HospitalInspections.org

Based on record review and interview, the registered nurse failed to supervise and evaluate the nursing care for each patient by failing to assess the care needs of patients at risk for elopement upon admission and when appropriate on an ongoing basis for 1 (Patient #1) of 3 sampled patients (Patients #1, #2, #3) in a total census of 18 patients.

Findings:

Review of the facility's policy #2015 revised 10/2013 for patient observation levels revealed, in part: Indication of...a desire to elope, increasing agitation...will be immediately evaluated by the staff member who becomes aware of such.
2. A. RN will assign a Special Precaution Level based on assessments, observation and history of the patient at time of admission...
B. RN may change the level of monitoring based on changes in the patient's behavior or condition. All changes must be documented to include the level of monitoring and the reasons for the monitoring level.

Review of the medical record for Patient #1 revealed he was admitted on 02/14/2024 with diagnoses including Schizoaffective disorder of bipolar type. Physician orders included level 2 observation (Line of sight - must be within 20 feet of a staff member at all times).

Review of the nursing admission assessments for Patient #1 revealed no documented evidence that he was assessed for risk factors related to potential for elopement.

Review of the nurse notes dated 02/14/2024 - 02/17/24 revealed Patient #1 was frequently restless, fidgety and noted pacing and wandering in the common areas and hallways. He appeared to be responding to internal stimuli and expressed paranoid ideas. He became aggressive and combative, and was attempting to break through locked doors.

Review of an incident report dated 02/17/2024 at 10:40p.m. revealed Patient #1 broke through the fire door on the North (women's) hall. Staff went out to get the patient and redirected him back in.
There was no documented evidence that the patient was reassessed for elopement risk, or that any changes were made to the observation level of the patient.

Review of an incident report dated 02/17/2024 at 11:30p.m. revealed Patient #1 ran down the North hall and busted through the door. Staff were unable to hold him, and notified 911. Staff were able to locate him at 11:41p.m. and talked him into returning.
There was no documented evidence that the patient was reassessed for elopement risk, or that any changes were made to the observation level of the patient.

Review of an incident report dated 02/18/2024 at 1:44p.m. revealed Patient #1 left the building via the South Hall (men's) door running toward the highway. S2MHT quickly ran after him. Before the patient could be reached, he darted into traffic and was struck by a vehicle. EMS was notified and Patient #1 was sent to the hospital.

Further review of the medical record for Patient#1 revealed no evidence that a nursing assessment was conducted regarding the patient's elopement risk at any time prior to or after elopement attempts and no documented changes were made to his level of observation.

On 03/12/2024 at 11:30a.m., an interview with S1DON confirmed that there were no documented risk assessments conducted for Patient #1 and that the hospital did not have a procedure for conducting elopement risk assessments for any patients. When asked why the facility doors were kept locked, she stated it was so patients couldn't leave the building. She also confirmed that there was a high population of patients in the building that would be considered at risk for elopement. She further confirmed that the nurse should have reassessed Patient #1 and increased the observation status to level 1 (1:1) following the initial elopement attempt.

Based on record review and interview, the hospital failed to maintain accurate medical records for each patient by failing to accurately and completely document the patients' observation levels and activity on the Observation Sheets for 3 of 3 sampled patients in a total census of 18 patients.

Findings:

Review of the facility's policy #2015 revised 10/2013 revealed, in part:
Procedure- 1. In order to provide protection to patients, three levels of staff monitoring are provided.
A. Level I: constant monitoring within arms-length distance
B. Level II: constant monitoring within 20 feet distance
C. Level III: monitoring on a routine basis every 15 minutes

Review of the Observation Sheets for Patient #1 dated 02/14/2024-02/18/2024 revealed there was no documentation on the forms of the observation level of the patient. Further review revealed inaccuracies and incomplete documentation of activities on the Observation Sheet as follows:

On the Observation Sheet dated 02/17/2024 from 7:00p.m.-6:45a.m., Patient #1's location and activity is documented as follows: from 7:00p.m.-9:45p.m the location is noted as D-Day Room; activity is noted as 8-Other. There is no explanation on the form describing what the "other" activity includes; from 10:00p.m.-6:45a.m the location is noted as P-Patient Room; activity is noted as 1-Sleeping.

Review of an incident report dated 02/17/2024 at 10:40p.m. revealed Patient #1 broke through the fire door on the North (women's) hall. Staff went out to get the patient and redirected him back in.

Review of an incident report dated 02/17/2024 at 11:30p.m. revealed Patient #1 ran down the North hall and busted through the door. Staff were unable to hold him, and notified 911. Staff were able to locate him at 11:41p.m. and talked him into returning.

On the Observation Sheet dated 02/18/2024 from 7:00a.m.-6:45p.m., Patient #1's location and activity is documented as follows: from 8:45a.m.-1:15p.m the location is noted as D-Day Room; activity is noted as 8-Other. There is no explanation on the form describing what the "other" activity includes; from 1:30p.m.-6:45a.m the location is noted as MD-Doctor; activity is noted as 8-Other. There is no explanation on the form describing what the "other" activity includes.

Review of an incident report dated 02/18/2024 at 1:44p.m. revealed Patient #1 left the building via the South Hall (men's) door running toward the highway. S2MHT quickly ran after him. Before the patient could be reached, he darted into traffic and was struck by a vehicle. EMS was notified and Patient #1 was sent to the hospital.

Review of the Observation Sheets for sampled Patient#2 and Patient #3 revealed they were current patients in the hospital on the days of the survey 03/11/2024-03/12/2024. The current forms contain no documented evidence of the patients' observation levels, and entries for activities noted as 8-Other contain no detail of the activity.

On 03/12/2024 at 11:45a.m., an interview with S1DON confirmed that the above Observation Sheets were inaccurately and incompletely documented for the observation level, location and activities of Patient #1. She further confirmed that the current Observation Sheets for Patient #2, #3 and all other patients do not contain the observation levels and there is no provision on the form to include an explanation when the activity level is documented as 8-Other.