Emory Houston Hospital Warner Robins

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 52769 Based on review of facility policies and procedures, medical records, facility documents, and staff interviews it was determined that the facility failed to protect and promote the rights of two patient (P) (P#1 and P#6), of seven patients reviewed (P#1, P#2, P#3, P#4, P#5, P#6 and P#7) when: 1. P#1, with a history of dementia left his room without staff detection and was observed sitting on a bench near a door to the outside on 9/28/25 at approximately 6:22 a.m. P#1 was returned to the unit unharmed. 2. P#6 eloped from the facility on 11/10/25 without staff detection after removing telemetry monitoring equipment and an intravenous (IV) catheter. P#6 was unable to be located by staff. Findings included: Cross refer to A0144 as it relates to the facility’s failure to provide care in a safe setting.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 52769 Based on review of facility policy and procedures, medical records, facility documents, and staff interviews it was determined that the facility failed to ensure that two patient (P) (P#1 and P#6) of seven patients reviewed (P#1, P#2, P#3, P#4, P#5, P#6 and P#7) received care in a safe environment. Specifically, P#1 and P#6 eloped from the unit without staff detection. Findings included: A review of the facility’s policy titled “Patient Rights and Responsibilities,” effective 8/18/25 revealed the facility was committed to improving the outcome of all patients by respecting and understanding the patient’s rights, responsibilities, and values. A review of the facility policy titled “Constant Visual Observer and Visual Observer Assessment, Implementation, and Discontinuation,” effective 7/26/23 revealed that a Visual Observer (VO) Level 2 Close Observation was a person or persons provided by the facility to frequently observe and document on patient’s status. (Physician ORDER was required). The facility recognized that Constant Visual Observers (CVO) may be utilized to provide continuous observation of a patient to support safety. The nurse used a clinical assessment approach to determine clinically based assignment and implementation. There was a process in place to monitor CVO usage to ensure appropriate assignment and management of resources. Patients that needed visual observation included patients that had a secondary diagnosis such as dementia, substance abuse affecting cognitive issues, unable to follow safety instructions due to factors such as blindness, were at risk for falls or injury, interfered with vital medical devices or pulled out lines, and if they were at risk for elopement. 1. A review of the nurses notes dated 9/25/25 at 4:52 p.m. revealed that P#1 constantly tried to get out of the bed. P#1 attempted to remove monitoring equipment and attempted to remove the Coban (elastic bandage) covering his intravenous (IV) access. It was further documented that P#1 was a fall risk. A review of the provider’s history note dated 9/25/25 at 7:52 p.m. revealed that P#1’s family member reported that he had memory loss and depression. Further review under physical exam revealed that P#1had altered mental status and memory loss. The providers note continued to document P#1’s dementia was chronic with moderate severity was present on admission. A review of the attending physician’s discharge instructions on 9/27/25 at 11:32 a.m. documented that P#1 was not mentally back to his baseline. The attending documented a psychiatric consult for P#1’s waxing and waning confusional and delirious state in setting of dementia. A nursing note dated 9/28/25 at 8:11 a.m. revealed that Registered Nurse (RN) DD received a call reporting that P#1 was found outside sitting on a bench at approximately 6:22 a.m. on 9/28/25. RN DD documented that she found P#1 sitting calmly on the bench on the inner facility exit door. P#1 was taken back to his room by wheelchair. It was noted that P#1’s private sitter was found sleeping at the time he was missing. Continued review revealed that RN DD last visited P#1’s room at 5:49 a.m. to give morning medications and the patient clinical technician (PCT) last visited P#1’s room at 5:56 a.m. to check P#1’s blood glucose levels (measurement of sugar in your blood from the food you eat). RN DD noted after finding P#1, she called his family member to report the incident. P#1’s family member requested a sitter from the hospital at that time. A review of P#1’s interval history documented by the physician on 9/28/25 revealed that P#1’s daughter was upset because P#1 walked out his room and took the stairs to the facility lobby. Continued review revealed that a private sitter was in P#1’s room at the time he left the room, but the sitter had been asleep and did not see the patient leave the room. After this incident, the family requested a hospital sitter for night shifts, and the family would continue to pay for a