HospitalInspections.org

Based on observation, interview, record review, and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire hospital including accountability for the effective oversight of staff to comply with the requirements under the Conditions of Participation (COP) for hospitals. The hospital census was 45. (refer to A-0057)

Additionally, after the discovery of an unsafe patient care environment and limited recognition by the hospital of continued risks to the health and safety of patients and negative patient outcomes, the situation constituted an Immediate Jeopardy (IJ) and placed all patients in the hospital at risk. (refer to A-0385)

The hospital submitted a document to remove the IJ on 08/20/20, to provide an acceptable plan of correction to prevent further risk to patients.

This resulted in the hospital being out of compliance with 42 CFR 482.23; COP: Nursing Services and 482.12; COP: Governing Body.

Based on observation, record review, policy review, and interviews, the hospital failed to properly monitor and protect four patients at risk for harm when they eloped from the Emergency Department, and failed to monitor patients using the appropriate number of staff. Nursing staff failed to ensure that proper precautions were in place, or to adjust precautions as necessary to prevent these elopements.

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

See deficiencies A0395 and A0057.

Additionally, after the discovery of an unsafe patient care environment and limited recognition of the potential for negative patient outcomes, the situation constituted an Immediate Jeopardy (IJ) and placed all patients at the hospital at increased risk. The hospital submitted a document to remove the IJ on 08/20/20, and provided an acceptable plan of correction (POC) to prevent further risk to patients.

The POC submitted by the hospital dated 08/20/20, showed that they implemented the following action plan to remove the IJ:
- A new policy that addressed the evaluation of psychiatric patients upon admission was created.
- All Emergency Department and Psychiatry staff would be educated on the new policy.
- The Elopement policy was updated and a new elopement assessment tool was implemented.
- All employees would receive education on elopement precautions.


39840

Based on observation, interview, record review, and policy review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire facility including accountability for the effective oversight of staff to comply with the requirements under 42 CFR 482.23; Conditions of Participation (COP): Nursing Services. This failure had the potential to affect the quality of care and safety of all patients.

Findings included:

The CEO failed to ensure compliance with the COP of Nursing Services as evidenced by failure to protect a total of four patients, one current (#2) and three discharged (#9, #10, #12) when they did not assess, recognize, and identify the potential for elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and
monitor three current patients (#22, #23, and #24) of three current patients observed, with the correct ratio of nurse to patients.

This failure created a situation of immediate jeopardy by placing them, and every patient that presented to the hospital for treatment, at risk of serious harm, injury, impairment, or death. (refer to A-0385)

Review of the hospital's Medical Staff Bylaws, dated 2019, showed that the term "Chief Executive Officer" meant the President of the hospital designated by the board and was responsible for the operational supervision of all of the affairs of the hospital.

Based on interview, record review, policy review, and video recording review, the hospital failed to follow their policy to respect the right to privacy and dignity for one discharged Emergency Department (ED) patient (#13) of one discharged ED patient reviewed, when patient care staff left a patient in four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others), in the hallway with their genitals exposed, where other patients and/or visitors could have seen them. This failure had the potential to affect all patients admitted to the hospital with respect to their privacy and dignity when restrained. The hospital census was 45. The hospital ED saw an average of 800 patients a month in the past six months, with 31 episodes where restraints were used.

Findings included:

Review of the hospital's policy titled, "Patient's Rights and Responsibilities," dated 05/2019, showed that all patients have a right to be cared for in a private environment.

Review of the hospital's policy titled, "Restraints or Seclusion," dated 03/2020, showed that when restraints are used:
- The individual's dignity and well-being is preserved.
- The individual's modesty and visibility to others will be preserved.
- The care and treatment will demonstrate respect for the patient as an individual.

Review of Patient #13's medical record showed that he was a 54-year-old male that was homeless and had a history of substance misuse and intoxication that came into the ED on 04/29/20 at 11:35 PM with a chief complaint of a puncture wound to his shin. After the patient was registered, he became verbally and physically aggressive towards staff. The patient was medicated and placed in four-point restraints in room, "Hallway1", which was located in the hallway between the nurses' station and the ED psychiatric room 11. The patient remained in four-point restraints for approximately one hour and 15 minutes.

