HospitalInspections.org

A115

This CONDITION is not met as evidenced by:

Based on medical record review, policy review, document review, and interviews, it was determined that the facility failed to protect and promote the rights of all patients as evidenced by the lack of monitoring for Patient #1 by nursing staff, which resulted in an elopement from the facility (A0144).

On 11/17/23 at 04:15 PM, an Immediate Jeopardy was identified for the CoP of Patient Rights. The facility implemented immediate interventions that included: education on the definition of wandering, requirements to evaluate patients for the risk of wandering, escape precaution interventions, and the documentation of the escape precautions was provided to all nursing staff. The escape precaution evaluation will be audited weekly for four weeks to ensure that patients identified as risk for wandering are receiving appropriate monitoring. Results will be reviewed by the Nursing Quality Office and presented at the Nursing Practice Quality and Safety Steering Committee.

On 11/20/23 at 11:45 AM, the Immediate Jeopardy was removed based on onsite surveyor verification of the immediate actions implemented by the facility through observations, policy review, document review, and interviews.

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting.

Based on policy review, medical record review, and interview, the facility failed to provide care in a safe setting for Patient #1. Specifically, the lack of assessment and monitoring by staff resulted in Patient #1 eloping from the facility and being found by the police approximately eight hours later. Additionally, the hospital does not have a policy for wandering precautions.

Findings include:

Review of the policy "Continuous Observation of Patients for Behavioral Reasons," last revised 11/10/21, indicated that the need for observation should be assessed by a registered nurse every shift and documented in the medical record. Documentation of the observation for behavioral reasons includes a description of patient behavior, the steps taken to ensure safety, the healthcare providers contacted, the interventions attempted that failed, and any other data to support the measures taken. The frequency is determined according to patient need. If the patient needs to be checked more frequently than once every 4 hours for behavioral reasons, the patient must be observed continuously. Intermittent observation consisting of visual and verbal patient checks (frequency established for each individual patient) are instituted for the patient for behavioral reasons. Documentation is done in the medical record with a registered nurse summarizing the assessment at least every 8 hours/end of shift.

Review on 11/17/23 of the medical record for Patient #1 revealed the following:
- On 10/23/23, Patient #1 was brought to the emergency department for a mental health evaluation by patient safety officers after being found wandering in one of the research buildings. At 10:03 AM, Staff (MM), Physician documented that Patient # 1 had a history of hypertension, dementia, and presented with concerns for altered mental status. Patient # 1 had other admissions after being found wandering. On 09/29/23, Patient #1 was admitted to another local hospital due to wandering. Patient #1's wandering and confusion may all be manifestations of dementia. Patient #1 requires 24/7 supervision by their sister, but has been found wandering unattended, suggesting that this is not routinely happening. Patient #1 is pleasantly confused, laughs, answers all questions, and is alert to self only. The plan is that Patient #1 has been admitted to the hospital for further observation and possible placement.
- On 10/23/23 at 02:47 PM, Staff (YY), Nurse Practitioner ordered Patient #1 to be admitted for altered mental status, Rhabdomyolysis (condition where skeletal muscle breaks down), and Leukocytosis (condition with elevated white blood cells). "No" is documented in the section indicating Patient #1 required a private room, any type of precautions, and/or psychiatric 1:1 monitoring.
- From 10/23/23 to 10/27/24, Patient #1 was seen and examined daily by the attending physician and a resident who document that Patient #1 is confused and does not know where they are/what city they live in currently. The need for 24/7 supervision and a safe discharge due to wandering is documented daily. (No absconding/wandering precautions, supervision orders, or observation/monitoring orders were placed prior to 10/28/23).
- On 10/27/23 at 10:42 AM, Staff (WW), Social Worker documented spending 30 minutes with Patient #1. (This is the last documentation of staff observation of Patient #1 on 10/27/23). At 07:42 PM, Staff (H), Registered Nurse documented that at approximately 06:00 PM, Patient #1 had an unwitnessed exit from the unit. The provider, patient safety officers, and police were notified. (No additional documentation by nursing services related to Patient #1 eloping from the facility and/or being returned to the facility is documented).
- On 10/28/23 at 05:41 AM, Patient #1's pain was assessed, and medication was administered. (This is the first nursing documentation after Patient #1 was returned to the hospital). At 06:34 AM and 06:48 AM (documented under the 02:02 AM section), Staff (I), Registered Nurse documented vital signs and a full systems review. Patient #1 was confused but followed commands. Patient #1 has poor safety awareness/judgement. "Yes", is documented in the section for frequent rounding, the bed alarm, and bedside observation/monitoring.
- On 10/28/23 at 07:16 AM, Staff (VV), Physician Resident documented that Patient #1 was examined this morning with the bedside nurse. Patient #1 wandered off the unit at approximately 06:00 PM yesterday, was found, and returned to the unit. (This is the first provider documentation after Patient #1 was returned to the hospital at approximately 02:00 AM).

Interview on 11/16/23 at 01:30 PM with Staff (H), Registered Nurse, revealed they worked from 07:00 AM to 07:30 PM the day Patient #1 eloped from the hospital. Staff (H) did not recall a handoff being completed on 10/27/23. Patient #1 was having a good day but was constantly leaving their room coming to the nurse's station to talk and doing laps around the unit. Frequent rounding means looking in and checking on patients every two hours. Documentation in the medical record every two hours is not required. The flowsheet would be used if a patient was on a 1:1 observation, which Patient #1 was not on. Patient #1 was identified missing at approximately 06:00 PM by the dietitian. Patient #1 was unable to be located. Patient #1 was returned to the hospital wearing her personal clothing. Patient #1 did not need to be on 1:1 observation they did not display exit seeking behaviors. The bed alarm was discontinued because Patient #1 was always up and out of bed causing the alarm to constantly go off. Patient #1 was placed on virtual monitoring after returning to the hospital.

Interview on 11/16/23 at 03:30 PM with Staff (I), Registered Nurse, arrived at 07:00 PM to work the evening shift and found out Patient #1 eloped during report. On 10/28/24 at approximately 02:00 AM, the police brought Patient #1 back to the unit. Patient #1 never exhibited any signs of exit seeking. Normally staff round every two hours, but Patient #1 was always in the staff ' s line of sight. Nursing staff do not document every two-hour monitoring checks. Patient #1 went out the front exit and would not be able to get back in.

Interview on 11/17/23 at 02:30 PM with Staff (Y), Attending Medicine Physician, revealed that Patient #1 was found in one of the research buildings. Patient #1 had been admitted for similar wandering episodes in the past. Patient #1 was residing with their sister, although it was suspected this was not actually happening. After a review of Patient # 1's previous hospitalizations, exit seeking behaviors were not identified as a problem. Staff (Y) stated they would have ordered a higher level of intervention if they felt Patient #1 was a high elopement risk.

Interview on 11/17/23 at 01:30 PM with Staff (D) Associate Quality Officer, revealed the hospital does not have a policy for wandering precautions.