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.

ST. AGNES HOSPITAL HOSPICE 430 E DIVISION ST FOND DU LAC, WI 54935 June 16, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interviews, observations, and record review, the facility failed to ensure the safety of 1 of 1 patient (Patient #1) deemed an elopement risk out of a total of 10 patient records.

Findings:

The facility failed to ensure patients were receiving care in a safe setting. (See tag A-0144)

An Immediate Jeopardy (IJ) was determined on 6/5/20 at 2:15 PM, under 42 CFR 482.23 Condition of Participation: Nursing Services because the facility failed to adjust the care of a patient based on assessment and presenting and escalating behaviors. At 3:45 PM, President B, VP Nursing C, Accreditation Coordinator D, and System Compliance Director L were notified of the IJ and the IJ template was provided via encrypted email.

The IJ was removed on 6/16/20 at 12:30 PM after the facility presented a plan of correction detailing that on 6/5/20 all Administrative Supervisors were assigned the responsibility for identifying all inpatients with altered mental status who are at risk for elopement and provided real-time staff education if an at-risk patient was identified including: initiating 30 minute safety checks/rounding, use and documentation of 30 minute safety checks on the elopement rounding log, placing wanderguard bracelet securely on patient (i.e. alternative placement and use of coban, if indicated) and constant visual observation for those making active attempts to elope or wander (i.e. 1:1 sitter or video monitoring.) The deficient practice remains at a condition level until the facility is able to demonstrate long-term and systemic corrections.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, observations, and record review, the facility failed to ensure the safety of 1 of 1 patient (Patient #1) deemed an elopement risk out of a total of 10 patient records.

Findings:

During an interview with Nurse Manager E and VP Nursing C on 6/4/20 at 3:45 PM, Nurse Manager E stated, "[A] asked if he/she should come in and sit with the patient after the incident. We offered a staff sitter and [A] was ok with that. There was no conversations regarding needing a sitter or [A] wanting to come in and sit with [#1] before the elopement. [#1] had some small strokes and increasing confusion, he/she was a little agitated, but safe to be up on his/her own. He/She was not on a hold, no activated POA. We had no legal authority to keep the patient in the facility. No staff felt [#1] needed a sitter prior to this." VP Nursing C stated, "We put immediate interventions in place to ensure [#1] stayed safe and didn't elope again." When asked if there were any facility-wide communication or interventions put in place, VP Nursing C stated, "No facility-wide interventions. We are exploring other options such as telesitting and other screening options during admission. There are no timelines or projects open yet; we are just evaluating our options."

During an interview with VP Nursing C on 6/5/20 at 8:30 AM, when asked about what follow up activities have occurred as a result of the incident, VP Nursing C stated, "There wasn't a formal RCA (root-cause analysis), but a lot of discussion between me, [Nurse Manager E], Patient Experience, and the unit director to discuss gaps and how to put immediate interventions in place. We have not discussed this at the facility-wide safety huddle. Reeducation and reinforcement of current processes were discussed at shift huddles."

During an interview with Accreditation/Risk Coordinator D on 6/5/20 at 9:09 AM, when asked about follow up activities, Accreditation/Risk Coordinator D stated, "This happened less than 2 weeks ago. We'll develop an action plan in the future. I'll make sure things will be formally documented with improvements, action plan, timelines, and the RCA ...Part of the RCA will be formalized reeducation of staff and understanding where our gaps in communication are."

During an interview with VP Nursing C on 6/5/20 at 3:03 PM, when asked about expectations for documenting the presence of a wanderguard or sitter, C stated, "There is no standard location for documenting that." When asked about an elopement risk assessment and associated interventions, C stated, "We don't currently have an elopement risk assessment or elopement care plan. Nurses can document that elopement precautions are in place, but there aren't specific or standard interventions. That is what we're looking into."

