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Based on medical record review, document review, and interview, the facility failed to assess patients for elopement risk and implement measures to prevent patient elopement.

This failure was identified in 1 of 10 medical records reviewed.

Please see tag 144 Patients Rights: Care in Safe Setting for Condition Level findings

Based on medical record (MR) review, document review, and interview, the facility failed to assess patients for elopement risk and implement measures to prevent patient elopement. This failure was identified in 1 of 10 MRs reviewed. Immediate Jeopardy was identified. Specifically, the facility's failure to conduct patient elopement risk assessment and to address multiple patient elopement attempts and implement immediate precautions resulted in the patient's elopement from the facility. If left uncorrected, it is likely to cause serious injury, serious harm, serious impairment, or death to other patients. Immediate action is required. After the patient's elopement, the facility failed to implement facility wide corrective actions to ensure staff are fully trained to assess, identify, and implement elopement precautions to prevent recurrence

Findings include:

-- Per MR review, Patient #1, an 83-year-old patient with a history of dementia, anxiety, recent COVID, recent urinary tract infection (UTI) (treated with antibiotic) and other medical conditions was brought to the emergency department (ED) via EMS from a nursing home on 3/27/2023 at 7:51 pm with increasing confusion.

-- The patient was triaged on 3/27/2023 at 8:00 pm. Vital signs were normal. Complete blood count showed Hemoglobin 8 grams/deciliter (g/dl) (normal 12.0 - 16.0) and Hematocrit 24.4 percent (normal 37.0 - 47.0). Urinalysis showed a UTI. Chest x-ray showed features of atypical pneumonitis, COVID-19 pneumonia versus atelectasis.

The patient was admitted to the Medical Surgical Unit.

-- Admission history and physical (H&P) on 3/28/2023 revealed patient confused and disoriented, worse than her baseline. Plan was to continue gentle hydration and treatment of UTI. Medications for agitation as needed.

-- Physician note on 3/29/2023 revealed Patient #1's principal diagnosis was dementia with mood disturbance. Mini Mental Status Exam (MMSE) completed indicated mild to moderate cognitive impairment.

-- Nursing documented on 4/2/2023 at 6:00 pm, "Patient with known dementia - ongoing confusion, anxiety and agitation. Patient required 1:1 sitter at bedside at all times today. MD called to unit several times due to patient being combative and physically aggressive with staff. Patient trying to leave the hospital to go home and unable to be redirected. While trying to get patient to walk back towards room, she grabbed multiple staff members and hit them, and attempted to bite them. Patient was screaming and near hyperventilation, then appeared to pass out and became unresponsive for several seconds- this episode happened several times throughout the day, and physicians were notified each time. All contact numbers for patient's family members were called multiple times- daughter, son-in-law, and son. Each time, the call was either not answered and voicemails were left, or the phone was answered and once we started to talk, they would hang up. Medications were administered with no effect. Eventually, one time dose of intramuscular (IM) medications ordered and administered as per medication administration record (MAR). Patient currently resting in bed and appears to be asleep. Bed alarm on."

-- Inpatient consult with geriatric medicine completed on 4/3/2023 revealed Patient #1 with advancing neurodegenerative disorder of dementia with concomitant delirium presenting to the hospital with increasing confusion. Patient recently with COVID-19 which can lead to further worsening of cognition as well as recent UTI. Reviewed medication and she is already on Aricept and Namenda (medications for dementia) and cognition continues to worsen. Medication changes were recommended. Given long term use dementia medications and cognition is worsening, likely no medications will substantially improve symptoms. Continue support reassurance structure. As far as agitation, other medications could be added. Looking at clinical situation she would do well transitioning to a longer-term care setting as she was not doing well in the assisted living facility that she was in.

-- Per review of Risk Event form, dated 4/5/2023, Patient #1 attempted to elope from the hospital on 4/4/2023 at 3:02 pm. She was found on the first floor of the hospital in admitting. The MR lacked documentation of this attempted elopement.

-- Nursing documented on 4/4/2023 at 6:09 pm, "Patient resting comfortably in chair with no complaints. Sitter is present in room (per nursing intervention). Patient became slightly agitated during the afternoon and tried leaving to go home multiple times."

-- Nursing documented on 4/5/2023 at 1:30 am, "Patient confused and restless throughout the evening, continues to attempt to leave room saying that she needs to go home. 1:1 sitter throughout the evening. Patient disagreeable about taking her evening meds but eventually did agree to take them. Refused finger stick at bedtime (HS). Report given to oncoming nurse who will be taking over patient's care. Safety maintained."

-- Nursing documented on 4/6/2023 at 6:20 am, "Alert, calm this shift. Confused but fairly cooperative, No attempts at elopement ... Slept well overnight this shift, alert this am, calm and pleasant, watching TV."

-- Nursing documented on 4/7/2023 at 3:59 am, "Patient #1 found on rounds missing from room. Floor searched, then code elopement called. Utica Police Department (UPD) notified. Pt found and returned by UPD. No apparent injury. Attempted to call family, no answer, message was left. Placed on 1:1 per physician order."

-- Nursing documented on 4/7/2023 at 7:12 pm:, "Patient remains free from falls and injury. MD ordered 1:1 sitter ... Patient did become anxious and restless, demanding to let her leave. Patient medicated with one dose of Zyprexa today. Patient encouraged to relax and remain on the unit. Patient redirected to her room a couple times. Bed kept low and locked, side rails x 2. Sitter present, call bell within reach."

