HospitalInspections.org

Based on document review, policy review, medical record review, video recordings review and interview, the hospital failed to promote the Patient's Right to receive care in a safe setting when elopement precautions were not implemented for a patient with potential elopement tendencies and untrained Security Guards monitoring the exit doors allowed an intellectually and physically disabled patient to leave the hospital at night by herself without checking with nursing staff prior to letting the patient leave.

The findings include:

1. Review of the Security Services agreement dated May 23, 2018 revealed, "...Duties will include patrolling, monitoring and other security functions as agreed upon by Client and District Manager. See existing Post Orders for a more detailed description..."

Review of the Security Post Orders undated revealed, "Ensure that safety regulations are in place and followed in order to prevent unsafe conditions and eliminate unnecessary safety risks".

2. Patient #1 was admitted on 3/24/2022 with complaints of right-side weakness due to a stroke.

Review of a Psychiatrist note presented by the patient's mother on the patient's second day of admission to the hospital dated 3/18/2022 revealed, "...The patient is continuing to deteriorate - she is having issues with self-toileting, taking too many things, roving/elopement...engaging in kleptomania...[Patient #1's mother] states that the patient is sundowning. [Patient #1] is shoplifting from hotels and doctor's office...The patient has left the house a couple of times and gone into the backyard and wandered..."

Review of the consultation dated 3/28/2022 from Psychologist #1 revealed, "...The patient's psychiatric history is significant for...vascular dementia, according to a recent psychiatric evaluation...Her mother reports that she has "sundowners" daily and becomes agitated and restless...She has engaged in kleptomania related to her cognitive dysfunction. She is followed by [Psychiatrist #1] and had a recent neuropsychological evaluation...Her judgement and insight are poor cognitive dysfunction..."

There was no documentation of safety interventions implemented to protect the patient from eloping.

In an telephone interview on 5/3/2022 beginning at 8:45 AM, Patient #1's mother stated that on the second day of the patient's admission (3/25/2022) she met with the Director of Quality/Risk Management (DRM) and Psychologist #1 and presented them with a copy of the Psychiatrist report.

In an interview on 5/17/2022 at 11:33 AM in the conference room the DRM stated, "...On the second day of admission [Patient #1's mother] did share with me that the patient had a neuro/psych history and shared with me the report from [Psychiatrist #1]. I also called the attending physician and let [Psychologist #1] know..."

Review of a Security Services Incident Report dated 4/6/2022 at 5:25 AM revealed a statement from Security Guard #1, "...Around 12:25 PM [4/5/2022] a patient [Patient #1] came down to the lobby...I opened the door for her, thinking she was just a visitor that was leaving late. [Visitor visitation had ended at 8:00 PM]. I didn't see which way she went...At 5:19 AM, I received a call from [Nurse Supervisor #1] saying a patient was missing. It was the lady I mistaken as a visitor..."

Review of the Security Services Incident Report's statement from the On-site Security Guard Manager revealed "...As I arrived to my work site [on 4-6-22] a police officer pulled in behind me and entered the building I asked if he needed any help and the officer replied that a patient was missing from the facility..."

Review of the physician progress note on 4/6/2022 at 4:09 PM revealed, "...Unfortunately, patient eloped last night and was found this morning..."

Review of an e-mail correspondence to the Human Resources Director (HRD) on 4/7/2022 at 1:58 PM from the Night Supervisor revealed, "...I was notified around early 5am [5:00 AM] that the patient was missing. Then we called the police, family and provider around 5:30..."

Review of an e-mail correspondence to the HRD on 4/7/2022 at 2:01 PM from the Night Supervisor #1 revealed,"...I also called security and security stated that the camera was not working so she was not able to determine if she had left the building or not. She did state that she saw a lady downstairs by door..."

Review of Rehabilitation Nurse Tech (RNT) #1 typed written statement dated 4/8/2022 revealed, "...That night was kind of hectic and everything...After that, I saw her a little bit before 10pm [10:00 PM] and she was sitting there. I couldn't see her in the bed like I normally can so I went into her room and she was in the chair and she asked me for help with her arm...I could not say what time she left the building because I was stationed in the back because the front was closed...I can't say how she left the building or what..."

