policy regarding Section 12's, when requested.

D.) telemetry monitor alarms were not audible to the Medical Surgical Unit staff.

The Doctors Orders, dated indicated 8/24/13 at 11:21 A.M. indicated doctors ordered Patient #1's telemetry (transmission of signals to a monitor displaying heartbeat information) continue on the MSU.

The Nursing Note, dated 8/24/13 at 15:10 P.M., indicated that the nurse placed Patient #1 on telemetry.

The Nurses Notes dated 8/22/13 through 8/26/13 indicated nurses performed telemetry checks on Patient #1.

RN #1 said Patient #1 was on telemetry.

RN #3 said Patient #3 was on the telemetry monitoring system for her entire shift and she did not take him/her of the telemetry monitoring system because there was not a doctor's order to do so.

The Nursing Note, dated 8/26/13 at 12:56, documented by RN #4, indicated that Patient #1 left the Hospital AMA.

The Surveyor interviewed the Clinical Informatics Nurse (CIRN), in person, on 9/4/13 at 9:30 A.M. The CIRN said there was not a doctor's order to discontinue Patient #1's telemetry monitoring.

The Surveyor interviewed the Risk Manager on 9/13/13 at 9:55 A.M. The Risk Manager said because of the low alarm tone, when telemetry monitor leads are off a patient and alarm fatigue (desensitization to frequent non-significant alarms) were possible reasons Patient eloped without staff being alerted. The Risk Manager said Patient #1 was on telemetry the day he/she eloped and that the nursing staff told her they did not remember Patient #1's telemetry alarm sounding. The Risk Manager said it was unknown how Patient #1 came off the telemetry monitoring system unnoticed by Hospital staff.

The Surveyor observed, during a tour facilitated by Nurse Director #1 of the Medical Surgical Unit (MSU), on 8/28/13 at 2:45 P.M., that Patient #1's was a semi-private room adjacent to the MSU exit door.

Based on review of 1 of 10 medical records (Patient #1), interviews, and 2 Hospital policies titled, Management of Physician Orders and Social Work High Risk Screen, the Hospital failed to ensure RN's #1 and #2 followed Hospital procedure because RN's #1 and #2 documented a verbal order for a Section 12 (emergency restraint and hospitalization of persons posing serious risk because of mental illness) for Patient #1, through a third-party (Social Worker #1) telephone order.

Findings include:

The Hospital policy titled, Management of Physician Orders, dated April 2012, indicated that:
1.) All medical orders are written on a physician order sheet or entered electronically and shall be transcribed, verified and acknowledged as soon as possible,
2.) Verbal orders are accepted only during emergency and or procedural situations and
3.) Third-party telephone orders are not accepted. A third party order is considered to be a physician or provider order received from an individual other than a physician, nurse practitioner, physician assistant or nurse midwife, speaking on behalf of these medical practitioners, that is a nurse or office staff member.

The Hospital policy titled, Social Work High Risk Screen, dated 3/2013, indicated once doctors medically cleared a patient for discharge and deemed at risk for self and others, the treating physician or psychiatrist and or Licensed Independent Clinical Social Worker (LICSW) obtained a Section 12.

The Surveyor interviewed Social Worker (SW) #1, on 9/3/13 at 8:20 A.M. SW #1 said she had a telephone conversation with Dr. #1 about Patient #1 requiring placement on a Section 12 and Dr. #1 said it was fine. SW #1 said RN #1 assisted with placing Patient #1 on a Section 12. SW #1 said she had not been involved with placing a patient on a Section 12 by verbal order.

The Emergency Services Program (ESP) Adult Comprehensive Assessment Form, dated 8/24/13 (time not documented), written by SW #1, indicated Patient #1 was on a Section 12, that Physician #1 authorized the Section 12 and Patient #1 required psychiatric inpatient hospitalization.

The Nursing Note dated 8/24/13 at 6:00 P.M. and written by RN #1, indicated that RN #1 had a conversation with Social Worker (SW) #1 and SW #1 assessed the Hospital should place Patient #1 on a Section 12. The Nursing Note indicated that SW #1 spoke with Physician #1 and he was agreeable to the Section 12. The Nursing Note indicated that RN #1 informed the Charge Nurse, RN #2, of the situation.

The Application for an Authorization of Temporary Involuntary Hospitalization form, dated 8/24/13 at 6:00 P.M., indicated RN #1 documented a telephone read back order (TORB, verbal order), from Physician #1 and RN #2 co-signed order.

The Surveyor interviewed RN #1, on 8/29/13 at 2:00 P.M. RN #1 said she asked the Charge Nurse (RN #2) to co-sign the Section 12 Form because RN #2 was the Charge Nurse that evening.

