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Based on observation, interview and document review, the hospital failed to ensure patient safety for 4 of 11 patients (P1, P2, P3, and P4) when they failed to provide appropriate supervision of patients on emergency holds pending civil commitment, court holds, or who were cognitively impaired, which led to each of the patients eloping from the facility; two of the patients (P2, P3) have not been found by law enforcement or the facility.

See A0144.

An IJ was identified on 9/22/21, at 3:25 p.m., related to patients receiving care in a safe setting. The IJ was removed on 9/24/21, at 12:26 p.m. after verification of implementation of an acceptable removal plan, but the hospital remained out of compliance at the Condition of Patient Rights. See A0144.

Based on observation, interview, and document review, the hospital failed to provide care in a safe setting for 4 of 11 patients (P2, P1, P3, and P4) reviewed for elopement when they failed to provide appropriate supervision to prevent elopement of patients on a court hold (P4), emergency holds pending civil commitment (P2, P3), and who were cognitively impaired (P1). This resulted in Immediate Jeopardy situation when P2, P1, P3, and P4 eloped from the facility.

The IJ began on 9/8/21, at approximately 7:00 a.m. when P2 eloped to the community while on an emergency hold pending civil commitment. Additionally, P1 eloped with a diagnosis of dementia and was lost in the community for over five hours, P3 eloped to the community while on an emergency hold pending civil commitment, and P4 eloped to the community while on a court hold pending involuntary treatment for chemical dependency. The Vice President (VP) of Performance Improvement and Safety, the Patient Safety Manager, the Accreditation Program Manager, Accreditation Program Specialist (APS)-A, and APS-B were notified of the IJ finding on 9/22/21, at 3:25 p.m. The IJ was removed on 9/24/21, at 12:46 p.m. after verification of an acceptable removal plan.

Findings include:

P2's Emergency Department (ED) Facility Note dated 8/29/21, at 12:43 p.m. indicated P2 was brought to the hospital by Emergency Medical Services (EMS) from a homeless tent camp, where bystanders saw him hanging from a tree by a rope noose; it was estimated he was hanging for less than 2 minutes.

P2's Initial Psychiatric Consult Assessment dated 8/31/21, at 1:10 p.m. indicated P2 was admitted to the hospital for acute mental status changes after a suicide attempt by hanging with a hyoid (neck bone) fracture, noting he was not a suicide risk "while in the hospital." The note also indicated P2 had prior suicide attempts, and had diagnoses of anxiety, depression, and borderline personality disorder.

P2's nursing progress note (PN) dated 9/1/21, at 9:18 p.m. indicated P2 was transferred from the Medical Intensive Care Unit (MICU) to the 5 Medicine floor (unlocked unit).

P2's Examiner Statement in Support of Petition for Commitment dated 9/3/21, indicated P2 was not at risk of taking his life in the hospital, but he was at high risk of re-attempting suicide in the outpatient setting, and should be civilly committed for mental health and chemical dependency treatment.

P2's Psychiatry Consult Note dated 9/3/21, at 1:02 p.m. indicated P2 could be transferred to an inpatient psychiatry unit (locked unit) once he was medically cleared.

P2's provider PN 9/3/21, at 3:00 p.m. indicated P2 was medically cleared for transfer to a psychiatry unit. Provider PN on subsequent days (9/4/21, 9/5/21, and 9/6/21) indicated P2 was on a 72-hour hold, and waiting for transfer to an inpatient psychiatry unit.

P2's nursing PN dated 9/6/21, at 3:44 p.m. indicated nursing staff were concerned P2 was a high elopement risk because P2 attempted to elope while exercising on the unit.

P2's provider PN dated 9/7/21, at 2:34 p.m. indicated P2 had substance abuse issues with methamphetamine and opioids, and was medically stable waiting for transfer to an inpatient psychiatry unit.

