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I. Based on document review, observations, and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure 1 of 1 patient received care in a safe setting (Patient #1) by preventing Patient #1's elopement from the hospital. Please refer to A-0144.

2. Implement corrective action to ensure the safety of hospitalized patients at risk of elopement from leaving the hospital.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure patients at risk of elopement received sufficient supervision to prevent elopements and receive care in a safe setting.

II. During the investigation of incident 64225-I, the on-site surveyor identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Patient's Rights (42 CFR 482.13).

1. The administrative staff failed to develop and implement a corrective action plan to ensure the immediate safety of all hospitalized patients at risk of eloping from the hospital, following Patient #1's successful elopement on 11/8/16 (10 days prior to the investigation)

2. After the Centers for Medicare & Medicaid Services (CMS) Regional Office (RO) staff informed the hospital administrative staff of the IJ situation, the administrative staff failed to create an acceptable corrective action plan prior to the exit date of the investigation. The administrative staff did not remove the Immediate Jeopardy situation prior to the exit date of the investigation. A Condition Level deficiency also remained for the Condition of Participation in Patient's Rights.

Based on document review, observations, and staff interviews, the acute care hospital staff failed to provide a safe environment for 1 of 1 patient reviewed (Patient #1) that eloped from the facility. The administrative staff failed to implement corrective action to prevent other patients from eloping. The hospital administrative staff identified 17 patients on the same inpatient nursing unit as Patient #1 at the time of the elopement.

Failure to provide care in a safe environment led to 1 patient eloping from the hospital and spending an hour outside while hospital staff searched for the patient. Failure to implement corrective actions to prevent future elopements potentially resulted in a patient eloping from the facility and potentially could result in patients dying from exposure to the elements or injury without staff oversight for safety.

Findings included:

1) Review of Patient #1's medical record revealed that Patient #1 was admitted to the hospital on 11/5/16 at 9:07 PM. Patient #1 was admitted to the hospital for a choking episode at home with possible aspiration pneumonia and evaluation for long-term care placement due to dementia. Registered Nurse (RN) A documented on 11/5/16 at 9:07 PM that Patient #1 did not speak English as their primary language.

2) During an interview on 11/18/16 at 09:30 AM, RN C stated she was the lead nurse on the unit and assigned to provide care to Patient #1 on the overnight shift from 11/7/16 to 11/8/16. Patient #1 had dementia and did not natively speak English. RN C stated she attempted to use a professional translator over the phone to communicate with Patient #1 on 11/8/16, but the translator stated that Patient #1's statements did not make sense in either language.

3) Review of Patient #1's medical record revealed that Hospitalist A (a physician who only provides care to hospitalized patients) ordered the nursing staff to use the bed alarm on Patient #1's bed at all times due to Patient #1's risk of wandering on 11/5/16 at 8:40 PM. Hospitalist E's progress note from 11/7/16 revealed Patient #1 stated to Hospitalist E that Patient #1 wanted her/his wallet and identification cards.

4) During an interview on 11/18/16 at 7:00 AM, Patient Care Technician (PCT) D stated that they activated Patient #1's bed alarm on the overnight shift of 11/7/16 to 11/8/16 (the night of the elopement). Patient #1 was sleeping each time PCT D checked on Patient #1. PCT D stated each time she checked on Patient #1, the indicator light on the bed indicated the bed alarm was active. PCT D stated she did not hear Patient #1's bed alarm sound during the overnight shift. PCT D thought Patient #1 turned off the bed alarm, as Patient #1 walked a short distance off the nursing unit without the alarm sounding.

5) During an interview on 11/18/16 at 9:30 AM, RN C stated that Patient #1 stated during the night that he wanted to go home. RN C stated she was admitting another patient to the inpatient nursing unit around 4:30 AM on 11/8/16. During the admission process, RN C saw Patient #1 walk by the exit towards the elevators. RN C caught up to Patient #1 and redirected him back to his room. Patient #1 kept telling RN C that he wanted to go home. RN C reassured Patient #1 he needed to stay in the hospital. RN C returned Patient #1 to his bed and activated the bed alarm.

