Aurora Medical Center Sheboygan County

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 27433 This CONDITION is NOT MET as evidenced by: Based on record review and interview, the facility failed to follow policy, monitor, and react timely to prevent the elopement for 1 of 1 patients (Patient #1). Findings include: The facility failed to implement interventions adequate to prevent the elopement of Patient #1. SEE TAG A-0144 34337 Immediate Jeopardy was determined on 7/3/2024 at 2:35 PM under 42 CFR 482.15 regarding the facility’s failure to implement safety precautions adequate to mitigate elopement risk based on patient need. Facility staff were notified of the Immediate Jeopardy on 7/3/2024 at 2:35 PM. The Immediate Jeopardy was removed on 7/3/2024 at 4:45 PM after the facility discontinued use of camera monitoring as a safety intervention for high risk patient behaviors and developed and implemented an elopement precautions protocol on the behavioral health unit. The deficient practice remains at a Condition level pending evidence of ongoing sustainable and systemic implementation of corrective actions.”

“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: 34337 Based on record review and interview, facility staff failed to implement safety precautions adequate to mitigate elopement risk for 1 of 4 patients reviewed with high risk for elopement (Patient #1) in a total sample of 15 patients reviewed. Findings include: Review of facility policy “BH Patient Observation and Monitoring” dated 1/25/2024 revealed “IV. Policy A. The provider will order the appropriate level of monitoring or patient safety checks for patients admitted to the inpatient BH program. B. Patient safety checks and level of monitoring status will continue until the provider performs an in-person assessment to determine whether to continue/discontinue safety checks... Only a provider can order/move a patient to a less restrictive category... C. A Registered Nurse may initiate safety precautions (safety checks and/or level of observation/monitoring) at any time based on their patient need/safety assessment.” Definitions for patient observation and safety monitoring are documented as follows: “Continuous Observation Safety Monitoring: A teammate is exclusively assigned to the patient at all times and will remain within proximity to the patient to deter falls, etc. and/or to intervene with assistance related to patient safety. The patient must be within teammate sight at all times. Continuous Observation Suicidal Monitoring: A teammate is exclusively assigned to the patient at all times and will remain within close proximity to the patient and have unobstructed line of sight to deter and/or intervene with suicidal/self-harm behaviors. Patient Safety Checks: Safety checks involve the monitoring of patients by the assigned teammate according to the time specifications ordered by the provider (e.g., every 15 minutes). This includes determining respiratory status. Unit Safety Rounds: A visual inspection of the unit that occurs at the end of each shift...” The policy does not address camera monitoring as a method for patient observation and monitoring. Review of facility policy “Behavioral Health Ligature Risk Monitoring” dated 9/20/2021 revealed “Camera Monitor: a team member role assigned to continuously monitor all camera feeds showing ligature risk points in unit hallways on the inpatient behavioral health unit(s). Hallway Monitor: a team member role assigned to continuously monitor, in-person, ligature risk points in the hallways, on an individual inpatient behavioral health unit.” The policy does not address camera monitoring as a method for patient observation and monitoring. Review of medical record for Patient #1 revealed Patient #1 was admitted on 4/22/2024 for inpatient treatment of Psychotic Disorder and Depression. Review of Patient #1’s initial psychiatric evaluation dated 4/22/2024 revealed Patient #1 was admitted under Chapter 51 emergency detention due to command hallucinations. “Patient was noted to be running at a park... at the park he noted that the voices commanded him to remove his clothing and when police arrived they told him to take off running. He was eventually tased and brought to the ER. ...He is very polite and cooperative... States that he does not want to go to court and wants to get out of here. Although he is cooperative he is not a great historian. He also has very poor insight. States ‘I am better now, so I can leave the hospital.’” Patient #1 refused antipsychotic medication as recommended upon admission. Review of Patient #1’s medical record revealed Patient #1 continued to refuse medication throughout his inpatient admission. Safety precautions ordered included 15 minute checks and camera monitoring. In a court hearing on 4/25/2024, Patient #1’s legal hold was extended pending a decision regarding settlement or commitment. In a nursing note dated 4/25/2024 at 10:01 AM: “...after court he still requested to leave and that he ‘needs to be outside.’ ...Patient was explained in detail what it meant to be at the inpatient mental health hospital involuntarily. Patient continued to insist on 72 hours, that he was promised to only be here for that duration and that he ‘has to leave.’” In a social worker note dated 4/25/2024 at 10:32 AM: “Patient was alert and oriented to his surroundings. Patient stated he would like to leave... ‘I’m fine now I’m ready to go home.’ ...Upon entering patient’s room patient was observed to be standing up on his windowsill looking out the window. Patient did respond to the writer entering the room and did comply with direction to safely come down. Patient was informed he cannot climb or stand on the windowsill... Patient stated he understood. Camera person was notified along with 15 minute checks.” Review of a nursing note dated 4/25/2024 at 4:30 PM revealed “Patient was observed on cameras standing on his window looking outside, writer told the patient he shouldn’t stand up there. Later camera monitoring showed him throwing a chair in his room. Writer told him he was not allowed to throw chairs at the hospital. Patient stated he was going to go home and leave the hospital. Writer reiterated he was here on a legal hold and could not leave until discharged. Patient seems to have impaired insight and required a lot of redirection. ...Interventions: Maintain current plan of care.” Review of nursing note dated 4/26/2024 at 9:00 AM revealed “Patient stated he cannot continue to be locked up here and must go home now. Patient assured his safety and explained he is currently under a medical hold and must wait for his court date. Was dismissive of my answer and said no I have to go today... Interventions: Maintain current plan of care.” In a team meeting note dated 4/26/2024 at 9:30 AM: “Significant events: ...Patient was throwing chairs at the window and standing on the window sill in his room. Patient did not take meds. Recommendations: continue current plan.” Review of a social worker note dated 4/26/2024 at 2:03 PM revealed “Nursing mentioned patient needing to be in blue scrubs for elopement concerns.” There were no orders in Patient #1’s chart for elopement precautions. Review of nursing note dated 4/26/2024 at 6:52 PM revealed “Patient wandering on other patients rooms, and exit seeking, redirection not effective. RN called doctor to get an order for a wing restriction. Wing restriction now in place.” In a nursing note dated 4/26/2024 at 7:56 PM: “Public safety was called to the unit to do a formal report, day shift RN and writer were both present at shift change for the encounter and explained that physical contact and behaviors he was exhibiting is prohibited on the unit and that is why he is on a wing restriction. Patient understands the rules... and has not wandered to other areas outside of his wing at this time.” Per review of nursing note dated 4/26/2024 at 9:52 PM: “Patient was given [antipsychotic medication at 8:15 PM] and at the time of medication administration, patient was laying in bed, flat affect, and quiet. At [8:38 PM] patient was observed on camera monitoring waking [sic] out of bed slowly, looking outside, moving the chairs and smashing the window with one of the chairs. Staff responded to the sound of loud banging on the unit. At [8:39 PM] patient was through the window and off of the unit just as staff was coming to his room. Duress button [emergency staff assist] was pressed by [RN and CNA]. Writer also pressed duress button in nurses station. Writer called house supervisor to alert them there was an elopement.” Review of an Emergency Department note dated 4/26/2024 at 9:22 PM revealed “Patient eloped from BH after using chair to break the window. Patient reports ‘I could no longer stay there locked.’ Patient was found by [police department] and brought back to the ambulance bay and was reported to be about 1000 meters off the hospital grounds. Patient reports no pain or wounds from the glass.” Patient #1 was transferred from the emergency department to another inpatient psychiatric facility for continued treatment. During an interview on 7/3/2024 at 9:15 AM, Manager C stated “we had been using camera monitoring in patient rooms, but after review of our policies, we stopped using [camera monitoring] for patient behaviors... if there are safety concerns, patients should be on 1:1 [supervision].” During an interview on 7/3/2024 at 2:45 PM, Manager C stated “we were using camera monitoring outside the scope of the policy, and staff took comfort in being told that the windows [in patient rooms] were not breakable.” Manager C went on to state that chairs are being removed from rooms of high risk patients and the hospital is in the process of replacing windows in the unit. Per C, if there was a similar patient/situation, “they would likely be on a 1:1 now.””