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Based on record reviews and interviews, the hospital failed to ensure services were provided free of neglect. This deficient practice was evidenced by failure to provide strict visual contact (SVC) to ensure patients on a Physician's Emergency Certificates (PEC) or Coroner's Emergency Certificates (CEC) were free from neglect for 4 (#2, #3, #4, #5) of 7 (#1-#7) patients sampled who were all on SVC psychiatric observation.
Findings:

Review of the hospital policy and procedure titled, "Patient Rights and Responsibilities" revealed, in part, IV. Procedure: c. Patient Rights: 2. You have the right to receive care in a safe setting or environment free from all forms of abuse, neglect, harassment or mistreatment.

Review of the hospital policy titled, "Abuse and Neglect" revealed, in part, the purpose of the policy was to protect any patient suspected of being a victim of abuse, neglect and/or violence. Any staff member, patient, parent or significant other reporting that the patient or a victim of abuse, neglect, violence of rape will result in an investigation. The policy defined "neglect" as the failure, by a caretaker or other parties, to provide the proper or necessary support of medical, surgical or any other care necessary for the individual's well-being.

Review of the hospital policy and procedure titled, "Consultation and Placement Regarding Psychiatric Patients" revealed, in part, 14. All Emergency Department patients with psychiatric or behavioral disturbances should be monitored by staff, in trauma room or in private room only if 1:1 monitoring by staff member is available.

Review of the hospital policy and procedure titled, "Emergency Certificate - PEC/CEC" created on 05/1997, last reviewed 11/04/2021 revealed, in part, 7. Due to severity of patient's mental illness and potential inappropriate behavior, care is provided to meet the needs of the patient. b) provide strict visual contact i) constant observation of patient by staff at all times. NOTE: If visitors present, staff is still required to maintain constant observation. Security should be aware and check belongings.

Patient #2

Review of the electronic medical record revealed Patient #2 was admitted through the Emergency Department (ED) on 06/17/2022 at 11:08 p.m. for suicidal ideation with a plan. Further review revealed on 06/17/2022 at 11:25 p.m. Patient #2 was PECd and placed on SVC.

Review of the Observation Flowsheet with SVC for Patient #2 failed to reveal documentation of every 15 minute rounds from 06/17/22 at 11:26 p.m. through 06/18/2022 at 3:58 a.m.

Patient #3

Review of the electronic medical record revealed Patient #3 was admitted to the ED on 06/17/2022 at 2:05 a.m. Further review revealed Patient #3 displayed paranoid behavior and refused to take her medication, on 06/20/2022 at 1:23 a.m. was PECd and placed on SVC, then on 06/20/2022 at 8:44 a.m. was CECd.

Review of the Observation Flowsheet with SVC for Patient #3 failed to reveal documentation of every 15 minute rounds on 06/20/2022 at 1:30 p.m. and 1:45 p.m. and on 06/22/2022 at 6:45 p.m.

Patient #4
Review of the electronic medical record revealed Patient #4 was admitted to the ED on 05/14/2022 at 12:49 p.m. with audio-visual hallucinations and alcohol abuse. Further review revealed Patient #4 was PECd on 05/14/2022 at 3:35 p.m.and placed on SVC.

Review of the Observation Flowsheet with SVC for Patient #4 failed to reveal documentation of every 15 minute rounds on 05/14/2022 at 10:00 p.m., 10:15 p.m. and 10:30 p.m.

Patient #5

Review of Patient #5's electronic medical record revealed Patient #5 was admitted to the ED on 06/15/2022 at 12:04 a.m. after being found unresponsive following a suicide attempt with an intentional opiate overdose. Further review revealed Patient #5 was PECd on 06/15/2022 at 1:30 a.m. and placed on SVC then on 06/17/2022 at 9:56 a.m., Patient #5 was CECd.

Review of the Observation flowsheet with SVC for Patient #5 failed to reveal documentation of every 15 minute rounds on 06/15/2022 from 10:30 a.m. through 06/17/2022 at 2:30 a.m. and failed to reveal documentation of every 15 minute rounds from 06/17/2022 at 3:45 a.m. until Patient #5 eloped from the hospital on 06/17/2022 at 3:07 p.m.
Further review of the SVC flowsheet revealed that documentation was "chart on computer", however, review of the electronic record failed to reveal every 15 minute SVC rounds as noted on the flowsheet.

