HospitalInspections.org

A. Based on document review, medical record review and staff interview, it was determined the facility failed to provide care in a safe setting by not ensuring the continuous monitoring of a patient on suicide and elopement precautions in one (1) of ten (10) medical records reviewed (patient #1) resulting in the elopement of this patient. This failure has the potential to adversely impact the care and condition of all patients.

Findings include:

1. The facility's policy entitled " Procedure for Suicide/Homicidal/Elopement Precautions", last revised 11/08, was reviewed. The policy states, under Key Points #4, "there must be 1:1 observation."

2. Review of the medical record of Patient #1 revealed presentation to the ED for self-inflicted bilateral lacerations to the wrists. The record revealed suicide precautions and elopement precautions initiated per nursing judgement with a Behavior Observation Sheet initiated at that time. Documentation revealed multiple references to the patient being "tearful" and "crying". Documentation revealed the patient verbalized wanting to leave the facility on more than one (1) occasion.

3. An interview was conducted with RN #1 on 5/20/13 at 1425. She reported that on 4/8/13 Patient #1 attempted to leave the facility multiple times during her shift, 7 AM-7 PM, and stated, in part, "I chased her all around that day". She reported the patient was in Room # 11 with continuous monitoring via camera ongoing. She stated Patient #1 had visitors at the bedside at the end of her shift who appeared to be causing the patient increased agitation.

4. An interview was conducted with RN #2 on 5/21/13 at 0730. She reported that on 4/8/13 she assumed care of Patient #1 at approximately 1930 following shift report. She described the patient's status at this time as "suicidal", "agitated" and "angry". She reported being at the nurse's station when the security officer assigned to watch the monitor left the monitor to assist with a violent patient in the hallway. She stated she then left the nurse's station unattended to assist the security officer. She stated that when she returned to the nurse's station she discovered Patient #1 had fled. She stated she is aware of the facility policy regarding monitoring of the suicidal/homicidal/elopement policy. She reported her understanding of elopement precautions as "able to visualize continuously". She agreed that Patient #1 had not been monitored continuously during the time she was absent from the nurse's station on 4/8/13.
She denied she had participated in any type of disciplinary action, counseling, or re-education following this incident. She stated during the interview "I don't think I did anything wrong."

5. An interview was conducted with the ED Clinical Nurse Manager on 5/20/13 at 1100. The Nurse Manager stated she is familiar with the facility policy on suicidal/homicidal/elopement patients. She stated her expectation of staff care of patient on elopement precautions as " let the guard know and remove belongings and clothing". She stated that she was not present when Patient #1 eloped on 4/8/13.
She stated her first knowledge of the event was on 4/9/13 when the Night Shift ED Charge Nurse reported the elopement to her. She stated the report she received was the security officer had left the monitor to assist with a violent patient and had instructed RN #2 to remain at the monitor. RN #2 had left her post at the monitor to assist with the violent patient at which time the elopement took place. She stated she counseled RN #2 regarding the importance of continuous monitoring of the suicidal/elopement patient. She stated she did not document this counseling session. She reported she did file a Safety Report of "failure to monitor" on 4/12/13. She denied any further interventions with her staff.

B. Based on document review, medical record review and staff interview, it was determined the facility failed to provide care in a safe setting by not completing an Incident Report per hospital policy about a known elopement of a patient on suicide/elopement precautions, in one (1) of ten (10) medical records reviewed resulting in a failure to report, identify and take corrective action. This failure has the potential to adversely impact the care and condition of all patients.

Findings include:

1. The facility's policy entitled, "Incident and Sentinel Event Reporting", last revised 02/2012, was reviewed. The policy states, under the heading II. Definitions: "Safety Event/Incident" is an event, situation, activity, or lack of activity no consistent with the normal or usual operation of the hospital, which either did or could have resulted in injury or loss to a patient." Under the heading III. Procedure, it states: "The Safety Event/Incident Report should be completed in its entirety as soon after the event as possible, but in any event prior to the end of the shift in which the event happened or was discovered."

2. Review of Patient #1's medical record revealed the elopement took place on 4/8/13 at 1950.

3. An interview was conducted with RN #2 on 5/21/13 at 0730. RN #2 stated she was responsible for the care of Patient #1 on 4/8/13 at the time of the elopement. RN #2 stated she had not completed an Incident Report. She stated she did not feel an Incident Report was required, as she considered this to be and "AMA" (Patient leaving Against Medical Advice). She stated she is aware of the facility policy regarding Incident Reports. She stated she has not been counseled regarding Incident Reports since 4/8/13.

4. A telephone interview was conducted with the Night Shift Charge Nurse ED on 5/21/13 at 0950. She stated she was the Charge Nurse at the time of the elopement of Patient #1 on 4/8/13. She stated when the elopement was reported to her, she did not complete an Incident Report, nor did she request RN #2 to complete an Incident Report. She stated she was aware of the facility policy regarding Safety Events/Incident Reports. She was unable to give any reason why she did not complete an Incident Report per policy.

5. An interview was conducted with ED Clinical Nurse Manager on 5/20/13 at 1100. She stated when she learned of the elopement of Patient #1 upon her arrival to work the morning of 4/9/13, she did not inquire of RN #2 or of the Charge Nurse if an Incident Report had been completed. She stated that she herself did not complete an Incident Report at that time. She reported she did complete a Safety Event Report regarding the elopement of Patient #1 on 4/12/13.

6. A joint interview was conducted with the Risk Manager and the ED Clinical Nurse Manager on 5/21/13 at 1115. The Risk Manager reported that the elopement of Patient #1 on 4/8/13 was treated as an AMA and was therefore grouped with other AMA's for scheduled monthly review, as is the normal procedure for CAMC. She did agree this was not an AMA but, rather, an elopement of a suicidal/elopement-risk patient. She agreed this elopement fit the description of a Safety Event/Incident as defined in policy, and also agreed that an Incident Report should have been completed. She agreed the Safety Event Report completed by the ED Clinical Manager on 4/12/13 did not meet the time requirement of the policy as stated. The Clinical Nurse Manager reported that she had initiated no interventions with her staff regarding completion of Incident Reports since 4/8/13.