The Surveyor interviewed RN #2, on 8/29/13 at 1:20 P.M. RN #2 said she was the Charge Nurse the evening of 8/24/13. RN #2 said she co-signed Patient #1's verbal order for the Section 12 with RN #1 because she was the Charge Nurse and Social Worker #1 needed the Section 12.

The Surveyor interviewed Physician #1, (ICU Physician), on 9/3/13 at 10 A.M. Physician #1 said he was not aware that nurses took his verbal conversation with the SW as a verbal order to implement the Section 12 and that he did not sign the order.

The Surveyor interviewed Nurse Director #1, in person, on 8/28/13 at 2:45 P.M. and 8/29/13 at 10:00 A.M. Nurse Director #1 said it is not customary for nurses to take a verbal order to place a patient on a Section 12.

The Surveyor interviewed the Nurse Supervisor, on 9/3/13 at 3:04 P.M. The Nurse Supervisor said that a Physician or psychiatric clinician completes a Section 12.

Based on review of 1 of 10 medical records (Patient #1), and Hospital policy titled, Patient Reassessment, Care Planning, the Hospital failed to ensure Registered Nurses (RN) on the Medical Surgical Unit (MSU) updated Patient #1's Nursing Care Plan (NCP) to include that he/she was at risk for self harm by assigning a safety monitor to view Patient #1 at all times.

Findings include:

The Hospital policy titled, Care and Management of the Patient at Risk for Suicide, dated 9/17/09, indicated the patient determined to be at risk for suicide will have a safety monitor assigned and will be kept in view at all times.

The Hospital policy titled Patient Reassessment, Care Planning and Documentation, dated 6/2012, indicated that the RN, in order to initiate an appropriate plan of care, uses information collected during the assessment process. In addition, nurses review the nursing care plan daily as evidenced by documentation, addition and completion of assessments and interventions.

The Nursing Care Plan, dated 8/24/13, did not indicate nursing assigned a safety monitor to view Patient #1 at all times, consistent with Hospital policy for patients identified at risk for self harm.

Based on review of 1 of 10 medical records (Patient #1), interviews, and the 4 Hospital policies titled:
(1.) Patient Reassessment, Care Planning & Documentation and Care & Management of the Patient at Risk for Suicide,
(2.) Chain of Command,
(3.) Social Work High Risk Screen and
(4.) Hand-Off Communication, the Hospital failed to ensure Patient #1's safety needs and ongoing assessment of safety needs was met.

Findings include:

A.) RN's #1 and #2 failed to arrange a safety monitor to view Patient #1 at all times, according to 2 Hospital policies, Care and Management of the Patient at Risk for Suicide and Chain of Command, after Social Worker (SW) #1 evaluated Patient #1 to be at risk of self harm.

The Surveyor interviewed SW #1, on 9/3/13 at 8:20 A.M. SW #1 said a friend of Patient #1 reported he/she wanted to throw himself/herself in front of a train.

The Surveyor interviewed RN #1, on 8/29/13 at 2:00 P.M. RN #1 said she admitted Patient #1 to the Medical Surgical Unit (MSU) and SW #1 told her Patient #1 should be placed on a Section 12 because she (SW #1) evaluated Patient #1 was at risk for harming himself/herself. RN #1 said she did not assign a safety monitor to view Patient #1 at all times because Patient #1 was not at risk to harm him/her from a fall and Patient #1's alcohol withdrawal scores were not high enough to warrant a safety monitor to view him/her at all times.

The Surveyor interviewed RN #2, on 8/29/13 at 1:20 P.M. RN #2 said she was the Charge Nurse the evening of 8/24/13. RN #2 said she did not assign Patient #1 a safety monitor to view him/her at all times because, her nursing assessment was, Patient #1 was not a suicide risk and did not require a safety monitor to view him/her at all times.

The Surveyor observed on 8/29/13 at 1:20 P.M. RNs #1's and #2's signatures on the Section 12 Form indicating they knew Patient #1 was at risk for self harm and they did not arrange for a safety monitor to view Patient #1 at all times.

B.) RN's #1 and #2 failed to communicate, according to the Hospital policy, Chain of Command, with the Nursing Supervisor and the appropriate covering Physician about executing Patient #1's Section 12 (emergency restraint and hospitalization of persons posing serious risk because of mental illness) when they were uncertain how to execute the Section 12.

The Hospital policy titled Chain of Command, dated 2/2013, indicated the purpose of the policy was to provide the nursing staff with the chain of command to assist in conflict resolution in the management of patients. The algorithm included in the policy demonstrated the communication chain of command flowed from the Staff Nurse communicating with Charge Nurse, who communicated with the Nurse Director or Nurse Supervisor, who would communicate with the Chief Nurse Officer or Hospital Administrator. The algorithm also demonstrated that the communication chain of command flowed from the Staff Nurse to the physician and communication flowed from the Charge Nurse to the physician.

