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Based on medical record (MR) review, document review, and interview, in one (1) of eleven (11) MRs, the facility failed to maintain a safe environment for patients.

This failure resulted in a serious adverse outcome for Patient #4.

Findings:

The facility failed to:

- (A) Identify a vulnerable patient as an elopement risk; and (B) Arrange appropriate transportation to return a vulnerable patient to their residential skilled nursing facility (SNF).
(See Tag A-0144)

- Identify a verbal complaint as a complaint or grievance.
(See Tag A-0118)

Based on medical record (MR) review, document review, and interview, in one (1) of six (6) grievances, the facility failed to identify a verbal complaint as a complaint or grievance.

The failure to identify a complaint/grievance increased the risk to all patients that potentially unsafe situations or practices were not resolved timely.

Findings:

Review of Patient #4's medical record (MR) identified the following:

- A Psychiatry Progress Note, dated 7/17/2023 at 9:00AM, noted that Staff L (Psychiatry Crisis Liaison) had a telephone conversation with a nurse and supervisor at Patient #4's residential skilled nursing facility (SNF) and informed them Patient #4 would be returning to the SNF.

- A Physician Note in the Discharge Instructions, dated 7/17/2023 at 11:14AM, stated Patient #4 was "to be discharged back to the skilled nursing facility." A Discharge Note dated 7/17/2023 at 11:55AM stated, "Departure Mode: By self."

- A Progress Note by Staff B (Director of Emergency Department/ED), dated 7/18/2023 at 3:00PM, stated that the facility received a call from Patient #4's residential SNF informing them Patient #4 had not returned to the SNF after discharge from the ED and that a missing person's report was filed with the police.

- A Progress Note by Staff G (Chief Medical Officer/CMO) dated 7/24/2023 at 4:58PM stated that the facility received a call from the SNF informing them Patient #4 was found on 7/20/2023 in Manhattan after suffering a seizure, and that Patient #4 was currently admitted to another hospital for treatment.

The facility's Complaint/Grievance Log dated from 6/1/2023 to 7/31/2023 identified no complaints or grievances or subsequent investigations related to this verbal complaint. There was no documented evidence this verbal complaint was entered into the ED Unit Complaint Log, nor that Patient Relations was informed of the complaint.

The policy and procedure (P&P) titled, "Patient Complaints and Grievances," last reviewed 12/2022 stated, "...The complaint will be entered on the Unit/Departmental Concerns/Complaint Log, including the details of the issue, and the outcome. The Log will be faxed to the Patient Relations Department."

During interview of Staff B (Director of ED) on 8/15/2023 at approximately 9:40AM, Staff B confirmed that the facility did not identify this verbal complaint as a complaint or grievance and did not formally investigate it.

These findings were shared with the Staff B, Staff G, Staff D (ED CMO), Staff K (Director of Risk Management), and Staff M (Vice President/VP Quality Management) on 8/15/2023 at 10:56AM.

Based on medical record (MR) review, document review, and interview, in one (1) of eleven (11) MRs, the facility failed to: (A) Identify a vulnerable patient as an elopement risk; and (B) Arrange appropriate transportation to return a vulnerable patient to their residential skilled nursing facility (SNF).

These failures resulted in a serious adverse outcome for Patient #4.

Findings for (A):

Review of Patient #4's MR identified the following information: This 53-year-old with a past medical history of Schizophrenia and Seizure Disorder, was brought to the Emergency Department (ED) by ambulance from a SNF on 7/16/2023 at 9:43AM, for a psychiatric evaluation after physically abusing a fellow resident.

A SNF Note dated 7/16/2023 at 8:20AM stated that the Wandershield (an electronic device that alarms when a person at-risk for wandering/elopement wanders from a designated area) worn by Patient #4 "24-hours a day, 7-days a week," was removed from Patient #4's right ankle prior to ambulance transport.

There was no documented evidence an elopement risk assessment was performed, or elopement precautions initiated during Patient #4's ED stay.

During interview of Staff J (ED Physician) on 8/15/2023 at 9:30AM, Staff J confirmed no elopement risk assessments are performed on ED patients.

The facility policy and procedure (P&P) titled, "Patient Elopements, Regardless of Area," last reviewed 12/2022, did not contain an elopement risk assessment. The policy lacked guidance directing staff when and how to perform elopement risk assessments, and when to implement elopement precautions.

