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NORTH CENTRAL BRONX HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on medical record review, document review and interview, in one (1) of 25 medical records reviewed, the facility did not develop and implement policies to ensure that patients received care in a safe setting. Specifically, the facility did not ensure that a patient with a history of psychiatric illness received an assessment upon admission to mitigate the risk of elopement (Patient #1).
These lapses may have placed patients at risk for harm.
Findings include:
Review of the medical record for Patient #1 identified: On 1/13/17, a 56-year-old male was admitted to a medical unit with generalized weakness and fever. The patient's Psychiatric history was significant for Schizophrenia.
On 1/16/17 at 5:00 pm nurse reported the patient stated that he wanted to leave the hospital and he was redirected.
On 1/18/17 nursing note of 4:15 pm indicated that staff assigned to check the patient's vitals discovered he was missing from the unit at 4:00 pm.
There was no documentaion in the medical record that the patient was assessed and identified as an elopement risk.
Review of facility's policy and procedure titled "Absent Without Authorization," last revised 2/1/15, stated the following: "Patients who are developmentally delayed or have a history of wandering will be placed on one to one observation for elopement risk immediately upon arrival".
The policy did not include the assessment of other categories of patients who might be at risk for elopement.
At interview with Staff A, Nurse Manager on 2/13/17 at 12:30 PM, she acknowledged the findings.
NURSING CARE PLAN
Tag No.: A0396
Based on medical record review and interview, in one (1) of 25 medical records reviewed, nursing staff did not develop a care plan, and implement actions necessary to ensure the safety of a patient at risk for elopement.
Findings include:
Review of the medical record for Patient #1 identified: On 1/13/17, a 56-year-old male was admitted to a medical unit with generalized weakness and fever. The patient's Psychiatric history was significant for Schizophrenia.
On 1/16/17 at 5:00 pm, the nurse reported the patient stated he wanted to leave the hospital and he was redirected.
On 1/18/17 nursing note of 4:15 pm indicated that staff assigned to check the patient's vitals discovered he was missing from the unit at 4:00 pm.
The nursing plan of care developed for Patient #1 on admission on 1/13/17 on 8:09 pm did not address the patient's risk for elopement due to his history of psychiatric illness. There was no revision of the plan after the patient expressed a desire to leave the facility on 1/16/17 at 5:00 pm.
At interview with Staff A, Nurse Manager on 2/13/17 at 12:30 PM, she acknowledged the finding and reported that nursing staff does not conduct elopement risk assessment for every patient admitted to the Medical/Surgical unit, including patients with psychiatric health concerns.