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CONNECTICUT VALLEY HOSP SILVER ST MIDDLETOWN, CT 06457 Aug. 2, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
This Condition has not been met as Patient #1 was not maintained in a safe setting resulting in an elopement.

Patient #1's diagnoses included schizoaffective disorder, personality disorder, with a history of becoming mute and of attempts at elopement/AWOL (absent without leave). A psychiatrist's progress note dated 6/3/13 identified that Patient #1 was restless, trying to get out of the unit via the exit door, and continued to require 1:1 observation. Physician orders dated 6/18/13 discontinued 1:1 observation and directed every (q) 15 minute checks for AWOL risk. Physician assessments were reviewed with the Director of Quality and identified that there was no physician assessment on 6/18/13 when Patient # 1's observation level was downgraded from 1 to 1 to q15 minute checks. On 6/23/13 at 1:15 PM, Patient #1 was noted to be missing from the secured unit. Interview with Registered Nurse (RN) #1 on 7/25/13 at 11:15 AM identified that he/she was not notified that Patient #1 was missing until 1:55 PM (40 minutes after Patient #1 was noted to be missing). Patient #1 was found in a nearby wooded area by police dogs on 6/25/13 at 10:00 AM (approximately 45 hours later). Patient #1 was returned to the facility at 6:30 PM with a reported poison ivy rash on the hands and legs. Assessments documented by the admitting nurse and psychiatrist identified that Patient #1 had "ticks diffusely over his/her body" and approximately "30 ticks were removed."

Interviews with the Vice President (VP) of Patient Care Services, the Director of Regulatory Compliance and the Nursing Supervisor identified that it remained unclear exactly how Patient #1 was able to exit the secured unit and exit the building without being noticed. On 8/1/13 hospital leadership reported that staff in the general psychiatric division had been reeducated on the AWOL policy which included timely notification if a patient was missing, and the need for heightened awareness of who is allowed to pass through the unit doors. However, an additional on-site visit made on 8/2/13 which included interviews with staff and review of hospital documentation identified that staff on the affected unit had not been reeducated and the hospital could not provide evidence that education occurred throughout the general psychiatric division.


Please see A144 related to care in a safe setting.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 1 (Patient #1) of 10 patients who resided on a secured unit and required special observation monitoring, the hospital failed to ensure that the patient was maintained in a safe setting, failed to ensure that the elopement/escape and unauthorized absence policy was followed, failed to reassess the patient when an observation level was downgraded, and failed to reeducate staff which resulted in a finding of Immediate Jeopardy. The findings include:


Patient #1 was admitted on [DATE] on a 15 day Physician Emergency Certificate (PEC) from an acute care hospital with diagnoses that included schizoaffective disorder and personality disorder, with a history of becoming mute and of attempts at elopement/AWOL (absent without leave) as recently as May 2013. A psychiatrist's progress note dated 6/3/13 identified that Patient #1 was restless, trying to get out of the unit via the exit door, and continued to require 1:1 observation. Physician orders dated 6/18/13 discontinued 1:1 observation and directed every (q) 15 minute checks for AWOL risk. Physician assessments were reviewed with the Director of Quality and identified that there was no physician assessment on 6/18/13 when Patient # 1's observation level was downgraded from 1 to 1 to q15 minute checks. A treatment plan dated 6/19/13 identified Patient #1 had fluctuating delusional thoughts, had periods of hypomania, refused eye contact and had made attempts to follow staff out of the unit. Review of the unit assignment sheet dated 6/23/13 and interview with the charge nurse, Registered Nurse (RN) #1 on 7/31/13 at 9:45 AM identified that the lead mental health assistant (MHA) completed the 6/23/13 assignment sheet, per hospital expectations. Interview with the lead mental health worker, MHA #3 identified that MHA #1 was assigned to observe Patient #1 every 15 minutes on 6/23/13 between 12:00 PM - 1:00 PM and MHA #2 was assigned to observe Patient #1 every 15 minutes between 1:00 PM and 2:00 PM.

Review of the Special Observation Form dated 6/23/13 and interview with MHA #1 on 7/25/13 at 2:30 PM identified that Patient #1 was observed every 15 minutes sitting in a chair next to the exit door between 12:00 PM to 1:00 PM with no behavioral concerns.