During interview of Staff B (Director of ED) on 8/15/2023 at 10:14AM, Staff B confirmed the facility did not have an elopement risk assessment in their elopement policy or protocol.
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Findings for (B):

Review of Patient #4's MR identified the following: This patient was brought by ambulance to the ED from a SNF on 7/16/2023 at 9:43AM. A SNF Note dated 7/16/2023 at 8:20AM stated that Patient #4 was at risk for elopement/wandering and that a Wandershield had been removed from the patient's right ankle prior to transport to the ED. A medical evaluation was performed on 7/16/2023 at 9:50AM, and a psychiatric evaluation was performed on 7/16/2023 at 11:30AM. Patient #4's medication dosages were increased, and Patient #4 was observed and monitored overnight. On 7/17/2023 at 9:56AM, Patient #4 was cleared for discharge. A Physician Note, dated 7/17/2023 at 11:14AM, stated Patient #4 was "to be discharged back to the skilled nursing facility." A Discharge Note, dated 7/17/2023 at 11:55AM stated, "Departure Mode: By self."

A Progress Note by Staff B (Director of Emergency Department/ED), dated 7/18/2023 at 3:00PM, stated that the facility received a call from Patient #4's residential SNF informing them Patient #4 had not returned to the SNF after discharge from the ED.

A Progress Note by Staff G (Chief Medical Officer/CMO), dated 7/24/2023 at 4:58PM, stated that a call was received from the SNF informing them Patient #4 had been found on 7/20/2023, and was taken by ambulance to an ED after suffering a seizure at Penn Station in Manhattan, and falling down the escalator steps sustaining a head injury. Patient #4 also sustained adrenal gland injury with hemorrhage and was admitted to the other facility's psychiatric unit.

A contracted Taxi Service Invoice dated 8/1/2023 identified that a taxi was called for Patient #4 on 7/17/2023 at 12:04PM to return Patient #4 to their residential SNF.

During interview of Staff H (Security Manager) on 8/16/2023 at 10:00 AM, Staff H confirmed that a security officer in the ED Discharge Waiting Area was requested by Staff F (Registered Nurse, ED) to contact the contracted transportation vendor to arrange taxi service transport for Patient #4's return to the SNF.

Per interview of Staff I (Security Director) on 8/16/2023 at 10:16AM and review of video surveillance photographs dated 7/17/2023, Patient #4 was escorted by Staff F (ER Nurse) to the ED Discharge Waiting Area by the security booth at 11:58:09AM. The second photo identified Patient #4 standing in the ED Discharge Waiting Area by the security booth at 12:01:09 PM. Nine (9) seconds later, the third photo identified Patient #4 outside of the ED, throwing his discharge instructions into the garbage at 12:01:18PM. Twenty-three (23) seconds later, the last photo identified Patient #4 walking toward the main road outside of the hospital at 12:01:41PM.

Upon request, the facility did not furnish a policy or procedure (P&P) for the return/discharge transport of SNF patients arriving to the ED by ambulance.

Per interview of Staff B on 8/15/2023 at 10:11AM, Staff B confirmed that the ED did not have a written policy or process for the return transport of SNF patients upon ED discharge. Staff B stated the facility had an inpatient policy that only applied to inpatients, but it did not apply to the ED. Staff B stated the ED uses a process where the discharging physician completes a form [untitled] that allows the physician to indicate the reason ambulette or ambulance service is being requested for patient transport. Staff B confirmed this form was not completed for Patient #4 during this encounter.

An Immediate Jeopardy (IJ) situation was identified on 8/24/2023 at 12:08PM for the deficiencies cited regarding the facility's failure to: (1) Identify a vulnerable patient as an elopement risk; and (2) Arrange appropriate transportation to return an at-risk patient to their residential skilled nursing facility (SNF). These failures resulted in a serious adverse outcome for Patient #4.

The facility provided an IJ Removal Plan to survey staff on 8/24/2023 at 8:20PM. The plan included:
- The development of an Elopement Risk Assessment Tool.
- The revision of the "Patient Elopement Regardless of Setting" Policy to include the need to perform Elopement Risk Assessments.
- The revision of the "Admission/Discharge of Patients in the Emergency Department [ED]" Policy to include language that all patients returning to a skilled nursing facility (SNF) from the ED will be transported by ambulance.
- Staff Education on the revised policies and the new Elopement Risk Assessment Tool.