-- Through the rest of her hospital admission, Patient #1 remained intermittently agitated and was treated with oral Zyprexa as needed. 1:1 sitter remained in place throughout the remainder of her hospitalization. Patient #1 was discharged to a memory care unit at a skilled nursing facility.

-- Review of the Risk Event received 4/5/2023 indicated Patient #1 attempted to elope on 4/4/2023 at 3:02 pm. Daily supervisor report documented patient confused and left room and was found down at main admitting, patient was assisted back to room with no issues or injuries noted.

-- Review of Risk Event received 4/7/2023 indicated Patient #1 was found to be missing from her room during rounds on 4/07/2023 at around 2:00 am - 2:30 am. Code elopement called, and staff searched for patient on the unit and throughout the hospital. (The patient was last seen around 12:30 am -1:00 am when the bed alarm went off. The alarm was placed back on, and the patient settled back into room.) Utica Police Department (UPD) were notified. A call was received from nearby nursing home that the patient was found and was in their custody. The patient was brought back to the hospital around 3:30 am.

-- Per review of Risk Management Investigation Summary, not dated, on 4/7/2023, a code elopement was activated at 2:36 am on unit 3C. At approximately 2:25 am, a staff member noticed Patient #1 was missing from her room. A unit search was initiated, then UPD was called. Security footage showed the Patient exiting the building just before 1:45 am. The patient left the hospital campus and walked to a nearby nursing home 0.9 miles from the hospital campus. The video indicated that the patient appeared to have stopped at a van parked at the edge of the parking lot and then continued walking northbound on Genesee Street. Security footage showed the patient being wheeled back into her room at 3:20 am.

-- Per interview of Staff A, RN on 6/28/2023 at 8:45 am, Patient #1 had been up in her room frequently that night (4/7/2023). On 4/7/2023, the patient had a sitter while awake, but once asleep, at approximately 10:00 pm, there was not a constant 1:1 sitter. Usually after Patient #1 fell asleep, she would stay in bed. At around 12:30 pm a staff member provided care to Patient #1. Staff A walked by Patient #1's room about 2:00 am and she was not there. All staff looked throughout the unit and called a code elopement and then the police department. Staff A believed the patient went down the back stairway. Staff were all around the desk so Patient #1 could not have walked by them. Staff A was not aware that the patient had attempted to elope on 4/4/2023.

-- During interview of Staff B, Director of Quality Management and Regulatory Affairs and Staff C, Director of Medical Surgical Nursing & Nursing Quality on 6/30/2023 at 4:15 pm, they acknowledged the above findings.

Based on document review and interview, in 2 of 5 risk event reports reviewed, the hospital lacked a process to ensure that all risk event report investigations were documented timely and adequately. This could lead to repeat safety events occuring.

Findings include:

-- Review of the Risk Event Referral, event #23-2591, received 4/5/2023, indicated Patient #1 attempted to elope on 4/4/2023 at 3:02 pm. Daily supervisor report documented patient confused and left room and was found down at main admitting, patient was assisted back to room with no issues or injuries noted. This report was referred to Nursing Station 3C on 5/18/2023. A response was expected by 6/7/2023. As of our entrance conference on 6/26/2023, no investigation was documented.

-- During interview of Staff D, Nurse Manager of 3 C on 6/27/2023 at 8:30 am, he/she/they had not gotten back into Midas (incident reporting electronic system) to document his/her investigation.

-- Review of the Risk Event Referral, event #23-2642, received 4/7/2023, indicated Patient #1 was noticed to be missing from her room around 2:00 am - 2:30 am. Code elopement called, and staff searched for patient on the unit and throughout the hospital. (The patient was last seen around 12:30 am - 1:00 am.) Utica Police Department (UPD) were notified. A call was received from nearby nursing home that the patient was found and was in their custody. The patient was brought back to the hospital around 3:30 am.

-- Review of the Risk Management Investigation Summary, not dated, revealed on 4/7/2023, a code elopement was activated at 2:36 am on unit 3C. At approximately 2:25 am, a staff member noticed Patient #1 was missing from her room. A unit search was initiated, then UPD was called. Security footage showed the Patient exiting the building just before 1:45 am. The patient left the hospital campus and walked to a nearby nursing home 0.9 miles from the hospital campus. The video indicated that the patient appeared to have stopped at a van parked at the edge of the parking lot and then continued walking northbound on Genesee Street. Security footage showed the patient being wheeled back into her room at 3:20 am. Action plan included 1:1 sitter and ongoing education to staff in regard to bed alarm on high risk patients, patients wearing hospital gowns, frequent rounding and documentation of rounding on all patients but especially on high risk elopement patients and policy review. The facility had no documention to show any of the identified actions had occurred.

-- Per interview of Staff D on 6/27/2023 at 8:30 am, he/she/they provided elopement related education to staff in daily huddles. A power point has been developed but has not been given to staff yet. Staff D also participated in a meeting with family.

-- Per interview of Staff E, Senior Vice President (SVP)/Chief Quality Officer (CQO) on 6/29/23 at 10:30 am and various other times, the facility recognized this lack of closing the loop on investigations. They are in the process of changing the Quality Management Department and one person will be in the role to review risk reports and ensure investigations are completed and closed out timely.

-- During interview of Staff E SVP/CQO and Staff D, Director Medical Surgical Nursing & Nursing Quality on 6/29/2023 at 12:00 pm, they acknowledged the above findings.