HospitalInspections.org

Based on interview and record review the hospital failed to ensure the safety of one of 15 patients (Patient 7) by allowing her to exit the emergency department (ED) unobserved and access a loading dock. This failure to prevent elopement put the patient's safety at risk.

Findings Include:

Review of the hospital policy titled, " ... EM-004 EMTALA-Medical Screening Examination and Stabilization ..." last revised on 04/01/18 included, " ...Elopement. If an individual leaves the hospital without notifying Hospital personnel (i.e., elopement) this should be documented by Emergency Department staff. The documentation should reflect that the individual had been at the Hospital and the time the individual was discovered to have left the premises ..."

The hospital failed to provide any other policy related to elopement.

Review of Patient 7's electronic medical record (EMR) revealed report was called to the ED at 12:51 PM on 05/17/20 by the ambulance service. The charge registered nurse (RN) Staff B documented she was to be placed in Room ED 11 for evaluation and treatment. Patient 7 was to be seen in the ED as a result of an unwitnessed fall at the nursing home where she lived. She sustained a laceration to the back of her head. She was to be evaluated for a head injury and the need for sutures or staples to the wound. The ED physician ordered a computerized tomography (CT) scan. The CT revealed "no gross abnormalities." The laceration was 1.5 centimeters (cm) in length at the crown of her scalp, two staples were used to close the wound. The physician then told the nurse Patient 7 was ready for discharge.

Further review of Patient 7's ED Record titled, "History and Physical," completed by the Physician Assistant on 05/17/20 and signed at 3:13 PM, revealed Patient 7's medical history included Dementia, Depression, Epilepsy and Schizoaffective Schizophrenia. The history and physical further showed Patient 7 stated she was chronically short of breath, had difficulty with balance and has had frequent falls.

Additional review of the EMR showed Patient 7's assigned RN, Staff A documented that she contacted the nursing home on 05/17/20 at 3:46 PM. Staff A RN provided a verbal report of Patient 7's condition and the treatment provided. She documented, " ... they are calling transportation to set up ride back to facility ... " in her note. A second note was written by Staff A RN at 5:13 PM documenting, " ... Patient was informed that (facility name) was called for transportation back to facility by this RN. Staff A informed Patient 7 that per a RN at her facility, she needed to wait in her room until transportation arrived to transport her back to (facility name.) Patient 7 gave a "thumbs-up" and verbalized understanding. Staff A RN placed call button by patient and closed door for patient privacy... "

Transportation arrived to pick up Patient 7 about 5:00 PM on 05/17/20. Staff A went to exam room ED 11 to get Patient 7 and found the room empty. At some time between 4:00 PM and 5:00 PM, Patient 7 exited the exam room closing the door behind her. Staff A initiated a search of the ED, checking the rest rooms, other exam rooms and the halls in the ED. She reported Patient 7 as missing to Staff B, RN then went to security to see if they could locate and follow the patient on the cameras. Security was not able to locate Patient 7 on the cameras. Video tape footage was not available for the surveyor to view as part of the investigation as the facility only keeps it for 90-days.

Staff A and Staff B began searching outside of the ED to locate Patient 7. She was located at 5:15 PM on a loading dock at the rear of the hospital by Staff A.

Staff A attempted to get Patient 7 return to the ED and the transportation back to the facility. Patient 7 refused to return stating, " ... I'm not going back in the (expletive) hospital. I don't want to be in there anymore (sic). I want to go back home." This RN explained that transportation was here from (facility) to take her back home. A wheelchair was obtained by Staff A and the transportation driver wheeled patient back to the transportation van. Patient 7 was alert and oriented and speaking in complete sentences. Patient 7 was warm and dry and ambulatory. Nursing home was notified of patient's elopement from department. All discharge paperwork was given to facility's transportation diver (sic) ... " as documented in Staff A's note at 5:13 PM on 05/17/20.

During an interview on 10/27/20 at 3:50 PM, Staff B RN stated that she was the charge nurse on 05/17/20 and she recalled the incident. She stated that Patient 7 seemed alert and oriented when she saw her. She stated that she thought it was about 30 minutes from the time she was last seen and when she was found on the loading dock. She stated that she assisted Staff A looking for the patient.

The hospital was not able to determine exactly how the patient exited the hospital as there were multiple paths she could have taken leading to the outdoors. A tour of the possible routes conducted on 10/28/20 at 11:00 AM showed the route the Safety Officer, Staff C felt was the most likely route Patient 7 followed.It involved exiting ED exam 11, accessing a secure corridor with several exits. An individual would not be able to return the way they came as the one of the doors required a key card access to open it and the last door was an egress door to the outside of the hospital. Once outside, a person would only have to walk to the corner approximately 40 feet and turn left to be at the loading dock. A second route the patient could have taken would have been out the main entrance of the ED and a third route would have required accessing a dark hallway that led to the receiving area of the loading dock. Patient 7 was in the ED on Sunday and the receiving area would not have been occupied. The hallway was dark and out of the normal hospital visitor areas.

