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Based on review of policies, procedures, documents, medical records, and interviews with staff and patients, the Administrative Staff failed to ensure to educate staff to minimize the risks and opportunities for elopements by court committed patients and Emergency Department (ED) patients.

1. A court committed patient eloped on 5/7/15 from an inpatient unit while being treated for detoxification from alcohol. The hospital staff notified the police after finding the patient had eloped.

On 5/7/15, the police returned the patient to the ED. After being examined in the ED, the patient was admitted to Horizons Substance Abuse Services, an offsite residential and outpatient substance abuse service unit of the hospital. The patient quickly eloped within 15 minutes of arrival at Horizons.

2. The medical/surgical nursing staff failed to provide patient care for court committed patients that required specific monitoring, patient cares, and visual contact.

3. The Risk Management/Quality Assurance (QA) Director identified 4 ED patients eloped before the ED visit was completed, and they received discharge instructions. These ED elopements occurred between their correction date of 4/24/15 through 5/10/15, the day prior to the revisit.

4. The medical/surgical nursing staff reported a lack of knowledge related to patient care for court committed patients requiring specific monitoring, patient cares, and periodic visual contact.

5. The Administrative Staff documentation failed to show an evaluation of the elopements, an action plan, development and implementation of interventions, policies and procedures to prevent and eliminate the risk for patient elopements throughout each hospital patient area including provider based offsite locations.

(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 ED patients. This resulted in the patient elopements from the medical/surgical unit, Horizons Substance Abuse Unit, and the ED.

I. Based on review of documents, policies, procedures, medical records, video footage, and interviews with staff and patients, the Administrative Staff lacked evidence showing the hospital staff protected court committed patients in one of the hospital's Medical/Surgical units and in the hospital's Horizons Substance Abuse Unit, offering an outpatient and residential substance abuse treatment.

Failure to ensure court committed patients remained safe and secure in the hospital's patient care areas resulted in a court committed patient eloping from the Medical/ Surgical unit. The patient left the hospital wearing only paper scrubs and socks. After staff notified police, the patient was found and returned to the Emergency Department (ED). The patient was still wearing paper scrubs at the time. The patient was examined in the ED and then admitted to Horizons Substance Abuse unit. The patient eloped within 15 minutes after arrival at Horizons (Patient #1).

The Risk Management/Quality Assurance (QA) Director identified an average daily census of approximately 5 court committed chemical substance patients on the Medical/Surgical Nursing Units. The Behavioral Health Director identified an average daily census of approximately 8 court committed patients at Horizons Substance Abuse Unit. The Risk Management/QA Director reported 7 elopements of court committed patients from Horizons from 8/29/14 to 3/21/15, which were not reported during the complaint investigation of #52245-I which ended on 3/15/15.


Findings Include:

1. Review of policy titled Patient Rights and Responsibilities dated 12/14, stated in part, "...For your safety as a patient...we will implement additional safety measures as needed including moving you closer to the nurses' station...alarms and personal alarms...if these safety measures do not seem to be effective and you are still at risk of...injury...the Secure Sitter Program will be offered...as a patient you have the rights to...receive...care consistent with sound...nursing practice..."

2. Review of a document titled, "Elopement Guidelines" received from the Vice President of Medical Affairs on 5/12/15. The definition for non-decisional patients stated in part, "...For non-decisional patients, we are obligated to make every reasonable effort to keep them from departing for their own safety. For patients who are non-decisional, not fully characterized regarding decision-making capacity or who are court committed, elopement and LWBS (Left without being seen) must result in efforts to locate the patient and return him/her to the patient care area. This could include notifying security...notifying Waterloo Police Department, and attempting to contact the patient and/or their family members. For these patients who are non-decisional or court-committed, elopement potential must be assessed and appropriate elopement prevention precautions put in place."

3. At the time of the revisit, the surveyor asked if any patients had eloped from the hospital. The Risk Management/QA Director reported 1 court committed patient eloped on 5/7/15 from a Medical/Surgical Unit and the same patient eloped again on 5/7/15 from the Horizons Substance Abuse Unit (Patient #1). The Risk Management/QA Director reported 7 elopements of court committed patients from Horizons from 8/29/14 to 3/21/15, which were not reported during the complaint investigation of #52245-I which ended on 3/15/15.

