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Based on observation, clinical record review, policy review and staff interviews it was determined the Director of the Intensive Care Unit (ICU) failed to prevent neglect of one (1) of one (1) patients (patient #8) who were cared for by Registered Nurse (RN) #1. This failure has the potential for all patients to be at risk for neglect and injury. (See tag A 044 and A 145).

A. Noncompliance: RN #1 failed to monitor patient #8 in room number five (5), call a Code Armstrong for assistance and provide patient care in a safe setting when the patient became agitated. RN #1 discovered the patient missing and then had eloped after contacting the patient's mother. This failure was revealed in one (1) out of thirty (30) clinical record reviews (patient #8).

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: This failure has the potential for all patient's admitted to the unit to be at risk for neglect and harm to self or others.

C. Need for Immediate Action: An immediate plan of correction was received and sent to the State agency program directors. It was accepted and the facility abated the IJ on 12/18/19 at 12:22 p.m.

Based on observation, clinical record review, policy review and staff interviews it was determined the Director of the Intensive Care Unit (ICU) failed to ensure Registered Nurse (RN) #1 continued to monitor patient #8 when the patient became agitated. This failure was revealed in one (1) out of thirty (30) clinical record reviews (patient #8). This failure has the potential for all patients to be at risk for neglect and injury.

Findings include:

1. An observation was conducted on 12/18/19 at approximately 11:35 a.m. The entrance/exit into the Intensive Care Unit (ICU) is located to the immediate right of and in direct view of the nursing staff sitting at the nurse's station.

2. Review of clinical record for patient #8 revealed RN #1 documented on 12/03/19 at 6:03 p.m. and states in part: "Patient became very angry and started jerking around in the bed and cussing so I left the room in fear for my safety and retreated to the nurse's station."

3. Review of the clinical record for patient #8 documented on 12/03/19 at 6:15 p.m. states in part: "Patient not in room at this time. Myself and physician #3 was at nurse's station and never saw him leave. Went to patient room and intravenous (IV) was disconnected but no IV was present. Notified supervisor and patient's mother ... She called patient and he pulled the IV out on his way home."

4. Review of the policy titled "Code Armstrong Call For Able Bodied Staff," revised date 09/19, states in part: "In the event a patient, visitor or employee would become violent or the potential to become violent ... Staff should go to the nearest phone and dial 511, then make the following announcement, Code Armstrong and the location of the incident three (3) times over the intercom system. All able bodied staff should then report to the location of the Code Armstrong."

5. Review of Human Resource policies and hospital policies revealed there is not an Abuse/Neglect policy by staff.

6. An interview with RN #1 was conducted on 12/17/19 at approximately 1:13 p.m. When asked if he left patient #8 alone in his room when he became agitated, RN #1 stated in part: "I'm going to always watch out for myself. My safety is priority."

7. An interview with the Director of ICU was conducted on 12/17/19 at approximately 1:20 p.m. When asked if RN #1 should have called the supervisor, notify the physician and call security when the patient became agitated, she stated, "RN #1 did not follow policy and procedure of the facility to keep the patient safe."

8. An interview was conducted with the Director of Nursing on 12/18/19 at approximately 8:00 a.m. When asked if RN #1 neglected and failed to monitor patient #8 and call a Code Armstrong, she concurred.

Based on observation, clinical record review, policy review and staff interviews it was determined the Director of the Intensive Care Unit (ICU) failed to prevent neglect of one (1) of one (1) patients (patient #8) who were cared for by Registered Nurse (RN) #1 when the patient became agitated. This failure was revealed in one (1) out of thirty (30) clinical record reviews (patient #8). This failure has the potential for all patients to be at risk for neglect and injury.

Findings include:

1. An observation was conducted on 12/18/19 at approximately 11:35 a.m. The entrance/exit into the Intensive Care Unit (ICU) is located to the right of and in view of the nursing station.

2. Review of clinical record for patient #8 revealed RN #1 documented on 12/03/19 at 6:03 p.m. and states in part: "Patient became very angry and started jerking around in the bed and cussing so I left the room in fear for my safety and retreated to the nurse's station."

