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Based on medical record (MR) review, video footage review, document review, and staff interview it was determined the facility failed to provide care appropriate for a patient who presented to the Emergency Department (ED) via Emergency Medical Services from an Assisted Living Facility, with a diagnosis of dementia, which contributed to the patient's elopement (See Tag A 144). As a result of this failure, Immediate Jeopardy (IJ) was identified and the facility was notified on 2/28/22 at 3:35 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, that was verified by the State Survey Agency on 3/2/22 at 10:02 a.m.

The following interventions were implemented to resolve the IJ:

The ED Nurse Manager and ED Clinical Coordinator will continue to educate all ED nursing staff that if an unaccompanied patient leaves who is from a care facility or sixty-five (65) and older, they will notify the next of kin, hospital security, law enforcement and the care facility that the patient has left the facility.

The facility's Governing Board received a full review of the event and completed actions on 3/1/22 at the board meeting. Education was provided regarding the governing body's roles and responsibilities in oversite of quality and safety throughout the organization.

The facility's Governing Board made the following motion: It was moved and seconded to direct Administration to regularly update the Board's Executive Committee on compliance with the Action Plan developed in response to the 12/30/21 event.

Cross Reference: 482.13(c)(2) Patient Rights: Care in a Safe Setting

Based on video footage review, medical record (MR) review, document review and staff interview it was determined the facility failed to ensure care was rendered in a safe setting. The facility failed to provide care appropriate for a patient who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) from an Assisted Living Facility, with a diagnosis of dementia, and failed to provide adequate re-education to all staff to prevent this from occurring again. This failure was identified in one (1) of one (1) medical record reviewed (patient #1). This failure has the potential to adversely affect all patients who present to the ED by EMS.

Findings include:

A review of the medical record for patient #1 revealed the patient presented to the ED, via EMS, on 12/30/21 at 4:11 p.m. The EMS run sheet stated patient #1 came from an Assisted Living Facility. The medical record revealed triage was completed at 4:11 p.m., with a chief complaint of fever. Patient #1 is documented as leaving against medical advice (AMA)/without treatment on 12/30/21 at 6:55 p.m., and an AMA form was completed on 12/30/21 at 6:50 p.m. Patient #1 was an acuity four (4) and nursing documented patient #1 as alert and oriented times three (3) (person, place and time). Patient #1 was not seen by the physician in the ED. There was no documentation in the medical record the Assisted Living Facility, Security or the Police Department were notified when the ED staff realized the patient had left the facility.

A review of the documentation sent to the facility by the patient's assisted living facility with EMS revealed patient #1 had a diagnosis of hypertension and dementia.

An interview was conducted on 2/28/22 at 12:10 p.m. with staff member #1. Staff member #1 stated a silver alert went out on 1/5/22 for patient #1 (a silver alert is for broadcasting information about missing persons-especially senior citizens with dementia). The facility became aware of the patient elopement on 1/12/22. Staff member #1 stated, "I saw on the news on 1/11/22 about a silver alert for patient #1 and patient #1 had been at the facility on 12/30/21." Staff member #1 further stated, "I contacted leadership of the ED and got the run around. I sent emails about what kind of action plan was being conducted to ensure this did not happen again. I was told no patient with dementia would be at the Assisted Living Facility, they don't have dementia patients there. There is no documentation anyone was called after [the patient] left the emergency room without treatment. The triage nurse triaged [the patient] as alert and oriented times three (3). The video doesn't portray [the patient] as being normal. Triage had documented the patient as arriving by private vehicle on a stretcher. During the Sentinel event action review, no dates were given for training. I was told they would get back with me on the dates. The Sentinel event review was conducted on 2/25/22, after the patient was found deceased on 2/21/22. No inpatient staff training was completed as of 2/25/22 regarding the elopement. During the review of video, it revealed EMS gave papers to the triage nurse. The triage nurse looked at the papers and gave them back to the EMS worker, who gave them back to the patient. No one knows where the EMS paperwork is. They are unsure what was given to the triage nurse because they cannot find the paperwork."

A review of the video of the ED on 12/30/21 was conducted on 2/28/22 at 2:59 p.m. with the supervisor of Security. On 12/30/21, the video revealed patient #1 walked into the ED accompanied by an EMS worker at 4:04 p.m. The EMS worker walks down by the nurse's station, gets a wheelchair and puts patient #1 in the wheelchair. At 4:05 p.m., EMS brings the patient to the nurse's station. At 4:09 p.m., EMS brings paperwork to the triage nurse, the triage nurse takes the paperwork and appears to be talking to EMS while typing on the computer. Pharmacy was noted standing beside registered nurse (RN) #1. At 4:16 p.m., the triage nurse gives the paperwork back to EMS. At 4:16:10 p.m., EMS gives the paperwork back to the patient. At 4:17:05 p.m., the triage nurse comes to patient #1 and puts an armband on the patient. At 4:17:09 p.m., the triage nurse leaves the patient. At 4:18 p.m., patient #1 is taken to the waiting room by EMS and placed in the waiting room area of the ED in a wheelchair. At 4:44 p.m., patient #1 walks over to registration. At 4:44:49 p.m., patient #1 lays paperwork on the registration desk. At 4:49 p.m., patient #1 leaves the registration desk with the paperwork. It should be noted a zoom of the video shows the paperwork is the same paperwork sent to the hospital with the patient and it is the same paperwork sent to the state agency) At 5:00 p.m., patient #1 is noted in the ED rear waiting room area, on the right side. At 6:06 p.m., patient #1 comes from the left side ED waiting room area and walks to the outside door of the ED. At 6:06:44 p.m., patient #1 passes a deputy sheriff while walking out the ED doors to the outside. During the video review, the supervisor of Security informed the surveyor of the right and left areas of the ED waiting room area. The Security supervisor stated the video had showed patient #1 coming back into the front entrance of the hospital on 12/30/21 at 8:15 p.m. and was speaking to the guest service representative. The security officer was unsure when the patient left and was having difficulty retrieving video the day of video review.