Review of a Security Services Incident Report dated 4/14/2022 revealed a statement from Operational Manager, "...On April 6 2022 I received a call at 6:00 AM from the site supervisor in regards to the missing patient. I were [was]informed the officer on third shift let a patient out around 11 PM [11:00 PM]...patient was located near MLG and W [Memphis Light Gas Water]".

Refer to A144

Based on review of facility policy, medical record review, review of facility video recordings, and interviews, the facility failed to ensure nursing performed assessments and reassessments of patients and identified patients' safety needs for 1 of 1 (Patient #1) sampled patients who eloped from the hospital and was missing for greater than 10 hours.

The findings included:

1. Review of the facility's "Plan for the Provision of Patient's Care" policy dated "03/07/201" revealed, " ...Our focus is to treat the whole patient as an individual with unique and complex physical, psychosocial...attributes contributing to his or her identify. Care is planned and provided via an interdisciplinary approach utilizing information contributed by the patient, family, and other support persons...Individual patient goals and interventions...All individuals responsible for the assessment, treatment or care of patients are competent in the following...The ability to obtain and interpret information in terms of the patient's needs ..."

Review of the facility's "Assessment, Re-assessment" policy with a reviewed date of "08/19/2021" revealed, "...All inpatients will be assessed and reassessed by clinical disciplines...Reassessment are performed by each discipline according to the patient's...status or condition...RNs [registered nurses] conduct daily assessments of the patient's condition as documented in the medical record...When there is a significant change in the patient's condition, a full reassessment is performed..."

2. Patient #1 was admitted on 3/24/2022 for rehabilitation with diagnoses including Right Sided Weakness following a stroke. The patient was intellectually and physically disabled. Patient #1's mother had provided the hospital staff a Psychiatry note that was dated 3/18/2022 which identified the patient as an elopement potential and documented that Patient #1 demonstrated, "neurocognitive disorder, panic disorder and depression...is continuing to deteriorate... roving/elopement...engaging in kleptomania...The patient has left the house a couple of times and gone into the backyard and wandered..."

Review of the nursing admission assessment dated 3/25/2022 at 12:00 AM under the section titled Nursing and Elopement Risk revealed, "...Is the patient independently mobile?: Yes...Does the patient have impaired decision making capability?: No ...Does the patient wander?: No...Does the patient have exit seeking behavior?: No...Is there a past history of wandering or exiting a home or facility without the needed supervision?...Elopement Risk Total: 1...[low risk]" There was no documentation nursing had performed a reassessment of Patient #1's needs and identified Patient #1 as a potential elopement risk.

Review of the consultation report dated 3/28/2022 from Psychologist #1 revealed, "...The patient's psychiatric history is significant for major depressive disorder and panic attacks, as well as vascular dementia, according to a recent psychiatric evaluation and neuropsychological evaluation, which were completed in 03/2022...She is alert and oriented to person; mostly to place; not to time...Her mother reports that she has "sundowners" daily and becomes agitated and restless...[Patient #1] reported she had no sisters, but her mother reports she has two sisters who check on her regularly...She has engaged in kleptomania related to her cognitive dysfunction..."

In a telephone interview on 5/3/2022 beginning at 8:45 AM, Patient #1's mother stated that on the second day [3/25/2022] of Patient #1's admission she met with the Director of Quality/Risk Management and Psychologist #1 and presented them a report from Psychiatrist #1 which stated Patient #1 had problems with elopement and was taking things that did not belong to her.

Interview on 5/17/2022 at 11:33 AM in the Conference Room the Director of Quality/Risk Manager stated, "...[Patient #1's mother] did share with me a report from the patient's psychiatrist that the patient had a neuro/psych history. I also called the attending physician and let the Psychologist #1 know..."

Patient #1's admission assessment was not updated after Patient #1's mother had spoken with the Director Quality/Risk Manager in which potential elopement concerns had been shared with the hospital; and after Psychologist #1 had identified potential elopement concerns.