Review of video of the North ED Hallway, dated 04/30/20, from 00:50:10 to 02:08:31, showed Patient #13 was left on a stretcher, in four-point restraints, with his pants down to his hips, and his genitals exposed. Several patient care staff were viewed and shown to have walked by and provided no privacy to the patient.

During a telephone interview on 08/26/20 at 2:15 PM, Staff CC, Patient Care Technician (PCT), stated that:
- He did not recall he had been responsible for that patient the night of 04/20/20.
- He remembered the patient had his pants down at some point, but he had not pulled them up or provided him with a blanket.
- He should have covered the patient.

During a telephone interview on 08/26/20 at 2:35 PM, Staff DD, ED Registered Nurse (RN), stated that the patient's pants were down on the bed in the hallway, but he was too agitated to cover him; she should have covered the patient to provide privacy.

During an interview on 08/26/20 at 1:35 PM, Staff V, ED RN, stated that:
- She remembered the patient, but she had only taken part at the time he was discharged.
- Patient #13's pants were not down when she gave him his discharge instructions.
- If a patient was found to have had their genitals exposed, any staff member was expected to cover the patient up and protect their privacy.
- If she had witnessed staff that walked past a patient that was exposed, she would have directed them back to the patient and made sure their privacy was protected.

During a telephone interview on 08/26/20 at 3:05 PM, Staff AAA, Security Officer (SO), stated that he had assisted with the placement of the patient's four-point restraints, but denied seeing the patient's pants down; he had no recollection of any education about patient's privacy or what to do if a patient was found exposed.

During a telephone interview on 08/26/20 at 10:40 AM, Staff HH, SO, stated that he had not seen the patient's pants falling down and did not recall any education provided about patient's privacy or what to do if a patient was found exposed.

During an interview on 08/20/20 at 9:50 AM, Staff S, ED Psychiatric Intake RN, stated that any patient in four-point restraints were placed in one of their three locked camera rooms used for psychiatric patients.

During a telephone interview on 09/01/20 at 2:45 PM, Staff G, RN, stated that a patient in four-point restraints was placed in an ED psychiatric room 11 or 12; and, if a patient was found with their genitals exposed, it was expected that any hospital staff could have covered the patient.

During an interview on 08/25/20 at 10:57 AM, Staff N, ED Manager, stated that a patient in four-point restraints was placed in a room and not left in the hallway; she expected that if a patient's genitals were exposed, that staff would have covered them.

During an interview on 08/25/20 at 10:18 AM, Staff L, Chief Nursing Officer (CNO), stated that:
- Staff DD, ED RN, had not offered Patient #13 a blanket and she was unsure how long the patient had been exposed.
- It was not always possible to have placed a patient that was in four-point restraints in a room for privacy due to staff shortage.
- She expected staff to have covered an exposed patient.

During a telephone interview on 09/01/20 at 5:43 PM, Staff BB, Psychiatrist, stated that:
- If a patient was seen in the hallway, on a stretcher, uncovered with genitals exposed, he expected a nurse to have covered them.
- It was not his job to cover a patient because he was a physician, it was a nurse's job.
- He did not know if it was appropriate to leave a patient in the hallway, in four-point restraints, with their pants down, because that was determined by hospital protocol and he was not a part of the development of hospital protocols.

Two attempts were made by telephone on 08/26/20 at 2:30 PM, and on 09/01/20 at 7:01 PM, to contact Staff FF, ED RN, for an interview. No return call was received.

Two attempts were made by telephone on 09/01/20 at 3:23 PM, and on 09/02/20 at 3:00 PM, to contact Staff II, Paramedic, for an interview. No return call was received.

Two attempts were made by telephone on 09/01/20 at 5:36 PM, and on 09/02/20 at 9:00 AM, to contact Staff EE, ED Physician, for an interview. No return call was received.

