HospitalInspections.org

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Based on document review, video review, medical record review and interview, the facility failed to protect patients at risk for elopement. Specifically, the facility's failure to: (1) conduct an elopement risk assessment of all patients presenting to the Emergency Department (ED), identify patients at risk for elopement, and implement appropriate preventive measures, resulted in the elopement of Patient #1; (2) failure to ensure a safe environment in a locked unit resulted in the elopement of Patient #2.

These failures caused the elopement of Patient #1 and Patient #2 and may have contributed to the death of Patient #1 and an unknown outcome for Patient #2.

Findings include:

The medical record of Patient #1 identified a 74-year-old who was brought into the ED by ambulance from a nursing home on 02/03/2023 at 12:46 PM, for an evaluation of a left neck mass pain that was getting worse. The patient was triaged at 12:50 PM and assigned an Emergency Service Index (ESI) 2-emergent. ED nursing assessment documented screenings for fall, suicide, violence, decubiti, alcohol, and drugs.

The patient received a physician evaluation at 1:30 PM with plan to transport the patient to another facility for oncology workup.

At 9:12 PM, ED nurse's note documented that the patient walked out of the ED between 7:30 PM and 8:00 PM.

The Nursing Home packet sent to the ED with the patient indicated the patient was at risk for elopement.

Review of the patient's medical record from another hospital revealed that the patient was brought into their ED by Emergency Medical Services (EMS) personnel on 02/04/2023 at 8:07 AM as a cardiac arrest notification. Patient was found outside, in the street, in asystole with frozen extremities, urinary catheter and an intravenous line were in place. EMS performed Advanced Cardiac Life Support (ACLS) but was unable to intubate the patient due to the patient's frozen jaw. The patient was pronounced dead at 8:08 AM at the facility. The immediate cause of death was hypothermia.

Patient #2 was a 59-year-old with a history of Schizoaffective Disorder, Neurocognitive type who was admitted to the inpatient psychiatry unit on 11/29/2022 at 1:45 AM on emergency status. The patient's admission status changed to involuntary admission on 12/07/2022.
On 12/31/2022, at approximately 10:45 AM, the patient eloped from a locked Behavioral Health Unit.

During interview with Staff G, Chief Medical Officer on 02/09/2023 at approximately 4:00 PM, staff confirmed that the whereabouts of the patient was still unknown.
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Based on medical record review, document review, video review and interview, in two (2) of seventeen (17) medical records reviewed, the facility failed to protect patients at risk for elopement (Patient #s 1 and 2). Specifically, the facility's failed to: (1) conduct an elopement risk assessment of all patients presenting to the Emergency Department (ED), identify patients at risk for elopement, and implement appropriate preventive measures to ensure the safety of patients; (2) ensure a safe environment in a locked unit.

These failures resulted in a serious adverse outcome for Patient #1 and an unknown outcome for Patient #2.

Findings include:

Review of the medical record of Patient #1 revealed a 74-year-old who was brought into the ED by ambulance from a nursing home on 02/03/2023 at 12:46 PM, with a complaint of worsening left neck mass pain. The patient had a medical history of restlessness and agitation and squamous cell carcinoma of the scalp and neck. Psychiatric history was significant for Adjustment Disorder Acute, Nicotine Use Disorder and primary Insomnia.

A nursing home packet sent to the ED with the patient documented a psychiatric assessment of the patient on 01/31/2023, which noted behavioral problems of exit seeking behavior, wanderer, and may attempt to exit.

The patient was triaged at 12:50 PM and assigned an ESI (Emergency Severity Index) of 2, emergent.

Internal ED nursing assessment documented screenings for fall, suicide, violence, decubiti, alcohol, and drugs.

The patient was evaluated by the physician at 1:30 PM with a plan to transfer the patient to another facility for an oncology workup.

At 9:12 PM, ED nurse's note documented the patient walked out of the ED between 7:30 PM and 8:00 PM.

Review of security video on 02/08/2023 at 12:22 PM, in the presence of Staff K, Director of Security, revealed that the patient walked out of the facility fully clothed via the ambulance ramp on 02/03/2023 at 8:22 PM.

The facility's ED policy for elopement, titled "Elopement of the Psychiatric Patient or Patient who Lacks Capacity from the ED", last reviewed February 2022, included procedures to follow whenever a patient elopes from the ED but did not include requirements for assessment of patients to determine their risk for elopement.