During a tour of the 5W inpatient unit on 6/4/20 at 10:22 AM conducted via FaceTime and concurrent interview with Accreditation Coordinator D, Inpatient Director H, and Nurse Manager E, it was revealed that the 5W unit consists of 20 private medical rooms, primarily serving the neurological population, and 5 Inpatient Rehab rooms. Rooms #524 through 528 are designated as Inpatient Rehab rooms. 2 nurse's stations were observed. Medical rooms #527 through 530 and 534 through 544 were observed to not be in direct view of either nurse's station, with rooms 534 through 544 located on the backside of the unit. There were 2 stairwells observed; one on either end of the back hallway. A total of 3 Wanderguard alarm systems were observed on the unit; 1 at each stairwell and 1 at the main entrance of the unit. The doors to the stairwells are not locked, as they are fire exits. There were no locked exits observed on the unit, and no additional security alarms at any exit. Inpatient Director H confirmed that there are ways to exit the unit without passing a nurse's station. When asked about the average registered nurse to patient ratio on the unit, Nurse Manager E stated, "On days, it is 1 nurse for 3 to 4 patients; on PM's (evenings), 1 nurse for 4 to 5 patients, and on nights, 1 nurse for 5 to 6 patients." When asked if certified nursing assistants are scheduled on the unit, E stated, "On days and PM's we have 2 and on nights we try to have 1. We have 1 open position." When asked about patient placement, E stated, "We try to put patients with dementia closest to the desk." When asked about the use of sitters, Inpatient Director H stated, "We have a sitter verification form the nurses use to guide them in determining if a sitter is needed, and that is sent to the administrative supervisor for review and assignment." When asked about the process if a sitter was not available, H stated, "Then we'll utilize a CNA (certified nursing assistant)." When asked about rounding expectations, Nurse Manager E stated, "we do hourly rounding between 6:00 AM and 10:00 PM, and every 2 hours between 10:00 PM and 6:00 AM." When asked if the rounding frequency changes based on patient needs or behaviors, E stated, "The baseline does not change based on need. We have the wanderguard system, bed alarms, and posey chair alarms." When asked about criteria for the use of a sitter, Inpatient Director H stated, "We have a sitter justification tool that can help guide the nurses to decide if a sitter is needed; it's at the nurse's discretion. We typically use them if the patient is unsteady and could fall. This patient was up independently."

Record review of Patient #1's medical record revealed Patient #1 was admitted on [DATE] with confusion and altered mental status and was being assessed for guardianship. A wanderguard alarm system was placed on Patient #1's wrist, however no additional interventions such as a sitter or placing the patient in a room in view of the nurse's station were implemented; and no additional interventions were implemented following the 2 documented elopement attempts. Patient #1 was observed in her room on 5/19/20 at approximately 4:00 AM. At 5:50 AM (1 hour and 50 minutes later), a lab technician discovered Patient #1 missing from her room. A missing person alert was initiated, and Patient #1 was not found on the premises after a search. Local police were notified, and discovered Patient #1 walking approximately 1.5 miles away from the facility. Patient #1's wanderguard was found as having been removed ("slipped off wrist") and was located with the patient's belongings in the room. Patient #1 was returned to the facility with no reported injuries at approximately 6:55 AM, 1 hour and 5 minutes after she was discovered missing, and nearly 3 hours after the last documentation of nursing care/rounding.

Per policy titled "Elopement-Missing Person/Adult" revised 5/21/2019 revealed "Policy statement: All employees are involved in safeguarding the wandering patient and protecting him/her from potential harm or injury."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interviews, observations, and record review, the facility failed to implement adequate interventions for patients who were deemed an elopement risk in 1 out 5 discharged patient records reviewed, out of a total of 10 patient records.

Findings:

The facility failed to adjust the care of a patient based on assessment and presenting and escalating behaviors. (See tag A-396)

An Immediate Jeopardy (IJ) was determined on 6/5/20 at 2:15 PM, under 42 CFR 482.23 Condition of Participation: Nursing Services because the facility failed to adjust the care of a patient based on assessment and presenting and escalating behaviors. At 3:45 PM, President B, VP Nursing C, Accreditation Coordinator D, and System Compliance Director L were notified of the IJ and the IJ template was provided via encrypted email.

The IJ was removed on 6/16/20 at 12:30 PM after the facility presented a plan of correction detailing that on 6/5/20 all Administrative Supervisors were assigned the responsibility for identifying all inpatients with altered mental status who are at risk for elopement and provided real-time staff education if an at-risk patient was identified including: initiating 30 minute safety checks/rounding, use and documentation of 30 minute safety checks on the elopement rounding log, placing wanderguard bracelet securely on patient (i.e. alternative placement and use of coban, if indicated) and constant visual observation for those making active attempts to elope or wander (i.e. 1:1 sitter or video monitoring.) The deficient practice remains at a condition level until the facility is able to demonstrate long-term and systemic corrections.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, observations, and record review, the facility failed to implement adequate interventions for patients who were deemed an elopement risk in 1 out 5 discharged patient records reviewed, out of a total of 10 patient records.

Findings:

During an interview with Nurse Manager E and VP Nursing C on 6/4/20 at 3:45 PM, Nurse Manager E stated, "[A] asked if he/she should come in and sit with the patient after the incident. We offered a staff sitter and [A] was ok with that. There was no conversations regarding needing a sitter or [A] wanting to come in and sit with [#1] before the elopement. [#1] had some small strokes and increasing confusion, he/she was a little agitated, but safe to be up on his/her own. He/She was not on a hold, no activated POA. We had no legal authority to keep the patient in the facility. No staff felt [#1] needed a sitter prior to this." VP Nursing C stated, "We put immediate interventions in place to ensure [#1] stayed safe and didn't elope again." When asked if there were any facility-wide communication or interventions put in place, VP Nursing C stated, "No facility-wide interventions. We are exploring other options such as telesitting and other screening options during admission. There are no timelines or projects open yet; we are just evaluating our options."