4. Review of Patient #1's medical records revealed the following information.

a. On 5/6/15, the Police Officer presented to the ED with Patient #1 and court committal documents. The court committal documents were dated 4/29/15. The documents indicated Patient #1 was a person with a substance-related disorder and was likely to injure himself or herself if allowed to remain at liberty.

b. "Physician's Report of Examination Pursuant to Iowa Code 125.80, Code of Iowa" dated 5/6/15, Practitioner B, the Psychiatrist, stated in part, "...It is probable or reasonable that the respondent (Patient #1) would physically injure him/herself or others if allowed to remain at liberty. The respondent is likely to seriously endanger his/her health. The patient can't be evaluated on an outpatient basis and full time hospitalization is necessary for treatment. The respondent needs inpatient treatment......"

c. "History and Physical" by Practitioner H, the Advanced Registered Nurse Practitioner (ARNP) was dated 5/6/15, at 4:05 AM, stated in part, "...The patient with a history of alcohol abuse was brought in the emergency room tonight by Sheriff for alcohol intoxication. The patient was placed on a 48 hour hold for concerns for the patient's safety. The patient is heavily sedated after being aggressive in the emergency room secondary to alcohol intoxication. The patient's blood alcohol level is 322. At 5:34 AM the patient was admitted to 4 floor med/surg unit. The diagnosis on admit: Acute alcohol intoxication...."

d. "Nursing Note" dated 5/7/15, at 11:40 AM, stated in part, "...The staff informed the lead RN that the shower was running in Patient #1's room but the patient was not in her room. Staff reported the patient's IV pole was found in the patient's bathroom with the IV fluids running into the bathroom sink. The staff were unable to locate the patient. Patient was only wearing scrubs..."

e. "ED Physician Note" by Practitioner A, a physician was dated 5/7/15 at 4:18 PM, and stated in part, "...wearing paper scrubs patient eloped from Covenant Medical Center (CMC) today as detox committal. Patient presents to the ED for detox via police. The patient was admitted yesterday per court order but around 10:45 AM this morning the patient eloped. The patient problems are Alcohol dependence - acute alcoholic intoxication in alcoholism - court committal with elopement...blood alcohol level - none detected. My decision is to admit patient to Horizons."

f. "Nursing Note" by Horizons RN Staff L, dated 5/7/15, at 8:25 PM,stated in part "...patient arrives with Emergency Medical Technician (EMT) from Covenant ER. Court Committal Blackhawk County for alcohol. Denies need to be here. Court committal process explained...patient eloped from hospital and was brought back to ER by police this evening..." A second "Nursing Note" by Staff L..."dated 5/7/15, at 8:40 PM, "...patient eloped from unit via elevator. Seen on camera leaving front door of building. Sheriff dispatch notified..."

5. Review of a document titled, "Incident ID: 33483" dated 5/7/15 stated in part, "...On 5/6/15 Court committal Patient #1 was admitted with a result of an Alcohol level of 322 upon admission. At 10:10 AM the patient requested to talk to the lawyer. At 11:03 AM the staff reported the shower was running and assumed the patient was in the shower. At 1130 AM, the Lead Nurse discovered patient was not in the room and the shower was running. At 11:45 AM staff informed the security and the Black Hawk County Dispatch that a court committed patient had left the hospital. Staff K in security reported they had received a phone call an hour earlier from an employee that there had been a person wearing hospital scrubs knocking on doors on 9th street. Security had also received a phone call that the patient that eloped was at the patient's house wearing blue scrubs and hospital slippers..."

6. Review of document titled, "Actions-Incident ID: 33483" dated 5/11/15 stated in part, "...Risk Management/Quality Assurance Director Follow up is Completed. Previous comments were reviewed and it appeared that the nursing associates did return to check on her, heard the shower running, and assumed she was in the shower. It wasn't until they rounded again and the shower was still running that they determined she was gone. The result of this event, the small focus group meeting evaluated the cost of placing alerts/alarms on exit stairwells as a preventative measure. Elopement policies were reviewed. The discussion about placing not only our high risk fall patients closer to the nurse's station but also our court committal patients near the nurse's station as well. On this day the census was high and beds near the nurses' station were not readily available..."

7. The surveyor, along with Staff K, the Security Manager, viewed the video footage recorded on the hospital's security cameras on the day Patient #1 eloped (5/7/15). The video footage showed on 5/7/15 at 10:39 AM Patient #1 dressed in blue paper scrubs and white socks eloped from an unlocked exit door on the 4th floor Medical/Surgical unit. The patient entered and ran down the side of the hospital parking lot, across the grass and then proceeded towards West 9th street (a busy intersection running parallel to the hospital). The Security Manager reported the unsecured exit door to the outside was located in the hospital chapel.