private sitter during the day. A review of a nurse practitioners’ history of present illness notes, dated 9/28/25 at 11:39 a.m. revealed P#1 was a resident at memory care facility. Further review of P#1’s mental status exam, revealed that P#1 had significant difficulty with his memory and had moments of confusion. It was also noted that P#1 had some episodes of paranoia (intense distrust and suspicion of others) and delusions (a firm, false belief that is resistant to reason or evidence). A review of the facility Complaint and Grievance Log revealed that P#1’s family member submitted a complaint on 9/28/25 related to an elopement on 9/28/25 The facility’s incident report indicated that P#1 was discovered to be outside sitting on a bench at 6:22 a.m. on 9/28/25. The hospital staff was unaware that P#1 walked outside. The nurse last saw P#1 in his room at 5:49 a.m. and the Patient Care Technician (PCT), last saw P#1 in his room at 5:56 a.m. P#1 had a personal sitter provided by the family who had fell asleep in P#1’s room. 2. A review of P#6’s medical record revealed that she had presented to facility emergency department via emergency medical services on 11/9/25 and was admitted. Review of a nursing note dated 11/10/25 at 9:58 a.m. revealed that at 9:30 a.m., P#6 was not in her room and the patient’s telemetry box, and intravenous (IV) line were found at the bedside. A nursing note on 11/10/25 at 10:03 a.m. revealed that the writer was notified by the primary nurse that P#6 was no longer in her room. The record further revealed that the writer and nurse searched several areas of hospital and could not locate P#6. During an interview with the Director of the Medical Unit (DMU) BB 11/18/25 at 9:15 a.m. on the second-floor main unit, she explained that the back door on unit two required a badge to exit. DMU BB further explained that the stairwell in the back of the unit did not require badge access and that anyone could exit at any time. During a phone interview with the Registered Nurse (RN) DD on 11/18/25 at 10:27 a.m. ,she recalled that she was the night nurse for P#1 on the morning of his elopement. RN DD recalled that she received a phone call reporting that P#1 was sitting on a bench in the hospital corridor. RN DD explained that she then found P#1 sitting on a bench just inside an exit door. RN DD recalled that P#1 informed her that he was waiting for the bus. RN DD learned of P#1’s elopement with the phone call and she had observed P#1 in his room 20 minutes prior to getting the phone call. RN DD reported that she believed P#1 left the unit by going down the stairwell that was close to his room. She recalled that the unit secretary and the charge nurse were sitting at the front desk and would have seen him (P#1) if he took the elevator. An interview was conducted with Assistant Nurse Manager (ANM) RR on 11/19/25 at 9:40 a.m. in the conference room. She recalled that on 11/10/25, the primary nurse notified her that P#6 was not in her room and that the telemetry box and IV were still in the room. She said a search of the hospital was conducted and the house supervisor and doctor were made aware. ANM RR stated that to her knowledge, P#6 didn’t give any indication that she wanted to leave. She said considering the location of P#6’s room, P#6 would have had to walk past the nursing station to take the elevator downstairs. A follow up interview was conducted with Assistant Nurse Manager (ANM) RR on 11/19/25 at 10:49 a.m. in the conference room. ANM RR recalled that P#1’s family member asked for a patient sitter on 9/26/25. ANM RR explained that a patient sitter assessment was used to determine if patients met the criteria to qualify for a patient sitter. ANM RR reported that P#1 did not score a six on the assessment tool, which was the number needed to qualify for a sitter. ANM further reported that P#1’s family member was given a resource list she could use to hire a private sitter. ANM RR further reported that she did not have documentation that the sitter tool was used for P#1.. An interview was conducted with Patient Relations Representative (PRR) TT on 11/19/25 at 11:10 a.m. in the conference room. PRR TT remembered talking to P#1’s family member about the complaint. PRR TT further reported the P#1’s family member wanted a sitter for P#1 because she (family member) was unable to stay at the hospital 24 hours a day. PRR TT recalled that she spoke to ANM RR about the request for a sitter on 9/26/25 and ANM RR confirmed that she would follow up with P#1’s family member. An interview was conducted with Patient Relations Representative (PRR) UU on 11/19/25 at 11:28 a.m. in the conference room. PRR UU recalled following up with P#1’s family member on 9/27/25 to see if ANM RR responded to the request for P#1 to get have a sitter. P#1’s family member reported that ANM RR did not stop by to speak to her. PRR UU stated that P#1’s family member reported that she paid for a private