During an interview on 10/28/20 at 11:58 PM, Staff A, RN stated that she performed hourly rounding in accordance with the facility policy. She stated that she told Patient 7 at 4:00 PM on 05/17/20 the nursing home was sending transportation for her. She said that she wrote the information down for the patient as she was very hard of hearing and had requested staff write information down for her and she would respond verbally to it. Staff A stated that the patient seemed alert, oriented and responded to questions appropriately. Staff A stated that the patient responded with a thumbs up, she left the room and closed the door after placing the call light close to the patient. Shortly after, she stated that she was involved with a patient in respiratory distress that arrived in the ED and was "all hands-on deck". When transportation arrived, she went to get Patient 7 to discharge her and send her back to the nursing home with the driver. Patient 7 was not in ED 11 and so, Staff A began a search. She stated that she found the patient approximately 10 minutes after finding her missing and discharged the patient and notified the nursing home of her elopement from the ED.

Staff B, RN notified the Director of the ED Staff Fé at 5:30 PM on 05/17/20 of Patient 7 eloping from the ED. The Administrator of the nursing home contacted the hospital to question how Patient 7 was able to elope from the ED. She spoke directly to the former Director of Risk Management, who retired in the months since the incident occurred. The current Director of Risk Management, Staff D stated that the concern went directly to the former Risk Manager, who delegated the investigation to the Director of the ED, Staff F.

During an interview on 10/29/20 at 4:00 PM, Staff D, Director of Risk Management shared the investigation conducted by Staff F, Director of Emergency Department on 06/23/20. Staff F, Director of Emergency Department spoke with the nursing home Administrator on 06/23/20 and Patient 7 was described as a " ... flight risk ..." The investigation was unable to determine conclusively how the patient exited the ED and found her way to the loading dock. Staff F found the hospital did not do anything wrong. During the tour of possible escape routes Patient 7 could have taken, Staff D, Director of Risk Management identified some areas of concern and planned to reach out to the Fire Marshall to make changes to the access hall. Staff D verified that no changes have been completed at the time of the survey.

Based on interview and record review the hospital failed to ensure one of 15 patients (Patient 7) was free from neglect due to inadequate supervision that allowed the patient to exit the emergency department (ED) unnoticed. The hospital's failure to provide necessary supervision put the patient at risk for injury and harm.

Findings Include:

Review of the hospital policy titled, " ... EM-004 EMTALA-Medical Screening Examination and Stabilization ..." last revised on 04/01/18 included, " ...Elopement. If an individual leaves the hospital without notifying Hospital personnel (i.e., elopement) this should be documented by Emergency Department staff. The documentation should reflect that the individual had been at the Hospital and the time the individual was discovered to have left the premises ..."

The hospital failed to provide any other policy related to elopement.

Patient 7 presented to the ED on 05/17/20 at 12:51 PM after an unwitnessed fall at the nursing home in which she obtained a 1.5-centimeter (cm) laceration to the back of her head. She was placed in ED exam room 11 for evaluation and treatment of the laceration. She was seen by a physician and received two staples to close the laceration.

Review of Patient 7's ED Record titled, "History and Physical," completed by the Physician Assistant on 05/17/20 and signed at 3:13 PM, revealed Patient 7's medical history included Dementia, Depression, Epilepsy and Schizoaffective Schizophrenia. The history and physical further showed Patient 7 stated she was chronically short of breath, had difficulty with balance and has had frequent falls.

Review of the "ED Course & Medical Decision Making," dated 05/17/20 showed ...Patient has multiple complaints including her chronic vomiting, dyspnea, frequent falls and now today's fall with head injury. Will do basic evaluation and monitor while in department ...Laceration Repair: 05/17/20 at 3:20 PM. Two staples, tolerated well, no immediate complications. "Final Impression," Unspecified Fall, Laceration of scalp and Multiple falls. Plan: ..."evaluate for fall risks at nursing home to prevent future falls."

Patient 7's assigned registered nurse (RN) Staff A documented in the Electronic Medical Record (EMR) she contacted the nursing home on 05/17/20 at 3:46 PM. Staff A provided a verbal report of Patient 7's condition and the treatment provided. She documented, " ... they are calling transportation to set up ride back to facility ..."

A second note was written by Staff A at 5:13 PM documenting, " ... Patient was informed that (facility name) was called for transportation back to facility by this RN Staff A. This RN Staff A informed patient that per a RN at her facility, she needed to wait in her room until transportation arrived to transport her back to (facility name.) Patient gave a "thumbs-up" and verbalized understanding. This RN [staff A] placed call button by patient and closed door for patient privacy... "

Review of the hospital "Flow Record" for Patient 7 showed a shift assessment at 2:41 PM, a reassessment at 3:33 PM, and not again until 5:33 PM. The hospital record showed the patient discharged at 5:27 PM.

