HospitalInspections.org

Based on medical record review, document review, and staff interview, in one of six medical records reviewed, the facility did not ensure the patient received care in a safe setting. Specifically, the patient who was assessed at elopement risk was not escalated to the nurse manager and the physician in accordance with facility's policy.


Findings include:


Review of the Occurrence Report dated 6/5/18 timed 5:20 AM documented: Floor 4 South. Nature of Occurrence: Elopement. Admitting Diagnoses: Hypertension, Diabetes, Gout, and history of Dementia. The patient was alert and oriented, last seen around nursing station at approximately 5:20 AM. Nursing supervisor, physician, and security made aware. Police Department notified. At 7:45 AM, patient was brought back by NYPD.


The Medical Record review (MR) documented Patient #1, a 77 year old male who presented to the emergency department on 6/2/18 at 8:07 AM. The patient walked in and was triage with chief complaints of hypertension and shortness of breathing. The patient also complained of pain and swelling with tenderness of right elbow. A comprehensive work-up was done and patient was admitted.


The Columbia Screening on 6/2/18 at 8:13 AM documented negative for suicidal and/or homicidal tendencies.


Review of the Elopement Risk Screenings from 6/2/18, 6/3/18, and 6/4/18 documented patient was not at elopement risk. Documentation indicated patient was alert and oriented x3, cooperative and follows commands appropriately.


On 6/4/18 at 11:37 AM, Registered Nurse (RN) Progress Note documented, "The patient was received back from Echo awake and confused. Patient agitated stating he was not sick and wanted to go home. The patient refused telemetry box. Yellow gown was placed on patient, frequent rounding done related to elopement risk."

There was no documentation that the patient's elopement risk assessment was escalated to the nurse manager and the physician.


On 6/5/18 at 5:30 AM, RN Progress Note documented the patient was alert and oriented. The patient was last seen at 5:20 AM walking around nursing station and later was not found on the unit. The nursing supervisor, physician, and security were notified. The Police Department was notified.


The Physician's Note on 6/2/18 at 6:30 AM documented he was notified by nurse that the patient had eloped and was not found at his bedside. Nursing supervisor and security was aware.


FDNY Pre-hospital Care Report Summary dated 6/5/18 documented the patient was found at 6:34 AM along Van Wyck Expressway. The patient was alert and in no signs of distress. The patient was standing on the sidewalk with NYPD wearing a hospital gown, and hospital bracelet. The patient stated, "I'm just trying to get home."


Review of the facility's policy and procedure on "Chain of Command and Escalation" with Date Issued: 1/2018, documented "Chain of Command: In all circumstances where patient care and safety, and the safety of hospital staff or visitors are or maybe affected, hospital personnel MUST escalate concerns to: Immediate Supervisor/Manager, and physician/chief resident..."


On 10/17/18 at 11:37 AM, STAFF L, RN Medicine was interviewed with STAFF I, RN Nurse Manager.

Staff L read her note of 6/4/18 at 11:37 AM. "When I received the patient from echocardiogram, the patient was agitated, and verbalized that he wanted to go home. I put the patient on yellow gown and did close observation related to elopement.

I did close observation and frequent rounding. Which means every 15-20 minutes.

I do not recall I documented the every 15 minutes observation.

I do not recall I escalated the patient's condition to the charge nurse or the physician.

I could not recall I handed patient off as elopement risk. My notes stated I put patient on yellow gown."


On 10/17/18 at 10:23 AM, STAFF K, RN Medicine/Surgical was interviewed.

Staff K stated, "I received the patient during handoff. The patient was handed-off to me not on elopement risk. I continued the hourly rounding."


On 10/17/18 AT 2:52 PM, STAFF I, RN Manager was interviewed.

Staff I stated, "All nurses in the unit are trained to identify patients at risk for elopement.

I was not made aware by the nurse that this patient was identified at risk for elopement. The nurse did not escalate the situation, including her assessment to me and to the physician."


On 10/17/18 at 12:10 PM, STAFF F, Resident (Post Graduate Year-I) was interviewed. He read his medical record entry.

Staff F explained, "I was doing night shift. I was working in the ED doing admission when I was notified by the floor nurse that the patient left the unit.

I right away went to the unit. We notified the nurse supervisor, and the security staff. A patient search was done. The family was also called. 911 was notified. An incident report was completed. The nursing supervisor was there. Family was made aware.

I did not see the patient prior to the event. There was no outstanding or significant information during the check out (handoff). There was no issue for me to assess the patient.

I was not aware patient was an elopement risk."


The facility did not ensure that the facility's protocol on "Chain of Command and Escalation" was followed to ensure a safe environment, and prevent elopement.