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A. Based on medical record review, staff interview, review of video surveillance footage, and review of facility policy and procedure, it was determined that the facility failed to ensure that the patient observer maintained continuous visual observation with the patient at all times in one (1) out of one (1) medical record reviewed (#2).

Findings include:

Reference: Facility policy titled: "Patient Safety Watch" states: " ...A Patient Safety Watch shall be utilized to prevent self-injury or injury to others in those patients whose behavior is impulsive and unpredictable as to require presence and observation by a staff member ..... A patient safety watch may be initiated for behavioral situations, which are unsafe for the patient and/or others, and in which interventions have proven unsuccessful ... PROCEDURE: ...a. Prior to requesting a physician/Licensed Practitioner order for a patient safety watch, the RN [registered nurse] will attempt alternatives ... b. An order is obtained ... c. Patients will have eye-to-eye contact by a staff member as per order; a one to one observation patient safety watch requires continuous visual observation by a staff member ....."

1. A review of the medical record for Patient #2 identified a form titled, "Suicide/Safety Watch Record." There were two (2) staff members identified on the form that corresponded to the initials on the form that was being filled out in fifteen (15) minute intervals.

2. An interview with Staff #10 stated that the patient was on a one to one safety watch, and Staff #18 was the sitter assigned to the patient at the time the patient had eloped from the Emergency Department (ED).

3. The Video Surveillance Footage from 9/11/2021 was reviewed in the presence of Staff #10, Staff #12, and Staff #14. Prior to the patient eloping, it was observed on the video footage, Staff #18 leaving the patient room and walking down the hallway to get a linen cart and then returning to the patient's room. A second observation identified Staff #18 leaving the patient room again with the linen cart and bringing it down the hallway, and then returning to the patient room.

4. An interview with Staff #9 confirmed that Staff #18 was assigned as the one to one for Patient #2 , and that Staff #18 did not maintain continuous visual observation of the patient when he/she left the room twice.


B. Based on medical record review and staff interview, it was determined that the facility failed to ensure that the patient observer filled out the safety observation form at the appropriate times in one (1) out of one (1) medical record reviewed (#2).

Findings include:

1. A review of the medical record for Patient #2 identified a form titled, "Suicide/Safety Watch Record." There were two staff members identified on the form that corresponded to the initials on the form that was being filled out in fifteen (15) minute intervals.

2. An interview with Staff #10 stated that the patient was on a one to one safety watch, and Staff #18 was the sitter assigned to the patient at the time the patient had eloped from the Emergency Department (ED) on 9/11/2021 at approximately 11:30 AM.

3. A review of the "Suicide/Safety Watch Record" identified that the form had been filled out on 9/11/2021 at 11:30 AM, 11:45 AM, and 12:00 PM with the initials of the patient safety sitter, but then had been scribbled out.

4. Staff #1 and Staff #10 confirmed the above findings, and that Staff #18 had made a safety observation entry of the patient when the patient was no longer in the ED.

C. Based on review of the daily assignment sheet of the Emergency Department (ED) for 9/11/2021, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure that there is adequate staffing in the ED.

Findings include:

Reference: Facility policy titled: "Main Emergency Department Scope of Service" states: " ... Staffing Plan: ...Nursing staff is scheduled to adequately manage the ED (Emergency Department) on a 24 hour basis ... VII. Recognized Standards/Practice Guidelines Used ... b. Emergency Nurses Association ... 2021 Staffing Guidelines for the Emergency Department Adjusted Based on Volume ..."

1. Upon request to Staff #1, the facility Daily Staffing for 100 patients staffing grid and the Emergency Department Daily Staffing Sheets were provided for the date 9/11/2021. The staffing grid and staffing sheets were reviewed with Staff #14 and the following was identified:

a. At 7:00 AM, there were six (6) Registered Nurses (RN) assigned plus two (2) RN's that were still on orientation and five (5) technicians. Per the staffing grid provided, there should have been eight (8) RN's and five (5) technicians, therefore leaving the ED in a deficit of two (2) RN's.

b. At 10:00 AM, there were seven (7) RN's and seven (7) technicians assigned. Per the staffing grid there should have been nine (9) RN's and six (6) technicians, therefore leaving in the ED in a deficit of two (2) RN's.