P2's Coordinated Care Clinic (CCC) Assessment dated 9/7/21, at 11:35 a.m. indicated psychiatry did not have a bed available for P2.

P2's nursing PN dated 9/8/21, at 8:03 a.m. indicated P2 eloped around 7:30 a.m. and a remote visual monitor (VM) was in his room and alarmed, but P2 unplugged the VM, which silenced the alarm.

P2's VM record dated 9/8/21, indicated P2 was sleeping from 12:00 a.m. through 7:00 a.m. At 7:00 a.m. the record indicated P2 unplugged the VM, and there was no further documentation on the VM record.

P2's Discharge Note dated 9/8/21, indicated P2 was admitted after a suicide attempt by hanging, and he was placed on a 72-hour hold because of concerns for his safety. Psychiatry filed for civil commitment after he "perseverated on wanting to discharge." The note indicated the civil commitment was in process, but P2 eloped prior to completion of the commitment process.

The facility's event report dated 9/8/21, indicated after P2 eloped on 9/8/21, the nurse manager reviewed the situation with involved nursing staff, and provided a refresher on the elopement policy to all staff on the unit on 9/14/21.

During an interview on 9/20/21, at 3:43 p.m. registered nurse (RN)-H stated she provided care for P2 on 9/8/21 and left the floor for a few minutes around 6:00 a.m.; when she returned, she was informed P2 had left by unplugging the VM. RN-H stated when she entered P4's room the VM was unplugged in the room.

During an interview on 9/21/21, at 1:06 p.m. medical doctor (MD)-J indicated P2 had been on a 72-hour hold and civil commitment papers had been filed with the court. MD-J stated P2 eloped before the court could act. MD-J stated he was concerned about the patient in the community, and he did not know P2 eloped until 9/21/21.

During an interview on 9/22/21, at 7:31 a.m. visual monitor technician (VMT)-O stated she started her shift at 7:00 a.m. on 9/8/21, and the night shift informed her P2 had been causing trouble all night. VMT-O stated she observed P2 at the door to his room, so she sounded the alarm and he went back to his bed. About 20 minutes later, VMT-O stated P2 went to the door again and she sounded the alarm but P2 unplugged the VM so the alarm would stop; she called the floor and spoke to a nurse who's name she could not remember, informing her about P2 unplugging the VM.

During an interview on 9/22/21, at 10:57 a.m. RN-F stated P2 had a 1:1 attendant early in his stay because of his suicide attempt, but was placed on remote VM after psychiatry placed him on a 72-hour hold pending civil commitment. RN-F stated the commitment process was started, but P2 eloped before any court orders were received. RN-F stated on the morning of 9/8/21, she learned about P2's elopement by the charge nurse because she never heard the VM alarm. RN-F stated P2 had not been located by the facility or law enforcement.

P1's ED PN dated 9/1/21, at 10:58 p.m. indicated P1 was transferred from an outside hospital related to a closed odontoid fracture secondary to a fall which occurred on 8/31/21. P1 was found to be a very poor historian, even with a Spanish interpreter.

P1's Shift Summary PN dated 9/1/21, at 9:10 p.m. indicated P1 was admitted around 7:00 p.m. in which he was alert and oriented to self. He was a poor historian, very forgetful, restless, combative and agitated when staff attempted to lock up his wallet and checkbook, and made numerous attempts to exit the bed. VMT was ordered and bed alarm was placed. The associated Nursing Assessment Head to Toe identified P1 was shown to have poor judgement and safety awareness with poor attention and concentration. P1 was disoriented to place and time and was impulsive, anxious, and restless.

P1's Surgery Staff Daily PN dated 9/2/21 at 6:20 p.m. indicated P1 "has some degree of dementia."

P1's provider PN dated 9/2/21, at 7:57 p.m. indicated the medical provider was paged as P1 exhibited increased agitation and wanted to leave against medical advice (AMA). P1 was unable to tell the medical provider where he was, why he was there, and was unable to explain the risks if he left the facility. The PN identified, "Daytime provider also noted that [P1] was confused and there is concern for hospital related delirium." P1 was not redirectable and was placed on a 72 hour hold.