Review of the hospital's video recording of the hallway where Patient #1's room was located revealed on 4/5/2022 the last time nursing rounded on Patient #1 was at 9:37 PM. Nursing had documented in the patient's medical record that the patient had been assessed throughout the night.

Review of the hospital's Security Services statement from the Operational Manager dated 4/14/2022 revealed Patient #1 was missing from the hospital and had been let out of the hospital by a Security Guard who was monitoring the front door on 4/5/2022 at 11:00 PM.

Review of the physician progress note on 4/6/2022 at 4:09 PM revealed, "...Unfortunately, patient eloped last night and was found this morning ..."

There was no documentation a complete nursing assessment or reassessment had been performed upon Patient #1's return to the hospital following an elopement.

There was no documentation on Patient #1's care plan of elopement risks being identified and no documentation safety interventions had been developed and implemented.

Refer to A144, A395 and A396.

Based on document review, policy review, medical record review, video recordings review and interview, the hospital failed to ensure patients received care in a safe setting when 1 of 1 patients (Patient #1) who was intellectually and physically disabled eloped from the hospital and was missing for greater than 10 hours without the staff's knowledge.

The findings include:

1. Review of the facility's "Elopement" policy with a reviewed date of "3/03/2022" revealed, "...If patient is not located within 10 minutes...A Nursing Supervisor shall ...Contact the Chief Nursing Office or Administrator on Call...Notify the attending physician...Complete the incident report...Chief Nursing Officer shall initiate contact with the local law enforcement agencies (Police Department) and notify the authorities of a missing patient...Description of patient (height, weight, color of eyes, hair, race, etc [and so on] shall be provided as well as a picture of the patient if available....The Chief Nursing Officer or designee shall notify the hospital CEO [Chief Executive Officer]. The Chief Nursing Officer or designee shall notify the family or significant other...Chief Nursing Officer and/or the Administrator on Call shall initiate contact with the local law enforcement agencies (Police Department) and notify the authorities of a missing person..."

Review of the Security Services agreement dated May 23, 2018 revealed, "...Scope of Services: [Named Security Services] provides professional Unarmed Security Services. Duties will include patrolling, monitoring and other security functions as agreed upon by Client and District Manager. See existing Post Orders for a more detailed description...Special Instructions: [Named Security Services] provides 1 officer 24/7 [twenty four hours a day/7 days a week]..."

Review of the Security Post Orders undated revealed, "Ensure that safety regulations are in place and followed in order to prevent unsafe conditions and eliminate unnecessary safety risks".

2. Medical record review revealed that Patient #1 was admitted on 3/24/2022 with diagnosis that included Vascular Dementia, Acute Infarction of the Left Thalamus and Right Sided Weakness.

Review of a Psychiatrist note dated 3/18/2022 and presented to the hospital by Patient #1's mother at the time of the patient's admission revealed, "...[Patient #1] is seen for neurocognitive disorder, panic disorder and depression ...The patient's mother is interviewed as well as the patient...The patient is continuing to deteriorate - she is having issues with self-toileting, taking too many things, roving/elopement...engaging in kleptomania...[Patient #1] does not recognize her own house. [Patient #1's mother] states that the patient is sundowning. [Patient #1] is shoplifting from hotels and doctor's office...[Patient #1] does not remember my name and I reintroduce myself to her...[Patient #1's mother] states that the patient is sleeping more during the day and getting her days and nights mixed up; [Patient #1] is sundowning an moving furniture around at night...The patient has left the house a couple of times and gone into the backyard and wandered..."

