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UNIVERSITY OF KANSAS HOSPITAL 4000 CAMBRIDGE STREET KANSAS CITY, KS 66160 July 26, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
The hospital reported a census of 651inpatients. Based on medical record review, personnel interviews, and policy review the hospital failed to follow standards of practice to ensure their patients received care in a safe setting for 1 of 12 medical records reviewed (patient # 1). The hospital must protect vulnerable patients and provide protection for the patient's emotional health and safety as well as his/her physical safety. The hospital failed to have a written policy stating the patient has the right to receive care in a safe setting. This deficient practice has the potential to cause harm or death to the patients and for their staff to be unaware of all the patient rights requirements.


Findings Include:

- Medical record reviewed on 7/24/2017 revealed Patient #1 was not compliant with the telemetry pack monitoring the doctor ordered (portable heart monitor that you wear around your neck or waist or in the pocket of a hospital gown) and the high risk fall bundle rules on the following days 7/6/2017, 7/8/2017, 7/9/2017, and 7/10/2017. Patient #1 was considered a high fall risk. On 7/6/2017 Cardiologist Staff Q told staff Patient #1 they can go to the cafeteria. There was no order found on Patient #1's chart that they were allowed to leave the floor. There was no order that patient could have the telemetry pack off. The staff did not chart when Patient #1was non-compliant with the high risk fall bundle. On 7/10/2017 at 2:45 PM, Patient #1 was threatening to leave. RN Staff # M called MD Staff N. MD Staff N told Staff M that Patient #1 cannot leave AMA (Against Medical Advice) because they are not at capacity to make their own decisions and Staff N stated he will soon be in unit, just finishing a dismissal. On 7/10/2017 at 3:05 PM, Staff N went up to see the patient Shortly after Staff N left, Patient #1 became belligerent and agitated. At 3:30 PM the same day, the BRT (Behavior Response Team) and police were called. Patient #1 tried to leave, patient was acting out, displayed physical aggression, physical threats, was uncooperative and verbally threatening and aggressive. While the BRT was trying to calm Patient #1, he pulled his IV out. At 4:00 PM, Patient #1 was placed in 4 point soft restraints (both wrists and both ankles). Nurse Practitioner (NP) Staff O was notified and immediately on unit ordered soft restraints, Haldol 5 mg IM (medication used to treat agitation) and Constant Observation. At 4:30 pm, Patient #1 was cooperative, calm, and restraints were removed. Constant Observer continued at patient's bedside. At 7:30 PM, Police came to Patient #1's room and gave a court order for hime to appear in municipal court regarding the earlier incident. Patient #1 was calm upon receiving the news. On 7/11/2017 Psychiatric consult was ordered and Constant Observation was discontinued approximatedly 7:30 The medical record lacked the required every 15 minute documentation from a Constant Observer in Patient #1's room from 4:30 PM on 7/10/2017 to 7/11/17 at 7:30 AM. On 7/11/2017 at 7:30 AM, Patient #1, accompanied by a visitor, was wheeling around the unit and seemed in good spirits. Staff M wheeled Patient #1 back to his room at 8:50 AM to have blood drawn, patient was compliant. After the blood draw, Patient #1 told Staff M he was going to continue wheeling himself around the unit and be back for 10:00 AM medications. At 10:00 AM, Patient #1 was not in his room. Staff M check the whole unit, care technicians checked all floors of the heart hospital and were unable to locate Patient #1. Around 10:15 AM, the discharge nurse checked the cafeteria and first floor. At 10:35 AM, Staff M went into Patient #1's room and saw the patient's visitor from earlier in the morning at the bedside. The visitor indicated he had no idea where Patien t#1 was. At 10:58 am, Staff K alerted KUPD (Kansas University Police Department). At 11:00 AM KUPD searched the unit, the lobby and the commons area. Nurse Manager Staff P notified Staff N. MD Staff N was on the unit during the start of the search for Patient #1 and was aware of the situation. Public Administrator and Patient #1's guardian, and risk management were notified. The Guardian gave the hospital permission to use Patient #1's information and publication of patient's information to him. At 5:47 PM, Patient #1 still not on unit and the hospital considered it an elopement. discharged patient per their policy that an elopement had occurred.


Interview with the Director of Accreditation and Regulatory Compliance Staff E on 7/26/2017 at 11:15 AM indicated they did looked into the situation the day of the elopement. They called their Safety Response Team that day to look at the situation and to make sure everything and everyone was safe and no risk to others at that time. Staff E they are having a Root Cause Analysis meeting tomorrow. This surveyor asked Staff E if they had already started to look into the incident to prevent it from happening again prior to the surveyors entering their hospital on July 19th 2017. Staff E stated only thing they had done was call the Safety Response Team to the unit the day of the incident when the patient eloped.

Interviewed RN Staff R Manager of Medical Telemetry Unit, on 7/26/2017 at 9:00 AM. Staff R explained a patient can leave the unit and be taken off their telemetry pack by getting a doctor's order. If a patient wants to go smoke they have to sign a waiver form. Staff R mentioned if the patient is a high fall risk a staff member must go with them.

Interviewed RN Staff Q, Manager of Medical Surgical Unit on 7/26/2017 at 9:10 AM. Staff Q explained the patients who want to smoke have to sign a waiver form but there is not a form if a patient wants to leave unit. They just need to tell their nurse. High fall risk patients' need a staff member to escort them.

RN Staff S Registered Nurse (RN) was interviewed on the Telemetry Floor on 7/26/17 at 8:59 AM. Staff S explained the patients on this floor do not leave the floor as they are on monitors. They further explained that if a patient or family wanted the patient to go off the floor and they were not being monitored, the doctor would need to write an order.

RN Staff T was interviewed on the Ortho/Family Medical Floor on 7/26/17 at 9:05 AM. Staff T explained patients can leave the floor to smoke if they sign a smoking waiver and the doctor agrees. She told me that the patient is provided education as to the risks of smoking and recovery. Staff T explained there are no other forms signed by a patient if they would go to the cafeteria or go off unit by themselves. Staff T stated the nursing staff uses their clinical judgement and it is a case by case basis if they are safe to leave the floor or not.

RN Staff H was interviewed on the CTP (Cardiothoracic Progressive) Unit on 7/25/17 at 9:57 AM. Staff H verbalized understanding of the Elopement policy and and patient rights. Staff H explained the nursing staff attempts to educate the patients that may be an elopement risk on patient safety and why they need to stay in the hospital. She told me that some patients have the right to go out to smoke if they have a doctor's order. The patients can go alone or if they are assigned a constant observer they will assist the patient off the floor.

RN Staff I was interviewed on the CTP floor on 7/25/17 at 10:08 AM. Staff I verbalized understanding of the Elopement policy and procedure and patient rights. Staff I explained patients are only allowed to leave the floor with permission, and if a constant observer has been assigned to a patient they will accompany them. If families come to visit and want to take the patient off the floor they also need to get approval from their nurse before leaving the floor. Staff I explained the patients have rights and they will be honored in all ways.

Policy titled "Patient Rights" reviewed on 7/24/2017 revealed the hospital failed to include the right for patients to receive care in a safe setting.

The hospital did not have a policy and procedure in place directing staff regarding patients leaving the patient floors, going to the cafeteria, going for walk outside, etc.