The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GRAND ITASCA CLINIC AND HOSPITAL 1601 GOLF COURSE ROAD GRAND RAPIDS, MN 55744 June 19, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and document review the hospital was found not to be in compliance with 42 CFR 482.13, the Condition of Participation of Patient Rights. The hospital failed to implement policies/procedures that ensure each patient's rights when the hospital failed to provide supervision and safety for 1 of 10 patients reviewed Patient #1 (P1). P1 was placed on a 72 hour emergency hold for his own safety and was allowed to elope from the hospital and was found deceased 14 days later in the vicinity of the hospital, still wearing the hospital gown and slippers. In addition to P1, the failure had the potential to affect 1.92 patients per day who arrive at the hospital due to either chemical dependency or mental health concerns and may require a higher level of supervision for their safety. The hospital's Vice President of Patient Care Services, Chief Executive Officer and Director of Patient Access were notified of the IJ findings on 6/18/2013 at 12:10 p.m. The IJ was removed on 6/18/2013 at 4:00 p.m. related to substantial action taken by the hospital to correct the IJ, including procedure revisions related to one to one supervision and staff training

Findings include:

Based on interview and document review the hospital failed to provide care in a safe setting for 1 of 10 patients reviewed, Patient #1 (P1), who was placed on a 72 hour emergency hold for his own safety and was allowed to elope from the hospital and was found deceased 14 days later in the vicinity of the hospital, still wearing the hospital gown and slippers. An Immediate Jeopardy (IJ) situation was identified for the 1.92 patients per day who would be potentially affected, who arrive at the hospital due to either chemical dependency or mental health concerns and who might require a higher level of supervision for their safety.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review the hospital failed to provide care in a safe setting for 1 of 10 patients reviewed, Patient #1 (P1), who was placed on a 72 hour emergency hold for his own safety and was allowed to elope from the hospital and was found deceased 14 days later in the vicinity of the hospital, still wearing the hospital gown and slippers. An Immediate Jeopardy (IJ) situation was identified for the 1.92 patients per day who would be potentially affected, who arrive at the hospital due to either chemical dependency or mental health concerns and who might require a higher level of supervision for their safety.

Findings include:

P1's medical record was reviewed. P1's discharge summary dated 5/22/2013 was reviewed and revealed P1 was admitted on [DATE] via ambulance and diagnosed with alcohol withdrawal seizures, alcohol withdrawal delirium, malnutrition, nasal bone fracture, falls and alcoholism.

P1's Request for Emergency hospitalization form dated 5/17/2013 was reviewed and revealed P1 was placed on a 72 hour emergency hold due to P1 having no insight into the true consequences of his severe alcohol abuse leading to recurrent seizures, bone marrow dysfunction, and nasal bone fracture. P1 continued to drink alcohol between hospitalization s despite being offered inpatient treatment and despite being told that his alcoholism is affecting his brain, bone marrow and nutrition status.

P1's Physician statement in support of petition for commitment dated 5/17/2013 was reviewed and revealed P1 had no insight into his severe alcohol abuse and recurrent seizures, malnutrition, bone marrow dysfunction, developing memory loss, and hospitalization s for recurrent alcohol withdrawal seizures on 3/28/2012, 8/26/2012 (requiring intubation and ventilation), 1/10/2013 and 5/15/2013.

P1's progress notes and flow sheets were reviewed and revealed the following:

Progress note dated 5/17/2013 at 3:23 p.m. revealed P1 was placed on an emergency 72 hour hold by Physician D (MD)-D related to severe alcoholism. P1 stated to MD-D that he did not want to go to treatment because he did not want to stop drinking beer and and did not have a problem with it. P1 stated he just wanted to go home.

Progress note dated 5/17/2013 at 4:23 p.m. revealed P1 relayed to Social Worker (SW)-E that he did not want to pursue chemical dependency treatment.

Progress note dated 5/18/2013 at 3:55 p.m. revealed P1 was noted by MD-D to be unsteady on his feet, disoriented to day, month and president. MD-D documented the following: The patient is clearly a threat to himself and does not have the insight/capacity to understand the consequences of his alcohol abuse.

Progress note dated 5/19/2013 at 4:13 a.m. revealed P1 was noted by RN staff to have increased confusion and be unsteady on his feet. One to one supervision was placed with P1 for his safety.

Progress note dated 5/19/2013 at 5:54 a.m. revealed P1 was noted to remain confused but be calmer with one to one supervision. P1 was noted to sleep little.

Progress note dated 5/19/2013 at 5:55 p.m. revealed P1 was noted to be very agitated, pacing, swinging fists, urinating on floor, wanting to leave the building. P1's physician was called and he was medicated with Haldol.

Progress note dated 5/19/2013 at 7:26 p.m. revealed P1 was more relaxed and aggressive behavior had ceased.

Progress note dated 5/19/2013 at 10:30 p.m. revealed P1 was noted to be agitated on and off and remain confused.

Flow sheet dated 5/19/2013 at 11:37 p.m. revealed P1 was on one to one supervision ordered by physician.

Flow sheet dated 5/20/2013 at 12:11 a.m. revealed P1 was noted to be inconsistent in following commands, with confusion present.

Progress note dated 5/20/2013 at 8:42 a.m. revealed P1 was noted by physician (MD)-F to want to leave the building.

Flow sheet dated 5/20/2013 at 3:55 p.m. indicated P1 was disoriented, confused and impulsive.

Progress note dated 5/20/2013 at 9:08 p.m. revealed P1 was clearly hallucinating stating there was a man under his bed. P1 was medicated.