During interview on 02/08/2023 at 12:01 PM, Staff A, ED Triage Nurse, stated that the initial patient assessment includes screening for Suicide risk and Fall risk but not for Elopement risk which is not a requirement at triage. Staff A added that only ED boarders get an elopement risk assessment. Patients must be in the ED for 12 hours to be considered a boarder.

During interview on 02/08/2023 at approximately 1:51 PM, Staff D, Vice President of Patient Services confirmed that elopement screening is done for ED boarders, that is patients in the ED greater than 12 hours and that elopement assessments were not done for all patients.

There was no documented evidence that Patient #1, a nursing home resident with behavioral problems and exit seeking behaviors was assessed for elopement.

Review of the patient's medical record from another hospital indicated on 02/04/2023 at 8:07 AM, the patient was taken by Emergency Medical Services (EMS) personnel to the ED in cardiac arrest via notification. He was found on Centre Street with an unknown amount of time spent outside. He had a urinary catheter and an intravenous line in place. The patient was frozen which prevented intubation. The patient was pronounced dead at 8:08 AM at the facility.

Patient #2 was a 59-year-old who was brought into the hospital's Comprehensive Psychiatric Emergency Program (CPEP) by the New York Police Department (NYPD) on 11/28/2022 after reportedly swinging a block of wood at people in the community. The patient was evaluated by a psychiatrist and diagnosed with schizoaffective disorder. He also had a history of neurocognitive disorder.
The patient was admitted to the inpatient psychiatry unit on 11/29/2022 at 1:45 AM on emergency status for psychosis and mood instability and was converted to involuntary admission on 12/07/2022. The patient was assessed as being at no risk for elopement.

The facility's Focused Incident Review dated 02/03/2023 revealed that on 12/31/2022, at approximately 10:45 AM, the patient eloped from the locked unit when an environmental staff member was entering the unit. The patient walked out before the door was fully closed. The security officer was not at his assigned post at the unit entry door during the time of the elopement.

During interview with the Chief Medical Officer on 02/09/2023 at approximately 4:00 PM, staff confirmed that the whereabouts of the patient was still unknown.

An Immediate Jeopardy (IJ) situation was identified on 02/13/2023 at 03:05 PM, due to the facility's failure to protect patients at risk for elopement. The facility's administrators and leadership were notified.
The facility failed to: (a) assess all ED patients for risk for elopement; identify all patients at risk for elopement, and implement measures to prevent elopement; (b) ensure elopement education was provided to all applicable ED staff, including security officers, (c) re-training of all In-patient RNs in response to the elopement event.

The facility provided an IJ Removal Plan to survey staff on 02/13/2023 at 9:20 PM.
The plan included:

Senior hospital leadership reviewed the following applicable policies and procedures to ensure effectiveness:
(1) (i) All Emergency Department patients will be screened for elopement risk in the electronic medical record at time of initial triage
(ii) A process was developed and implemented for handling and scanning home documentation upon arrival to the ED.

(2) Security Officer coverage is now assigned to the locked Behavioral Health Unit (8B) entry door 24 hours 7 days a week including scheduled breaks, weekends, and holidays.

Leadership immediately provided in-service practice alerts to all nursing staff and security staff regarding revisions to policies titled, 'Elopement Risk Assessment, Prevention and Post Elopement Interventions' and 'Transfers from Nursing Homes.' One hundred percent of staff currently on shift in the ED were in-serviced. Staff on incoming shifts were in-serviced prior to the start of shift.

Interviews conducted on 02/14/2023 at 10:30 AM with Senior Leadership, confirmed staff members that had not been in-serviced were not allowed to return to work until the training was completed.

Surveyors conducted tours and interviews in the ED and 8 Bernstein (Behavioral Health Inpatient Unit) to verify training of staff members on duty.

The IJ was lifted on 02/14/2023 at 3:12 PM based on onsite verification and validation of staff training and re-education to the reviewed and revised Policies and Procedures. The IJ was abated when 59% of staff working in the Main ED, 64% of staff working on 8 Bernstein and 43% of hospital Security Staff were in-serviced to these policies. Attestations/signature pages were signed for all policy in-services.