P1's Occupational Therapy (OT) Acute Initial Evaluation report dated 9/3/21, at 10:12 a.m. indicated P1 was confused and inconsistently followed commands, in which he was unable to state where he was or why he was there. He was not able to provide information about his home or who he lived with and was not able to complete basic functional problem solving tasks. He required 24/7 physical assist and would benefit from post acute placement.

P1's orders dated 9/3/21, at 4:17 p.m. indicate P1 was ordered continuous Elopement Precautions.

P1's care plan dated 9/3/21, identified P1 was identified as an elopement risk with an accompanied goal he remained free from elopement during his hospitalization. Interventions documented were as follows: secure clothing and belongings in a locked designated area, room with visual sightline to the patient care staff/desk area, video monitoring, wanderguard, bed alarm, bedside sitter.

P1's nurse Shift Summary PN dated 9/5/21, at 12:15 p.m. indicated P1 was more alert and oriented than seen by writer over last 2 days, now ready for trial to VMT vs 1:1 sitter, no longer pulling at Miami J collar (cervical collar) straps or peripheral IV.

P1's nurse Shift Summary PN dated 9/5/21, at 5:51 p.m. indicated P1 exhibited minor impulsive activity and was at his baseline for ambulation during the trial period for VMT vs 1:1 sitter; however, he was observed to pull off his cardiac monitors and neck brace. He was placed in shirt and shorts vs a hospital gown.

P1's nurse Shift Summary PN dated 9/6/21, at 3:49 a.m. indicated P1 was alert and oriented with some confusion and he continued on 15 minute checks; however, a health care assistant (HCA) had spent the majority of the shift as a 1:1 sitter at P1's bedside for safety as P1 was more restless, and ensured P1 kept the Miami J-collar on at all times.

P1's nurse Shift Summary PN dated 9/8/21, at 2:41 a.m. indicated P1 was intermittently confused and required a sitter at bedside for elopement risk and multiple attempts to take of the Miami J collar. P1 required stand by assist (SBA) to use the bathroom.

P1's Physical Therapy (PT) PN, dated 9/8/21, at 12:11 p.m. indicated P1 was less willing to follow cues and refused to use the walker for gait and safety. P1 looked for exits and wanted to leave which required multiple redirection attempts before he agreed to remain in the hospital. P1's PT post discharge recommendations identified post-acute placement, and if he were to discharge home he required 24 hour supervision due to his cognitive limitations.

P1's nurse Shift Summary PN dated 9/8/21, at 3:20 p.m. indicated P1 stated he was ready to go home and kept asking for staff to let him leave. He walked with the 1:1 sitter.

P1's Social Worker (SW) Assessment PN dated 9/9/21, at 1:26 p.m. indicated P1 was recommended for TCU (transitional care unit) placement with an expected discharge date of 9/10/21. The PN identified P1's wife was also a hospital patient, and staff worked on a discharge location that accepted both P1 and his wife together.

P1's OT PN dated 9/9/21, at 3:26 p.m. indicated P1 believed he was in Mexico and it was March 1941. P1 required frequent redirection but lacked carryover of information. During an attempted contextual memory test, P1 was very distracted with poor recall which indicated severe cognitive impairment. P1 required 24/7 assist and post acute placement.

P1's nurse Shift Summary PN dated 9/9/21, at 7:39 p.m. indicated P1 continued on 1:1 supervision as he was very forgetful and wandering when he felt like it.

P1's SW Follow-Up Note dated 9/10/21, at 11:57 a.m. indicated P1 needed to be off of 1:1 supervision 24 hours before discharge.

P1's nurse PN dated 9/10/21, at 4:16 p.m. indicated P1's 1:1 supervision was discontinued that morning at 10:30 a.m. P1 had been forgetful, was easily redirectable, was up in halls independently with steady gait. The PN also indicated P1 was preoccupied with going to visit wife in the hospital.

