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Based on review of policies, procedures, hospital documents, video footage, medical records, and interviews with staff, the administrative staff failed to develop and implement both an at risk elopement assessment and an elopement policy and procedures to ensure physicians and nursing staff evaluated patients to minimize the risks and opportunities for elopements by court committal patients and/or by patients with impaired decision making ability who are admitted in the hospital and/or the Emergency Department (ED).

A court committed patient eloped on 6/9/16 from the Med/Surg (Medical/Surgical) unit while being treated for an overdose and suicidal ideation. The physicians and hospital staff failed to ensure the patient remained safe and secure in the Med/Surg unit. The Security Officers notified the police after the patient had eloped. On 6/9/16, the police returned the patient to the ED.

1. The physicians failed to assess and implement a treatment plan to ensure court committed patients remained safe and secure in the hospital. that required specific monitoring, patient cares, and visual contact. (Refer to A 144)

2. The nursing staff failed to provide patient care for court committed patients that required specific monitoring, patient cares, and visual contact. (Refer to A 144)

3. The administrative staff failed to develop and implement a specific policy/procedure to provide guidance for staff to have knowledge to provide a safe and secure environment for patients at risk of eloping. (Refer to A 144)


(Refer to A-144)

The cumulative effect of these systemic failures and deficient practices resulted in the hospital's inability to ensure the protection of all court committed patients and patients with impaired decision making ability. This resulted in a court committed patient elopement from the Med/Surg unit.

During the survey, the surveyor identified an Immediate Jeopardy (IJ) situation, a situation that placed the patients at risk for harm, related to Patient Rights (42 CFR 482.13).

The surveyor notified the Chief Executive Officer, the Chief Medical Officer, the Chief Nursing Officer and the Compliance Officer of the Immediate Jeopardy concerning Patients' Rights on 6/17/16 at approximately 4:00 PM. In response to the Immediate Jeopardy, the Chief Executive Officer, the Chief Medical Officer, the Chief Nursing Officer and the Compliance Officer took action and put a corrective action plan in place. The surveyor confirmed the immediate corrective actions taken and the hospital removed the Immediate Jeopardy situation prior to the survey exit date. However, a Condition level deficiency remained for Condition of Participation: Patient Rights (42 CFR 482.13).

In response to the IJ, the staff developed and implemented a corrective action plan. The corrective action plan removed the IJ and included in summary:

1. Effective immediately, prior to staff working at the hospital, in-services will be completed for the following new policies and procedures: P-702: Elopements (Unauthorized Departures), Elopement Screening, and Missing Patient, DPS-026 Elopements. Effective immediately verification will be evident by hospital specific in-service forms and checklists signed off for each staff prior to the staff working in this hospital.

2. Staff developed and implemented a revised Elopement Risk Screen in the Meditech electronic documentation system to include: Effective immediately, Nursing staff and ED Crisis Team will complete the Elopement Risk Screen on all patient admissions. If the patient has one "yes" answer, the patient will be considered high risk for elopement and elopement precautions will be implemented. The Elopement Risk Screen will be repeated daily and as indicated by behaviors or by changes in behaviors (new confusion,etc.) and after any attempted or successful elopement.

3. Staff immediately revised, developed and implemented elopement precautions and interventions for patients at risk for elopement (included in revised policy P-702). Effective immediately, staff nurse or charge nurse will initiate elopement precautions and the following interventions: all elopement risk patients will be provided tan scrubs for quick identification, placed in a room closest to the nurses' station, continuous one to one monitoring, documented 15 minute patient status, and restricted to the unit.

4. Staff developed and implemented a new procedure for an acute impending elopement of a court-ordered patient and/or a patient with impaired decision making ability (included in revised policy P-702). Effective immediately, in the event of an acute impending elopement situation of a court-ordered patient or patient with impaired decision making ability, staff will take the following actions: Call 2466 for Public Safety elopement risk assistance, staff in the area will immediately respond to the unit exits and the unit doors will be shut, Public Safety will assist with redirecting the patient, the attending physician will be notified for medications, if applicable, a new elopement risk screen will be completed, the patient will be changed into tan scrubs.