RN #1 said that she had never have placed a patient on a Section 12 before and it was better to have the Charge Nurse co-sign the Section 12. RN #1 said that she had not attended education on Section 12's and did not consult with the Nursing Supervisor or refer to a Hospital Policy. RN #1 said she did not know how to do differently than what she had done.

The Hospital did not have a policy or procedure for patients placed on a Section 12.

RN #2 said she co-signed Patient #1's verbal order for the Section 12 with RN #1 because she was the Charge Nurse and Social Worker #1 needed the Section 12. RN #2 said co-signing the Section 12 was similar to the process of a do-not-resuscitate order (DNR) that required two signatures and because the Section 12 was a protective order, where Patient #1 could not leave the Hospital. RN #2 said that a verbal order for a Section 12 was not typical procedure.

C.) RN's on the Medical Surgical Unit (MSU) failed to:
(1.) communicate correct and pertinent data, facts and knowledge about Patient #1's risk for self harm, according to the Hospital policy, Hand-Off Communication,
(2.) communicate correct and pertinent data, facts and knowledge about Patient #1's Section 12 status (active or expired) or know a Section 12 was active for 3 days, according to Massachusetts General Law,
(3.) communicate correct and pertinent data, facts and knowledge about physicians discharge plan for Patient #1 (discharge to home or transfer for psychiatric hospitalization) and
(4) communicate correct and pertinent data, facts and knowledge about the status Patient #1 left the Hospital [against medical advice (AMA) or eloped].

The Hospital policy titled, Hand-Off Communication, dated 12/12, indicated communication was to provide correct and pertinent data, facts and knowledge about a patient's care, treatment and services, current condition and any recent or anticipated changes. The policy also indicated that staff providing direct patient care and support services are responsible for ensuring that information is exchanged correctly and quickly to facilitate timely response related to patient care delivery. This type of "hand-off " communication involves information exchanged between nursing personnel, nursing personnel and medical staff.

The Hospital Disposition Form, dated 8/24/13 at 5:15 P.M. and The Emergency Services Program (ESP) Adult Comprehensive Assessment Form, dated 8/24/13 (time not documented) and documented by SW #1, indicated Patient #1 had a history of dangerous impulsivity (a tendency to act quickly without thinking about the consequences of his/her actions and was moderate risk for self harm.

The Surveyor interviewed RN #1, on 8/29/13 at 2:00 P.M. RN #1 said she did not receive any information during hand-off about Patient #1 having suicidal thoughts.

The Surveyor interviewed RN #2, on 8/29/13 at 1:20 P.M. RN #2 said she was the Charge Nurse the evening of 8/24/13. RN #2 said that if she did know about Patient #1's suicide risk she would have notified the Nurse Supervisor.

The Surveyor interviewed RN #3, on 9/5/13 at 8:15 A.M. RN #3 said she did not receive in shift hand-off that Patient #3 was on a Section 12. RN #3 said she would definitely remember if the previous shift nurse told her, Patient #1 was on a Section 12.

The Nursing Note, dated 8/26/13 at 11:26 and documented by RN #4, indicated that Patient #1 wanted to go home, did not want to go to a treatment program and was going to sign out of the Hospital AMA if a doctor did not discharge him/her. The Nursing Note indicated that Doctor #2 said Patient #1 could not sign out of the Hospital AMA because he/she was on a Section 12. The Nursing Notes indicated RN #4 informed the Charge Nurse (RN #5).

The Surveyor interviewed RN #4, on 8/29/13 at 7:50 A.M. RN #4 said she did not receive the information that Patient #1 had a psychiatric history or that Patient #1 was on a Section 12, in her shift report the morning of 8/26/13 (the day Patient #1 eloped). RN #4 said Doctor #2 said Patient #1 could not leave AMA because he/she is awaiting placement to a psychiatric hospital and is on a Section 12. RN #4 said this was the first time that she heard that Patient #1 was on a Section 12 and she viewed the Section 12 Form in Patient #1's medical record. RN #4 said Doctor #1 signed the Section 12 Form on 8/24/13 and the date was now 8/26/13. RN #4 said the Section 12 Form had expired because Section 12's were active for 24 hours. RN #4 said she informed Physician #2 and the Charge Nurse that Section 12 for Patient #1 was expired. RN #4 said Doctor #2 told her that he does not sign the Section 12; the Department of Children and Families (DCF) signs the Section 12 Forms. RN #4 said she progressed with Patient #1's nursing care and Patient #1 was not on a Section 12 because it had expired and because DCF was scheduled to evaluate Patient #1 at 3:00 P.M. on 8/26/13. RN #4 said she informed the Charge Nurse (Nurse Educator #1 covering for the Charge Nurse, RN #5), Physician #2 and Nurse Educator #1 informed Nurse Director #1 and the Case Manager that Patien