Review of the clinical record, review of the routine observation form dated 6/23/13 and interview with MHA #2 on 7/31/13 at 12:35 PM identified that Patient #1 was noted to be missing at 1:15 PM. MHA #2 proceeded to look for Patient #1 on the unit because the patient had a history of hiding in different places. MHA #2 asked 2 other MHA's (MHA #4 and MHA #5) to look for Patient #1. Although MHA #2 indicated that he/she notified the charge nurse that the patient was missing at approximately 1:30 PM, review of the clinical record and interview with RN #1 on 7/25/13 at 11:15 AM identified that he/she was not notified by anyone that Patient #1 was missing until approximately 1:55 PM (40 minutes after Patient #1 was noted to be missing). RN #1 immediately notified the police, the nursing supervisor, and the conservator as per policy, and a Silver Alert was initiated.

Review of the elopement/escape and unauthorized absence policy identified that any person discovering that a patient has eloped shall immediately notify the Head Nurse.

Progress notes dated 6/25/13 identified that Patient #1 was found in a nearby wooded area by police search and rescue dogs on 6/25/13 at 10:00 AM (approximately 45 hours later). Patient #1 was transported via ambulance to an acute care hospital emergency department (ED). Review of the progress notes and hospital ED record identified that Patient #1 was dehydrated, had multiple superficial abrasions and altered mental status with verbal unresponsiveness. Although the ED physician identified that Patient #1 was medically cleared, he/she identified that "there certainly was psychiatric trauma from being outdoors last night." Patient #1 was transported back to the facility on [DATE] at 6:30 PM.

Review of Patient #1's clinical progress notes dated 6/25/13 identified that Patient #1 was returned to the facility at 6:30 PM with a reported poison ivy rash on the hands and legs. Assessments documented by the admitting nurse and Psychiatrist identified that Patient #1 had "ticks diffusely over his/her body" and approximately "30 ticks were removed." Antibiotic therapy was ordered for Patient #1 due to deer tick bites.

Interviews with the Vice President (VP) of Patient Care Services, the Director of Regulatory Compliance and the Nursing Supervisor on 7/25/13 at 10:15 AM, 7/31/13 and 8/1/13 identified that AWOL signs are posted next to the locked unit exit doors to alert others of the risk of patient elopement. Although it remained unclear exactly how Patient #1 was able to exit the secured unit and exit the building, staff identified that the patient could have somehow passed through the locked unit exit door while another person was exiting. Once through this door, Patient #1 could then exit through the unlocked stairwell door (that is located just beyond the locked exit door). Subsequent to Patient #1's elopement, the stairwell door (not a fire egress) was locked and staff received education on patient elopement/missing patient policies.

On 8/1/13 at 11:00 AM, the Director of Regulatory Compliance reported that staff in the general psychiatric division had been reeducated on the AWOL policy which included timely notification if a patient was missing, and the need for heightened awareness of who is allowed to pass through the unit doors. However, an additional on-site visit was made on 8/2/13 which included interviews with security staff at 8:35 AM, MHA's and custodian from 8:50 AM to 9:55 AM, and the Head Nurse at 9:55 AM. The aforementioned interviews with staff and review of hospital documentation identified that staff on the affected unit had not been reeducated and the hospital could not provide evidence that education occurred throughout the general psychiatric division.

In addition, interviews with the Clinical Manager on 8/2/13 at 10:00 AM, the Director of Regulatory Compliance on 8/2/13 at 11:30 AM, and the Director of Quality on 8/2/13 at 12:10 PM identified that only staff have the ability to unlock the unit doors, and that it could have only been a staff member that allowed Patient #1 to leave the unit.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of clinical records, review of hospital policy, review of hospital documentation and interviews with hospital personnel for 2 (Patients #7 & #10) of 10 patients who required special observation monitoring, documentation and interviews failed to reflect that the Special Observation Policy was followed. The findings include:



Patients #7's physician orders dated 7/12/13 directed to place the patient on continuous observations for assaultive behaviors. Patient #10's physician orders dated 6/21/13 identified to monitor every (q) 15 minutes for inappropriate behaviors. Review of the special observation forms for Patients #7 and #10 identified that monitoring checks were not documented and/or were incomplete (per policy) as follows:

Patient #7: 7/12/13 10:45 PM-11:30 PM; 7/18/13 8:45 PM- 9:30 PM and 2:30 AM-3:30 AM; 7/23/13 9:45 PM-10:45 PM.

Patient #10: 6/21/13 5:45 PM - 11:00 PM and 6/22/13 1:15 AM-3:30 AM; 6/22/13 7:00 AM-3:30 PM.


Review of the special observation policy identified that the fifteen minute observation was used when the patient's behavior, health or mental status required closer attention. The assigned nursing staff member was responsible for checking on the patient's safety and well being every 15 minutes.