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.

DEACONESS HOSPITAL INC 600 MARY ST EVANSVILLE, IN 47747 Sept. 6, 2018
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on document review and interview, the hospital failed to have adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients as needed in accordance to their staffing guidelines for 4 of 7 days on 1 unit.

Findings include:

1. Review of the hospital staffing grid and guidelines for the orthopedic/neurological (ortho/neuro) unit, updated 10/2017, indicated the following for staff of RN (registered nurse), PCA/PCT (patient care assistant/patient care technician), census as noted:
A. Census 43: Day shift: 12 RN, 6 PCA. Evening shift 1: 11 RN, 5 PCT. Evening shift 2: 10 RN, 5 PCT. Night shift 8 RN, 4 PCT.
B. Census 41: Day shift: 11 RN, 5 PCA. Evening shift 1: 11 RN, 4 PCT. Evening shift 2: 10 RN, 4 PCT. Night shift 8 RN, 4 PCT.
C. Census 40: Day shift: 11 RN, 5 PCA. Evening shift 1: 11 RN, 4 PCT. Evening shift 2: 9 RN, 4 PCT. Night shift 7 RN, 4 PCT.
D. Census 39: Day shift: 11 RN, 5 PCA. Evening shift 1: 10 RN, 4 PCT. Evening shift 2: 9 RN, 4 PCT. Night shift 7 RN, 4 PCT.
E. Census 38: Day shift: 11 RN, 4 PCA. Evening shift 1: 10 RN, 4 PCT. Evening shift 2: 9 RN, 4 PCT. Night shift 7 RN, 4 PCT.
F. Census 37: Day shift: 11 RN, 4 PCA. Evening shift 1: 9 RN, 4 PCT. Evening shift 2: 8 RN, 4 PCT. Night shift 7 RN, 4 PCT.
G. Census 36: Day shift: 10 RN, 4 PCA. Evening shift 1: 9 RN, 4 PCT. Evening shift 2: 8 RN, 4 PCT. Night shift 7 RN, 4 PCT.
H. Census 33: Day shift: 9 RN, 4 PCA. Evening shift 1: 8 RN, 4 PCT. Evening shift 2: 7 RN, 4 PCT. Night shift 6 RN, 3 PCT.
I. Census 32: Day shift: 9 RN, 4 PCA. Evening shift 1: 7 RN, 4 PCT. Evening shift 2: 7 RN, 3 PCT. Night shift 6 RN, 3 PCT.
J. Census 30: Day shift: 9 RN, 4 PCA. Evening shift 1: 7 RN, 3 PCT. Evening shift 2: 6 RN, 3 PCT. Night shift 6 RN, 3 PCT.
K. Census 29: Day shift: 9 RN, 3 PCA. Evening shift 1: 7 RN, 3 PCT. Evening shift 2: 6 RN, 3 PCT. Night shift 6 RN, 3 PCT.
L. Census 28: Day shift: 8 RN, 3 PCA. Evening shift 1: 7 RN, 3 PCT. Evening shift 2: 6 RN, 3 PCT. Night shift 6 RN, 3 PCT.

2. Review of the One Week Staffing Pattern Worksheet for the ortho/neuro unit completed for the week of 8/15/18, 8/16/18, 8/17/18, 8/18/18, 8/19/18, 8/20/18, 8/21/18 and 8/22/18, indicated the unit lacked documentation of adequate numbers of nursing/patient care staff as follows:
A. On 8/16/18: Evening shift 2, census 7, lacked 1 RN
B. On 8/17/18: Evening shift 1, census 40, lacked 3 RNs. Evening shift 2, census 40, lacked 1 PCT.
C. On 8/21/18: Day shift, census 43, lacked 1 RN and 2 PCAs. Evening shift 1, census 43, lacked 1 RN. Evening shift 2, census 43, lacked 2 RNs and 1 PCT.
D. On 8/22/18: Day shift, census 43, lacked 1 RN and 2 PCAs. Evening shift 1, census 43, lacked 1 RN and 1 PCT. Evening shift 2, census 43, lacked 2 PCTs.

3. On 9/6/18 between approximately 3:30 p.m. and 4:00 p.m., A8, Unit Manager, indicated that the staffing grid provided was revised and adopted in October of 2017. A8 verified staffing documentation indicated the hospital did not have adequate numbers of patient care staff on dates/times in accordance with their guidelines.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review and interview, the hospital failed to ensure prompt resolution of a patient grievance for 1 patient in 1 facility (P3) and failed to follow their policy for identification of a grievance versus complaint.