3. Review of the clinical record for patient #8 documented on 12/03/19 at 6:15 p.m. states in part: "Patient not in room at this time. Myself and physician #3 was at nurse's station and never saw him leave. Went to patient room and intravenous (IV) was disconnected but no IV was present. Notified supervisor and patient's mother ... She called patient and he pulled the IV out on his way home."

4. Review of the policy titled "Code Armstrong Call For Able Bodied Staff," revised date 09/19, states in part: "In the event a patient, visitor or employee would become violent or the potential to become violent ... Staff should go to the nearest phone and dial 511, then make the following announcement, Code Armstrong and the location of the incident three (3) times over the intercom system. All able bodied staff should then report to the location of the Code Armstrong."

5. Review of Human Resource policies and hospital policies revealed there is not an Abuse/Neglect policy by staff.

6. An interview with RN #1 was conducted on 12/17/19 at approximately 1:13 p.m. When asked if he left patient #8 alone in his room when he became agitated, RN #1 stated in part: "I'm going to always watch out for myself. My safety is priority."

7. An interview with the Director of ICU was conducted on 12/17/19 at approximately 1:20 p.m. When asked if RN #1 should have called the supervisor, notify the physician and call security when the patient became agitated, she stated, "RN #1 did not follow policy and procedure of the facility to keep the patient safe."

8. An interview was conducted with the Director of Nursing on 12/18/19 at approximately 8:00 a.m. When asked if RN #1 neglected and failed to monitor patient #8 and call a Code Armstrong, she concurred.

Based on document review, clinical record reviews and interviews it was revealed the Director of the Intensive Care Unit (ICU) failed to prevent neglect of one (1) of one (1) patients (patient #8) who were cared for by Registered Nurse (RN) #1. This failure was revealed in one (1) out of thirty (30) clinical record reviews (patient #8). This failure has the potential for all patients to be at risk for neglect and injury.

Findings include:

1. Review of clinical record for patient #8 revealed RN #1 documented on 12/03/19 at 6:03 p.m. and states in part: "Patient became very angry and started jerking around in the bed and cussing so I left the room in fear for my safety and retreated to the nurse's station."

2. Review of the clinical record for patient #8 documented on 12/03/19 at 6:15 p.m. states in part: "Patient not in room at this time. Myself and physician #3 was at nurse's station and never saw him leave. Went to patient room and intravenous (IV) was disconnected but no IV was present. Notified supervisor and patient's mother ... She called patient and he pulled the IV out on his way home."

3. Review of the policy titled "Code Armstrong Call For Able Bodied Staff," revised date 09/19, states in part: "In the event a patient, visitor or employee would become violent or the potential to become violent ... Staff should go to the nearest phone and dial 511, then make the following announcement, Code Armstrong and the location of the incident three (3) times over the intercom system. All able bodied staff should then report to the location of the Code Armstrong."

4. Review of Human Resource policies and hospital policies revealed there is not an Abuse/Neglect policy by staff.

5. Review of the job description for the Director of Emergency Services and Intensive Care Unit states in part: "Assumes responsibility and accountability for the overall quality of patient care in Emergency Care Center and Intensive Care Unit. ...Provides continuous evaluation and counseling of employees."

6. An interview with RN #1 was conducted on 12/17/19 at approximately 1:13 p.m. When asked if he left patient #8 alone in his room when he became agitated, RN #1 stated in part: "I'm going to always watch out for myself. My safety is priority."

7. An interview with the Director of ICU was conducted on 12/17/19 at approximately 1:20 p.m. When asked if RN #1 should have called the supervisor, notify the physician and call security when the patient became agitated, she stated, "RN #1 did not follow policy and procedure of the facility to keep the patient safe."

8. An interview was conducted with the Director of Nursing on 12/18/19 at approximately 8:00 a.m. When asked if RN #1 neglected and failed to monitor patient #8 and call a Code Armstrong, she concurred.