An interview was conducted with the supervisor of Security on 2/28/22 at 3:50 p.m. When asked what the expectations would be for the staff of the ED if anyone who presented to the facility may have a diagnosis of dementia and leaves the facility, the supervisor stated, "Normally a Code Walker is called. Nurses inform Security a patient has left and gives the description. The nursing supervisor is called and sometimes the Police Department is called. Sometimes Security can locate a patient on the grounds." The supervisor stated, "Expectation is for nursing to call whenever an Assisted Living Facility patient leaves the facility without treatment."

A review of the Safety Review Form completed by the facility on 2/25/22 stated in part:

"NOTES: [the triage nurse] copied EMS vitals. [ED nursing staff] did not chart that they called for the patient x 3 with no answer. No hx. [history] of dementia in chart or by EMS unless it was on paperwork [sent from the assisted living]. Paperwork not in sight after going to registration [per video, patient no longer carrying paperwork from the assisted living that was given back to EMS by triage nurse].

ACTIONS:
1) Staff education provided on 1/19/2022 and 1/21/2022 included: VS [vital signs] must be obtained at triage and not transcribed from EMS form. For rare occasions that a patient with a history of dementia needs to be housed in the waiting room, handoff communication to charge nurse and triage nurse must take place including increased vulnerability of the patient.

2) Cerner [electronic medical record] enhancement created on 2/24/22 that added a field to the AMA forms for care facilities and/or next of kin information to be completed on all patients 65 years and older as well as all patients known to have history of dementia. This education was completed on MM/DD/YYYY [no date listed in safety review form, just the date format].

3) AMA policy updated on 2/22/2022 to include notifying facility and/or emergency contact when a patient over age 65 or with known dementia has left AMA or eloped. Process includes triage RN or primary RN to place calls for these patients as appropriate. This education was completed on MM/DD/YYYY [no date listed in safety review form, just the date format].

4) House-wide AMA policy to mimic ED AMA policy. This education with inpatient staff was completed on MM/DD/YYYY [no date listed in safety review form, just the date format].

5) ED will conduct daily audits of AMA/Elopement events to ensure compliance with above measures.

6) (Registration) will gather a subcommittee to discuss measures to improve triage to registration times in order to ensure accurate information. This was completed on MM/DD/YYYY [no date listed in safety review form, just the date format]."

It should be noted completion dates are only noted at the time of exit; no dates were provided on education either by written sign-in sheets or email read receipts. No other action plans have a completion date noted. No training for elopement of Assisted Living Facility patients is noted.

A tour of the ED conducted on 3/1/22 at 8:55 a.m. with the Security supervisor revealed the ED has a bed capacity of twenty-seven (27) beds and a current census of twenty-three (23). The ED has nine (9) RN's, one (1) graduate nurse, two (2) ICU borders and eleven (11) Medical/Surgical borders. During the tour, the supervisor showed the surveyors the rear area of the ED waiting room, where patient #1 was located prior to leaving the facility.

An interview was conducted with RN #1 on 3/1/22 at 9:33 a.m. When asked what the staff member remembered about patient #1, RN #1 stated, "[Patient] was brought in for a fever. I remember the patient walked in with EMS." When asked how RN #1 verified patient was alert and oriented, RN #1 stated, "I verified name and date of birth with the patient." When informed the video showed a four (4) second encounter between RN #1 and patient #1, RN #1 was asked how did you determine the patient was alert and oriented times three (3) (person, place and time) in four (4) seconds. RN #1 stated, "(the patient) answered with (the patient's) date of birth and name." When asked if proper education was completed about a true triage assessment, RN #1 stated, "Yes." RN #1 stated re-education on assessments, vital signs and basic triage was completed. When RN #1 was asked if they received paperwork from EMS about the patient, RN #1 stated, "I don't remember the paperwork." When asked if any training was conducted on Code Walker or elopement policy since this occurrence on 12/30/21, and the facility being notified of the incident on 1/12/22, RN #1 stated, "No. I don't even know what the process is for Code Walker calling, but I was re-educated on triaging."