Review of the self-report submitted to LDH revealed on 06/17/2022 at 3:07 p.m., Patient #5 eloped from the hospital.

In interview on 07/18/22 at 2:20 p.m., S5MSDir indicated during the investigation, there were no additional 15 minutes observation rounds located for Patient #5.

In interview on 07/19/2022 at 1:50 p.m., S1CNO verified the above information related to Patients #2, #3, #4 and #5.

In interview on 07/19/2022 at 10:33 a.m., S8RN indicated he was assigned to Patient #5. S8RN further indicated he gave report to S10PCT1 at the beginning of the shift which included Patient #5 was PECd; S8RN also stated, during the shift he went on a break and upon his return, S10PCT1 and Patient #5 could not be located and he reported the elopement to the charge nurse.

In interview on 07/20/2022 at 9:15 a.m., S10PCT1 indicated on 06/17/2022 she was reassigned from the rehab unit to be a sitter for Patient #5. S10PCT1 stated she left her assignment at the request of the patient and visitor. When shown a copy of the Observation Flowsheet with SVC form, S10PCT1 indicated she had never seen or used the form and did not complete the form for Patient #5. S10PCT1 did not recall being educated about the use of the form.

In interview on 07/19/2022 at 8:35 a.m., S2EDDir indicated there was no policy and procedure related to the Observation Flowsheet with SVC.

In interview on 07/19/2022 at 9:25 a.m., S5MSDir indicated the hospital did not follow policy to ensure the right of Patient #5 to be free of neglect.

Based on record review and interview, the hospital's Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to an identified elopement that affected patient safety and quality of care. This deficient practice was evidenced by failure of the hospital to create and implement policy, identify lack of the documentation of 15 minute strict visual contact (SVC) observation rounds, provide hospital-wide staff education, and initiate a plan for increased monitoring of staff supervision of patients for 4 (#2, #3, #4, #5) of 7 (#1-#7) patients sampled. These failed practices had the potential to impact the safety of all patients on SVC because this level of observation may be ordered for any patient within the hospital on a Physician's Emergency Certificate (PEC) or Coroner's Emergency Certificate (CEC).
Findings:


Review of the policy and procedure titled, "Performance Improvement and Patient Safety Plan", revealed, in part, the Quality Assurance-Performance Improvement (QAPI) Program is founded on the principles of continuous quality improvement, exceptional customer service, and the provision of healthcare by practitioners and providers in accordance with applicable quality of care and safety standards. The principles and characteristics of quality healthcare that are promoted include: Delivery of care by competent, professional healthcare practitioners in safe settings. Further review revealed, the Patient Safety Program is focused on reducing clinical risks to patients through ongoing assessment, using internal and external knowledge and experience, to prevent error occurrences, maintain and improve patient safety. The goal is to effectively reduce health system errors and hazardous conditions by creating an environment to identify and manage actual or potential risks to patient safety. The Program goals and objectives read, in part, 3. To determine priorities for PI activity based on identified need, risk potential, performance variation, and to utilize data sources, organizational and patient focused performance measures to establish performance baselines and identify areas where improvement opportunities exist. 5. To identify and address the educational needs and competencies of staff utilizing staffing effectiveness indicators to evaluate competency of staff related to clinical care outcomes.

Review of the hospital's policies and procedures revealed no policy and procedure related to the observation and documentation of a patient placed on SVC using the form titled, "Observation Flowsheet with Strict Visual Contact".

In interview on 07/19/2022 at 8:35 a.m., S2EDDir indicated there was no policy and procedure related to the process of conducting or documenting SVC observation rounds every 15 minutes.

Patient #2
Review of the electronic medical record revealed Patient #2 was admitted through the Emergency Department (ED) on 06/17/2022 at 11:08 p.m. for suicidal ideation with a plan. Further review revealed on 06/17/2022 at 11:25 p.m. Patient #2 was PECd and placed on SVC.