Based on interview, record review, policy review, and video recording review, the hospital failed to follow their policy and complete a face-to-face assessment within one hour after four-point restraints (medical cuffs applied to both arms and both legs to prevent someone from causing harm to themselves or others) were placed on one discharged Emergency Department (ED) patient (#13) of one discharged ED patient reviewed. This had the potential to affect all patients when restraint or seclusion were used. The hospital census was 45. The hospital ED saw an average of 800 patients a month in the past six months, with 31 episodes where restraints were used.

Findings included:

Review of the hospital's policy titled, "Restraints or Seclusion," dated 03/2020, showed a physician, licensed independent practitioner (LIP), specifically trained Registered Nurse (RN), or a physician assistant (PA), must see the patient within one hour to assess:
- The patient's immediate situation.
- The patient's reaction to the intervention.
- The patient's medical and behavioral condition.
- The need to continue or terminate restraint and/or seclusion.

Review of the hospital's document titled, "ED Restraint Log," dated from 03/2020 to 08/2020, showed that there were 31 episodes where restraints were used.

Review of Patient #13's medical record showed that he was a 54-year-old male that was homeless and had a history of substance misuse and intoxication that came into the ED with a chief complaint of a puncture wound to his shin. After the patient was registered, he became verbally and physically aggressive towards staff. The patient was medicated and placed in four-point restraints in room, "Hallway1", which was located between the nurses' station and the ED psychiatric room 11. The patient remained in four-point restraints for approximately one hour and 15 minutes.

Review of the Restraint and Seclusion Face-to-Face Evaluation, dated 04/30/20, showed that Staff BB, Psychiatrist, was called on 04/30/20 at 1:00 AM, and a face-to-face assessment was documented as performed on 04/30/20 at 1:05 AM, by Staff BB. The assessment showed that Staff BB reviewed the patient's vital signs (one hour and 35 minutes before the first set was documented as taken). A physical and psychological assessment was documented, which indicated the patient had denied any complaints (the patient was documented as verbally abusive from 1:00 AM to 1:45 AM on the restraint flow sheet), there were no signs of injury, skin was intact, and the patient's emotional comfort was within normal limits (the patient was documented as verbally abusive from 1:00 AM to 1:45 AM on the restraint flow sheet), and the answer to the question for the need to have continued the restraint event was, "yes." There was no explanation documented, although the assessment required it with an answer of "yes." The face-to-face evaluation was signed on 04/30/20 at 4:45 AM.

Review of video of the North ED Hallway, dated 04/30/20, from 00:50:10 to 09:02:52, showed Patient #13 was placed in four-point restraints and left on the stretcher. The video showed that no face-to-face assessment was completed during the approximate one hour and 15 minute restraint episode. There was no face-to-face assessment viewed as completed the entire ED visit. The patient was discharged and assisted out of the ED at 09:02:50.

During an interview on 08/20/20 at 10:10 AM, Staff U, ED Registered Nurse (RN), stated that a face-to-face evaluation was to have been performed at the bedside by a physician or a specially trained nurse, within an hour from when restraints were applied.

During an interview on 09/01/20 at 2:45 PM, Staff G, ED RN, stated that a face-to-face evaluation was to have been performed by a physician at the bedside of the patient within one hour after restraints were applied.

During an interview on 08/26/20 at 1:35 PM, Staff V, ED RN, stated that a face-to-face evaluation was to have been performed by a physician at the bedside of the patient within one hour after restraints were applied.

During an interview on 08/20/20 at 10:25 AM, Staff S, ED Psychiatric Intake RN, stated that a face-to-face evaluation was performed at the bedside by a physician and by some nurses that were trained, no later than one hour after the placement of the restraints.

During an interview on 08/26/20 at 2:35 PM, Staff DD, ED RN, stated that:
- A face-to-face evaluation was to have been performed by a physician at the bedside of the patient within one hour.
- She was not sure if the physician actually completed a face-to-face evaluation.
- If she was not at the bedside at the time the face-to-face was performed, she had to take the physician's word that it was completed.

During an interview on 08/18/20 at 12:10 PM, Staff N, ED Manager, stated that:
- Any physician in the ED and any trained nurse could have completed a face-to-face evaluation.
- The healthcare provider that completed a face-to-face evaluation had to have done a physical assessment and had to talk to the patient in person.
- She reviewed the video and had not seen a face-to-face evaluation performed, but it was documented as if it was completed.
- Staff K, DQRM, and Staff O, ED Medical Director, were fully aware of the incident.

