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Based on staff interviews and record review the facility failed to assure that all staff utilized the established Adverse Event reporting system or Emergency Involuntary Procedures to identify a potential adverse event and opportunity for improvement, analysis, development and implementation of actions and mechanisms for learning throughout the hospital, following a confirmed patient event involving 1 of 10 patients [Patient #6] of the sample group.
Findings include:
Per record review of the hospital ' s Event Reporting policy " Event reporting is an important part of the organization ' s patient safety program and environment of care, which is a key component of the Quality Assessment and Performance Improvement Program " . The policy lists " elopement " and " inappropriate behavior " as examples of an event, and states " All staff are required to complete an Event report or ensure an Event report is completed whenever they discover, witness, or an event is reported to them " .
On 9/8/14 at approx. 3:00 P.M. Patient #6 attempted to elope from the hospital ' s Progressive Care Unit [PCU]. The patient ran from the PCU to the Intensive Care Unit [ICU] where s/he laid on the floor next to a chair. During this time a " Code 33 " was called and Security staff and the Code team arrived on the ICU. Per interview with the Director of Security on 10/8/13 at 1:30 P.M. security assisted the patient to h/her feet and CPI [crisis prevention] technique was used to escort the patient from the ICU back to PCU. The Director reported a " hands on " technique was used, with staff to the right and left of the patient holding on to each forearm " to control the limb " and " prevent any flailing out or injury " .
Per interview on 10/9/14 at 1:13 P.M. the Director of the hospital ' s 5th floor patient unit stated Patient #6 ' s elopement attempt and behavior would qualify as an Adverse Event and if CPI hands on technique was used it would be recognized as a restraint and it would be documented on the hospital ' s Emergency Involuntary Procedures form. The Director reported that the Emergency Involuntary Procedures form would be sent to the hospital ' s Regulatory Compliance person who would then register it as an adverse event.
The Director demonstrated that ' CPI technique ' is the first item listed under ' Type of Involuntary Procedure " on the Emergency Involuntary Procedures form, and noted other options to be checked off included if Code 33 was called and if Security support was used during the event. The Director confirmed Patient #6 ' s medical record contained no Emergency Involuntary Procedures form for the event on 9/8/14.
Per interview with the Chief Quality Officer on 10/9/14 at 2:04 P.M. any restraint episode is reported to the Performance Improvement department on a daily basis. The Chief Quality Officer confirmed there was no Adverse Event Report or an Emergency Involuntary Procedures form filed as required for the incident on 9/8/14 which included a code being called, Security involvement, and a hands-on restraint of the patient ' s arms.

Based on interview and record review, Nursing staff failed to document an incident involving 1 of 10 patients [Patient #6] of the sample group, who attempted to elope from the Progressive Care unit (PCU) resulting in Security staff involvement and hands-on restraint being used.
Findings include:
Per record review of the hospital ' s Event Reporting policy " Event reporting is an important part of the organization ' s patient safety program and environment of care, which is a key component of the Quality Assessment and Performance Improvement Program " . The policy lists " elopement " and " inappropriate behavior " as examples of an event, and states " All staff are required to complete an Event report or ensure an Event report is completed whenever they discover, witness, or an event is reported to them " . On 9/8/14 at approx. 3:00 P.M. Patient #6 attempted to elope from the hospital ' s Progressive Care Unit [PCU]. The patient ran from the PCU to the Intensive Care Unit [ICU] where s/he laid on the floor next to a chair. During this time a " Code 33 " was called and Security staff and the Code team arrived on the ICU. Per interview with the Director of Security on 10/8/13 at 1:30 P.M. security assisted the patient to h/her feet and CPI [crisis prevention] technique was used to escort the patient from the ICU back to PCU. The Director of Security reported a " hands on " technique was used, with staff to the right and left of the patient holding on to each forearm " to control the limb " and " prevent any flailing out or injury " . Per interview on 10/9/14 at 1:13 P.M. the Director of the hospital ' s 5th floor patient unit stated Patient #6 ' s elopement attempt and behavior would qualify as an Adverse Event and if CPI hands on technique was used it would be recognized as a restraint and it would be documented on the hospital ' s Emergency Involuntary Procedures form. Per record review and confirmed by the 5th floor Director, the only reference in Patient #6's chart regarding the incident on 9/8/14 is a brief Nursing Note that states " ' Code 33 ' called when patient ran out of room to ICU. Security and team arrived and needed to briefly use CPI technique to settle patient. " The Director confirmed Patient #6 ' s medical record contained no Emergency Involuntary Procedures form as required for the event on 9/8/14. Per interview on 10/9/14 at 2:04 P.M. The Chief Quality Officer confirmed there was no Adverse Event Report or an Emergency Involuntary Procedures form filed for the incident on 9/8/14 which included a code being called, Security involvement, and a hands-on restraint of the patient ' s arms.