5. Staff developed and implemented a new procedure for a court-ordered patient and/or a patient with impaired decision making ability who is actively eloping and a new overhead announcement "Patient Elopement" (included in revised policy P-702). Effective immediately, the following actions will be taken: Staff will immediately call 350, the operator will initiate the overhead announcement "Patient Elopement", the police department will be notified, Public Safety staff will monitor main exit doors, and last known location and exit door of the patient, medical center staff will step into nearby hallways and look around that area for the patient, the Fixed Post Public Safety Officer will be posted in Signal 3 monitor the security cameras, take phone calls, and relay information to other Officers via two-way radios. In the event of a patient elopement from the Emergency Department and the Fixed Post Officer is in contact with that patient, the Officer may follow and attempt to detain the patient, while maintaining contact with other Officers. The Officer in the dispatch office and communicate status of patient, and a second announcement will follow as soon as possible with a description of the eloping patient. Any staff member seeing the person matching the announced description will alert Public Safety at Ext 2466. Staff are not responsible for apprehending the patient, but should encourage the patient to remain with them. Public Safety will assist in returning the patient to the unit and the attending physician will be contacted.

6. Staff developed and implemented a new procedure for a court-ordered patient and/or a patient with impaired decision making ability is missing (included in revised policy P-702). Effective immediately, the following actions will be taken: Staff will immediately call 350, the operator will initiate the overhead announcement "Missing Adult", an in-depth search of the entire area will be conducted, followed by an in-depth search of the entire hospital, all units will perform a patient head count, Public Safety staff will monitor main exit doors, and last known location and exit door of the patient, medical center staff will step into nearby hallways and look around that area for the patient,Environmental Services staff will respond to assigned exits and Plant Operations staff will monitor grounds, one Public Safety Officer will monitor cameras in the dispatch office and communicate status of patient, a second announcement will follow as soon as possible with a description of the missing patient, and any staff member seeing the person matching the announced description will alert Public Safety at Ext 2466. Staff are not responsible for apprehending the patient, but should encourage the patient to remain with them. Public Safety will assist in returning the patient to the unit and the attending physician will be contacted.

7. Staff developed and implemented a new procedure for "Pursuit of Patients" (included in revised policy P-702). Effective immediately, in the event an unaccompanied patient wearing tan-colored scrubs is seen outside the patient care units, to prevent the patient from eloping, staff should immediately take the following actions: Call 2466 for Public Safety for assistance, attempt to redirect the patient, and track the patient's location by keeping in line of sight. Staff is not responsible for apprehending or physically restraining the patient, staff should remain calm with the patient for their safety, interacting in a calm manner in an attempt to deescalate the situation, when witnessing a patient eloping from the building or grounds, take note of the direction the patient was going, description of clothing, vehicle, license plate number, and provide this information to the police department. Patients eloping from the hospital will not be actively pursued beyond the hospital grounds. This restriction is designed to prevent patient injury from occurring as a result of running into traffic or other environmental hazards.

8. Staff developed and implemented a new procedure for "Follow-up and Debriefing after a Patient Elopement" (included in revised policy P-702). An immediate debriefing of all involved staff. A team meeting will be held within two business days of the incident to conduct a root cause review.

9. On 6/17/16, all staff who were on duty were educated regarding a patient at identified at risk for elopement, actively eloping, or missing. Teach-back was utilized by the educator at the time of the face-to-face education on the weekend of 6/17/16, through 6/19/16 to validate staff understanding. Staff will be educated and tracked on the policy and process changes on their next shift worked via the electronic Healthstream education system with reinforcement and competency completion by supervisors.

10. Initiated immediately and completed by 7/6/16, all Public Safety Officers will be educated regarding Elopement and Missing Person new policies and process by the Operations Director of Ancillary Services and Manager of Public Safety.

11. Initiated immediately and completed by 7/6/16, the Switchboard Operators were educated regarding the new elopement policies and procedures by the Customer Relations Director and the Chaplin Supervisor.

12. The Governing Body will meet daily to monitor compliance with this plan of correction.

I. Based on review of policies, procedures, documents, medical record, video footage, and interviews with staff, the administrative staff lacked evidence showing the hospital staff protected court committed patients who are admitted in the hospital.

Failure to ensure patients remained safe in the hospital resulted in 1 of 1 court committed patient eloping from the Med/Surg unit. The patient left wearing tan scrubs, ran down the hallway, 2 flight of stairs, and exited out of the unlocked, unalarmed fire exit door in front of the hospital cafeteria.