During an interview on 09/01/20 at 5:43 PM, Staff BB, Psychiatrist, stated that:
- According to the medical boards, a face-to-face evaluation should have occurred within a few minutes after the restraints were applied.
- A face-to-face evaluation was only considered completed if it was performed at the bedside.
- He always went to the bedside and performed the face-to-face evaluations.
- He had no recollection that he provided care for the patient.

During an interview on 08/25/20 at 11:00 AM, Staff O, ED Medical Director, stated that:
- A face-to-face evaluation was documented as completed, but was not viewed as completed on the video.
- A face-to-face evaluation was to have been performed within one hour of when medical or physical restraints were applied.
- In the ED, a face-to-face should have been performed within minutes after restraints were applied; any ED physician had the ability to complete a face-to-face evaluation.
- He reviewed the video with Staff BB, Psychiatrist, and discussed the face-to-face evaluation that was documented as completed.
- Staff BB was removed from the ED schedule, and his contract was terminated.

During an interview on 08/18/20 at 2:58 PM, Staff K, DQRM, stated that:
- Any physician and any nurse that was trained could have completed a face-to-face evaluation.
- Although there was documentation that showed a face-to-face evaluation was completed, when the video was reviewed, it was clear there had been no face-to-face evaluation.
- He requested that Staff O, ED Medical Director, speak with Staff BB, Psychiatrist, about the documentation completed and the care that was not provided per video review.

Based on observation, interview, record review, and policy review, the hospital failed to protect a total of four patients, one current (#2) and three discharged (#9, #10, #12) when they did not assess, recognize, and identify their potential for elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and to monitor three current patients (#22, #23, and #24) of three current patients observed, with the correct ratio of nurse to patients based on observation level. This failure created a situation of Immediate Jeopardy (IJ) and placed all patients that presented to the hospital for treatment, at risk of serious harm, injury, impairment, or death. The hospital census was 45.

Findings included:

Review of the hospital's nursing policy titled, "Close Observation/Sitter/1:1 Monitoring," dated 08/2020, showed that:
- All patients are assessed for safety risks, if a risk is identified, staff will immediately initiate the appropriate level of observation.
- The observation levels are close observation (CO), sitter-within line-of-sight or sitter-1:1 monitoring.
- CO measures can be hourly rounding and/or moving the patient closer to the nursing station, etc.; when implemented the nurse must document the need for CO and the measures implemented. CO does not require a physician order.
- Observation level sitter-line-of-sight or 1:1 sitter requires a physician order.
- Appropriate level of observation is based on the assessment of risks and may include risk of injuring themselves or others, fall precautions, elopement precautions, and/or non-compliance with medical care.
- Observation level sitter-line-of-sight allows one sitter to monitor up to two patients in close proximity.

Review of the hospital's nursing policy titled, "Dr. Ryan," revised 06/2019, showed that:
- There are procedures to manage aggressive (behaviors that cause psychological or physical harm to another individual) or combative patients.
- All staff members that are trained in de-escalation, and safe handling of combative patients, are to respond to assist.
- All incidents that result in a Dr.Ryan will be reviewed to identify successful strategies or to provide alternatives for improvement.
- Staff will document a patient debriefing in the progress notes of the medical record.
- Changes will be made to the treatment plan as applicable.

Review of the hospital's psychiatric services policy titled, "Patient Observation/Safety Rounds," revised 09/2019, showed that safety rounds are conducted every 15 minutes and documented to ensure the safety of all patients. Precautions ordered for the patient will be documented on the observation sheet.