Based on interview and record review, the hospital failed to ensure the integrated service provided by Social Services to the Emergency Department (ED) was effective with the provision of patient care resources and communication of patient needs to Emergency Department staff for 1 of 6 applicable patients. ( Patient # 1) Findings include:

1. Per record review, on 8/28/14 Patient # 1 was brought via ambulance to the ED after sustaining a fall in a bathtub at home after a possible syncopal (fainting/brief loss of consciousness) episode. Patient # 1 is an 84 year old female with developmental disabilities dependent on caregivers for all activities of daily living. Due to cognitive impairments, Patient #1 was unable to provide input regarding complaints of injuries or ability to express concerns associated with her/his home environment. While in the ED, Patient # 1 received a medical screening exam to include CT of the cervical spine and brain, x-rays and laboratory testing to include blood and urine. Upon completion of the examination of Patient #1, ED Physician #1 recommended the patient be admitted for observation due to concerns regarding a urinary tract infection.

Upon Patient #1's arrival to the ED an investigator for Adult Protective Services (APS) also presented to the ED. The APS investigator was recently assigned to investigate concerns regarding this vulnerable adult and the impact of Patient #1's health and welfare within the patient's present home environment. On 8/28/14 the APS investigator's concerns were brought to the attention of the hospital social worker assigned to the ED. The social workers progress note for 8/28/14 states: ".....alerted to this patient by ......APS who is assisting family. Patient is developmentally delayed and non-verbal. Patient ' s caregivers are his/ her legal guardian and guardian's husband who provides the majority of care to the patient but is becoming overwhelmed. Met with caregiver and discussed possibly pursing a temporary respite placement in a SNF for patient, which s/he was somewhat receptive to, however, stated his wife would not agree....... explained to APS.... that it will be difficult to find placement for the patient, however a referral to CHT social worker.... will be initiated to explore possible options with the caregivers future." Per interview on 10/8/14 at 9:15 AM, the APS investigator confirmed the conversation and concerns s/he expressed to the social worker while in the ED on 8/28/14 regarding admitting Patient #1 to the hospital as a possible "social" admission due to the potential for an unsafe discharge if returned to his/her home environment. The APS investigator further stated: "I believe I was clear with that concern". However, when the APS investigator later contacted the ED about the disposition of Patient #1, s/he was informed Patient #1 had been discharged and returned home.

Although the hospital social worker had documented on 8/28/14 s/he was going to make a referral to the Blueprint Community Health Team social worker it was later confirmed on the afternoon of 10/8/14 that there was no record of a referral being made on Patient #1's behalf by the hospital social worker which could have provided more opportunities for additional community services.

Per interview on 10/8/14 at 10:58 AM, the ED nurse who provided care to Patient #1 on 8/28/14 acknowledged s/he recalled the patient and the discussion regarding discharge, however did not recall seeing or speaking with the social worker assigned to the ED or the APS investigator. Per interview on 10/8/14 at 1:40 PM the ED Medical Director confirmed ED Physician #1 had conducted the exam and recommended Patient #1 be admitted for observation. However, after being examined by the admitting hospitalist, Patient #1 did not meet medical criteria for admission and although one of the caregivers felt it was difficult to continue to provide care for Patient #1 at home, the guardian disagreed with ED Physician #1 to admit the patient for observation and agreed with the hospitalist to return the patient home. Despite decisions made by the hospitalist and/or the patient's guardian, the ED Medical Director stated he would have expected information from APS would have been shared by the hospital social worker with ED Physician #1 which would have impacted the decision for discharge. This was further confirmed with ED Physician #1 who stated on 10/9/14 at 10:35 AM, that the social worker did not speak with him/her regarding concerns expressed by APS. In addition, both the ED Medical Director and ED Physician #1 both acknowledged when APS presents a case of concern to them or any other ED physician the expectation is to follow the APS directive as appropriate.

The Operational Framework for the Social Work Department for 2014, states regarding "Scope of Care and/or Services : The Social Work Department collaborates as a team to provide comprehensive bio-psychosocial assessments and indicated services to patients and families, such as education, counseling and referrals". As part of the integrated services provided to patients in the ED, it was the expectation of both the ED Director and ED Physician #1 that social services maintain an ongoing collaboration however in this instance there was an identified failure of communication by the social worker regarding Patient #1. Subsequently, shortly after 8/28/14, Patient #1, with the assistance of Council on Aging, was eventually admitted to a licensed facility where a higher level of care could be provided.