Findings include:

1. A hospital policy titled, "Patient Rights and Responsibilities" Policy: P-0107 Revised 3/2014, included in part, "...Safety...The patient has a right to receive care in a safe setting...medical center will protect vulnerable patients...intended to provide protection for the patient's emotional health and safety as well as physical safety...(D-1401, Security Management Plan, D-1501, Patient Safety Program Management Plan)...Source Document: CMS (Centers of Medicare and Medicaid Services) Conditions of Participation..."

A hospital policy titled, "Assessment of Patients" Revision: 10/2014 included in part, "...Procedure: When appropriate, the assessment process will address special needs for the following populations...those patients with emotional or behavioral disorders...A risk assessment will be performed in the ED and all inpatient units identifying patients at risk for self harm or harm to others. Any patient assessed to be at risk will have their immediate safety needs addressed and as determined by the provider, a referral to the Crisis Team or Psychiatric Services..." The policy did not include procedures to ensure staff performed an elopement risk assessment in the ED and all inpatient units.

2. A hospital document titled, "Broadlawns Medical Center QM LIVE" Date 6/13/16, USER: Chief Nursing Officer, Notification Type: INCIDENT REPORT, included in part, "...[Patient #1] admitted 6/9/16...Event Information...ELOPEMENT...Patient admitted with a 48 hour hold. Patient was identified as an elopement risk...monitored with a one on one sitter at all times. Patient and sitter sitting...front of the nurses station...patient broke the IV (Intravenous) out of his arm and ran out the door...one on one sitter and another nurse in pursuit of the patient. The patient was able to outrun those in pursuit and left the Broadlawns building...a code green was called and security was notified. When the patient left the Broadlawns grounds, staff called the Des Moines Police Department...Event Date 6/10/16 Time 1:30 PM Shift 2 Evening...Event Location Med/Surg (Medical/Surgical)...Exact Location Comments Patient was sitting in the triangle patient sitting area in between the nurses station and...conference room...Statement of Facts...Objective Description of Events...Entered by Registered Nurse [RN A]...Pre Event Conditions...Patient identified as a flight risk...Discussed with patient the importance of remaining for treatment...safety...court order...patient willing to state to this nurse that he would remain on the Med/Surg floor...Entered by Registered Nurse [RN A]...Witnesses statements...(blank)...Corrective Actions...Committee Review...Target/Complete Date 06/13/16..."

A hospital document titled, "Department of Public Safety (DPS) Case/Incident Report" Date 6/10/16 Time 3:55 PM included in part, "...Elopement-Court Order...Med/Surg...Victim...[Patient #1]...[Public Safety Officer B], [Public Safety Officer C], and [Public Safety Officer D]...On 6/10/16 at 3:55 PM DPS received a call from Med/Surg...needed assistance on the unit with an out of control patient...[Public Safety Officer B] and [Public Safety Officer C] were responding when [Public Safety Officer D] received another call...an altercation outside of the Sands (Behavioral Health Unit) entrance...As all units arrived outside we were informed that [Patient #1] a court ordered patient on the Med/Surg (Medcal/Surgical) unit ripped out his IV and eloped...No DPS officers seen [Patient #1] outside but were informed from a witness...was running westbound on Hickman Road...this information...I informed Med/Surg to contact Polk County and inform them of the elopement...At 5:50 PM...Polk County had found him and was returning him...we were not informed of his arrival up to 8:00 PM..."

3. On 6/17/16 at 9:30 AM, the surveyor, the Med/Surg Manager, and the Chief Nursing Officer walked along with Maintenance Staff E as he measured the distance Patient #1 traveled on 6/10/16 when he eloped from the Med/Surg unit. The Med/Surg Manager reported [Patient #1] ran out of the Med/Surg lobby and approached the 2 flight of stairs. The distance is approximately 300 feet. Patient #1 then ran down the 2 flights of stairs, turned right and ran down a hallway towards the hospital cafeteria. The distance is approximately 991 feet. Patient #1 turned right, exited through an unlocked, unalarmed fire exit door and immediately ran onto Hickman Road (A heavily traveled road running parallel to the front of the hospital.) The distance from the fire exit door to Hickman Road is approximately 505 feet. The total distance Patient #1 traveled after he eloped from the Med/Surg unit and entered onto Hickman Road is approximately 1796 feet.