RN C stated RN F (another nurse on the unit) offered to stay at the nurses' station and would help watch to see if Patient #1 left his room. RN C finished admitting the other patient and returned about 10 minutes later to check on Patient #1 in his room. RN C found the nurses' station empty and Patient #1 was not in his room. RN C questioned RN F about staying at the nurses' station. RN F replied, "dude, I have my own patients."

RN C started searching the nursing unit for Patient #1. After RN C was unable to locate Patient #1 on the nursing unit, RN C contacted security.

6) During an interview on 11/18/16 at 06:00 AM, Security Officer G stated he received a phone call on 11/8/16 at approximately 4:45 AM from RN C informing him Patient #1 eloped. Security Officer G started searching the smoking and vending areas on campus. When Security Officer G failed to locate Patient #1, Security Officer G went to the security office and reviewed the cameras. Security Officer G discovered Patient #1 went down the stairs and exited the building on the Bloomington Avenue side of the hospital. Security Officer G informed the Assistant Director of Nursing (ADON) H (the on-site person in charge of the hospital outside business hours) that Patient #1 exited the building. Security Officer G stated he used a hospital vehicle to begin searching for Patient #1 and spoke with the Iowa City Police Department officers to coordinate the search for Patient #1.

7) During an interview on 11/18/16 at 6:45 AM, Environmental Service Staff Member (ESS) I stated she was informed around 5:15 AM on 11/8/16 that Patient # eloped and she needed to help search for Patient #1. The emergency department staff provided ESS I with flashlights and a coat. ESS I started searching the area around the hospital with another staff member. While walking by a house with a porch across Bloomington Avenue from the hospital, ESS I thought she saw something under a porch swing. ESS I approached the porch and observed Patient #1 under the swing. Patient #1 stated he was cold, so ESS I gave Patient #1 her coat and contacted Security Officer G. Security Officer G returned Patient #1 to the hospital. ESS I stated she found Patient #1 at approximately 5:40 AM on 11/8/16 (about 1 hour after Patient #1 left the hospital).

8) Review of a hospital document titled "Synopsis of Investigation," dated 11/16/16 at 5:31 PM, revealed the temperature outside the hospital was 54 degrees Fahrenheit when Patient #1 eloped.

9) Observations made on 11/18/16 at 8:15 AM included the surveyor walked to the house where the staff located Patient #1. The surveyor walked at a casual pace and took 1 minute 20 seconds to walk from the door where Patient #1exited the hospital to where staff found Patient #1. The house was across Bloomington Avenue, a residential street, from the hospital with minimal traffic noted on the street.

10) During an interview on 11/18/16 at 8:30 AM (10 days after Patient #1 eloped), the Patient Safety Coordinator, the Inpatient Nursing Director, the Director of Quality, the Chief Nursing Officer, and the 3 West Unit Manager discussed interventions placed following Patient #1's elopement. They stated the group discussed several longer-term interventions. The administrative staff failed to implement any of the longer-term interventions at that time. The administrative staff spoke with direct patient care nurses and PCTs about the elopement. The direct care staff had a heightened awareness of patients at risk of elopement and reinforced the use of bed alarms for patients at risk of elopement.

11) During an interview on 11/18/16 at 7:00 AM, PCT D could not state any new interventions implemented by the administrative staff following Patient #1's elopement to prevent other patients from eloping.

12) During an interview on 11/18/16 at 7:30 AM, RN F could not state any new interventions implemented by the administrative staff following Patient #1's elopement to prevent other patients from eloping.

13) During an interview on 11/18/16 at 9:30 AM, RN C could not state any new interventions implemented by the administrative staff following Patient #1's elopement to prevent other patients from eloping.

14) During an interview on 11/18/16 at 8:00 AM, ADON H could not state any new interventions implemented by the administrative staff following Patient #1's elopement to prevent other patients from eloping.

15) During an interview on 11/18/16 at 11:59 AM, the Director of Quality and Chief Nursing Officer stated the hospital had a policy for patient elopements from the skilled nursing unit, which closed earlier in the calendar year. The hospital currently lacked a policy that instructed staff how to identify patients at risk of elopement, interventions to prevent patients from eloping, and how to react if a patient eloped.

