HospitalInspections.org

Based on interview and document review, the hospital failed to report in a timely manner an allegation of patient/patient abuse to the State Agency (SA) for 1 of 2 patients (P1) who had been assessed as a high elopement risk and eloped from the facility.

Review of a vulnerable adult (VA) report dated 10/3/2022, at 2:48 p.m. for P1. The report indicated P1 had eloped from inpatient medicine (unsecured - non locked) unit on 10-1-22 at 7:00 p.m. The report indicated the patient (P1) was in a private room and on a 1:1 for increased supervision as P1 had been assessed as a high elopement risk and also had been a CD commitment The VA report indicated the incident occurred on 2/1/20, at 8:30 p.m. but was not submitted to the SA until 10/3/2022, at 1:34 p.m. (2 days after the incident occurred).

On 10/6/22, at 2:51 p.m. during an interview registered nurse (RN)-A confirmed the VA report was not submitted until 10/3/22. RN-A stated she had been instructed to file the report with the SA on 10/3/22. RN-A confirmed the VA report involving P1's elopement should have been filed within 24 hours after the incident.

On 10/6/22, at 10:02 a.m. during an interview RN-B unit manager confirmed the VA report was not submitted until 10/3/22. RN-B stated the charge RN working on 10/1/22, had failed to file the VA report timely. RN-B stated there had been some confusion between the RN charge working and the house supervisor as to who had been responsible to file the VA. RN-B confirmed the VA report involving P1's elopement should have been filed within 24 hours after the incident.

Review of the facility Vulnerable Adults policy review date 4/26/2021, directed staff to report suspected abuse encounters to the SA within 24 hours. The policy further indicated the reporting obligation is especially important for those patients unable or unlikely to report maltreatment without assistance.