P1's nurse Shift Summary PN dated 9/10/21, at 5:33 p.m. indicated P1 was not on a 1:1 supervision status, and he wanted to contact his wife. He was restless until he was wheeled to his wife's room.

P1's nurse Shift Summary PN dated 9/11/21, at 3:46 a.m. indicated P1 was up independently frequent walking up and down on unit, and made multiple attempts to take off his Miami J collar.

P1's nurse PN dated 9/11/21, at 4:48 p.m. indicated P1 was last seen at the front desk at approximately 10:40 a.m. He usually walked out to the desk to talk with the nurses and headed back to his room after. Staff conducted a search for P1 and security was notified. P1 was unable to be located. At 2:10 p.m. the Minneapolis police department was notified. At 4:07 p.m. over five hours since he was last seen, staff were notified an OT staff identified P1 as he sat on a retaining wall outside of the hospital on a few blocks away. P1 appeared unharmed. His face was flushed and his neck collar pads were falling out.

P1's nurse Shift Summary PN dated 9/11/21, at 5:57 p.m. indicated P1 required 1:1 sitter and was oriented with intermittent confusion.

P1's Discharge Note dated 9/17/21, at 10:39 a.m. indicated P1 was discharged to a TCU that day at 9:45 a.m.

The facility's Event Report ran on 9/21/21, indicated P1 eloped on 9/11/21. Contributing factors were identified as "Communication issue" and "Vulnerable adult." The report identified an entry on 9/13/21, by the clinical care supervisor (RN)-A that P1's sitter was discontinued in attempt to have P1 off of 1:1 supervision for 24 hours. P1 got up out of bed to ambulate to the nurses station to talk to staff; however, the staff believed they would see him if he wandered off the unit. An entry on 9/20/21, by the patient safety manager (PSM)-D identified opportunities for improvement in which P1 should have remained in spice scrubs for elopement risk even after hold removed, and elopement alert should have been called.

During interview on 9/21/21, at 9:49 a.m. RN-B stated elopement risk determination was complicated. RN-B stated the main aspects reviewed were the patients diagnosis, cognitive status, and history of elopement. RN-B stated if a patient demonstrated cognitive impairments or a history of elopement, then an elopement risk would be continued and interventions utilized. RN-B stated P1 was an elopement risk and he exhibited wandering behavior; however, due to TCU discharge requirements to remain off of 1:1 supervision for 24 hours, she questioned P1's medical provider on 9/10/21, for an order to remove the 1:1 supervision. RN-B stated on 9/10/21, P1 was weaned off of the 1:1 supervision and staff performed 15 minute safety checks. During the 15 minute checks, P1 was observed at times to exit his room and visited the nurses station. RN-B stated that evening, staff closed the hallway doors as a gentle reminder for P1 to stay down that hall. On 9/11/21, at approximately 10:45 a.m. RN-B stated RN-C updated her P1 was not in his room. A search was initiated and it was determined he was last seen at the front desk by patient coordinator (PC)-A. Security was updated and cameras reviewed, which failed to identify P1 had left the unit and/or his whereabouts. Once found P1 was brought back to the unit without apparent harm, placed on a 1:1 and discharge plans were placed on hold.

When interviewed on 9/21/21, at 11:34 a.m. PC-A stated nursing staff updated her on patients who required "watching" and if she observed those patients she contacted the nurse or charge nurse. If seen, she conversed with the patient and redirected them back to their room. PC-A explained P1 wandered around or walked around with staff, and he liked to converse with them. PC-A further explained he "usually goes down the north hallway" (patient's room was on the south hallway) after he spoke to staff at the north nurses station. PC-A stated on 9/11/21, she received a phone call while she conversed with P1 and thus adjusted her attention to the phone call. She thought he walked down the north hallway as she felt that was his routine. She stated P1 usually went back to his room after he walked; however, "that day was different for him."