Transportation arrived to pick up Patient 7 about 5:00 PM on 05/17/20. Staff A RN went to exam room ED 11 to get her and it was empty. At some time between 4:00 PM and 5:00 PM Patient 7 exited the exam room and she closed the door behind her. Staff A RN initiated a search of the ED, checking to rest rooms, other exam rooms and the halls in the ED. She reported Patient 7 as missing to Staff B RN then went to security to see if they could locate and follow the patient on the cameras. However, they were not able to locate Patient 7 on the cameras. Video tape was only kept for 90-days and was unavailable for review during the investigation.

Staff A RN and Staff B RN began searching outside of the ED to locate Patient 7. She was located at 5:15 PM on a loading dock at the rear of the hospital by Staff A RN.

Staff A attempted to get Patient 7 to return to the ED and transportation back to the facility. Patient 7 refused to return stating, " ... I'm not going back in the (expletive) hospital. I don't want to be in there anymore (sic). I want to go back home." This RN [Staff A] explained that transportation was here from (facility) to take her back home. Staff A RN and transportation driver wheeled patient obtained a wheelchair back to transportation van. Patient was alert and oriented and speaking in complete sentences. Patient was warm and dry and ambulatory. Nursing home was notified of Patient 7's elopement from department. All discharge paperwork was given to facility's transportation diver (sic) ... " as documented in RN Staff A's note at 5:13 PM on 05/17/20.

During an interview with Staff B RN on 10/27/20 at 3:50 PM, she stated that she was the charge nurse on 05/17/20 and she recalled the incident. She stated that the patient [7] seemed alert and oriented when she saw her. She stated that she thought it was about 30 minutes from the time she was last seen and when she was found on the loading dock. She stated she assisted Staff A RN hunt for the patient.

The hospital was not able to determine exactly how the patient exited the hospital as there were multiple paths, she could have followed leading to the outdoors. A tour of the possible routes was conducted on 10/28/20 at 11:00 AM. The route the Safety Officer, Staff C felt was the most likely route followed involved exiting ED 11, accessing a secure corridor with several exits. An individual would not be able to return the way they came as the double doors to the hall did not allow them to be opened once inside, one door required a key card access to open it and the last door was an egress door to the outside of the hospital. Once outside one only had to walk to the corner approximately 40 feet and turn left to be at the loading dock. Another route out would have been out the main entrance of the ED and a third route would have required accessing a dark hallway that led to the receiving area of the loading dock. Patient 7 was in the ED on a Sunday and the receiving area would not have been occupied. The hallway was dark and out of the normal hospital visitor areas.

During an interview with Staff A RN on 10/28/20 at 11:58 AM, she stated that she performed hourly rounding in accordance with the facility policy. She stated she told Patient 7 at 4:00 PM on 05/17/20 the nursing home was sending transportation for her. She said she wrote the information down for the patient as she was very hard of hearing and had requested staff write information down for her and she would respond verbally to it. Staff A RN stated that the patient seemed alert, oriented and responded to questions appropriately. Staff A RN stated that the patient responded with a thumbs up, she left the room and closed the door after placing the call light close to the patient. Shortly after she stated that she was involved in a respiratory distress case that arrived in the ED and was all hands-on deck. When transportation arrived, she went to get Patient 7 to discharge her and send her back to the nursing home with the driver. Patient 7 was not in ED 11 and Staff A RN began a search. She stated she found the patient approximately 10 minutes after finding her missing and she discharged the patient and notified the nursing home of her elopement from the ED.

The Director of the ED Staff F was notified at 5:30 PM on 05/17/20 of Patient 7 eloping from the ED by Staff B RN. The Administrator [unnamed] of the nursing home contacted the hospital to question how Patient 7 was able to elope from the ED. She spoke directly to the former Director of Risk Management [unnamed], who retired in the months since the incident occurred. The current Director of Risk Management, Staff D stated the concern went directly to the former Risk Manager, who delegated the investigation to the Director of the ED, Staff F.

During an interview on 10/29/20 at 4:00 PM, Staff D, current Director of Risk Management, shared the investigation conducted by Staff F, Director of the ED, on 06/23/20. Staff F Director of the ED, spoke with the nursing home Administrator on 06/23/20 and Patient 7 was described as a " ... flight risk ..." The investigation was unable to determine conclusively how the patient exited the ED and found her way to the loading dock. Staff F Director of the ED found the hospital did not do anything wrong. Staff D Director of Risk Management during the tour identified some areas of concern and planned to reach out to the Fire Marshall to make changes to the access hall. No changes had been made since the elopement of Patient 7 on 05/17/20.