Review of the consultation note dated 3/28/2022 from Psychologist #1 revealed, "... The patient's psychiatric history is significant for major depressive disorder and panic attacks, as well as vascular dementia, according to a recent psychiatric evaluation and neuropsychological evaluation, which were completed in 03/2022...She is alert and oriented to person; mostly to place; not to time...Her mother reports that she has "sundowners" daily and becomes agitated and restless...During the interview, she displayed short-term memory issues as well as occasional problems with her long-term memory. [Patient #1] reported she had no sisters, but her mother reports she has two sisters who check on her regularly...[Patient #1] has engaged in kleptomania related to her cognitive dysfunction. [Patient #1] is followed by [Psychiatrist #1] and had a recent neuropsychological evaluation...Her judgement and insight are poor cognitive dysfunction, I would recommend that the patient have a 24-hour supervision upon discharge from the rehab hospital in order to monitor her safety and self-care..." . There was no mention in the consultation note about Patient #1's potential for elopement.

In an telephone interview on 5/3/2022 beginning at 8:45 AM Patient #1's mother verified that on the second day (3/25/2022) of Patient #1's admission she met with the Director of Quality/Risk Management and Psychologist #1 and presented them with a report from Psychiatrist #1 that stated Patient #1 had problems with elopement and was taking things that did not belong to her.

In an interview on 5/17/2022 at 11:33 AM in the Conference Room the Director of Quality/Risk Management (DRM) stated, "...On the second day of admission [Patient #1's mother] did share with me that the patient had a neuro/psych history and shared the report with me from the [Psychiatrist #1]. [Patient #1's mother] specifically told me [Patient #1] would rob the nurses blind. I spoke with the nurses and instructed them not to take the drug cart into the patient's room. I also called the attending physician and let [Psychologist #1] know...".

Review of a Security Services Incident Report dated 4/6/2022 at 5:25 AM revealed a statement from Security Guard #1 which read, "...Around 12:25 PM [4/5/2022] a patient came down to the lobby, leaving out the facility. I opened the door for her, thinking she was just a visitor that was leaving late. I thought that because most times all visitors don't leave at 10 PM [10:00 PM] when visitation is over [Visitor visitation is actually over at 8:00 PM]. I didn't see which way she went. Because I was assisting the EMTs [Emergency Medical Technician's] who were bringing a patient in. At 5:19 AM, [on 4/6/2022] I received a call from the [Nurse Supervisor #1] saying a patient was missing. It was the lady I mistaken as a visitor. She was later found around 9:45 AM..."

Review of the Security Services On-site Manager statement regarding the incident with Patient #2 dated 4/6/2022 revealed, "...As I arrived to my work site [on 4-6-22] a police officer pulled in behind me and entered the building I asked if he needed any help and the officer replied that a patient was missing from the hospital so I immediately called for the charge nurse to come down to speak with the officer...and she informed myself as well as the officer that the patient is not in the building... the night shift employees has searched all over so I called Plant Ops [operations] Director to inform his as well as Operations Manager... I searched the property inside too but [Patient #1] was not located on or near the property...maybe an hour later the patient was located at MLG and W [Memphis Light Gas and Water] location..."

Review of an e-mail correspondence dated 4/7/2022 at 8:25 AM from Licensed Practical Nurse (LPN) #1 (who was working on the floor and assigned to Patient #1 on 4/5/2022 and 4/6/2022) to the Director of Human Resources revealed the LPN had documented the following for Patient #1:
On 4/5/2022 Patient #1 was in her room number 208 and the patient's vital signs were taken between 7:15 PM - 7:45 PM.
On 4/5/2022 Patient #1 was administered medications at 8:00 PM.
On 4/5/2022 Patient #1 was ambulating in the hallway at 9:00 PM.
On 4/5/2022 at 10:09 PM, "...O2 Sat [ oxygen saturation - a test to measure the percent of oxygen circulating in your body]..
On 4/5/2022 Patient #1 was in bed at 11:00 PM.
On 4/6/2022, "4/6/2022 at 12:20 AM ...temperature and patient rounding...".
On 4/6/2022 Patient #1 was in the bathroom from 1:30 AM - 2:00 AM.
On 4/6/2022 at 2:23 AM, "Bed in low position. Call light within reach. Night light. Non-slip footwear. Personal items within reach, phone next to patient. Traffic path in room free of clutter, Upper/half-length side-rails up".
On 4/6/2022 Patient #1 was not in her room at 4:30 AM.