In addition, the surveyor viewed the video footage recorded on the hospital security cameras on the afternoon Patient #1 eloped. The security cameras captured Med/Surg RN P, Health Care Technician (HCT) F, HCT G and Patient #1 as they exited the second flight of stairs. The patient immediately turned right and ran down the hallway towards the hospital cafeteria. The video footage showed Med/Surg RN P, Health Care Technician (HCT) F, and HCT G ran behind the patient. The patient exited the unlocked door in front of the hospital cafeteria. The video showed the patient ran through the patio area and immediately ran toward Hickman Road. Both HCT A and HCT A ran behind the patient to the end of the patio area.

4. Review of Patient #1's medical record revealed the following:

a. The patient's ED record - A physician note on 6/9/16 at 11:15 PM, completed by ED Physician K, documented in part, "...IMPRESSION and PLAN: Patient will be placed in ICU (Intensive Care Unit)...will have a 1 to 1 sitter in the ICU...court ordered to stay..psych has consulted him and will see the patient in the morning...Superficial lacerations on arm...Activity: Fall Precautions...Code Status: Presumed Full..." The admission orders lacked an elopement risk assessment and/or initiation of elopement risk precautions.

b. The patient's ICU (Intensive Care Unit) record - A provider note on 6/10/16 at 8:47 AM, completed by Physician Assistant M, documented in part, "...Reason for Consult: Per Admission H & P...Earlier in the patient's ED visit, he told the ED physician that he was suicidal...currently he states that he does not want to harm himself...Plan...Although patient denies any suicide ideation at this time I recommend psychiatric care...patient is here secondary to suicide attempt...Patient...referred for a substance abuse consult..." The documentation lacked evidence of an elopement risk assessment and an order for specific elopement risk precautions.

c. A provider note on 6/10/16 at 8:55 AM, completed by 2nd Year Resident Provider I, documented in part, "...Assessment/Plan (ICU)...Problems: Suicide attempt Acute...Methamphetamine abuse Acute...Marijuana abuse Acute...General:...Awaiting conversation with mental health. Is medically stable for transfer to inpatient psych or to general medical floor with sitter....Due to drug abuse and child in home DHS report filed...Attestation:...Patient admitted overnight and staffed but not seen by attending. Today, I personally interviewed and examined the patient...Patient admitted for overdose...denies intent to self harm on rounds. He has amphetamines in his system...History of unstable behavior..." The documentation lacked evidence of an elopement risk assessment and an order for specific elopement risk precautions.

d. The patient's Med/Surg record - A nurse note on 6/10/16 at 2:15 PM, completed by Med/Surg RN S, documented Patient #1 admitted to Med/Surg. Behavioral /Suicidal protocols initiated. Patient is agitated and wanting to leave...Patient assured that he had to be here until Monday morning. Patient is upset with this situation. Patient denies suicidal ideation. The note lacked documentation of an evaluation of Patient #1's agitation and desire to leave and/or initiation of interventions to keep the patient safe and meet the patient's needs. The patient's medical record lacked evidence of Med/Surg RN S's initiated Behavioral/Suicidal protocols.

e. A physician note, on 6/10/16 at 4:40 PM, completed by Physician I, documented in part, "...received a call from nursing...[Patient #1] sprinted past the sitter, pulled out the IV, and left AMA (Against Medical Advice). Security Officers were called and were unable to locate the patient. A significant blood train found leaving the building and heading West on Hickman Road. Patient had been intermittently anxious about staying but had improved with Ativan and counseling. Patient well aware as of this morning that he was on a 48 hour hold court order and the consequences of leaving. The patient had questions about the court order process but did not give any indication that intended to flee..."

5. During an interview on 6/16/16 at 11:30 AM, Mental Health (MH) PA M stated, My primary job is seeing outpatient mental health patients. I cover for the inpatient unit to do psych consults, when needed. I do not admit patients however, I do recommendations for inpatient mental health admissions. When asked when MH PA M assessed Patient #1, MH PA M stated, "When I came to the unit I talked to him. He then got on his cell phone. I overheard him saying, "They are going to take the baby." When asked if MH PA M documented the visit, MH PA M stated, I still have my notes. I don't have my notes in the medical record." MH PA M stated, during my short encounter with him, he told me he had to go home because his cousin was coming from Nebraska and he had to let the cousin in the house. I confronted [Patient #1] because his girlfriend was at the house to let the cousin in. I explained to him that he was on a 48 hour hold and that he could not leave. He knew that before he bolted. MH PA M stated, "Before he took off I was in [Case Manager U's] office and she told me the patient was more agitated." When asked if MH PA M reported the patient's request to leave the hospital and agitation to the nursing staff or physician, MH PA M stated, "I don't remember."