During a telephone interview on 9/21/21, at 1:47 p.m. RN-D stated on 9/11/21, she worked with P1 the evening of his elopement event. RN-D stated P1 was in high spirits, and denied he showed cognitive differences from other shifts when she had worked with him. RN-D stated once P1 returned to the unit on 9/11/21, he was unable to explain why he left, where he was, or how he exited the facility. He was placed on 1:1 supervision. RN-D stated she was not able to remember P1's elopement risk, but acknowledged he was on a hold at some point in his hospitalization. RN-D stated she did not know the details of the hold. RN-D also stated a patient's elopement risk was assessed based on a series of questions on a flow sheet. RN-D stated she was unable to remember the questions, and was not 100 percent sure how often the assessment was required to be completed.

When interviewed via telephone on 9/21/21, at 2:15 p.m. RN-C confirmed he worked with P1 the morning of 9/11/21, when he delivered P1's morning medication around 8:00 a.m. RN-C stated after that, P1 was independent on the unit. RN-C stated around 9:00 a.m. or 10:00 a.m. he observed P1 at the nurses station "looking around." RN-C stated at approximately 11:00 a.m. he attempted to locate P1, he was unsuccessful. RN-C stated he searched for P1, and alerted the charge nurse of P1's absence. RN-C denied P1 mentioned wanting to leave that day; however, stated P1 "was forgetful" and "had periods of delusions." RN-C explained elopement risk was determined by completing a flowsheet each shift, but was unable to remember if P1 was an elopement risk prior to his elopement. RN-C stated P1 wandered the unit and went from nurses station to nurses station; however, P1 was never observed by him to leave the unit. RN-C stated P1 was easily redirected when staff attempted to keep him on his unit.

During interview on 9/21/21, at 2:34 p.m. security guard (S)-A stated security staff discussed patients who were involved in behavior response calls and paid closer attention to those patients. S-A stated security staff were not updated on which patients were determined to be high elopement risks. S-A stated once staff alerted security of an elopement event, security interviewed the staff and obtained patient identifier and other pertinent information. S-A stated camera footage was then reviewed, and if the patient could not be located law enforcement was contacted. S-A denied knowledge of P1 prior to the elopement.

During interview on 9/21/21, at 3:02 p.m. RN-E she explained patients were assessed for elopement risk daily through observation and assessment which also included communication with the patient, staff, and providers. RN-E stated P1 was a vulnerable adult and an elopement risk in which he "was trying to actively leave" on 9/2/21; however, he did not actually leave the unit. After that, "He did not show any overall concerns. He just walked the halls, one nurse's station to the next and would always come back [to his hallway]." RN-E explained staff watched him and his whereabouts in which P1 would not go through doors. RN-E stated if P1 were to have attempted to exit the unit, staff would have strongly encouraged him to return as he was confused and forgetful and required a "safe discharge plan" instead of him being allowed to just walk into the street. RN-E stated P1 was required to be off of 1:1 supervision for at least 24 hours in preparation for his pending discharge.


P3's ED PN dated 9/11/21, at 4:14 p.m. indicated P3 was brought to the ED via EMS with altered mental status, acute alcohol intoxication, alcohol withdrawal syndrome, and a head injury after being discharged from the facility's Special Care area earlier in the day.

P3's Provider PN dated 9/11/21, at 5:00 p.m. indicated P3 was discharged from the Special Care area around 2:00 p.m. after being treated for alcohol intoxication and was found asleep at a restaurant with food in front of him. Upon return to the ED, P3's breathalyzer registered 0.445 % blood alcohol concentration (BAC).

P3's ED PN dated 9/12/21, at 3:23 p.m. indicated P3 was placed on a 72-hour hold and was to be evaluated for civil commitment.

P3's provider PN dated 9/13/31, at 8:05 a.m. indicated P3 was being evaluated for civil commitment.