Review of the hospital's video recording of the patient's hallway revealed on 4/5/2022 the last time LPN #1 rounded on Patient #1 was at 9:37 PM.

Review of Rehabilitation Nurse Tech (RNT) #1 assignment sheet dated 4/5/2022 revealed the RNT was assigned to Patient #1. The RNT documented on 4/6/2022 at 12:49 AM she had assisted Patient #1 with toileting. The RNT did not realize that Patient #1 was missing from the hospital until 5:16 AM.

Review of an e-mail correspondence to the Human Resources Director (HRD) dated 4/7/2022 at 1:58 PM from the Night Supervisor revealed, "...I was notified around early 5am [5:00 AM] that the patient was missing. She [LPN #1] stated she saw her around 2ish [2:00 AM] before she came from lunch. She said she was checking her and found out she was no longer in her room. I began to look for her throughout the hospital. [RN #2] and the on call administrator [DRM] was called to figure out what to do next once we looked for her around the building. Then we called the police, and family and provider around 5:30..."

An additional e-mail correspondence to the HRD dated 4/7/2022 at 2:01 PM from the Night Supervisor #1 revealed,"...I also called security and security stated that the camera was not working so [Security Guard #1] was not able to determine if she [Patient #1] had left the building or not. [Security Guard #1] did state that she saw a lady downstairs by door. [Security Guard #1] said it seems like a family member and not a patient because she has came down to the lobby multiple times a night..."

Review of RNT #1's statement dated 4/8/2022 regarding the incident with Patient #1,which was typed by the Director of Quality/Risk Management, revealed, "...per [RNT #1]...That night was kind of hectic and everything. It was me, [LPN #1] and [RN #3] that actually working that front section. I talked to [Patient #1] a few times, she was upset about her right arm. She kept complaining about her right arm. She complains about her arm often. She was talking with [LPN #1] when I first made rounds. [LPN #1] was getting her a pillow and pillow case for her arm...When I made my next second run up there, she was talking to [LPN #1] about her arm. [LPN #1] explained she couldn't put her arm in a sling and she didn't understand why they didn't want her arm in a sling. [Patient #1] stated nobody tried to help her. [LPN #1] said we are trying to help you but we can't do that. [LPN #1] asked to speak with her doctor. Patient got angry and slammed the door...I did rounds to give her time to calm down...After that, I saw her a little bit before 10 [10:00 PM] and she was sitting there. I couldn't see her in the bed like I normally can so I went into her room and she was in the chair and she asked me for help with her arm...I went on and did rounds on the whole floor. I could not say what time she left the building because I was stationed in the back because the front was closed...I can't say how she left the building or what. If you need anything else from me call me...Security didn't call to the floor...I was constantly up in that area..."

Review of LPN #1's employee counseling form dated 4/13/2022 and the RNT #1 employee counseling form dated 4/15/2022 revealed both employees were dismissed for falsification of patient medical records.

Review of the Security Services statement from the Operational Manager regarding the incident with Patient #1 dated 4/14/2022 revealed, "...I received a call at 6:00 AM from the site supervisor in regards to the missing patient. I were informed the officer on third shift let a patient out around 11 PM [11:00 PM]. I immediately rushed to the client to address the situation. Upon arriving I reviewed the cameras with the Facilities Management Director and we discover and verified the patient left the facility around 11 PM [11:00 PM] and was missing Every since until 7:30 AM patient was located near MLG and W [Memphis Light Gas and Water]. However in response I had a meeting with [Security Guard #2] and third shift officer [Security Guard #1]. I had to emphasize the post orders company rules and regulations. [Security Guard #1] was very remorseful to the situation and made a commitment to be more assertiveness and aware..."

Review of the physician progress note on 4/6/2022 at 4:09 PM revealed, "...Unfortunately, patient eloped last night and was found this morning ...Instructed the patient that she is not to leave the room or the hospital. One-to-one sitter has been placed at the bedside..."

