HospitalInspections.org

Based on interview, observation, policy, and record review the facility staff failed to provide supervised nursing oversight for three (#1, #3, and #17) of three patients reviewed. The facility also failed to ensure a physician evaluation for three (#1, #3, and #17) of three patient's stability to leave the unit to go outside of the facility to smoke. The facility census was 23.

Findings included:

1. Record review of facility policy H-ML. 08-009, titled Tobacco Free Environment, dated 02/2012, showed the following direction:
-The designated smoking area is prohibited within 25 feet of any entrance to the building;
-Patient may request permission to smoke and access the designated smoking area after evaluation for ambulatory status;
-Ambulatory status will be evaluated by a physician to determine stability;
-if the patient is determined to be unstable, the patient will be accompanied to the designated smoking area;
-Patients may smoke when authorized by a licensed independent practitioner via written order based on medical criteria;

2. Observation on 12/12/12 at 12:30 PM showed the designated smoking area (receptacle to dispose of smoking materials) was located 13 feet from a door into the building.

3. Record review of Patient #3's medical record showed patient:
-Was admitted to facility on 11/21/12 for nutrition, physical therapy, abdominal fistula, and wound care;
-Was to be on TPN (total parenteral nutrition-nutritional requirements to be infused via intravenous access);
-Was to be NPO except for ice chips (patient was to have nothing by mouth except for ice chips);
-Had an abdominal fistula (an opening that allows the contents of the stomach or bowel to leak into the abdominal cavity or outside the body;
-Was ambulatory with assistance (can get up and walk only with help from someone) and a high fall risk (likely to fall unless supervised/assisted by staff);
-Was on isolation precautions for MRSA, (Methicillin Resistant Staph Aureus) and VRE, Vancomycin Resistant Enterococcus), both are bacteria that are contagious and do not respond to powerful antibiotics. They require special precautions to prevent passing infection to other patients, staff and visitors;
-Review showed no Physician assessment of ambulatory status to go outside to smoke or physician order authorizing patient to go outside to smoke.

4. Documentation note titled "change of condition" entered in Patient #3's medical record on 12/4/12 at 5:17 PM by Staff H, Nursing Supervisor, stated that, "Patient observed on parking lot by a family member visiting another patient. Visitor alerted security, security met patient in parking lot (about 50 yards from building) and redirected patient back to front of hospital. Supervisor notified. Wheelchair brought to patient, patient assisted into wheelchair. Patient brought back to room. Attending Physician notified."

5. Facility documentation of investigation revealed incident was categorized as a "near miss" and resulted from patient non compliance. Harm was reduced or avoided by active recovery or intervention, the likelihood of reoccurrence was uncommon. Severity if occurred again would be "Moderate".

6. During an interview on 12/12/12 at 11:10 AM Staff C, CEO, Chief Executive Officer, stated that this event was investigated and was identified as a "near miss" because the patient did not leave the premises. She stated that patients are allowed to go outside and smoke if alert and oriented and would be accompanied by staff if they are confused. She stated that the patients are told to advise the staff when they are going out and that they are not allowed to leave premises. She stated that it is everyone's responsibility to ensure that the patients' come back to floor. She stated that the facility does not have an elopement policy because elopements are considered Against Medical Advice (AMA, patient leaves the facility without a physician order) and that policy is followed. She stated that no processes have changed as a result of this incident.

7. During an interview on 12/11/12 at 11:15 AM Staff H, Nursing Supervisor, stated that the wheelchair was taken to the parking lot, not to the front of hospital as his note described. He stated that the patient was not harmed and did not leave premises. He stated that the patient was on the porch and decided to go to a local restaurant. He stated that he was not aware of any specific requirement for patients to be assessed to go out and smoke and staff does not go out with patients. He stated that patients are not allowed to leave hospital property but he is not sure how patient are made aware of this. He stated that he believes that the nurses tell the patients.

8. During an interview on 12/11/12 at 10:30 AM Patient #3 stated that:
-She can transfer from bed to wheel chair with help and can walk in the hallway with her walker and some support;
-She learned she cannot leave the premises when she was outside smoking and decided to go to get a sandwich at a local restaurant. She stated she used her walker and was in the middle of the parking lot when a visitor of another patient saw her and reported her to security;
-She was glad security came because she wasn't sure she could make to the restaurant or back to the facility without help;
-She knew she was not supposed to eat but really wanted a sandwich;
-there is not hospital staff present when she goes outside to smoke;

9. During an interview on 12/11/12 at 3:15 PM Staff J, RN (Registered Nurse), stated that she was the primary RN caring for Patient #3 on 12/04/12 at 5:00 PM (when the patient left the smoking area to go to a restaurant). Staff J stated that:
-Patient #3 usually told the staff when she needed to go outside to smoke and they get her into a wheel chair;
-Patient #3 did not tell her on this day that she was going outside to smoke;
-Patient #3 was usually alert and oriented but sometimes got confused;
-She was not aware that Patient #3 had ambulated away from building until the nursing supervisor notified her and she assisted patient back to the patient care area;
-If patient would have eaten anything it would impede her healing process (because of the abdominal fistula).

10. Observation and interview on 12/11/12 at approximately 9:40 AM showed Patient #1 in the hall. Patient #1 stated that she had been outside to smoke.

11. During an interview on 12/11/12 at 9:45 AM Staff Y, Certified Nurse Aide (CNA), stated that patients smoke on their own. She stated that she checked Patient #1's room and thought she was in the bathroom. She did not know Patient #1 left the unit to smoke.

12. During an interview on 12/11/12 at 5:00 PM Staff D, RN, stated that she was Patient #1's nurse and Patient #1 did not smoke before 10:00 AM.

13. During an interview on 12/12/12 at 9:45 AM Patient #17 stated that she smoked two to three times a day and did not notify staff when she left the unit.

14. During an interview on 12/12/12 at 9:50 AM Staff L, CNA, stated that none of his patients smoked and that Patient #17 was one of his patients.

15. During an interview on 12/12/12 at 9:55 AM Staff K, RN, stated that
she was the nurse for Patient #17. She stated that Patient #17 had not gone out to smoke.

16. During an interview on 12/12/12 at 11:05 AM Patient #17 stated that she had gone out to smoke in the early AM.

17. Record review of Patient #1 and Patient #17's medical record showed no specific stability assessment by physician.

18. During a telephone interview on 12/12/12 at 1:00 PM Staff Physician M stated that he has never written an order for a patient to go outside to smoke. Staff Physician M stated that he has never been asked to assess the ambulatory status of a patient to go outside to smoke and that ambulation safety is always a concern for patients in a Long Term Acute Care Hospital setting. Staff Physician M stated that he would prefer that patients not smoke, discouraged it and offers the nicotine patch but it is the patients' right to smoke and the patients are in this facility voluntarily.



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