I. Based on document review, observations, and staff interview, the acute care hospital's administrative staff failed to:

1. Ensure 1 of 1 patient received an adequate nursing assesment and appropriate supervision (Patient #1) by preventing Patient #1's elopement from the hospital. Please refer to A-0395.

2. Implement corrective action to ensure the safety of hospitalized patients at risk of elopement from leaving the hospital.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure patients at risk of elopement received sufficient supervision to prevent elopements and receive care in a safe setting.

II. During the investigation of incident 64225-I, the on-site surveyor identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Nursing Services (42 CFR 482.23).

1. The administrative staff failed to develop and implement a corrective action plan to ensure the immediate safety of all hospitalized patients at risk of eloping from the hospital, following Patient #1's successful elopement on 11/8/16 (10 days prior to the investigation)

2. After the Centers for Medicare & Medicaid Services (CMS) Regional Office (RO) staff informed the hospital administrative staff of the IJ situation, the administrative staff failed to create an acceptable corrective action plan prior to the exit date of the investigation. The administrative staff did not remove the Immediate Jeopardy situation prior to the exit date of the investigation. A Condition Level deficiency also remained for the Condition of Participation in Nursing Services.

Based on document review, observations, and staff interviews, the acute care hospital staff failed to provide an adequate nursing assessment and appropriate supervision for 1 of 1 patient reviewed (Patient #1) that eloped from the facility. The administrative staff failed to implement corrective action to prevent other patients from eloping. The hospital administrative staff identified 17 patients on the same inpatient nursing unit as Patient #1 at the time of the elopement.

Failure to provide an adequate nursing assessment and appropriate supervision led to 1 patient eloping from the hospital and spending an hour outside while hospital staff searched for the patient. Failure to implement corrective actions to prevent future elopements potentially resulted in a patient eloping from the facility and potentially could result in patients dying from exposure to the elements or injury without staff oversight for safety.

Findings included:

1) Review of Patient #1's medical record revealed that Patient #1 was admitted to the hospital on 11/5/16 at 9:07 PM. Patient #1 was admitted to the hospital for a choking episode at home with possible aspiration pneumonia and evaluation for long-term care placement due to dementia. Registered Nurse (RN) A documented on 11/5/16 at 9:07 PM that Patient #1 did not speak English as their primary language.

2) During an interview on 11/18/16 at 09:30 AM, RN C stated she was the lead nurse on the unit and assigned to provide care to Patient #1 on the overnight shift from 11/7/16 to 11/8/16. Patient #1 had dementia and did not natively speak English. RN C stated she attempted to use a professional translator over the phone to communicate with Patient #1 on 11/8/16, but the translator stated that Patient #1's statements did not make sense in either language.

3) Review of Patient #1's medical record revealed that Hospitalist A (a physician who only provides care to hospitalized patients) ordered the nursing staff to use the bed alarm on Patient #1's bed at all times due to Patient #1's risk of wandering on 11/5/16 at 8:40 PM. Hospitalist E's progress note from 11/7/16 revealed Patient #1 stated to Hospitalist E that Patient #1 wanted her/his wallet and identification cards.

4) During an interview on 11/18/16 at 7:00 AM, Patient Care Technician (PCT) D stated that they activated Patient #1's bed alarm on the overnight shift of 11/7/16 to 11/8/16 (the night of the elopement). Patient #1 was sleeping each time PCT D checked on Patient #1. PCT D stated each time she checked on Patient #1, the indicator light on the bed indicated the bed alarm was active. PCT D stated she did not hear Patient #1's bed alarm sound during the overnight shift. PCT D thought Patient #1 turned off the bed alarm, as Patient #1 walked a short distance off the nursing unit without the alarm sounding.

5) During an interview on 11/18/16 at 9:30 AM, RN C stated that Patient #1 stated during the night that he wanted to go home. RN C stated she was admitting another patient to the inpatient nursing unit around 4:30 AM on 11/8/16. During the admission process, RN C saw Patient #1 walk by the exit towards the elevators. RN C caught up to Patient #1 and redirected him back to his room. Patient #1 kept telling RN C that he wanted to go home. RN C reassured Patient #1 he needed to stay in the hospital. RN C returned Patient #1 to his bed and activated the bed alarm.