P3's Transfer note dated 9/13/21, indicated P3 was transferred from the MICU to the 5 Medicine unit.

P3's Medicine PN dated 9/13/21, at 11:29 a.m. indicated P3 was on a 72-hour hold with chemical dependency commitment under review.

P3's Nursing Assessment note dated 9/13/21, at 3:49 p.m. indicated P3 was on a 72-hour hold and remote VM.

P3's Nursing Assessment note dated 9/14/21, at 8:16 a.m. indicated an unidentified health care assistant (HCA) gave P3 ice cream at 6:45 a.m. At 7:00 a.m. RN-F entered the room and found P3 missing, with his spice-colored scrubs on the bed. The note further indicated RN-F called the VMT who reported they saw someone in a coat leave the room so they did not alarm the VM. The note continued to indicate there were two patients in the room, and the other patient was not on a hold, so he was not wearing spice-colored scrubs.

P3's VM report dated 9/13/21, indicated P3 was placed on VM at 10:45 a.m. with the VM outside the room facing the patient's door.

P3's VM report dated 9/14/21, indicated P3 was sleeping from 12:00 a.m. through 7:00 a.m. At 7:00 a.m. the report indicated P3 was out of the room and the RN was notified.

The facility's event report dated 9/14/21, indicated P3 eloped on 9/14/21, around 7:00 a.m. when the primary nurse found P3's spice-colored scrubs on the bed and him missing from the room. The report indicated the facility reached out to law enforcement for a welfare check and to the Homeless Consult Nurse to see if P3 was in a shelter. The report lack identification of any analysis of the event and any actions to prevent further elopements.

During an interview on 9/22/21, at 7:42 a.m. remote VMT-P stated P2 slept all night, and at 7:00 a.m. she gave report to the day VMT and then left. VMT-P stated P2 was still in his room at 7:00 a.m.

During an interview on 9/22/21, at 8:08 a.m. VMT-I stated P2 was already gone when she came on at 7:00 a.m. and VMT-P was on the phone with the nurse manager.

During an interview on 9/22/21, at 10:57 a.m. RN-F stated she became aware of P3's elopement when security arrived at her unit on 9/11/21, around 7:30 a.m. RN-F stated security informed her they could not call an elopement alert because they did not have an effective description of P3. RN-F stated she spoke to the RN providing care and the RN reported the VM alarm never alarmed, so she was unaware of the elopement. RN-F also stated the VM was moved out of P3's room into the hallway because he kept unplugging it. RN-F stated she reported P3 eloped sometime between 7:00 a.m. and 7:30 a.m. when he was found missing from the room and his spice-colored scrubs were on his bed. RN-F verified P3 had still not been located by the facility or law enforcement.

P4's ED note dated 9/14/21, at 9:16 a.m. indicated P4 was brought to the ED by EMS from a bus shelter when he was found unable to care for himself after ingesting hand sanitizer and alcohol resulting in acute mental status changes.

P4's ED provider note dated 9/14/21, at 9:58 a.m. indicated P4's initial breathalyzer was 0.227 % BAC and the licensed alcohol and drug counselor (LADC) informed the provider the clinic wished to pursue civil commitment and P4 was placed on a 72-hour hold.

P4's medical order dated 9/14/21, at 10:20 a.m. indicated P4 was placed on a 72-hour hold beginning on 9/14/21, at 10:19 a.m.

P4's Examiner's Statement in Support of Petition for Commitment dated 9/14/21, signed at 2:40 p.m. indicated P4 was unable to function safely in the community, and had suffered injuries from falls and assaults while he was intoxicated with limited decision-making capability. Additionally, the statement indicated because of his pattern of alcohol use and ingestion of hand sanitizer, he was "repeatedly put him in imminent risk of harm and are life threatening."

P4's Nursing Assessment dated 9/15/21, at 5:35 p.m. indicated P4 needed a remote VM for elopement precautions, demonstrating poor judgment and safety awareness.