Review of the hospital's administration policy titled, "Elopement," revised 07/2020, showed that:
- Staff will maintain patient's safety through the prevention of elopement.
- During the admission process, or any time during the encounter, interventions for safety may include placement close to the nursing station, addressing their concerns, requesting family to sit with them, utilization of a sitter-within line-of-sight or a sitter for 1:1 observation, and placement into paper scrubs.
- The physician, care givers, and appropriate personnel will be alerted to the elopement risk.
- A Code Green (an overhead page to alert staff that a patient has eloped, made an intentional,
unauthorized departure from the hospital) will be initiated for an elopement.
- Patients considered to be at risk are those that are involuntarily admitted, patients with guardians, suicidal or homicidal patients, confused patients, those from a locked nursing facility, or any patient that would further compromise their condition.
- If the patient does not return, the nurse will notify the physician, the patient's family, the patient's legal guardian, and the nursing home or long term care facility they are from.
- If the patient is a risk to self, others, or is vulnerable, such as confused, elderly, or has intravenous (IV, in the vein) access, the local police department will be notified with a detailed description, and pertinent details.

Review of the hospital's undated document titled, "Job Description - Chief Nursing Officer (CNO)," showed that the CNO has the responsibility to assure that all personnel comply with the established standards, practices, and regulatory requirements.

1. Review of Patient #2's Emergency Department (ED) medical record showed that:
- On 08/07/20 at 7:25 PM, he arrived to the hospital via Emergency Medical Services (EMS) from his residential facility.
- He had been involved in multiple altercations and was to have a psychological evaluation completed for his aggressive (behaviors that cause psychological or physical harm to another individual) behavior.
- The observation sheet, dated 08/07/20, starting at 8:00 PM, showed that he was to be on every 15 minute observations, fall precautions (FP, used to identify patients that are at an increased risk of falling related to medical or psychological problems), and CO.
- On 08/08/20 at 8:53 AM, an admission request form was completed, and the patient was ordered to be placed on assault precautions (AP, alerts staff that a patient has potential to become violent with staff or other patients), FP, and CO.
- At 9:45 AM, Staff G, ED Registered Nurse (RN), documented that a Dr. Ryan had been called on Patient #2 due to his agitation (a state of feeling irritated or restless), yelling, and pacing; he yelled that he "could leave if he wanted to"; and had requested to go out to smoke. No change in safety precautions were made.
- At 10:25 AM, he had become agitated after a phone call to his guardian; he agreed to take some medication to assist with relaxation.
- At 11:11 AM, a social worker documented an initial visit with Patient #2; she was aware of the Dr. Ryan that had been called after Patient #2 spoke with his guardian on the phone. No change in safety precautions were made.
- At 8:20 PM, Patient #2 had been on a call with his guardian when he asked about visitors, he was informed that visiting hours were over, and that a COVID-19 (highly contagious, and sometimes fatal, virus) visitation policy was in place; he approached the doors and exited, staff were unable to stop him, a Code Green and a Dr. Ryan were called.
- At 9:07 PM, Staff BBB, RN, charted that she had notified Patient #2's guardian of his elopement, and asked her to call the hospital if she heard from him.
- At 9:27 PM, Staff BBB, RN, charted that she notified Patient #2's residential facility of his elopement, she spoke to a RN.

During an interview on 09/01/20 at 2:30 PM, Staff G, RN, stated that:
- She had been Patient #2's primary nurse the morning of 08/08/20.
- He had not been on elopement precautions.
- After the phone call with his guardian, he had become angry, aggressive, and adamant that he wanted to leave.
- Patient #2 had specifically told her and the security officer that he wanted to leave.
- Patient #2 did not attempt to elope, if he would have gone towards the doors like he wanted to leave, that would have been an elopement attempt.
- She was unsure how precautions were supposed to be documented on the every 15 minute observation sheets.
- There was not a process in place to document elopement precautions.

Review of the hospital's document titled, "Unusual Occurrence Report," dated 08/08/20, at 9:43 AM, showed that Patient #2 had attempted to elope, exhibited threatening behavior, walked towards the exit doors, and yelled that he "wanted to leave". Staff were able to redirect him. Witness line signed by Staff G, RN.

Review of the hospital's document titled, "Security Report," dated 08/08/20, at 09:45 AM, showed that a Dr. Ryan had been called for Patient #2 in the ED. Staff felt that he had become aggressive and would attempt to leave.

