HospitalInspections.org

Based on observation, interview, record review, document review, and policy review the hospital failed to provide care in a safe setting by failing to ensure the communication of essential patient information is provided to all direct care staff in one of three patients reviewed (Patient 1), failed to assign experienced nursing staff to challenging patients in one of three medical records reviewed (Patient 1), and failed to ensure all direct care staff are empowered to communicate with directors/administrators during difficult situations in one of three medical records reviewed (Patient 1). Failure by the hospital to provide support, open communication, and education to all patient care staff places all patients at risk of unsafe care.

Findings Include:

Document review of the hospital policy titled, "Patient Rights and Responsibilities," last reviewed 04/2019, showed all staff are to treat patients with respect and protect their rights.

Document review of the hospital policy titled, "Elopement Prevention and Response," last reviewed 11/2018 defines elopement as the intentional departure from the hospital without notifying staff of the intent. Further, the policy shows upon discovery of a missing patient, staff are to conduct an immediate search of the unit and after 15 minutes if the patient is not located, the Unit Coordinator or Charge Nurse will notify the hospital police if the patient is a risk to self or others, notify the Nurse Manager/Nursing Administrator Coordinator (NAC), the attending physician, and the family/legal guardian. Consideration to notify the patient safety response team (PSRT) will be determined, and all facts of the elopement will be documented in the EMR. If appropriate, police will initiate a hospital wide search.

The hospital failed to provide a policy addressing missing patients who are not deemed an elopement risk and failed to provide a policy addressing patient care assignments and patient acuity.

Document review of the hospital policy titled, "Discharge Against Medical Advice," last revised 10/2015, showed the purpose of the policy is to provide staff guidance for the competent patient wishing to leave against medical advice (AMA) and ensure documentation in the EMR. Direction includes notification of the physician of the pending AMA, determining the reason for the pending AMA, evaluating potential interventions to avoid the AMA, and encouraging the patient to remain until the physician or designee can visit with them.

Review of the hospital document titled, "DON Orientation Checklist," revised 03/2018, showed direct care staff's orientation includes policies and professional references for approaches to care of individuals with violent or disruptive behavior, care of the complex behavioral health patient, patients requiring constant observation and patient safety, patients at risk of wandering or elopement, patient rights, and handoff communication.

Review on 01/27/20 of Patient 1's medical record, date of birth (DOB) 05/21/64, showed he presented to the hospital emergency department (ED) on 10/18/19 at 11:50 PM with complaints of bilateral leg edema and difficulty breathing. Following the initial assessment, he agreed to admit inpatient to unit HC 15. Tests performed during his hospitalization included multiple radiological studies, cardiac tests, and lab. Specialty consults included oncology, cardiology, psychiatry, and urology. Treatments included heart medications, blood pressure medications, diuretics, antidepressants, antipsychotics, and sedatives. A right heart catheterization was performed on 10/29/19.

The psychiatric consult conducted by Staff S, MD on 10/25/19 at 8:43 AM showed a diagnosis of major depressive disorder, adjustment disorder with disturbance in mood and conduct, recent suicide attempt two weeks prior to the hospital admission, sustained alcohol use remission, and tobacco use disorder. Treatment recommendations included preventing Patient 1 from leaving AMA because of a reported recent suicide attempt, possible intimate partner abuse, possible child abuse, and an elevated, unstable heart rate. Staff S deemed Patient 1 medically unstable for admission to the psychiatric unit. Additional recommendations included constant observation (CO) because of the recent suicide threat and continuous threat to leave AMA. He was uncooperative during the psychiatric assessment and attempted to physically assault Staff S resulting in activation of the behavioral response team (BRT) at 12:07 PM. During the response he assaulted responding Staff YY, police officer. The assault resulted in application of four-point (bilateral arms and legs) soft restraints and a CO was placed at the door. The restraints were removed on 10/25/19 at 5:25 PM. While restrained he received intramuscular (IM) Ativan (antianxiety medication) and Haldol (medication for agitation).