Review of the observation flowsheet on Patient #2 failed to reveal documentation of every 15 minute SVC rounds from 06/17/22 at 11:26 p.m. through 06/18/2022 at 3:58 a.m.


Patient #3
Review of the electronic medical record revealed Patient #3 was admitted to the ED on 06/17/22 at 2:05 a.m. Further review revealed Patient #3 displayed paranoid behavior and refused to take her medication and therefore, on 06/20/2022 at 1:23 a.m. Patient #3 was PECd, placed on SVC and on 06/20/2022 at 8:44 a.m. was CECd.

Review of the observation flowsheet on Patient #3 failed to reveal documentation of every 15 minute SVC rounds on 06/20/2022 at 1:30 p.m. and 1:45 p.m. Further review revealed a missing 15 minute SVC round on 06/22/2022 at 6:45 p.m.


Patient #4
Review of the electronic medical record revealed Patient #4 was admitted to the facility on 05/14/2022 at 12:49 p.m. with audio-visual hallucinations and alcohol abuse. Further review revealed on 05/14/2022 at 3:35 p.m. Patient #4 was PECd and placed on SVC.

Review of the observation flowsheet on Patient #4 failed to reveal documentation of every 15 minute SVC rounds on 05/14/2022 at 10:00 p.m., 10:15 p.m. and 10:30 p.m.

Patient #5
Review of the electronic medical record revealed Patient #5 was admitted to the ED on 06/15/2022 at 12:04 a.m. after being found unresponsive following a suicide attempt with an intentional opiate overdose. Further review revealed on 06/15/2022 at 1:30 a.m., Patient #5 was PECd and placed on SVC and on 06/17/2022 at 9:56 a.m., Patient #5 was CECd.

Review of the observation flowsheet on Patient #5 failed to reveal documentation of every 15 minute SVC rounds on 06/15/2022 from 10:30 a.m. through 06/17/2022 at 2:30 a.m. and from 06/17/2022 at 3:45 a.m. until Patient #5 eloped from the hospital on 06/17/2022 at 3:07 p.m. Further review of the SVC flowsheet revealed that documentation was "chart on computer", however, review of the electronic record failed to reveal every 15 minute SVC rounds as noted on the flowsheet.

Review of the self-report submitted to LDH revealed on 06/17/2022 at 3:07 p.m., Patient #5 eloped from the hospital.

In interview on 07/19/2022 at 1:50 p.m., S1CNO verified the above information related to Patients #2, #3, #4 and #5.

Review of the human resource files and disciplinary actions of S8RN, S14LPN or S10PCT1 1 failed to reveal documented evidence of re-education following the elopement of Patient #5 regarding neglect, care and monnitoring of PECd or CECd patients, supervision of patients on SVC, or documentation of every 15 minute rounds on patients who were on SVC.

In interview on 07/19/2022 at 9:25 a.m., S5MSDir indicated the staff involved received a final written warning, were verbally re-educated and given a copy of the PEC/CEC policy. S5MSDir further indicated there was no documented evidence of the staff being re-educated.

In interview on 07/19/2022 at 11:08 a.m., S3VPQM indicated the Quality Management (QM) department was not involved in the investigation related to the 06/17/2022 elopement of Patient #5. S3VPQM stated, she was informed about this elopement on 06/23/2022.

In interview on 07/19/2022 at 1:50 p.m., S1CNO indicated the QM Department should have identified opportunities for improvement related to the elopement of Patient #5 who was on a legal commitment.

In interview on 07/20/2022 at 8:34 a.m., S3VPQM indicated the QM Department failed to identify any opportunities for improvement following the elopement of Patient #5, take action, request or have knowledge of an action plan, and recognize the lack of documentation of 15 minute SVC observation rounds prior to 07/18/2022. S3VPQM acknowledged the re-education of the staff was ineffective as evidenced by electronic record review conducted during the survey failed to reveal sufficient documentation of every 15 minute observation rounds.

In interview on 07/20/2022 at 8:34 a.m., S3VPQM indicated QM should have taken a more active role in the investigation of this elopement and followed up related to corrective actions taken by the unit to ensure patient safety.