Review of the hospital's document titled, "Unusual Occurrence Report," dated 08/08/20 at 8:26 PM, Staff BBB, RN, showed that:
- Patient #2 eloped.
- Patient #2 had asked about visiting hours while on the phone with his guardian.
- He was informed that visiting hours were over, and that visitors were limited due to Covid.
- He appeared to understand the visiting policy, turned, walked towards the ED doors, pushed them open, and ran.
- A Dr. Ryan and Code Green were called.
- Patient #2's residential facility and guardian were notified of the elopement.
- Security notified local law enforcement.

Review of the hospital's document titled, "Security Report," dated 08/08/20 at 8:35 PM, showed that a Code Green was called after Patient #2 placed a call to his guardian, and he was informed he would not be able to have visitors. Staff XX, Security Officer, attempted to stop him, but he broke free and pushed through the doors. Local law enforcement was notified of the elopement.

During an interview on 09/01/20 at 5:15 PM, Staff BBB, RN, stated that:
- She had been the person to notify Patient #2's guardian that he had eloped.
- She had asked his guardian to please contact the hospital if he were to arrive at her home, but she did not hear back from the guardian.
- She had also been the staff member to notify the residential facility where Patient #2 resided.

During an interview on 08/20/20 at 10:27 AM, Staff V, RN, ED Charge Nurse, stated that if a patient had made a previous attempt to elope, she would expect the primary nurse to ensure that the patient was placed on EP.

Review of Patient #9's ED medical record showed that:
- On 05/04/20 at 7:04 PM, he arrived via EMS after being found at a bus stop.
- At 7:15 PM, his chief complaint was listed as intoxication (to be affected by alcohol or drugs where physical and mental control is markedly diminished), and unresponsive.
- At 7:40 PM, he remained unresponsive with no response to Narcan (a medication used to counter the effects of narcotic overdose).
- At 8:30 PM, his alcohol level was resulted at 555 milligram (mg, a measure of dosage strength)/deciliter (dl, a metric unit of capacity equal to one tenth of a liter), critically high (normal value would be less than or equal to 10 mg/dl).
- On 05/05/20, at 2:37 AM, the last set of vital signs was charted.
- At 5:42 AM, his alcohol level was resulted at 358 mg/dl.
- At 7:30 AM, a dayshift nurse entered Patient #9's room, the patient was not in his room; he checked the bathroom and waiting room, and the patient was not found.

Review of the hospital's document titled, "Unusual Occurrence Report," dated 05/05/20 at 8:00 AM, showed that:
- Patient #9 had eloped from the ED.
- Nursing staff entered his assigned room to find him missing.
- A staff member stated that they had observed a disheveled patient walking off the property, but they assumed it had been a discharged patient.
- Patient #9 eloped with his intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream) and urinary catheter (a small flexible tube inserted into the body through an opening of the urinary tract to drain urine) still in place.

The hospital was asked, but not able to produce a security report in regards to the elopement of Patient #9.

Review of Patient #10's ED medical record showed that:
- On 06/08/20 at 2:31 PM, she arrived via EMS.
- Her complaint was listed as an overdose.
- Per EMS, she had been taking lysergic acid diethylamide (LSD, or acid, a hallucinogenic [causing a person to see things which are not there] drug) for four days, and had not slept.
- She was described as being confused, mumbling, and exhibiting bizarre behaviors.
- She was actively psychotic (suffering from a mental disorder that causes abnormal thinking and perceptions), and required a psychiatric (relating to mental illness) evaluation.
- At 11:08 PM, the psychiatric evaluation had been completed, and Patient #10 had been placed on EP, CO, AP, and FP.
- At 11:24 PM, she walked through the ED doors and out of the employee entrance to the parking lot.
- No documentation of every 15 minute observations was found in the medical record.

Review of the facility's document titled, "Unusual Occurrence Report," dated 06/08/20, showed that:
- Patient #10 eloped from the ED at 11:22 PM.
- She walked through the doors, and out of the employee exit.
- Staff were able to catch her, and redirected her to the ED.
- They initiated EP at that time, after she eloped.

Review of facility's document titled, "Security Report," dated 06/08/20, showed that:
- A Code Green was initiated at 11:22 PM.
- Patient #10 had left out the back doors of the ED while staff were caring for other patients.
- Security had not been notified that she was a psychiatric patient, and her precautions had not been updated.