During an interview with VP Nursing C on 6/5/20 at 8:30 AM, when asked about what follow up activities have occurred as a result of the incident, VP Nursing C stated, "There wasn't a formal RCA (root-cause analysis), but a lot of discussion between me, [Nurse Manager E], Patient Experience, and the unit director to discuss gaps and how to put immediate interventions in place. We have not discussed this at the facility-wide safety huddle. Reeducation and reinforcement of current processes were discussed at shift huddles."

During an interview with Accreditation/Risk Coordinator D on 6/5/20 at 9:09 AM, when asked about follow up activities, Accreditation/Risk Coordinator D stated, "This happened less than 2 weeks ago. We'll develop an action plan in the future. I'll make sure things will be formally documented with improvements, action plan, timelines, and the RCA ...Part of the RCA will be formalized reeducation of staff and understanding where our gaps in communication are."

During an interview with VP Nursing C on 6/5/20 at 3:03 PM, when asked about expectations for documenting the presence of a wanderguard or sitter, C stated, "There is no standard location for documenting that." When asked about an elopement risk assessment and associated interventions, C stated, "We don't currently have an elopement risk assessment or elopement care plan. Nurses can document that elopement precautions are in place, but there aren't specific or standard interventions. That is what we're looking into."

During a tour of the 5W inpatient unit on 6/4/20 at 10:22 AM conducted via FaceTime and concurrent interview with Accreditation Coordinator D, Inpatient Director H, and Nurse Manager E, it was revealed that the 5W unit consists of 20 private medical rooms, primarily serving the neurological population, and 5 Inpatient Rehab rooms. Rooms #524 through 528 are designated as Inpatient Rehab rooms. 2 nurse's stations were observed. Medical rooms #527 through 530 and 534 through 544 were observed to not be in direct view of either nurse's station, with rooms 534 through 544 located on the backside of the unit. There were 2 stairwells observed; one on either end of the back hallway. A total of 3 Wanderguard alarm systems were observed on the unit; 1 at each stairwell and 1 at the main entrance of the unit. The doors to the stairwells are not locked, as they are fire exits. There were no locked exits observed on the unit, and no additional security alarms at any exit. Inpatient Director H confirmed that there are ways to exit the unit without passing a nurse's station. When asked about the average registered nurse to patient ratio on the unit, Nurse Manager E stated, "On days, it is 1 nurse for 3 to 4 patients; on PM's (evenings), 1 nurse for 4 to 5 patients, and on nights, 1 nurse for 5 to 6 patients." When asked if certified nursing assistants are scheduled on the unit, E stated, "On days and PM's we have 2 and on nights we try to have 1. We have 1 open position." When asked about patient placement, E stated, "We try to put patients with dementia closest to the desk." When asked about the use of sitters, Inpatient Director H stated, "We have a sitter verification form the nurses use to guide them in determining if a sitter is needed, and that is sent to the administrative supervisor for review and assignment." When asked about the process if a sitter was not available, H stated, "Then we'll utilize a CNA (certified nursing assistant)." When asked about rounding expectations, Nurse Manager E stated, "we do hourly rounding between 6:00 AM and 10:00 PM, and every 2 hours between 10:00 PM and 6:00 AM." When asked if the rounding frequency changes based on patient needs or behaviors, E stated, "The baseline does not change based on need. We have the wanderguard system, bed alarms, and posey chair alarms." When asked about criteria for the use of a sitter, Inpatient Director H stated, "We have a sitter justification tool that can help guide the nurses to decide if a sitter is needed; it's at the nurse's discretion. We typically use them if the patient is unsteady and could fall. This patient was up independently."

Record review of Patient #1's medical record revealed Patient #1 was admitted on [DATE] with confusion and altered mental status and was being assessed for guardianship. A wanderguard alarm system was placed on Patient #1's wrist, however no additional interventions such as a sitter or placing the patient in a room in view of the nurse's station were implemented; and no additional interventions were implemented following the 2 documented elopement attempts. Patient #1 was observed in her room on 5/19/20 at approximately 4:00 AM. At 5:50 AM (1 hour and 50 minutes later), a lab technician discovered Patient #1 missing from her room. A missing person alert was initiated, and Patient #1 was not found on the premises after a search. Local police were notified, and discovered Patient #1 walking approximately 1.5 miles away from the facility. Patient #1's wanderguard was found as having been removed ("slipped off wrist") and was located with the patient's belongings in the room. Patient #1 was returned to the facility with no reported injuries at approximately 6:55 AM, 1 hour and 5 minutes after she was discovered missing, and nearly 3 hours after the last documentation of nursing care/rounding.