MH PA M stated, "I assessed [Patient #1] that morning in the ICU and informed the staff he needed to go to the inpatient psych unit on a suicide risk." MH PA M stated, " This encounter was when I came back to the Med/Surg unit to see a different patient. That is when he asked me about going home to let his cousin in the house." When asked why the patient was on the Med/Surg unit instead of the Behavioral Health unit, MH PA M stated, Generally, I will call [Safety Coordinator V], the bed person. I may not have called her that morning. I can tell you there was a wait list for the Behavioral Health Unit.

During an interview on 6/16/16 at 1:10 PM, Case Manager U stated, "I assessed the patient that afternoon and he was very anxious and wanted to leave. I told the patient he was on a 48 hour hold. He focused the entire time I was with him on getting out of the hospital." When asked if she notified the nursing staff and physician about the patient's behavior, Case Manager U stated, "I immediately spoke with [Patient Navigator T] and contacted [Physician I] and told both of them the patient was a flight risk, he was anxious, continued to ask me when he could get out of the hospital, and wanted the 48 hour hold lifted. [Physician I] thanked me for notifying him of the potential problem. I did not receive any orders from [Physician I]." Case Manager U stated, " Soon after that I was on the telephone with DHS when the staff yelled, "He just ran." It was around 4:00 PM.

During an interview on 6/16/16 at 1:40 PM, Physician I, DO reported, on 6/10/16 in the morning during rounds in the ICU, he evaluated Patient #1. Physician I stated, "The patient denied suicidal ideation, was calm until we discussed the court order for the 48 hour hold." Physician I reported he told the patient to talk with the psychiatrist about removing the 48 hour hold. When asked if Physician I assessed Patient #1 for an elopement risk and ordered medications for the patient's agitation, anxiety, pacing, and elopement risk precautions, Physician I stated, "I manage the medical treatment. When asked if Physician I received training for elopement risk patients and if he was aware of the hospital elopement risk polices/procedures, Physician I stated, "All court committed patients have 1 on 1 sitters. This patient was a court committal and had a 1 on 1 sitter." Physician I reported he consulted [MH PA M] for a psych evaluation. Physician I stated, "Typically [Director of Mental Health Operations Psychiatrist O] manages the patient's psych medications. [MA PA M] completes the rounds on all the mental health patients on the unit and then she reports directly to [Director of Mental Health Operations Psychiatrist O]." Physician I stated, "I did receive a call that morning from a ICU nurse because the patient was crying uncontrollable. I gave the nurse a one time order for Ativan." Physician I reported he stopped by the ICU at noon to check on the patient. Physician I stated, "The patient was standing at the sink, brushing his teeth, not crying, and appeared to be medically stable. I deferred him to psych services for any additional psych medications." Physician I stated, "Around 4:00 PM I was on my back from the clinic to to do some discharges. I seen the blood trail on the second floor, the stairs, and down the hall to the cafeteria. I received a call from staff that the patient left. The staff called security and the patient was found later that night and was brought back." When asked what procedures did Physician I think should be in place for patients at risk for elopement, Physician I stated, "If the patient is a voluntary admission they have a right to leave. I have asked staff to call security to assist with patients."

During an interview on 6/23/16 at 12:15 PM, the Chief Nursing Officer agreed with the findings. The Chief Nursing Officer stated, "Our understanding with an involuntary admission the patient had the right to leave against medical advice. As we identified staff verified the last time the patient received medications but now I have a better understanding."


II. Based on review of policies, procedures, and interviews with staff, the administrative staff failed to develop and implement an elopement risk policy/procedure to provide staff with guidance and knowledge to provide a safe and secure setting for court committal patients and/or patients with impaired decision making ability. The administrative staff failed to establish and implement a specific elopement policy/procedure to provide staff with guidance and knowledge to follow specific procedures in the event a patient eloped from any department in the hospital.