During an interview on 01/21/20 at 11:15 AM, Staff D, hospital Patrol Commander stated the Behavior Response Team (BRT) respond to incidents within the hospital requiring a police presence to keep patients, staff and visitors safe. It is a hospital function that the police participate with the nursing administrator and psychology. He stated the police presence is a supportive role to staff and is an attempt to calm the patient. If a patient performs a criminal act such as breaking an item or hitting someone, then police step in. He further stated police complete 40 hours of crisis intervention (CIT) training in addition to police academy training and it is all geared toward safety.

During an interview on 01/29/19 at 8:15 AM Staff X, Nurse Manager of Unit 15 stated during Patient 1's hospitalization staff struggled to care for him and keep him, other patients, and staff safe. She stated he was extremely aggressive, and "our unit does not normally have patients who assault us making him more of a challenge to care for." She further stated he frequently tried to grab anything available to stab staff, threw things at physician's numerous times, and was very aggressive. He was placed on CO and it seemed to escalate some of his behaviors. She stated, "in retrospect she believes the staff followed policy to protect the patient, other patients, and staff and would not do anything different" in a similar circumstance.

The BRT was again activated on 10/26/19 at 5:21 AM by floor staff when Patient 1 became agitated, demanding, yelling, threatening staff, and refusing to follow redirection. He attempted to leave AMA. Police initially restrained him followed by the application of four-point soft restraints. IM Ativan and Haldol were administered.

Documentation dated 10/29/19 at 12:36 PM by Staff EEE, DO stated "given patient's consistent improvement in behavior, OK to discontinue sitter at this time" and may sign out AMA. Patient 1 now has capacity to consent to medical treatments, including heart cath. Staff EEE further documented no further psychiatric reasons to keep him hospitalized if medically stable.

Documentation on 10/29/19 at 4:47 PM by Staff ZZ, RN showed psychiatry discontinued CO and authorized Patient 1 to walk around the unit, but he must sign out AMA if he leaves the unit. He left the unit at 4:48 PM for heart catheterization procedure.

Documentation on 10/30/19 at 12:22 AM, Staff W, RN stated Patient 1 returned to the unit with transport on 10/29/19 at 9:12 PM following a heart catheterization. She documented the wound assessment and stated at approximately 9:35 PM he left the unit to go to the cafeteria. At 12:04 AM she attempted to contact him with no answer, checked his room and all his belongings were gone. She then documented she contacted the physician and at 1:40 AM documented suspected elopement with IV in place.

During an interview on 01/29/20 at 7:40 AM Staff W, RN stated when Patient 1 returned to the unit following the heart catheterization, "to her knowledge orders allowed him to be up and about." She then stated she was not told during handoff that an order had been written stating he had to sign out AMA if he chose to leave the unit. She stated he requested to go to the cafeteria and Staff W asked the unit charge nurse if he was allowed to leave the floor and the charge nurse told her it was ok. She stated she mentioned to her charge nurse "a couple of times" that Patient 1 had not returned to the unit and she then notified the attending physician. Finally, she acknowledged she did not contact anyone else or take any further action herself after notifying the physician and charge nurse of his absence and she assumed the charge nurse handled notifications. She confirmed that she had received some training regarding elopement and leaving AMA during her orientation. Staff W, RN further stated she was a new graduate nurse in the float pool and just completed orientation in 09/2019. She stated she works 7:00 PM to 7:00 AM and is approved to work on any unit except maternal/child, intensive care unit (ICU), and ED. Staff W stated her 10/29/19 assignment included Patient 1, the night he left the hospital AMA. She had not been assigned to him before that night. She stated he returned to the unit from the post anesthesia care unit (PACU) following a heart catheterization at approximately 9:00 PM. She assessed him at that time and he was cooperative. Staff W stated Patient 1 was wearing a green gown when he left the floor and she was aware patients at risk of elopement are to wear a yellow gown.

Staff W failed to review the physician orders for permission to leave the unit, she failed to follow the hospital policy for AMA by failing to notify the physician in a timely manner when Patient 1 did not return to the unit, and failed to contact the unit coordinator when the charge nurse did not respond to her concerns regarding Patient 1's absence from the floor.

The discharge summary dated 10/30/19 at 3:17 PM by Staff DDD, Doctor of Osteopathy stated Patient 1 left AMA and was not provided with instructions, medications or follow-up appointments.