Findings include:

1. Review of the hospital policy titled Patient Grievance/Complaint Policy, Revised Date: 7/19/17, indicated the following:
A. Definitions:
i. Complaint: Any verbal concern shared by a patient/family regarding services received that can be promptly resolved by staff present. Complaints may also present as: 4. Examples of minor issues, not typically considered grievances may include: *A change in bedding, housekeeping of a room, serving preferred food and beverages *Billing issues, unless there is a care, safety, abuse or neglect, compliance issue attached *Lost and Found
ii. Grievance: A formal or informal, written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) that is made to the hospital by a patient, or the patient's representative, regarding the patient care provided, abuse or neglect, or the hospital's compliance with CMS (Centers for Medicare and Medicaid Services) Hospital Conditions of Participation or Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR 489.
B. Complaint Procedure:
i. When a patient or visitor makes a complaint, as defined by this policy, the staff member receiving will acknowledge and clarify as needed. Staff present will address the complaint including discussing resolution with the patient/family.
ii. If staff present cannot resolve the complaint to the patient/family's satisfaction, Patient Relations (PR) should be notified. Complaints involving Patient Relations are recorded in the Midas Module.
C. Grievance Procedure:
i. Managers will conduct appropriate investigation and follow-up, completing documentation in Midas Patient Relations Module and communicating with PR staff.
ii. PR staff will monitor grievances, working to coordinate, analyze, facilitate and ultimately resolve identified issues in a timely manner. Upon completion of an investigation, PR staff will ensure that the patient or patient's representative receives a written response to identified patient grievances

2. Review of hospital complaints and grievances indicated that PR documented a "complaint" as follows:
A. Entered by A7, PR Manager 8/20/18: Received from F1 (family member of P3). S1, Nurse Manager, was informed and went to speak with patient's family, F2 and F3, who were at bedside. S1 reported he/she answered the family's concerns. I called F1 and informed. He/she was not happy with the response and demanded to talk to someone. I called S1 and explained F1 wanted to talk. S1 got permission from P3 and F3 (parent) for information to be given to F1. S1 called me and informed the conversation between the primary care nurse and F1 went well and questions were answered. I will consider this closed.
B. Entered by A7 on 8/20/18: On 8/17/18, I had a call from F4, family member of P3, regarding the patient, P3. Asking about POA (Power of Attorney) paperwork due to patient got out of hospital. Explained had Health Care Report form, but POA is with attorney and patient would need to be alert and oriented to complete this form. F4 had not spoken with the unit manager. I called, S1 and S8, unable to determine relation, came to the office and indicated had just spoken with patient's family F1. S1 to follow-up with family.
C. Entered by A7 on 8/22/18: F4 called and made appointment to see me. F4 reported concerns:
i. Last Thursday, P3 was confused and was a fall risk, went out in the middle of the night, called his/her family and told them he/she did not know where he/she was. They panicked and drove to find him/her. F4 reported the unit did not know he/she (the patient) was missing.
ii. Staff keeps forgetting to turn on bed alarm.
iii. Gowns: Arranged with S1 for patient to have a yellow gown to identify him/her as a risk of leaving. Staff put regular blue gowns in his/her room/cabinet after agreed on yellow. Staff act as if it is inconvenient.
iv. Personality conflict with a male/female staff member (S4). States he/she is in their conversation with S1, family requested he/she not be assigned to the patient again, but he/she was "last night".
v. Room has not been cleaned well, dust bunnies under chairs and bed.
D. Entered by A7 on 8/23/18: All information to S1 and I spoke with (housekeeping) regarding room cleanliness.
E. Entered by A7 on 8/23/18: FYI - (Family) did not want P3 to know the purpose of the yellow gown.
F. Entered by S1 on 8/24/18: Reviewed. I have met with family multiple times. Our most recent we discussed issue of S4 being the nurse after requested he/she not. I apologized. I had written on charge board, S4 "not 28", but assuming this got lost. I called S4, the RN (registered nurse), to let him/her know not to care for (patient in) "28". Discussed yellow gowns and placed paper in cabinet with note "No blue gowns".
G. Entered by A7 on 8/27/18: Followed up with family and patient prior to discharge. Patient and family stated they had no more issues.
H. Entered by A7 on 8/31/18: Based on continuous follow up by the nurse manager and family indicating that no additional issues, I am closing as a complaint.