An interview was conducted with the ED Nurse Manager on 3/1/22 at 10:05 a.m. When asked about the incident with patient #1, the Nurse Manager stated, "On 1/11/22, we knew this occurred. Initial action was we made a game plan, we had staff interviews and we looked at the video and looked at the policy. We addressed the employee involved regarding assessment guidelines. We had staff meetings on 1/19/22 and 1/20/22, this was an open discussion. On 1/12/22, [Clinical Coordinator] called the facility and asked if they had called a report to the hospital, we were told no. The facility [patient #1] was living at, was a least restrictive place, the environment is different from nursing homes. We did not have any paperwork. [RN #1] said [RN #1] was looking for the height and weight and saw the meds (in the paperwork they received from EMS). We have discussed points in policy that needed changed and points that didn't need a change. On 2/22/22, additional information about AMA and left without treatment was added to the policy. It was finalized on 2/25/22. Our action plan was done in phases."

An interview was conducted with the Director of the ED (DED)/Critical Care on 3/1/22 at 10:47 a.m. When asked about the incident, the DED stated, "I was informed by the VP (vice president) on 1/11/22 about the news broadcast. We told the team what to do, [the Clinical Coordinator] reached out to [RN #1]. I reached out to [RN #1] the next day. [RN #1] was retrained on triage and [RN #1] was disciplined. [RN #1] didn't follow policy for assessment; regardless of how busy the ED is, you must do your own assessment. [RN #1] was told not a good performance. We were following what information was provided, then we looked at policies. On the 22nd, we were in touch with the care connect team. No paperwork could be found from the facility. [RN #1] had two (2) critical patients that day." When asked if a Code Walker should have been called, the DED stated, "Code Walker would have been called if the dementia and assisted living had been known, and they would have called the Assisted Living Facility or the Police Department." When asked why the patient was listed as AMA instead of elopement, the DED stated, "Any patient who presents through EMS and leaves without treatment, it would be considered an AMA." When asked about re-education of the ED staff, the DED stated, "On 1/19/22 and 1/21/22, it was just discussions, it was not training." When asked about the phases of the action plan, the DED stated, "This occurred in phases." When informed an action plan should have been done immediately to prevent this occurrence from occurring again, the DED stated, "If the assessment would have been appropriate and [the patient] been placed at the nursing station appropriately, we would not be having this discussion. [RN #1] only did identification when putting on the armband and not orientation of the patient." The DED concurred no re-education was completed with the staff concerning the elopement of a patient who presented to the ED from an Assisted Living Facility and failed to provide care appropriate for the patient.

An interview was conducted with the Clinical Coordinator (CC) on 3/1/22 at 11:48 p.m. When asked what training was conducted with the staff, the CC stated there was one-on-one (1:1) training, AMA policy in Cerner, and correct triage note. When asked about an AMA policy/left without treatment or Code Walker policy for the ED, the CC stated, "Code Walker is only for inpatients not for the ED." The CC stated, "This just doesn't happen here."

A telephone interview was conducted with RN #5 on 3/2/22 at 9:40 a.m. When asked if RN #5 was aware of the situation with patient #1, RN #5 stated, "Yes." When asked about any additional training concerning the incident, RN #5 stated, "Multiple in-services on what we could have done differently. We've had in-services on people leaving the facility and who we can't send to the lobby. Some non-emergent patients, even if they come in by EMS, can go to the waiting room." When asked what the process is for paperwork received from another facility, RN #5 stated, "We keep the paperwork from all the facilities that they send, we don't always have paperwork, they are supposed to call a report. Even after discharge, any paperwork received should go with the patient chart."

An interview was conducted with RN #8 on 3/2/22 at 9:53 AM. When asked about the incident with patient #1, RN #8 stated, "I wasn't there at that time, I was on a leave of absence. We have had policy changes a few days ago. I don't remember any other changes. The ED is so busy now." RN #8 could not confirm what policy changes were made or what training had been completed.

An interview was conducted with RN #2 on 3/2/22 at 12:19 p.m. When asked if RN #2 was aware of the incident which occurred with patient #1, RN #2 stated, "We are not allowed to talk about it." When asked about any new training which has occurred since the incident with patient #1, RN #2 stated, "We have new policies in place." When asked if any training occurred before 2/25/22, RN #2 stated, "Yes. We have annual trainings." It should be noted RN #2 would not specifically say what training had been conducted prior to 2/25/22. RN #2 could not confirm what policy changes were made or what training had been completed.

A review of the policy titled "Code Walker Policy," reviewed 8/13/18, stated in part: "Purpose 1. To prevent risk of harm to at risk patients when missing from their care and treatment 2. To promote recovery of missing at risk patients ... Definitions: Elopement: Defined as occurring when a patient who is incapable of adequately protecting him/herself, and who departs the health care facility unsupervised and undetected areas. Security and the patient care nurse and/or charge nurse will call (Huntington) Police Department if an at risk patient has eloped. The patient care nurse and/or charge nurse shall provide information to the HPD when the call is placed."

During the interview conducted with the DED on 3/1/22 at 10:47 a.m., the DED concurred no re-education was completed with the staff concerning the elopement of a patient who presented to the ED from an Assisted Living Facility and failed to provide care appropriate for the patient.