Flow sheet documentation was reviewed and revealed P1 was placed on one to one supervision at 11:37 P.M. on 5/19/2013 and removed from one to one supervision at 10:07 a.m. on 5/20/2013. There was no documentation located related to why the one to one supervision was discontinued.

Progress note dated 5/20/2013 at 10:05 p.m. revealed staff on P1's unit was contacted by staff from another unit that P1 was wandering in the halls. Staff from P1's unit went to find P1 and P1 could not be found inside the facility or outside. The supervisor, Security and Police were contacted about the incident.

Progress note dated 5/20/2013 at 11:00 p.m. indicated the police were actively searching for P1.

Nursing Assistant (NA)-G was interviewed on 6/18/2013 at 9:40 a.m. and stated she was working between 3:00 p.m. - 11:00 p.m. on P1's unit on 5/20/2013. NA-G stated she was monitoring P1 on and off on 5/20/2013 while she was assisting other patients on the unit and he was wandering the halls and was wandering into other patient rooms. NA-G stated P1 was not stable on his feet. NA-G stated she redirected P1 away from other patient rooms several times between 3:00 p.m. and 7:00 p.m. NA-G stated P1 was confused and at about 5:00 p.m. he started kicking under his bed stating there was a man under his bed. NA-G stated he repeated the same behavior at about 6:30 p.m. NA-G stated she understood the plan to be that the health unit coordinator (HUC) who normally sits at the desk was to redirect P1 if she observed he needed redirection. NA-G stated there was another patient on the unit receiving one to one supervision and at 7:00 p.m. she took over that duty.

NA-H was interviewed on 6/18/2013 at 11:40 a.m. and stated she was assigned one to one supervision of another patient on P1's unit at 3:00 p.m. and traded duty with NA-G at about 7:00 p.m. NA-H stated her duties after 7:00 p.m. included giving baths, passing water and getting patient vital signs. NA-H stated she worked with P1 on another day during this hospitalization (she could not recall when), when P1 was exit seeking and she followed him and redirected him back to his room. NA-H stated she saw P1 on and off on 5/20/2013 and was in another patient room when she was notified P1 had left the unit and was walking toward the clinic. NA-H stated that she ran to find him and searched for 1/2 an hour outside but was not able to find him. NA-H stated security, supervisors and the police were called by hospital staff.

Registered Nurse (RN)-I was interviewed on 6/18/2013 at 11:25 a.m. and stated she received report on P1 at about 3:00 p.m. and was told P1 did not have one to one supervision because he did not need it as he was redirectable and not a danger to himself. RN-I stated she was told the HUC would watch P1 because the HUC is at the desk, but apparently the HUC did not see P1 leave on 5/20/2013. RN-I stated she assessed P1 at the beginning of the shift and he was not confused. RN-I stated she was informed of P1's hallucinations at about 9:00 p.m., but was not informed that P1 was wandering in and out of other patient rooms. RN-I stated that if 2 patients require one to one supervision at the same time, the practice is to pull staff from another area to be sure the one to one supervision are appropriately assigned.

Social Worker (SW)-J, county Social Worker was interviewed on 6/20/2013 at 10:25 a.m. and stated he saw P1 on 5/20/2013 at about 11:00 a.m. SW-J stated P1 was mentally able to participate in a conversation for about 15 minutes, then he started physically wandering and had to be redirected back to his room. SW-J stated P1 was disheveled was wearing a robe, slippers and an incontinence brief. SW-J stated P1 seemed to have some symptoms of confusion and he stated he needed to "get back to class." SW-J stated he discontinued the interview due to P1's confusion. SW-J stated he called the next day to see how P1 was and was told he had eloped on 5/20/2013. SW-J stated the weather that night was 30 degrees and raining. SW-J stated when he arrived on 5/20/2013 at about 11:00 a.m. P1 had one to one supervision and he thought that would continue as P1 was a vulnerable adult. SW-J indicated P1 was found about 2 weeks later deceased in a pond about 1.5 miles from the hospital and still dressed in hospital robe and slippers. Physician (MD)-D was interviewed on 6/17/2013 at 12:35 p.m. and stated that he admitted P1 to the hospital with symptoms of withdrawal. MD-D stated he placed P1 on a 72 hour emergency hold a few days later and in preparation for civil commitment for in-patient treatment because P1 could not make good choices for himself and he was concerned that P1 would not follow-up on treatment recommendations. MD-D stated P1's cognition was variable. MD-D stated a physician's order is required for a one to one supervision to be started for a patient or discontinued. MD-D stated he did not initiate the one to one supervision for P1 nor did he discontinue it.

Registered Nurse (RN)-C, House supervisor was interviewed on 6/18/2013 at 12:30 p.m. and stated she was the house supervisor on days until 7:00 p.m. on 5/20/2013. RN-C stated she thought P1 was placed on one to one supervision due to unsteady gait and impulsive behavior and she thought P1 was doing better later in the day. When queried how she knew why P1 was on one to one supervision, RN-C stated she thought she heard that from someone. RN-C stated she was not aware P1 was having hallucinations. RN-C stated she was not aware of any specific assessment for elopement risk that the hospital utilized. RN-C stated nursing can place a patient on one to one supervision, but if a physician orders it, a physician must discontinue it.

P1's medical record was reviewed with Registered Nurse (RN)-M on 6/18/2013 and no record of a physician's order for P1's one to one supervision could be found. Additionally no record of why the supervision was discontinued or who discontinued it could be located.

Hospital policies and procedures related to 72 hour emergency hold and one to one supervision were requested on 6/17/2013. Administrative staff stated the hospital had no policies related to those topics.