Review of Patient #12's ED medical record showed that:
- On 07/14/20 at 9:00 PM, he arrived via EMS.
- His complaint was listed as alcohol intoxication.
- He was disorientated, unable to identify the time, place, or situation he was in.
- His gait was abnormal.
- At 9:57 PM, his alcohol level of 207 mg/dl was considered critical high.
- The nurse's assessment was entered for the 9:00 PM time, but the actual entries were not placed in the computer until 07/15/20 at 12:39 AM.

Review of the facility's document titled, "Unusual Occurrence Report," dated 07/15/20, showed that:
- Patient #12 eloped from the ED at 11:50 PM.
- He had last been seen at 10:30 PM.
- The nurse found him missing when he went to check on him at 11:40 PM.
- He had left with his IVC still in place, there was no sign of it in the room.

Review of the facility's document titled, "Security Report," dated 07/14/20, showed that a Code Green was initiated at 11:46 PM, and security was unable to locate Patient #12.

During an interview on 08/18/20 at 9:27 AM, Staff K, RN, Director of Quality and Risk Management (DQRM), stated that:
- His access to view video in the ED area had been removed, he would only be able to view video with permission from the CNO or Chief Medical Officer (CMO).
- He was informed that any incidents in the ED would be reviewed by the ED Manager, whom would escalate to the CNO, if deemed necessary.
- There should be a Root Cause Analysis (RCA, tools and techniques used to uncover root causes of problems) completed with any elopement.
- He was aware that there had been patient elopements from the ED.
- There had not been a RCA completed on Patient #2.
- There was a locked area, known as the intake area, near the ED, but it was not open when Patient #2 eloped.

During an interview on 08/25/20 at 10:30 AM, Staff L, RN, CNO, stated that psychiatric patients should remain in their assigned ED rooms, and should not be allowed to wander in and out. That activity would not be ideal, but there had been some staffing issues.

During an interview on 08/18/20 at 10:35 AM, Staff O, ED Medical Director, stated that:
- Once psychiatry placed an admission order, the ED physician would only be responsible for emergent treatment.
- Psychiatric patients were boarded in the ED when there were no open beds on the psychiatric units.
- There was a locked intake area located in the ED that psychiatric patients could be boarded in, but it is not open all the time.
- The opening of the intake area was based on nursing availability to staff the area.
- He would expect that a patient at risk of elopement would be placed at the other side of the ED, away from the exit doors.
- A secure area would be best.
- Patient safety was the first priority.

During an interview on 08/18/20 at 12:08 PM, Staff N, RN, ED Manager, stated that:
- The intake area was not open all the time, staffing would dictate when it was open.
- Security staff were stationed at the ED ambulance entrance to assist with prevention of elopement of psychiatric patients.

During an interview on 09/01/20 at 2:30 PM, Staff G, RN, stated that:
- Psychiatric patients were commonly boarded in the ED for three to five days.
- Once they were admitted to psychiatry, their treatment started as if they were located on a psychiatric unit, even though they remained in the ED.

During an interview on 08/26/20 at 10:40 AM, Staff HH, Security Officer, stated that:
- Patients on EP were placed in specific ED rooms.
- Security would normally be notified if there was a change in precautions.
- Security would be stationed at the ED doorway to redirect patients to return to their assigned rooms.

2. Patient #22, Patient #23, and Patient #24's medical records showed physician orders, dated 08/17/20, for CO.

Observation on 08/17/20 at 1:43 PM, showed that Staff F, RN, observed and documented 15-minute observations for Patient #22, Patient #23, and Patient #24, in the ED.

During an interview on 08/17/20 at 1:46 PM, Staff F, RN, stated that she was assigned to observe Patient #22, Patient #23, and Patient #24, and she was aware that the policy stated that staff members were to observe no more than two patients at one time.

During an interview on 08/18/20 at 12:08 PM, Staff N, RN, ED Manager, stated that one staff member may be assigned to observe no more than two patients at one time.

During an interview on 08/20/20 at 9:55 AM, Staff L, CNO, stated that one staff member could not observe more than two patients at one time.


39840