Failure to ensure the administrative staff developed and implemented an elopement risk and a specific elopement policy/procedure to provide guidance for staff to follow in the event a patient eloped from any department in the hospital resulted in staff lacked the knowledge of specific procedures to follow at the time when 1 of 1 patient eloped from the Med/Surg unit. (Patient #1)

Findings Include:

1. A hospital policy titled, "Patient Safety Program Plan" Policy: D-1501, Revised 02/2014, included in part, "...The Patient Safety Program (PSP) is designed to identify and effectively resolve events that lead to or have the potential to lead to adverse patient care outcomes...PSP...to study current patient care processes to identify opportunities for improvements that lead to a reduction in risks of...adverse outcomes of care...Priorities for patient safety are identified, exceptions for safety are established, and evaluation of actions is performed...Patient safety related incidents will be reviewed by the Patient Safety and Environment of Care/Safety Committee (PSEC) with recommendations for corrective action forwarded to the appropriate department or Senior Leader. Patient safety occurrence information from aggregated data reports and individual incident occurrence reports will be reviewed by the PSEC Committee to prioritize organizational patient safety activity efforts. Types of patient safety information reviewed...Sentinel event alerts/ and other Special alerts...Analysis of the following data will be presented...Trends in incident reports, including falls, medication errors, equipment issues, and staff injury..." The administrative staff failed to ensure staff completed an analysis of patient elopements. The Environment of Care/Safety Committee failed to review individual incident occurrence reports for patient elopements in an effort to prioritize organizational patient safety.

A hospital policy titled, "Unplanned Patient Leave/Against Medical Advice" Policy: P-0129 Revised 08/2011 included in part, "...competent adult patients, except those involuntarily committed for psychiatric evaluation and/or treatment, have the right to refuse treatment and leave the medical center...If the patient meets the criteria for involuntary hospitalization, the attending physician will initiate court proceedings to recommend involuntary hospitalization in accordance with Iowa law...SEE ALSO: Organization wide Administrative Policy, P-0702, Pursuit of Eloping Patient..." The administrative staff failed to ensure staff had the knowledge to assess and monitor patients with impaired decision making ability as at risk of an elopement.

A hospital policy titled, "Pursuit of Eloping Patients" Policy: P-0702 Revised 11/2015 included in part, "When any patient elopes or is believed to be missing, it is the policy of Broadlawns Medical Center to act in accordance with the welfare of the patient and the public while patient rights...Elopement is defined as the leaving of an admitted patient without staff knowledge or prior to scheduled discharge...For patients who may have compromised judgement, disoriented, intoxicated patients or those with psychiatric disorders, elopement is considered to have occurred as soon as the patient is discovered missing...For patients with intact judgement, elopement is considered to have occurred if more than 90 minutes have elapsed since the patient was last seen on the unit...Procedures...eloping patient who is court ordered, the attending physician shall contact the court and Sheriff's office...BMC staff will not pursue an eloping patient outside of the medical center grounds, unless the patient is in danger of immediate physical harm or is court ordered and restraint is necessary to assure the patient's safety. In this situation, Public safety should be immediately notified and any pursuit done pursuant to Pubic Safety Policy S-206, Elopements...A patient who has eloped and has been discharged will be re-evaluated as a new patient in the event of his or her return to the medical center..." The policy lacked one specific procedure for staff, Public Safety Officers, and Security Officers to follow in the event a patient eloped from the ED or the hospital .

A hospital policy titled, "Elopements" Policy: S-026 Revised 12/2014, included in part, "...When a patient leaves the unit or hospital without appropriate physician's order or in violation of a court order, Public Safety is to follow the patient...policy is complement to Clinical Services Pursuit of Eloping Patients P-0702...Public Safety Officer who is following a patient will maintain radio contact with his/her fellow Officers at all times...contact the Broadlawns Medical Center (BMC) operator to request assistance from the Des Moines Police Department...In the event the patient leaves the hospital grounds and the police department has not yet arrived the BMC Officer may follow the patient off the grounds...In the case the BMC Officer is dealing with a court order, dangerous, or suicidal patient who is in danger of immediate physical harm, the Officer may restrain the patient..." The policy lacked one specific procedure for staff, Public Safety Officers, and Security Officers to follow in the event a patient eloped from the ED or the hospital.