sitter. A follow-up interview was conducted with DMU BB on 11/19/25 at 12:00 p.m. in the conference room. DMU BB reported that a sitter assessment tool was only completed if the patient was considered at high risk to receive a sitter. DMU BB further reported a patient with dementia could be placed in a room close to the nurse’s station if a room was available. An interview was conducted with Registered Nurse (RN) VV on 11/19/25 at 12:14 p.m. via telephone in the conference room. RN VV said she received a call from the telemetry technician that the patient was no longer in the room and left the intravenous line in the sink. RN VV said she informed the charge nurse about P#6’s absence and then they both conducted a hospital search for P#6. RN VV stated the last time she saw P#6 in her room was about an hour before she was discovered missing.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 49224 Based on medical record reviews, staff interviews, and facility policies and procedures, it was determined that the facility failed to follow facility policies and procedures for nursing care. Specifically, the facility failed to provide daily hygiene care for one patient (P) (P#1) of four patient medical records reviewed (P#1, P#2, P#3, P#4). Findings include: A review of medical records revealed that P#1 was admitted to the facility on 7/30/25 at 4:22 p.m. for left elbow pain post elbow surgery. P#1’s medical record revealed on 7/30/25 at 4:29 p.m. the implementation of a protocol started for daily hygiene to be conducted at 1:00 a.m. and 1:00 p.m. P#1’s medical record failed to reveal that P#1 received daily nightshift hygiene care on 7/31/25 through 8/4/25. The record also failed to reveal why P#1 did not receive hygiene care during nightshift on 7/31/25 through 8/4/25. A review of the facility’s policy titled “Nursing - Standards - Assessment Nursing Care and Documentation,” effective 11/15/23 revealed an initial nursing history/assessment was completed within eight hours of admission by an RN. Reassessment of the patient occurred no less than each shift and as warranted by current condition. Assessment data was utilized by the RN to develop a plan of care. The nursing staff, patient, and other members of the health care team implemented a plan of care for the patient and evaluated and revised its content as needed. Documentation of care would be concise, pertinent, and reflect the patient’s status, nursing intervention, and patient response. A review of the facility’s policy titled “Nursing - Standards: Of Care” effective 4/29/25 revealed hygiene and physical comfort measures were implemented to support activities of daily living that included periodic baths, hand washing, mouth care, hair grooming, fingernails and toes cleaned, skin care, assessment and changing of dressings, bandages, binders, or elastic stockings, and bed linen changes. Assistance in turning in the bed was given to the patient who could not turn themselves a minimum of every two hours and as needed. An interview was conducted with Registered Nurse (RN) EE on 8/11/25 at 3:16 p.m. in a conference room. RN EE stated he was the Nurse Manager for the Five North West Ortho-Surgical Unit. He said night-shift daily hygiene care of patients was expected to be completed and documented into the patient’s medical chart. RN EE agreed with this writer that P#1’s medical charting did not reflect the completion of night-shift daily hygiene care from 7/31/25 through 8/4/25. He said P#1’s medical chart was noted as documented to read, “not done; due to complete” hygiene care from 7/31/25 through 8/4/25. An interview was conducted with RN HH on 8/12/25 at 11:07 a.m. in the conference room. RN HH stated she was the clinical coordinator and conducted rounding and reviewed staff charting. She said patients in odd number rooms received hygiene care during the nightshift. She agreed that P#1’s EMR did not reflect that nightshift daily hygiene was completed for P#1 from 7/31/25 through 8/4/25. She said nightshift hygiene care was noted in P#1’s medical chart as “not done; due to complete” from 7/31/25 through 8/4/25. She said after “shift assessment” was selected and completed within a patient’s medical record within the facility’s electronic medical record (EMR) system, when more than two criteria was selected the EMR prompted interventions that should be implemented, such as “apply dressing”, etc. A follow-up interview was conducted with RN EE on 8/12/25 at 12:21 p.m. at the Five North West Unit’s nurse’s station. RN EE stated that patients in odd number rooms received daily hygiene care during nightshift and the patients in even number rooms received their care during the dayshift. An interview was conducted with Patient Care Technician (PCT) BB on 8/12/25 at 2:15 p.m. in the conference room. PCT BB stated he worked on Five North West on the dayshift and took care of P#1. He said, because P#1 didn’t speak too much, he checked up on P#1 more frequently. He said patients in odd number rooms received hygiene care during the nightshift and odd number rooms received their care during the dayshift. PCT BB stated the PCT’s documentation of hygiene care was done on the patient’s room board and the charge nurse was notified when hygiene care was done.