The hospital failed to identify upon the patient's admission and after a discussion with the patient's mother of the potential Patient #1 had for elopement; and safety measures such as frequent patient rounding were not implemented by the nursing staff to ensure the safety of the patient.

Based on review of facility policy, medical record review, review of facility video recordings, and interviews, the facility failed to ensure nursing services updated the patient's initial assessment for an identified elopement potential, conducted rounds on patients in order to determine patients' needs and completed a nursing reassessment when there was a change in the patient's status 1 of 1 (Patient #1) sampled patients who eloped from the hospital.

The findings include:

1. Review of the facility's "Assessment, Re-assessment" policy with a reviewed date of "08/19/2021" revealed, "...All inpatients will be assessed and reassessed by clinical disciplines...Physicians-complete a history and physical with 24 hours of admission...Nursing-RN [registered nurse] assessment is initiated as soon as possible but within 8 hours of admission. The assessment, including a functional assessment, is completed with 24 hours...Reassessment are performed by each discipline according to the patient's...status or condition...RN's conduct daily assessments of the patient's condition as documented in the medical record...Reassessment provides ongoing data about the patient's biophysical, psychological, spiritual and social needs...When there is a significant change in the patient's condition, a full reassessment is performed...Plan of Care and treatment may be adjusted as a result or the reassessment performed..."

2. Medical records review revealed that Patient #1 was admitted for rehabilitation following a stroke on 3/24/2022 with diagnosis that included Vascular Dementia, Acute Infarction of the Left Thalamus and Right Sided Weakness.

Review of the adult admission assessment dated 3/25/2022 at 12:00 AM revealed, "... Nursing...Elopement Risk...Is the patient exhibiting restlessness [left blank]...Is the patient independently mobile?: Yes...Is the patient cognitively impaired or did the patient fail the BIMS [Brief Interview for Mental Status]?: No...Does the patient have impaired decision making capability?: No...Does the patient wander?: No...Does the patient have exit seeking behavior?: No...Is there a past history of wandering or exiting a home or facility without the needed supervision?: No...Does the patient verbalize a desire to leave?: No...Has the patient asked questions about the facility rules about leaving the facility?: No...Is the patient exhibiting restlessness and/or agitation?: No...Elopement Risk Total: 1 [low risk]..."

Review of the notes from Psychiatrist #1 dated 3/18/2022 which was presented to the hospital's Director of Risk Management on 3/25/2022 by Patient #1's mother revealed, "...The patient is seen for neurocognitive disorder, panic disorder and depression...The patient's mother is interviewed as well as the patient...The patient is continuing to deteriorate - she is having issues with self-toileting, taking too many things, roving/elopement...engaging in kleptomania...[Patient #1] does not recognize her own house. [Patient #1's mother] states that the patient is sundowning. [Patient #1] is shoplifting from hotels and doctor's office...[Patient #1] does not remember my name and I reintroduce myself to her...[Patient #1's mother] states that the patient is sleeping more during the day and getting her days and nights mixed up; she is sundowning an moving furniture around at night...The patient has left the house a couple of times and gone into the backyard and wandered..."

Review of the consultation report dated 3/28/2022 by Psychologist #1 revealed, "... The patient's psychiatric history is significant for major depressive disorder and panic attacks, as well as vascular dementia, according to a recent psychiatric evaluation and neuropsychological evaluation, which were completed in 03/2022...She is alert and oriented to person; mostly to place; not to time...Her mother reports that she has "sundowners" daily and becomes agitated and restless...During the interview, she displayed short-term memory issues as well as occasional problems with her long-term memory. [Patient #1] reported she had no sisters, but her mother reports she has two sisters who check on her regularly...She has engaged in kleptomania related to her cognitive dysfunction. She is followed by [Psychiatrist #1] and had a recent neuropsychological evaluation...Her judgement and insight are poor cognitive dysfunction, I would recommend that the patient have a 24-hour supervision upon discharge from the rehab hospital in order to monitor her safety and self-care..." . There was no documentation nursing had conducted a reassessment of Patient #1 following the Psychologist's interview with the patient to determine any safety needs for Patient #1.