3. On 9/6/18 at approximately 3:30 p.m., A7 verified that he/she entered and closed the above as a complaint. A7 verified that from the Midas report documentation, it could not be determined what F1 was voicing as the complaint. A7 verified that the reported complainant, F1, was not satisfied with the initial follow up response, that another family member, S4, voiced additional complaints/grievances in person. A7 indicated some of the additional complaints presented by F4 were regarding patient care, or lack of patient care provided. A7 verified no written responses were sent to the patient or family for complaints/grievances related to P3.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the hospital failed to ensure patients received care in a safe setting for 3 of 10 patient's by failing to assess, identify and prevent elopement for 1 patient (P3); by failing to reassess, analyze, develop and implement a plan to meet patient needs following elopement of P3 and by failing to follow policies for fall precautions and hourly rounding for P2, P3 and P5.

Findings include:

1. Review of hospital policies and procedures (P&P) indicated the following:
A. Elopement of Patient, Revised Date 4/5/18.
i. Policy: It is the policy of the Hospital to assess, identify, and prevent the elopement of high risk patients and to maintain a safe patient environment.
ii. Procedures: 1. Unit Staff RN (registered nurse): When the patient's absence from the unit/care center is discovered, the staff will: a. Contact the unit Charge RN. b. Search the unit and contact the family.
iii. Recovery:
D. Upon return to the unit/care center, the staff will assess the patient and notify: 1. The physician. 2. The family. 3. The Department Manager/ADON (Assistant Director of Nursing). 4. The AOC (Administrator on Call). 5. Risk Management.
F. An incident report, detailing the sequence of events will be completed by the patient's nurse according to procedure.
G. Documentation in the medical record will reflect sequence of events or notifications in the event of an elopement.
B. Patient Assessment/Reassessment Plan, Revised Date: 8/1/18.
i. Policy: All patients, at The Hospital, will have an initial assessment and appropriate follow-up assessments based upon their individual needs. The patient's plan of care and treatment provided by the health care professionals will be based upon: B. The data will be analyzed to develop a plan to meet the patients individualized and unique care and/or treatment needs.
ii. Page 6, 1. a. Reassessments will be completed whenever there is a significant change in the patient's status or condition.
C. Fall Policy, Revised 7/19/17.
i. Policy:
a. Fall Risk Assessment Scales: Adult - Schmid Fall Scale: Score > or = to 3 indicates high fall risk.
b. Evaluation of fall prevention interventions will be done with every assessment or as indicated with any changes in assessment of the patient.
c. If the patient is identified as a high risk for fall, additional patient and family education about the fall prevention interventions will be initiated. Bed and/or chair alarms should remain on even if family is staying in the room with the patient.
d. Hourly rounding per hospital policy for any patient that is identified as having a high fall risk.
ii. Documentation:
a. Documentation of fall risk assessment, interventions, refusal of interventions by patient or family, care plan, and patient/family education should be completed in electronic medical record.

2. Review of medical records (MR) indicated the following:
A. Patient P2, admitted [DATE] and discharged [DATE], was assessed to be a high fall risk (HFR). The MR lacked documentation of "Hourly Visual Checks" and "Alarm On" (bed/chair alarm) during the following, but not limited to, times: On 8/14/18 between 0300 hours and 0728 hours, between 0959 hours and 1248 hours, and between 1248 hours and 1552 hours. On 8/15/18 between 0053 hours and 0415 hours, between 0953 hours and 1209 hours, between 1748 hours and 2005 hours, and between 8/15/18 at 2005 hours and 8/16/18 at 0718 hours.
B. Patient P3, admitted [DATE] and discharged [DATE], was assessed to be a HFR. MR documentation indicated the following on 8/17/17 at 0010 hours: Pt (patient) more impulsive. Pt able to turn off bed alarm and shut down IV (intravenous) pump. Pt found outside hospital near Subway. Pt states he/she wants to go home no matter what. Will contact MD (physician) for AMA (against medical advice) possibility. Pt convinced to return to bed and is now elopement risk. The MR lacked prior documentation of patient shutting down bed alarm or IV pump. The MR lacked documentation of patient assessment upon return to the unit, notification to family, notification to the Department Manager/ADON, notification to the AOC and/or officiating to Risk Management. The MR lacked documentation that reflected the sequence of events prior to the elopement or during the elopement. Unable to determine who discovered the patient missing or when the patient was found to be missing. The MR lacked documentation of analysis of the event and lacked documentation of implementation of a plan to prevent further elopement events. The MR lacked documentation of "Hourly Visual Checks" and "Alarm On" (bed/chair alarm) during the following, but not limited to, times: On 8/15/18 between 1230 hours and 1512 hours, and between 1512 hours and 1908 hours. On 8/16/18 between 0745 hours and 1133 hours, between 1133 hours and 1419 hours (which indicated the chair alarm was on, but lacked documentation of a visual check), between 1518 hours and 1920 hours, and from 8/16/18 at 2100 hours to 8/17/18 at 0049 hours. On 8/17/18 between 0133 hours and 0325 hours, between 0325 hours and 0603 hours, between 1100 hours and 1507 hours, between 1507 hours and 1949 hours, and from 1949 hours to 2243 hours (which lacked documentation of visual check).
C. Patient P5, admitted [DATE] and discharged [DATE], was a HFR as of 7/19/18 at 1626 hours. The MR lacked documentation of "Hourly Visual Checks" and "Alarm On" (bed/chair alarm) during the following, but not limited to, times: On 7/19/18 between 1633 hours and 1940 hours. On 7/20/18 between 0300 hours and 0556 hours, and between 0715 hours and 0918 hours. On 7/21/18 between 0046 hours and 0301 hours, and between 0726 and 1330 hours.