A hospital policy titled, "Elopement Screen, Precautions and Unauthorized Departures" Policy: NURS-GOV-0207 Revision 10/2015 included in part, "...Broadlawns Medical Center will ensure patients who are admitted with Behavioral Health disorders remain safe throughout the duration of his/her hospitalization by conduction a screen to identify who may be at high risk for elopement, implementing additional safety measures in the patients plan of care, and developing a process for reporting should a patient attempt or succeed with an elopement...Elopement Risk Screen...Completed on all Behavioral Health admissions...Nursing Staff/Crisis Team will complete...If the patient has one "yes" answer, the patient will be considered a high risk for elopement. Within 24 hours, and daily thereafter, the provider...will evaluate and determine when the high risk for elopement ends...Elopement Precautions for Behavioral Health Patients...Elopement precautions may be ordered on a patient who staff identifies as at risk to leave the facility, or verbalizes that they want to leave...Interventions for patients at risk for elopement may include...Use of hospital provided green shirt to quick identification of patients at risk for elopement...Assignment to a camera monitored room...Patients may be on one-to-one observation...Patients may have 15 minute observation checks...If a patient is on elopement precautions, the elopement tendencies will be addressed in the treatment plan/nursing care plan...If the patient is on elopement precautions, it will be indicated on the kardex, and will be reported at change of shift report so all staff will be aware of the elopement precautions...Unauthorized Departures...The following interventions pertain to voluntary patients...Nursing staff will pursue only within the medical center building, and then only in an attempt to convince the patient to return to the unit...If the patient is considered to be dangerous to self or others...The Psychiatrist will be notified. The unit director or designee will be notified. Law enforcement officials will be notified. The inpatient social workers and/or Crisis Team staff will initiate the involuntary court committal process...If the patient is considered not to be dangerous to self or others, the patient will be discharged against medical advise...The following pertain to involuntary patients (i.e. court committals)...Only appropriate MAB (Managing Aggressive Behaviors) techniques are used if physical intervention is required in order to detain any patient attempting to leave the hospital grounds...Notify Polk County Sheriff's Department...Notify the Sheriff's Department if the patient returns to the unit so the missing person's order can be terminated...The Magistrate will be notified...Department of Inspection and Appeals will be notified...Return of an Unauthorized Departure...When a patient returns from unauthorized departure, the patient will be processed through the Emergency Department...Unauthorized departure is understood to be "against medical advice" even though patient has not signed out of the hospital...Follow-Up...After any attempted or successful elopement, a team meeting will be held within two business days of the incident to conduct a root cause review..." The administrative staff failed to have a system in place to ensure all patients admitted to the hospital were safe and secure. The hospital policy lacked evidence of a specific elopement policy/procedure for staff, Public Safety Officers, and Security Officers to follow in the event a court committed patient and/or a patient with impaired decision making ability eloped from the ED or any department within the hospital, and not just the Behavioral Health unit.

A hospital policy titled, "Missing Child/Missing Adult Procedures" Policy: S-0302 Revised 03/2015, included in part, "...POLICY...a comprehensive medical center wide response to address children or adults suspected or reported missing...When a staff member has suspicion that a person is missing...immediately collaborate the manager/department director/designee of the department the child is missing from and ensure the following...Notify communications...Notify the appropriate manager/director of the area that the child/adult is missing from and the attending physician...Conduct in-depth search of entire area. Inpatient units will perform a head count of children and adults...When a "Missing Child/Adult" is announced, the departments adjacent to exterior doors will have at least one staff member report to that door and watch for a person matching the "Missing Child/Adult" announcements. Each door should have at least two staff monitoring and asking all patients and visitors with children that resemble the missing child to wait. Ask the child their name and if the adult is their parent...Secure the area to preserve any physical evidence; screen visitors to the the area...All staff on duty when the abduction occurred will remain on the unit or the department until authorities complete proper questioning..." The Missing Child/Missing Adult Procedures is the policy used for a child/adult abduction. The policy lacked evidence of a procedure for staff to follow in the event of a patient elopement.

A hospital policy titled,, "Security Assistance - Code Green - Management of Violent Person" Policy: P-0700 Revised 05/2015, included in part, "...Security Assistance - Code Green is the designation assigned to an emergency situation involving a potential violent person who loses control of behavior to the extent that staff present are unable to manage the person in a safe an effective manner without additional assistance to do so...The switchboard operator will...announce the exact location of the requested Security Assistance - Code Green overhead...people identified as responders...Medical Staff, when available...management staff in charge of the area, when available...house supervisor, when available...public safety officer...all other available appropriately trained personnel...If adequate numbers of staff do not respond, a second code may be called or paged again..." The Security Assistance -Code Green - Management of Violent Person policy lacked a specific procedure for staff to follow to initiate a "Code Green" in the event a patient eloped.