RN C stated RN F (another nurse on the unit) offered to stay at the nurses' station and would help watch to see if Patient #1 left his room. RN C finished admitting the other patient and returned about 10 minutes later to check on Patient #1 in his room. RN C found the nurses' station empty and Patient #1 was not in his room. RN C questioned RN F about staying at the nurses' station. RN F replied, "dude, I have my own patients."

RN C started searching the nursing unit for Patient #1. After RN C was unable to locate Patient #1 on the nursing unit, RN C contacted security.

6) During an interview on 11/18/16 at 06:00 AM, Security Officer G stated he received a phone call on 11/8/16 at approximately 4:45 AM from RN C informing him Patient #1 eloped. Security Officer G started searching the smoking and vending areas on campus. When Security Officer G failed to locate Patient #1, Security Officer G went to the security office and reviewed the cameras. Security Officer G discovered Patient #1 went down the stairs and exited the building on the Bloomington Avenue side of the hospital. Security Officer G informed the Assistant Director of Nursing (ADON) H (the on-site person in charge of the hospital outside business hours) that Patient #1 exited the building. Security Officer G stated he used a hospital vehicle to begin searching for Patient #1 and spoke with the Iowa City Police Department officers to coordinate the search for Patient #1.

7) During an interview on 11/18/16 at 6:45 AM, Environmental Service Staff Member (ESS) I stated she was informed around 5:15 AM on 11/8/16 that Patient # eloped and she needed to help search for Patient #1. The emergency department staff provided ESS I with flashlights and a coat. ESS I started searching the area around the hospital with another staff member. While walking by a house with a porch across Bloomington Avenue from the hospital, ESS I thought she saw something under a porch swing. ESS I approached the porch and observed Patient #1 under the swing. Patient #1 stated he was cold, so ESS I gave Patient #1 her coat and contacted Security Officer G. Security Officer G returned Patient #1 to the hospital. ESS I stated she found Patient #1 at approximately 5:40 AM on 11/8/16 (about 1 hour after Patient #1 left the hospital).

8) Review of a hospital document titled "Synopsis of Investigation," dated 11/16/16 at 5:31 PM, revealed the temperature outside the hospital was 54 degrees Fahrenheit when Patient #1 eloped.

9) Observations made on 11/18/16 at 8:15 AM included the surveyor walked to the house where the staff located Patient #1. The surveyor walked at a casual pace and took 1 minute 20 seconds to walk from the door where Patient #1exited the hospital to where staff found Patient #1. The house was across Bloomington Avenue, a residential street, from the hospital with minimal traffic noted on the street.

10) During an interview on 11/18/16 at 8:30 AM (10 days after Patient #1 eloped), the Patient Safety Coordinator, the Inpatient Nursing Director, the Director of Quality, the Chief Nursing Officer, and the 3 West Unit Manager discussed the current nursing assessment in the electronic medical record. The current medical record included sections for the nursing staff to assess the patient's fall risk and neurological/cognative status. The electronic medical record system did not include a section to assess the patient's risk of elopement. The administrative staff had discussed adding a decision making tool for nursing staff to identify patients at risk for elopement and provide suggested interventions for the nurse to implement. The administrative staff failed to implement a new assessment tool at the time of the interview.

11) During an interview on 11/18/16 at 7:00 AM, PCT D could not state any new interventions implemented by the administrative staff following Patient #1's elopement to prevent other patients from eloping.

12) During an interview on 11/18/16 at 7:30 AM, RN F could not state any new interventions implemented by the administrative staff following Patient #1's elopement to prevent other patients from eloping.

13) During an interview on 11/18/16 at 9:30 AM, RN C could not state any new interventions implemented by the administrative staff following Patient #1's elopement to prevent other patients from eloping.

14) During an interview on 11/18/16 at 8:00 AM, ADON H could not state any new interventions implemented by the administrative staff following Patient #1's elopement to prevent other patients from eloping.

15) During an interview on 11/18/16 at 11:59 AM, the Director of Quality and Chief Nursing Officer stated the hospital had a policy for patient elopements from the skilled nursing unit, which closed earlier in the calendar year. The hospital currently lacked a policy that instructed staff how to identify patients at risk of elopement, interventions to prevent patients from eloping, and how to react if a patient eloped.