c. At 11:00 AM, there were seven (7) RN's and seven (7) technicians assigned. Per the staffing grid there should have been twelve (12) RN's and six (6) technicians, therefore leaving in the ED in a deficit of five (5) RN's.

d. At 3:00 PM, there were seven (7) RN's and two (2) technicians assigned. Per the staffing grid there should have been thirteen (13) RN's and six (6) technicians, therefore leaving in the ED in a deficit of six (6) RN's and four (4) technicians.

e. At 7:00 PM, there were six (6) RN's assigned plus three (3) RN's on orientation and two (2) technicians. Per the staffing grid the should have been twelve (12) RN's and seven (7) technicians, therefore leaving the ED with a deficit of six (6) RN's and four (4) technicians.

f. At 11:00 PM, there were six (6) RN's and five (5) technicians assigned. Per the staffing grid there should have been eight (8) RN's and five (5) technicians, therefore leaving the ED with a deficit of two (2) RN's.

g. At 3:00 AM on 9/12/2021, one (1) technician left leaving four (4) technicians and the ED in deficit of one (1) technician.

2. An interview with Staff #14 on 9/30/2021 at 9:58 AM revealed that the staffing grid and staffing sheets provided accounted for both the main and the satellite campus of the ED.

3. Upon request to Staff #1, the Clinical Operations Manager Report was provided and reviewed. The following was identified:

a. At 7:45 AM, there were seven (7) patients holding in the ED including one (1) critical care unit (CCU) patient and there were two (2) safety sitters needed in the ED.

b. At 12:30 PM, there were seven (7) patients holding in the ED.

c. At 4:00 PM, there were fourteen (14) patients holding in the ED. The report did not specify the acuity of the patient holds at that time. In additional there was one (1) safety sitter needed in the ED.

d. At 7:00 PM, there were four (4) patients holding in the ED. The report did not specify the acuity of the patient holds at that time.

e. At 8:30 PM, there were seven (7) patients hold in the ED. The report did not specify the acuity of the patent holds at that time.

f. On 9/12/2021 at 12:30 AM, there were seven (7) patients holding in the ED. The report did not specify the acuity of the patient holds at that time. In addition, there were two (2) safety sitters needed in the ED.

4. An interview with Staff #9 and Staff #14 on 9/30/2021 at 10:08 AM confirmed the above findings and that the facility ED had staffing deficits on 9/11/2021.

5. Upon request to Staff #14, the facility was unable to provide evidence of the activation of a short staffing contingency plan.

D. Based on medical record review and staff interview, it was determined that the facility failed to ensure that patients are medically assessed by a physician upon return to the Emergency Department (ED) after eloping.

Findings include:

1. Patient #2 eloped from the facility ED on 9/11/2021 at approximately 11:30 AM. The patient was returned to the ED on the same day at 12:15 PM in the custody of local law enforcement after being retrieved from a nearby river.

2. A review of the medical record of Patient #2 identified a nurse's note written by Staff #19 on 9/11/2021 at 1:20 PM that stated: " ...The patient has scratches on the entire left of [his/her] rib cage ....." The medical record lacked evidence of a medical examination by a physician completed upon the patient's return to the ED.

3. An interview with Staff #1 and Staff #14 confirmed the above statements and that there should have been a medical examination by a physician.

Based on review of facility policy and procedure and the medical record of 1 of 3 patients who were physically restrained for behavior management (#6), it was determined that the patient did not have restraints discontinued at the earliest possible time, regardless of the length of time identified in the order.

Findings include:

Reference: Policy and procedure titled "Restraints for Violent or Self-Destructive Behavior (Behavioral Restraint)" states: ".....
PROCEDURE:
.....
F. Discontinuation of Restraint:
.....
Restraints may be discontinued when the patient:
.....
* Is no longer threatening other patients, staff or the environment
....."

1. Review of the medial record of Patient #6 revealed that the patient was ordered to be in 4-point locked physical restraint at 11:55 AM on 5/20/21 for "Violent/threatening behavior that presents immediate risk of harm to patient, staff, and others." Nursing documentation revealed that between 2:00 PM and 2:50 PM, the patient was sleeping. At 2:50 PM the patient was released from restraints.

2. Administrator #10 was made aware of the findings.