2. During an interview on 6/16/16 at 9:45 AM with ICU (Intensive Care Unit) RN N, when asked if she received training for patient elopements and/or if she knew if the hospital had an elopement risk assessment policy, or procedure, ICU RN N stated, "Not exactly. We would call security, the charge nurse, our staff can pull a lever under the desk at the nurses station and security comes immediately. We would try and talk to the patient to calm them down." When asked to explain what staff is expected to do when a patient elopes from the unit, ICU RN N stated, "If the patient is court ordered, I would have someone call security, the police, and the charge nurse. I would follow the patient as far as I could to see where he went and what he was doing." When asked what staff would do if the patient was not a court committal, ICU RN N stated, "Then the patient has a right to leave. We have to let the patient go. I would call the patient's doctor and the patient would be considered an AMA."

During an interview on 6/16/16 at 11:30 AM, Mental Health (MH) PA M stated, Outpatient mental health patients is my primary job. I cover for the inpatient unit to do psych consults, when needed. I do not admit patients. I do recommendations for admission for inpatient mental health."MH PA M stated, "I was on the Med/Surg unit that day you are referring to. I was there sometime between 3:00 PM and 4:00 PM when someone stopped me from walking in the blood that was on the floor. When asked if she witnessed the patient's elopement, MH PA M stated, "I questioned what we should do. The staff stated they called the police. There wasn't a whole lot that I could do so I went to my office because it was at the end of my day." MH PA M stated, "I left the Med/Surg unit and stopped by [Director of MH Operations, Psychiatrist O's] office to ask her what do we do. Psychiatrist O said we call the police." When asked if the hospital had an elopement risk policy or procedure, MH PA M stated, "If the patient is court ordered, we call the police. If patient is not a court order, the patient is allowed to leave. We can not keep patients against their will." When asked if she received training for patient elopements, MH PA M stated, "If I did, it was a long time ago. I am trained for patients being out of control. Elopements are more the nursing staffs' responsibility."

During an interview on 6/16/16 at 1:10 PM, Case Manager U, when asked if she received training for patient elopements, Case Manager U stated, "I know we call a code green. Specific elopement procedures or mock drills, probably the direct care workers have training. I know once a court committal patient elopes they call a code green and that alerts the Security Officers. If the patient is not a court committal the patient is an AMA."

During an interview on 6/16/16 at 2:45 PM, Med/Surg Unit Secretary X stated, "If the hospital goes on a lock down we can lock the doors in the hallway." When asked if a patient eloped would staff initiate a hospital lock down, Unit Secretary X stated, "No. It is initiated when a gun shot wound presents to the ED." When asked what patient elopement training Unit Secretary X received and staff's procedures to follow in the event a patient elopes, Unit Secretary X stated, "I think all court committed patients have a one to one sitter. I had the MAB (Manage Aggressive Behaviors) training. If any court committals leave the floor, it depends. We can call code 350 (Child/Adult missing/abduction policy) or if the patient is agitated I would call security. We can call a code green to get security to come to the unit. When asked if the patient eloped from the unit and you call a "Code Green" the Security Officers will automatically arrive on your unit, Unit Secretary X stated, "Yes." When asked at the time Unit Secretary X called for a "Code Green" did she give a description of the patient, the area the patient traveled, and/or information related to a patient elopement, Unit Secretary X stated, "A "Code Green" is called for Security Officers to assist us on the unit."

During an interview on 6/16/16 at 3:10 PM, when asked if Med/Surg RN A received patient elopement training, participated in mock drills for for patient elopements, and if he knew what the hospital elopement policy/procedure expected staff to implement for an elopement risk patient, RN A stated, "This was unique situation. Generally the patient sneaks off the unit. This time I notified security and the patient's emergency contact. The house supervisor contacted the police. I didn't leave the unit because I had other patients." When asked if the entrance doors to the Med/Surg unit were closed, RN A stated, "No, both double doors were open." When asked if RN A notified Physician I when Patient #1 was agitate, attempted to remove his IV, continued to pace in the area next to the nurse's station, RN A stated, "No. I was sitting at the nurse's station and all of a sudden I heard a commotion and then [Med/Surg RN P] and [(HCT) Health Care Technician G] ran off the unit." RN A stated, "I called the operator for a "Code Green". Although, the operator never called the "Code Green" over the intercom. After a couple minutes I called the operator again and she told me she had alerted the Security Officers." When asked if the Security Officers arrived on the Med/Surg unit, RN A stated, "No, they never did come to the unit." When asked if HCT G (one to one sitter) received training on patient elopements, RN A stated, "The sitter had questions about what his responsibilities were when a patient elopes. He didn't know if he should purse the patient and he asked me what he would do if he caught t