P4's nursing focused reassessment dated 9/16/21, at 3:54 p.m. indicated P2 attempted to elope two times on the day shift; the first time by removing his spice-colored scrubs and donning is clothing that was left unlocked in the room. The second time by removing his spice-colored scrubs and leaving in long underpants and a blanket wrapped around him. The note indicated he was caught and brought back to his room where his clothing was locked up and the VM was placed outside his room.

P4's behavioral emergency response team (BERT) note dated 9/16/21, at 4:17 p.m. indicated P4 attempted to elope from the hospital while on a legal hold, and interventions of verbal de-escalation, show of force, and medication was provided to keep him in the facility. The plan was for continued VM. There was no indication of change of level of supervision after these attempts to elope.

P4's Court Order dated 9/17/21, at 10:18 a.m. indicated a Hennepin County judge issued a court order holding P4 to the hospital for observation, evaluation, diagnosis, care, and involuntary treatment of chemical dependency. The Court Order also indicated the facility could transfer P4 to a detox unit with notification to the Court of such transfer.

P4's discharge note dated 9/17/21, at 12:00 a.m. indicated P4 was discharging to a detox unit and was on a district court hold for chemical dependency. The note also indicated P4 had multiple BERT calls because he tried to leave the facility. There was no indication of a change in level of supervision.

P4's provider PN dated 9/18/21, at 3:04 p.m. indicated the provider found P4's spice-colored scrubs on the bed and P4 gone. The roommate informed the provider P4 had been gone for a couple of hours. The note indicted the VM was outside the room, and the RN had last been in the room some time in the morning. The note indicated the provider let the charge nurse know the patient was on a court hold and to notify law enforcement.

P4's PN dated 9/18/21, at 3:30 p.m. indicated P4 was last seen at 11:30 a.m. The VM was outside the room and "does not appear to have gone off."

P4's PN dated 9/18/21, at 5:39 p.m. indicated P4's roommate saw P4 leave around 1:00 p.m. wearing a hospital gown.

P4's ED note dated 9/20/21, at 3:30 p.m. indicated P4 was on a court commitment and returned to the ED after eloping from his last admission (9/18/21). P4 reported drinking one liter of vodka and three bottles of hand soap believing they contained alcohol. The note indicated he would be admitted to a commitment bed in the detox unit or with a 1:1 attendant in a medical bed.

P4's VM report for 9/18/21, was requested and could not be located.

The facility's event report dated 9/18/21, indicated P4 eloped around 11:30 a.m. on 9/18/21, with his spiced-colored scrubs found on his bed. The report also indicated P4 returned to the ED on 9/20/21, and was readmitted. The report lacked evidence of any investigation or actions.

During an interview on 9/21/21, at 9:49 a.m. P4 stated he was claustrophobic, so he left over the weekend but came back because he was supposed to meet with his parole officer and he needed help with his addiction. P2 stated he knew he was on a court hold, and was given a copy of paperwork but lost it.

During an interview on 9/21/21, at 1:37 p.m. MD-M stated P4 was on a court hold for civil commitment and he was waiting for a detox bed to be discharged from the medical unit.

During an interview on 9/22/21, at 8:25 a.m. VMT-R stated she observed P4 on 9/18/21, through the remote VM and he tried to elope twice during her shift from 7:00 a.m. through 3:00 p.m. VMT-R sated she observed P4 remove his spice-colored scrubs, don a green hospital gown, and wrap a white towel around his head. VMT-R stated she called the unit staff to alert them to P4's attempts to elope. VMT-R stated staff were able to stop him from eloping. VMT-R stated she does not recall which staff she spoke to, they just had a general phone number to call the floor.