3. Review of hospital incident reports between 1/1/18 to 8/31/18 lacked documentation of an incident report form having been completed related P3 and the elopement event on 8/17/18.

4. The following was indicated in interview:
A. On 9/5/18, between approximately 12:30 p.m. and 4:30 p.m., during MR review, A2, RN Informatics Specialist, verified the MR for P2 lacked documentation of hourly visual checks and observation of bed/chair alarm on as per P&P. A2 also verified the MR for P3 lacked documentation of P3 shutting off his/her bed alarm or IV pump prior to 8/17/18, lacked documentation of details of the elopement event and lacked documentation of staff assessment upon return to the unit.
B On 9/6/18, between approximately 10:30 a.m. and 12:15 p.m., during completion of MR review, A2 verified the MR of P3 lacked documentation of what elopement precautions were implemented following the elopement event 8/17/18 and that the MR lacked documentation of notification to family, notification to the Department Manager/ADON, officiating to the AOC and/or officiating to Risk Management. A2 also verified the MR for P5 lacked documentation of hourly visual checks and observation of bed/chair alarm on as per P&P.
C. On 9/6/18, between approximately 12:30 p.m. and 2:30 p.m., A5, Risk Management Analyst, verified no incident report had been submitted related to the elopement of P3.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the hospital failed to ensure the nursing supervisor evaluated the nursing care for 2 of 10 patients (P3 and P10) by failing to ensure nursing staff completed an incident report as required by policy and procedure (P&P) for the elopement of patient P3 and left Against Medical Advice (AMA) for patient P10.

Findings include:

1. Review of hospital P&Ps indicated the following:
A. Elopement of Patient, Revised Date 4/5/18. VI. Recovery: F. An incident report, detailing the sequence of events will be completed by the patient's nurse according to procedure.
B. Against Medical Advice (AMA): Refusal of Operation, Procedure and/or Treatment, Revised Date: 7/19/17. V. Procedures: A. 2. Nurse will: Complete an incident report.

2. Review of medical records (MR) indicated the following:
A. Patient P3, admitted [DATE] and discharged [DATE], was assessed to be a HFR. MR documentation indicated the following on 8/17/17 at 0010 hours: Pt (patient) more impulsive. Pt able to turn off bed alarm and shut down IV (intravenous) pump. Pt found outside hospital near Subway. Pt states he/she wants to go home no matter what. Will contact MD (physician) for AMA (against medical advice) possibility. Pt convinced to return to bed and is now elopement risk.
B. Patient P10, admitted [DATE] left AMA on 8/2/18.

3. Review of hospital incident reports between 1/1/18 to 8/31/18 lacked documentation of an incident report form having been completed related to P3 and the elopement event on 8/17/18 and lacked documentation of an incident report for the AMA discharge of patient P10.

4. On 9/6/18, between approximately 12:30 p.m. and 2:30 p.m., A5, Risk Management Analyst, verified no incident report had been submitted related to the elopement of P3 and no incident report had been submitted for the AMA discharge of patient P10.