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Based on record review and interview, the hospital failed to ensure the patient's right to be free from all forms of neglect. This deficient practice was evidenced by failing to monitor a patient on wandering precautions while being transported off the inpatient unit for procedure.
Findings:

Review of hospital policy number 5056, titled "Reporting Abuse and/or Neglect," last reviewed 10/2023, revealed in part: "Scope: This policy applies to all health care providers. Purpose: The purpose of this policy is to: Protect patients whose physical or mental health and welfare are endangered by abuse and/or neglect and may be further threatened by the conduct of those responsible for their care and protection. Protect patients who cannot physically or mentally protect themselves and who are harmed or threatened with harm through action or inaction by themselves or by individuals responsible for their care."

Review of hospital policy number 5998, titled "Against Medical Advice, Wandering and Elopement," effective date 04/2023, revealed in part: "Purpose: To provide guidelines for preventing and addressing a discharge against medical advice (AMA), and prevention of elopement and wandering within patient care areas. Definitions: Wandering - The act of a patient moving beyond the view of staff or out of the care area with or without the intention of leaving. The patient may not have a specific destination in mind and may be unaware of their surroundings or personal safety. This situation is generally encountered with patients who are temporarily or permanently cognitively impaired. Cognitively Impaired - A person who may have trouble remembering, learning new things, concentrating, or making decisions affecting their everyday life. A patient may become temporarily cognitively impaired as a result of the treatment. Policy: B. Patients recognized as potentially at risk of wandering (those who are cognitively impaired) will have safety precautions implemented. Procedure: 2. Patient Wandering: a. Wandering precautions will be initiated for patients at risk, particularly for those who are cognitively impaired. Wandering precautions consist of: i. if possible, patients will be placed in a room near the nurse's station. ii. Bed alarms may be used. iii. Identify patient wandering risk during safety rounds. iv. Encourage family to stay with the patient. v. Assign a safety sitter as needed. b. In the event the patient is missing from the patient room/treatment area and suspected of wandering, begin a search of the unit immediately. e. If the wandering patient is not found on the unit, call for a Dr. Flight code and notify the following for immediate assistant in locating the patient: i. unit charge nurse/manager/director ii. House Supervisor iii. Public Safety iv. Resident/attending physician."

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 04/07/2025 with a diagnosis of Hypoxic Respiratory Failure and Severe Protein Malnutrition. Patient #1 had a history of Metastatic Cancer and a previous stroke. On 04/15/2025 the provider progress note revealed in part: Delirium/Agitation: Patient getting increasingly frustrated about staying in the hospital. Amenable to staying until imaging completed. On 04/15/2025 at 12:38 PM orders were placed for Wandering precautions and to Assign a virtual safety sitter. On 04/17/2025, self-report revealed in part: after completing radiation oncology testing Patient #1 was placed alone on a stretcher in the hallway to await transport back to his inpatient room. Prior to transport arriving to get Patient #1, Patient #1 walked out and exited the facility while he was unsupervised by staff.

Review of Patient #1's Physician Discharge Summary from 04/17/2025 at 9:46 AM, entered by S10RMD, revealed in part: Hospital Course: "During his stay, we were concerned about his full comprehension of the situation as well as whether he would follow-up outpatient for his treatments. Patient became increasingly agitated over staying in hospital, left AMA on 04/17/2025 morning." Further review of the Physician Discharge Summary revealed an attestation by S11MD, entered on 04/23/3035 at 11:52 AM. This attestation revealed in part: Apparently patient frustrated and agitated because he's still here in hospital. Notified by resident team that patient left AMA. We called patients neighbor who stated she can help patient sometime with his outpatient follow up appointments, but is unable to take patient to every appointment.

Review of Patient #1's nursing notes revealed in part the following:
04/17/2025 at 7:30 AM- Patient #1 attempted to leave room to walk to procedure. Received call from Tele-sitter of situation. RN attempted to redirect patient, patient continued to walk to elevator. Dr. Flight (elopement) called. Security met patient in elevator and was redirected back to his room where the MD met with patient. "Soon after transport took patient via stretcher off floor."
04/17/2025 at 8:39 AM- Transport told me they were requested to pick Patient #1 up, but when they arrived Patient #1 was unable to be located. MD notified via phone. Dr. Flight (elopement) called over intercom. Notified charge nurse of situation.
04/17/2025 at 10:51 AM- "Therapist called me at approximately 9:30 AM to report Patient #1 had walked out after receiving treatment while waiting on stretcher for transport. Notified charge nurse."

Further review of nursing notes for Patient #1 failed to reveal documented evidence that the sending nurse communicated to the receiving nurse/staff in the cancer center clinic that Patient #1 was on wandering precautions or that Patient #1 attempted to leave the inpatient unit just prior to being transported. Patient #1's medical record also failed to reveal documented evidence that Patient #1's safety precautions were maintained while Patient #1 was off the inpatient unit for a procedure.

In an interview on 05/20/2025 at 3:30 PM, S2RM and S9RN confirmed that there was no documentation that the sending nurse communicated to the receiving nurse/staff that Patient #1 was on wandering precautions. S2RM also confirmed that there is no documented evidence that Patient #1's wandering precautions were maintained while Patient #1 was off the inpatient unit for a procedure.

Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by failure of the registered nurse to supervise staff to ensure observations were being performed and documented hourly for 1 (#1) of 1 (#1) patients reviewed who had orders for a virtual safety sitter.
Findings:

Review of hospital policy number 6112, titled "Continuous Visual Monitoring Virtual Patient Sitter Policy," last revised 02/2022, revealed in part: "Purpose: Initiation of continuous visual monitoring is a nursing intervention. It can be utilized to ensure patient safety as an additional tool in the plan of care for patients at high risk for falls, confusion, impaired mobility, etc. Procedure: Virtual Patient Observation (VPO) Inclusion Criteria: Patient warrants a closer level of observation, based on the clinical judgement of the primary care giver, but does not meet any of the exclusion criteria. Examples of inclusion criteria include: ii. Delirium/Restlessness iii. Confusion, acute or chronic v. Elopement risk. Primary Care Giver Responsibility: Notify patient and family that continuous visual monitoring will be implemented to promote patient safety. If the patient/family refuse telesitter monitoring, a patient sitter will be placed in the room. Reassess patient at least every four (4) hours for the need to continue VPO. Respond in a timely manner when notified by the Tele-monitor staff or the Stat Alarm. Notify Tele-monitor staff when patient is removed from room for test, therapy, walks, etc. Tele-Monitor Staff Responsibility: Receive report on VPO candidate from primary care giver. Record initiation of Telesitter on patient log and the reason for continuous visual monitoring. Monitor patients and attempt to verbally redirect patient when necessary. Call floor staff directly by phone if an issue arises with the patient that needs staff attention. Activate Stat Alarm when a patient is not following direction and/or situation is emergent. Document patient's activities at least every two hours on the TeleSitter monitoring log if paper log is utilized. Perform hourly virtual rounds on patient. Rounds to include environmental check and verbal check-in if appropriate. Place status of patient when out of room (POOR) and follow up with expected return times. Provide report to oncoming staff regarding patient status and activity for the shift. Include notable behaviors or trends in overall patient activity."

Review of hospital policy number 5998, titled "Against Medical Advice, Wandering and Elopement," effective date 04/2023, revealed in part: "Purpose: To provide guidelines for preventing and addressing a discharge against medical advice (AMA), and prevention of elopement and wandering within patient care areas. Definitions: Wandering - The act of a patient moving beyond the view of staff or out of the care area with or without the intention of leaving. The patient may not have a specific destination in mind and may be unaware of their surroundings or personal safety. This situation is generally encountered with patients who are temporarily or permanently cognitively impaired. Cognitively Impaired - A person who may have trouble remembering, learning new things, concentrating, or making decisions affecting their everyday life. A patient may become temporarily cognitively impaired as a result of the treatment. Policy: B. Patients recognized as potentially at risk of wandering (those who are cognitively impaired) will have safety precautions implemented. Procedure: 2. Patient Wandering: a. Wandering precautions will be initiated for patients at risk, particularly for those who are cognitively impaired. Wandering precautions consist of: i. if possible, patients will be placed in a room near the nurse's station. ii. Bed alarms may be used. iii. Identify patient wandering risk during safety rounds. iv. Encourage family to stay with the patient. v. Assign a safety sitter as needed. b. In the event the patient is missing from the patient room/treatment area and suspected of wandering, begin a search of the unit immediately. e. If the wandering patient is not found on the unit, call for a Dr. Flight code and notify the following for immediate assistant in locating the patient: i. unit charge nurse/manager/director ii. House Supervisor iii. Public Safety iv. Resident/attending physician."

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 04/07/2025 with a diagnosis of Hypoxic Respiratory Failure and Severe Protein Malnutrition. Patient #1 had a history of Metastatic Cancer and a previous stroke.

Review of Patient #1's provider progress note on 04/15/2025 revealed in part: Assessment/Plan: Delirium/Agitation: "Patient getting increasingly frustrated about staying in the hospital. Amenable to staying until imaging completed. Wandering/Delirium precautions."

Review of Patient #1's physician orders revealed on 04/15/2025 at 12:38 PM the following orders were placed:
Wandering precautions
Assign a virtual safety sitter

Review of Patient #1's medical record for virtual safety sitter observation/documentation revealed in part the following:
04/15/2025 at 4:29 PM- Virtual Patient Observation sitter initiated. Indication for sitter- patient safety. Patient Observation Assessment: Location- Room, Activity- Laying in bed, Behavior- Quiet.
04/15/2025 at 6:00 PM- Virtual Patient Observation sitter continued. Indication for sitter- patient safety. Patient Observation Assessment: Location- Room, Activity- Laying in bed, Behavior- Quiet.

Review of Patient #1's medical record failed to reveal documentation that hourly virtual rounds were performed after 04/15/2025 at 6:00 PM by the virtual safety sitter. Further review of Patient #1's medical record revealed that on 04/17/2025 at 11:52 AM the virtual safety sitter order was automatically discontinued when Patient #1 was discharged AMA out the system.

In an interview on 05/20/2025 at 3:45 PM, S2RM and S3DQPS confirmed that hourly virtual rounds were not documented after 04/15/2025 at 6:00 PM by the virtual safety sitter per hospital policy on Patient #1. S2RM and S9RN also confirmed at this time that the only 2 virtual safety sitter observations documented were on 04/15/2025 at 4:29 PM and 6:00 PM.