Review of the hospital's video recording of the hallway where Patient #1's room was located revealed on 4/5/2022 the last time nursing rounded on Patient #1 was at 9:37 PM. Nursing had documented in the patient's medical record that the patient had been assessed throughout the night.

Review of the hospital's Security Services statement from the Operational Manager dated 4/14/2022 revealed Patient #1 was missing from the hospital and had been let out of the hospital by a Security Guard who was monitoring the front door on 4/5/2022 at 11:00 PM.

Review of the nurse practitioner progress notes dated 4/6/2022 at 1:19 PM revealed, "...patient wondered out of the facility. 911 was called and she was eventually found few hours later ...On examination, she was alert and oriented x 1...with periods of forgetfulness which is not new..."

Review of the physician progress note on 4/6/2022 at 4:09 PM revealed, "...Unfortunately, patient eloped last night and was found this morning ..."

Review of the nursing assessment dated 4/6/2022 at 9:45 AM revealed, "...On return from the elopement that occurred on 4/5/2022 at 23:00 PM [11:00 PM]. There was no documentation a complete nursing reassessment was performed following the patient's return to the facility. The patient had been missing from the facility for 10 and a half hours.

In an telephone interview on 5/3/2022 beginning at 8:45 AM with Patient #1's mother she stated that on the second day (3/25/2022) of Patient #1's admission she met with the Director of Quality/Risk Management and Psychologist #1 and presented them with the report from Psychiatrist #1 which stated Patient #1 had problems with elopement and was taking things that did not belong to her.

Interview on 5/17/2022 at 11:33 AM in the conference room the Director of Quality/Risk Management stated, "...On the second day of admission [Patient #1's mother] did share with me that the patient had a neuro/psych history. [Patient #1's mother] specifically told me [Patient #1] would rob the nurses blind...I told the nurse to leave the drug cart outside of the room and not to bring it in the room when they were administrating medications. I also called the attending physician and let [Psychologist #1] know. [Psychologist #1] saw [Patient #1] in a consult. The consult was referred by [Physician #1] for a confidential psychological consultation".

This adult admission assessment was not updated after Patient #1's mother had spoken with the Director Quality/Risk Manager and the Psychologist #1 about Patient #1's problem with elopement and Kleptomania.

In an interview on 5/17/2022 at beginning at 1:43 PM in the conference room the Director of Quality/Risk Management (DRM) stated, "...Nurses and RNTs [Rehabilitation Nurse Techs] are expected to round every two hours. Nurses do the odd hours and the RNT do even...".

Refer to A144.

Based on policy review, medical record review and interview, the hospital failed to ensure the nursing staff developed and implemented a nursing care plan which reflected individualized patient needs for 1 of 1 patients (Patient #1) patients who had identified safety needs and a care plan to meet those safety needs was not developed and implemented.

The finding include:

1. Review of the facility's "Plan for the Provision of Patient's Care" policy reviewed on "03/07/201" revealed, "...Our focus is to treat the whole patient as an individual with unique and complex physical, psychosocial...attributes contributing to his or her identify. Care is planned and provided via an interdisciplinary approach utilizing information contributed by the patient, family, and other support person...The rehabilitation patient care process consists of a plan and orderly sequence of individualized services designed to meet the unique needs of each person...Each member of the team is accountable for supporting and enhancing the plan of care being implemented by other members of the rehabilitation team...uses a problem-solving approach that includes...Individual patient goals and interventions...All individuals responsible for the assessment, treatment or care of patients are competent in the following...The ability to obtain and interpret information in terms of the patient's needs..."

Review of the facility's "Assessment, Re-assessment" policy with a reviewed date of "08/19/2021" revealed, "...All inpatients will be assessed and reassessed by clinical disciplines...Physicians-complete a history and physical with 24 hours of admission ...Nursing-RN assessment is initiated as soon as possible but within 8 hours of admission. The assessment, including a functional assessment, is completed with 24 hours...Reassessment are performed by each discipline according to the patient's ...status or condition...RN's conduct daily assessments of the patient's condition as documented in the medical record...Reassessment provides ongoing data about the patient's biophysical, psychological, spiritual and social needs...When there is a significant change in the patient's condition, a full reassessment is performed...Plan of Care and treatment may be adjusted as a result or the reassessment performed..."