The IJ was removed on 8/28/2023 at 3:06PM based on on-site verification of the IJ Removal Plan which included the following:
- Review of the In-Service Attendance Record verifying 74.4% total ED staff were re-educated on the new Elopement Risk Assessment Tool and the two revised policies for Elopement and Admission/Discharge of ED patients.
- 100% of staff interviews of the ED medical, nursing, and clerical staff present, verifying their knowledge and understanding of the revised policies and elopement risk assessment tool.
- Nine (9) of eleven (11) MRs with completed and documented risk assessments.
- Four (4) of four (4) MRs of patients who arrived at the ED by ambulance from a SNF and were returned to their SNF via ambulance/ambulette transportation.

The Condition of Participation for Patient Rights was not met.

Based on medical record (MR) review, document review and interview, the facility failed to ensure an adverse event was identified, documented, investigated, analyzed, and corrective actions implemented to improve patient safety.

These failures potentially raised the risk of serious harm and/or adverse outcomes for all patients.

Findings:

The "Hospital Performance Improvement and Patient Safety Plan for 2023," stated the purpose is "...To provide guidelines for collecting, analyzing, and using data to identify, address, and monitor performance to continually improve the quality of care provided by the hospital and create a culture of safety and quality, support safe decision making and identify and respond to changes...To "evaluate adverse events to assess whether system improvements can prevent or reduce the number of events...To establish mechanisms that support immediate response to manage actual or potential risks including unintentional patient outcomes or events."

Review of Patient #4's medical record (MR) identified the following information: This patient was brought to the Emergency Department (ED) via ambulance on 7/16/2023 at 9:43AM. Patient #4 has a past medical history of Schizophrenia and Seizure Disorder. Patient #4 reported to the triage nurse that he was hearing voices that were telling him to harm others. The Skilled Nursing Facility (SNF) Note dated 7/16/2023 at 8:20AM stated that Patient #4 was at risk for elopement/wandering and that a Wandershield (an electronic device that alarms when a person at-risk for wandering/elopement wanders from a designated area) had been removed from the patient's right ankle prior to transport to the ED. Patient #4 was observed and monitored overnight. On 7/17/2023 at 9:56AM, Patient #4 was cleared for discharge. A Physician Note, dated 7/17/2023 at 11:14AM, stated Patient #4 was "to be discharged back to the skilled nursing facility." A Discharge Note, dated 7/17/2023 at 11:55AM stated, "Departure Mode: By self."

Review of video surveillance photographs dated 7/17/2023 identified Patient #4 walking toward the main road outside of the hospital at 12:01:41PM. While awaiting the taxi transportation arranged by the facility to the SNF residence, Patient #4 left the ED.

A Progress Note by Staff B (Director of Emergency Department/ED), dated 7/18/2023 at 3:00PM, stated that the facility received a call from Patient #4's residential SNF informing them Patient #4 had not returned to the SNF after discharge from the ED.

A Progress Note by Staff G (Chief Medical Officer/CMO), dated 7/24/2023 at 4:58PM, stated that a call was received from the SNF informing them Patient #4 had been found on 7/20/2023, and was taken by ambulance to an ED after suffering a seizure at Penn Station in Manhattan, and falling down the escalator steps sustaining a head injury. Patient #4 also sustained adrenal gland injury with hemorrhage and was admitted to the other facility's psychiatric unit.

Review of the Complaints/Grievance Log dated 7/1/2023 to 7/31/2023 identified the notifications from the SNF were not listed as complaints or grievances and were not investigated.

The Emergency Department (ED) Occurrence Reports Log dated from 7/1/2023 to 8/13/2023 identified this event was not listed as an incident/occurrence when the hospital was notified that Patient #4 did not return safely to their residence after discharge.

The Quality Assurance Performance Improvement Meeting Minutes dated from 7/1/2023 to 8/14/2023 identified no evidence that the facility analyzed this event for opportunities for improvement.

Upon request, the facility did not furnish documented evidence that this event was investigated or analyzed to identify opportunities for improvement.

During interview of Staff M (Vice President Quality Management) on 8/14/2023 at 11:57AM, Staff M acknowledged these findings and stated that the hospital did not consider this event as an incident/occurrence, complaint, or grievance. Staff M confirmed that no investigations were performed and that this event was not analyzed for improvement opportunities.

These findings were shared with Staff B (Director of the Emergency Department/ED), Staff G (Chief Medical Officer/CMO), Staff D (ED Chief Medical Officer), Staff K (Director of Risk Management), and Staff M (Vice President/VP of Quality Management) on 8/15/2023 at 10:56AM.