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 49224 Based on observation, staff interviews, and facility policies and procedures, it was determined that the facility failed to follow facility policies and procedures for properly storing medications prior to administration. Specifically, on 8/12/25 at 11:57 a.m., a single one-gram vial of Cefepime (antibiotic) and one IV (a medical process that administers fluids, medications and nutrients directly into a person’s vein) mini bag were observed on top of a computer on wheels (COW) unsecured in the hallway. Findings include: On 8/12/2025 at 11:57 a.m., a computer on wheels (COW) was observed in the unit hallway for approximately two and a half minutes with a single one-gram vial of Cefepime and one IV mini bag on top of it. No staff members were presently visible in the hallway or standing next to the COW when the unsecured medication was observed. A review of the facility’s policy titled “Nursing - Medication: Floor Stock, (Non-Emergency) - Acquisition and Storage in Patient Care Areas,” effective 6/27/24, revealed unauthorized persons could not obtain access to medications. No medications would be left at the patient’s bedside, and no medications were left sitting out on counters, carts in hallways or unattended in any areas. Medication carts in hallways must be locked when not attended, and when not in use, must be at the Nursing Station under continuous observation. Medication administration assignments in Patient Care Areas would be strictly maintained to ensure adequate security for medications. A review of the facility’s policy titled “Pharmacy - Procedure: Medication Administration Guidelines,” effective 6/24/25 revealed no medications would be left unsecured or at the beside. An interview was conducted with Registered Nurse (RN) EE on 8/12/25 at 11:57 a.m. on the hallway outside a patient’s room. RN EE stated the medication and IV mini bag that this writer discovered unsecured on top of a COW was medication for a patient and the nurse that left the medication was getting more medication for a patient. RN EE stated it was not practice for staff to leave medication sitting out on top of the COW. He said medications were not to be left in the hallway unsecured but were supposed to be locked away inside the COW. An interview was conducted with RN KK on 8/12/25 at 11:59 a.m. on the hallway outside a patient’s room. RN KK stated she left the medication discovered by this writer on top of the COW. She said medications were not supposed to be left out unsecured. RN KK stated medications were supposed to be locked inside the COW cart.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 35697 Based on record review, interview, and facility policy review, the facility failed to ensure discharge instructions were provided for 1 (Patient #2) of 3 sampled patients reviewed for discharge instructions. Findings included: A facility policy titled, “[Facility Name] - Emergency Department - Process: Patient Discharge,” dated 08/25/2022, indicated, “C. Each patient, parent or responsible party is to receive a copy of the discharge instructions, have them explained and acknowledge understanding of instructions by signing the instruction sheet.” Patient #2’s “Patient Visit Information” dated 11/01/2023, indicated the patient was treated for left sided epistaxis (nosebleed). The Patient Visit Information included instructions for home care related to nosebleeds in adults, nasal packing, and included that the patient should follow-up with their healthcare provider and the nasal packing should be rechecked or removed within two to three days. The Patient Visit Information revealed the “Patient Signature Page” was unsigned by the patient in the area that indicated “I have read and understand the instructions given to me by my caregivers.” During interview on 06/10/2024 at 3:45 PM the Emergency Department (ED) Nurse Manager stated that the ED staff provided discharge education and would have the patient sign the paperwork prior to leaving the facility. On 06/11/2024 at 1:15 PM, the ED Nurse Manager stated that once a patient was educated on the discharge instructions and follow-up process, the patient signed the discharge paperwork. The ED Nurse Manager stated she was not sure if the signed patient signature page was than scanned into the electronic medical record (EMR) that was stored by the Medical Record’s department. On 06/11/2024 at 2:00 PM, the ED Nurse Manager confirmed that Patient #2’s signature was missing from the patient signature page, which would confirm the patient was educated on discharge instructions.”