2. Medical records review revealed that Patient #1 was admitted for rehabilitation following a stroke on 3/24/2022 with diagnosis which included Vascular Dementia, Acute Infarction of the Left Thalamus and Right Sided Weakness.

Review of the adult admission assessment on 3/25/2022 at 12:00 AM revealed, " ...Elopement Risk ...Is the patient exhibiting restlessness [left blank]...Is the patient cognitively impaired or did the patient fail the BIMS [Brief Interview for Mental Status]?: No...Does the patient have impaired decision making capability?: No...Does the patient wander?: No...Does the patient have exit seeking behavior?: No...Is there a past history of wandering or exiting a home or facility without the needed supervision?: No...Does the patient verbalize a desire to leave?: No...Has the patient asked questions about the facility rules about leaving the facility?: No...Is the patient exhibiting restlessness and/or agitation?: No...Elopement Risk Total: 1[low risk]..."

Review of the progress note from the Psychiatrist dated 3/18/2022 and provided to the hospital by Patient #1's mother revealed, "...The patient is seen for neurocognitive disorder, panic disorder and depression ...The patient's mother is interviewed as well as the patient...The patient is continuing to deteriorate - she is having issues with self-toileting, taking too many things, roving/elopement...engaging in kleptomania...[Patient #1] does not recognize her own house. [Patient #1's mother] states that the patient is sundowning. [Patient #1] is shoplifting from hotels and doctor's office...[Patient #1] does not remember my name and I reintroduce myself to her...[Patient #1's mother] states that the patient is sleeping more during the day and getting her days and nights mixed up; she is sundowning an moving furniture around at night...The patient has left the house a couple of times and gone into the backyard and wandered..."

Review of the consult on 3/28/2022 from Psychiatrist #1 revealed The patient's psychiatric history is significant for major depressive disorder and panic attacks, as well as vascular dementia, according to a recent psychiatric evaluation and neuropsychological evaluation, which were completed in 03/2022...She is alert and oriented to person; mostly to place; not to time...Her mother reports that she has "sundowners" daily and becomes agitated and restless...During the interview, she displayed short-term memory issues as well as occasional problems with her long-term memory. [Patient #1] reported she had no sisters, but her mother reports she has two sisters who check on her regularly...She has engaged in kleptomania related to her cognitive dysfunction. She is followed by [Psychiatrist #1] and had a recent neuropsychological evaluation...Her judgement and insight are poor cognitive dysfunction, I would recommend that the patient have a 24-hour supervision upon discharge from the rehab hospital in order to monitor her safety and self-care..." .

In an telephone interview on 5/3/2022 beginning at 8:45 AM with Patient #1's mother she stated, "...on the second day of [Patient #1's] admission I met with the [Director of Quality/Risk Management] and [Psychologist #1] and presented them a report from the Psychiatrist that stated [Patient #1] had problems with elopement and was taking things that did not belong to her..."

In an Interview on 5/17/2022 at 11:33 AM in the conference room the Director of Quality/Risk management stated, "...On the second day of admission [Patient #1's mother] did share with me that the patient had a neuro/psych history. [Patient #1's mother] specifically told me [Patient #1] would rob the nurses blind...I told the nurse to leave the drug cart outside of the room and not to bring it in the room when they were administrating medications. I also called the attending physician and let the Psychologist know. [Psychologist #1] saw [Patient #1]..."

Review of Patient #1's most current Interdisciplinary Plan of Care dated 3/25/2022 at 11:00 AM revealed no documentation of a diagnosis, problems, goals or interventions for Vascular Dementia, Kleptomania or Elopement.

Patient #1 eloped from the hospital on 4/5/2022 at 11:00 PM and was found 10 and one half later. There were no safety interventions in place to prevent Patient #1 from eloping from the hospital.

Refer to A144.