During an interview on 9/22/21, at 12:45 p.m. RN-K stated P4 had been sleeping most of the morning on 9/18/21, but she woke him at 10:30 a.m. to give him morning medications; she was aware he was on a 72-hour hold but thought it expired at noon; she was unaware he was on a court hold. RN-K stated she took a break around 1:00 p.m. and around 2:30 p.m. the MD asked her where P4 was; RN-K went into P4's room and found spice-colored scrubs on the bed. She stated they were unable to locate P4.

During observation on 9/20/21, around 3:30 p.m. remote VM were observed outside several rooms on the medicine floor. The VM was on a tall pole and consisted of camera, microphone, speaker, and an alarm. RN-G explained the VMT controlled the VM remotely on a different unit; the VMT could rotate the camera 360 degrees, talk to the patient, and listen to the patient. RN-G also explained that when the patient attempted to leave the room or elope, the VMT would sound an alarm that was on the VM and all nursing staff were to respond to the alarm by going to the room where the VM was alarming.

During observation on 9/22/21, around 3:30 p.m. the VMT room was observed on the Medicine-Surgery-Orthopedic (MSO) unit; two VMT were in the room and each VMT was observing 12 monitor screens. Each monitor screen showed one patient and to the side of the screen were notes with patient name, room number, age, possible adverse events, risk factors, and title bar notes, which contained descriptions of patients for some of the patients.

During an interview on 9/20/21, approximately 3:30 p.m. RN-F stated the VMT observed patients remotely through the VM and if they exhibited any undesired behavior, the VMT would sound an alarm with the expectation all nursing staff respond to the alarm by going to the direction of the alarm; sound was the only way of knowing where the alarm was coming from. RN-F stated when the alarmed stop, nursing staff would no longer need to respond. RN-F stated the VM could be rotated 360 degrees for viewing in the room as the patient moved around the room.

During an interview on 9/20/21, at 3:43 p.m. RN-H stated when a VM alarmed, staff ran to the location of the sound and stopped going to the sound when it ceased. RN-H stated patients on VM should be wearing spiced-colored scrubs and their belongings should all be locked up; if the patient was in a private room the VM was inside the room but if the patient was in a private room the VM was either inside the room or outside the room.

During an interview on 9/21/21, at 10:07 a.m. RN-I stated patients were evaluated for elopement risk and if they were high risk, they would be on a 1:1 attendant rather than remote VM. RN-I further stated patients on a hold, at risk of eloping or trying to elope, history of eloping, or at risk of harming self would be on a 1:1 attendant.

During an interview on 9/21/21, at 1:37 p.m. MD-M stated all patients on holds or waiting for a bed in detox or psychiatry should have either direct (1:1 attendant) monitoring or remote VM monitoring but it was up to the inpatient team to determine which should be used.

During an interview on 9/22/21, at 9:33 a.m. patient safety manager (PSM)-D stated after each elopement, the elopement was reviewed by the manager of the unit; she verified the only action taken was after P3's elopement when the unit manager reviewed the elopement policy with nursing staff. PSM-D stated the Safety Team had met once with the unit manager, the clinical care supervisor, and one other PSM to review elopements of P2 and P3 to complete their analyses and determine if any additional interventions would be appropriate. The PSM-D stated they were still in the process of analyzing those elopements and had not reviewed P4's elopement yet, and P1 was on a different unit so he was not included.

During an interview on 9/22/21, at 10:57 a.m. RN-F stated after P2's elopement leadership reviewed the elopement policy with nursing staff during day/evening huddles and night/day huddles; she also added the policies to the charge nurse binder. RN-F also stated no VMT were educated. RN-F reported after P3's elopement patient safety met with medicine floor leadership and was in the process of further analyzing the elopements and developing a plan for intervening but no further interventions had been implemented.

During interview on 9/22/21, around 3:30 p.m. VMT-I explained each VMT monitors up to 12 patients at one time; VMTs did a verbal hand-off during change of shift while at the monitors. VMT-I stated the hand-off took only a few minutes and they did the best they could to watch the patients at the same time they were doing verbal reports.

Th