HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to meet the Condition of Participation of Patient's Rights relative to care in a safe setting for 1 sample patient, Patient ID # 1.

Findings are as follows:

The hospital failed to provide Patient ID#1 who is cognitively impaired, and a known elopement risk, the necessary supervision to maintain safety when participating in an off unit outing.

(refer to A-144)

Based on record review, policy review and staff interview, it has been determined that the hospital failed to provide physical safety for 1 of 9 patients documented as returning from an outside activity, Patient ID #1.

Findings are as follows:

A. The hospital's "Patient Supervision Levels" Policy and Procedure dated November 2018, states, in part,
" ...IV. Definitions: Supervision levels are defined for each inpatient at [the hospital] and indicate the amount of freedom provided to each patient to enter and exit their unit or assigned building ... Assignment of the Supervision Level shall be based on the ability of the patient to safely manage a given level without unacceptable risk of serious harm to self or others ...

2. Supervision level B-This category allows the patient to leave the unit only with supervision ..."

The hospital's "Patient Observation Policy," last approved in February 2020, states, in part,
"Definitions: ...

3.2) 15 Minute Observation- This is the level of observation to be used on psychiatric units.

...4) Communication and Documentation of patients who leave the unit.

a ... The staff is responsible to ensure that the patient returns to the unit when required. If the patient does not return to the unit within the agreed upon time, the staff will notify the RN of potential elopement immediately ...."

The hospital's "Elopement Prevention and Resolution" policy and procedure, last revised in 2019, states in part, that an elopement is defined as the unauthorized absence of a patient from the hospital grounds without permission.

Review of the medical record for Patient ID #1 revealed she/he has been a court ordered patient at the hospital since 2/2020. Patient ID #1 has a past medical history of a traumatic brain injury that resulted in a subdural hematoma (bleeding under the outside lining of the brain) which required surgical intervention, and a history of neurocognitive disorder (a category of conditions that include dementia, delirium, and amnesia).

A Monthly Medical/Psychiatric Assessment performed on 5/14/2021 describes Patient ID #1 as being "disoriented to person, time, situation or president." She/he is also described as not knowing the date, year or season and was "unable to recall [the] state where [she/he] lives, [his/her] family members, friends, and [has] no recollection of being arrested and being in a hospital." This assessment further states that, for safety, she/he is a "B status [leave only with supervision when] off the unit."

Review of Patient ID #1's Provider Orders reveal she/he is on every 15-minute observation checks, while on the inpatient unit and that she/he is considered an elopement risk.

Review of the Nursing Progress note dated 5/17/2021 at 3:30 PM revealed that Patient ID #1 eloped when she/he went outside with other patients and staff supervision on 5/17/2021 at approximately 1:15 PM and that "Risk Management reported to staff that [the patient was] seen wandering outside."

Surveyor interview with the Chief Nursing Officer and Risk Manager on 5/20/2021 at approximately 10:30 AM revealed that several patients were returning from an outdoor activity accompanied by 2 staff members, Staff A and Staff B. As the staff and patients were walking through the hallways to take the elevator back to their unit, Staff A stopped at the Canteen (a snack area) with several patients as Staff B and some other patients proceeded onto the elevator and back to the unit.

The Risk Manager acknowledged that the Security Director reviewed the hospital's security video which revealed that Patient ID #1 walked from the hallway area, past the Security Desk and through the hospital's main lobby doorway to outside at 2:43 PM. The Security Director further stated that Patient ID #1 was inadvertently identified by an off-duty employee who notified the Nursing Supervisor. This notification prompted calling a Code E (Elopement) at 3:10 PM. The patient was located at the intersection of a 4-lane high traffic area without supervision. She/he was returned to the hospital at 3:20 PM.

During an interview with Staff C on 5/20/2021 at 11:00 AM, Staff C stated that there were between 9-11 patients outside for this activity, as Staff C recalled that when they counted the number of patients for snacks there were 11 patients. Staff C further stated that 2 of the 5 staff members outside with the patients left the activity early, and when a staff member leaves, they are usually replaced; they were not replaced on this date/time which led to 3 staff members being responsible for the return of several patients. Staff C recalled that she did not walk in the hallway with Staff A and Staff B, and had stayed behind with a couple of patients to clean up, which left the 2 staff members responsible for the remaining patients. Staff C could not identify who was responsible for transporting Patient ID #1 back to the unit safely.

During an interview with Staff B on 5/20/2021 at 11:35 AM, Staff B stated that there is no ownership for a patient unless the patient is a 1:1 status, also known as a constant supervision patient. Staff B further stated that, while walking in the hallway to return to the unit, Staff A was ahead with patients and went into the snack area. Staff B stated that his/her responsibility was for the 1:1 patient and a patient in a wheelchair who he/she brought to the elevator and upstairs when Staff A was in the snack area with others. Staff B acknowledged that he/she was not aware of the whereabouts of Patient ID #1.

Both the Chief Nursing Officer and the Risk Manager acknowledged that Patient ID #1 was unsupervised which resulted in him/her eloping.