8. During an interview on 5/13/15 at 9:40 AM, Staff G, Registered Nurse (RN) reported she was Patient #1's primary care nurse on the morning of 5/7/15. Staff G reported at 10:30 AM, she went to the patient's room, heard the shower running, although she did not actually visualize the patient because the bathroom door was closed. Staff G reported she failed to confirm the patient was present and safe because she "didn't" give her any indication earlier in the day that she was going to elope. Staff G reported at 11:30 AM, Staff H, RN told her that Patient #1 had eloped.

a. During an interview on 5/13/15 at 9:45 AM, Staff H, RN reported on 5/7/15 around 10:45 AM Staff E, the Nurse Director contacted her to report Patient #1 wanted to speak with the patient's lawyer. Staff E reported she went to the Medical/Surgical Unit at 11:30 AM and entered Patient #1's room. Staff H stated, "At that time she heard the shower, knocked on the door just to check on the patient, and when there was no response, she opened the door." Staff H stated, "The shower curtain was closed and when she opened the shower curtain, the stall was empty. The IV (Intravenous) catheter, IV tubing and IV bag of fluids were laid in the bathroom sink and remained running. The IV bag of fluid hung from the IV pole and pump." Staff H reported she called security and everyone on the nursing unit began to search to the patient. By that time, the patient had eloped 1 hour earlier according to video footage.

b. During an interview on 5/13/15 at 10:15 AM, Staff I, Patient Care Assistant (PCA) reported, she was Patient #1's PCA and at 10:45 AM entered in the patient's room to straighten up her bed on the morning of 5/7/15. PCA Staff I reported she heard the shower running and "assumed" the patient was in the shower. Staff I acknowledged she failed to confirm the patient was in the shower, safe, and in hindsight she should have checked. PCA Staff I stated, "Because, this is standard nursing practice and patient safety guidelines." She reported she left Patient #1's room and did not return, Shortly afterwards Staff H informed her that the patient had eloped.

c. During an interview on 5/13/15 at 11:55 AM, Staff E, RN/Nurse Director, acknowledged the PCA and the nursing staff failed to follow hospital protocol and standard nursing practice when they entered Patient #1's room and did not ensure the patient was in the shower, and remained safe on the Medical/Surgical Unit, and checked to see the patient had not fallen or was injured. Staff E stated, "Ideally it would have been nice if they knocked on the door to determine she was safe, make sure she was safe, and obviously they failed to do so and as a result the patient eloped."

9. On 5/7/15 the patient was located and returned to the ED by the police. At 8:25 PM the patient was admitted to the unlocked Horizons Substance Abuse Unit. At approximately 8:40 PM, the patient that had eloped from the medical/surgical floor and was a known flight risk, eloped 15 minutes after arrival at Horizons.

a. During an interview on 5/13/15 at 4:00 PM, Staff L, RN reported when Patient #1 arrived to the Horizon unit she knew immediately the patient did not intend on staying. She stated, "The patient's affect was flat. The patient was restless, the whole thing was "ridiculous" and approximately 15 minutes later walked towards the elevator and left." Staff L reported she contacted the sheriffs' department, called the physician and completed an incident report.

b. During an interview on 5/13/15 at 4:20 PM, Staff M, Certified Nurse Assistant (CNA) reported when Patient #1 arrived to the unit she was very anxious, fidgety and preoccupied. She stated, "She refused to give up her purse or cell phone. She was pacing up and down the hallway and in my opinion there was no way they could have convinced her to remain on their unit."

c. Review of a document, dated 5/19/15 at 4:35 PM, Practitioner A the ED Physician, stated in part, "...Court committal definition: I used to think that when a magistrate approved a court committal order the patient was mandated to stay in the facility where admitted until he or she later met with an arbitrator and those who requested the committal sit together and determine the way forward in regard to treatment and whatever issues needed to be addressed. I am now told by the police that a court committal is not a binding order and has no power to hold a patient in a facility. If a patient elopes only the county deputy can be contacted to see if they can find the patient. At least this is what the police told me the night Patient #1 presented to our ER. I am perplexed by all this as it seems a court committal has no real effective power at all. It's just another ED formality we have to complete for the "appearance" of all things legal. As for the question concerning alternative facilities, I made the decision to send the patient to Horizons as that is what the patient's attending physician requested me to do as the patient's alcohol level had dropped to zero which made her "eligible" for Horizons. I had no knowledge of Horizon's procedures or security methods. She was sent to Horizons by ambulance which is our routine method. I did not consider any alternatives as [they] have a waiting list a mile long and during my seven years at Covenant I have never sent an alcohol detox patient [to other area] hospitals."

d. During an interview on 5/13/15 at 12:40 PM, Staff A, the Behavioral/Horizons Director stated, "Court committal patients admitted to Horizons are free to go if they desire, staff would watch them leave on the monitor and then call the sheriff. The facility did not have security officers staffed to intervene in the event of a patient elopement."

e. During an interview on 5/18/15 at 11:00 AM, Staff A, the Behavioral/Horizons Director provided a document titled "Criteria for Admission to Behavioral Health" dated 5/18/15 stated in part, "...The admission criteria - Inpatient Adult - imminently dangerous to self/others - aggressive behavior..." The Behavioral/Horizons Director stated, "The court committal patients admitted to their hospital are the hospital's responsibility pending a court hearing. The behavioral health nursing unit would not accept a detox patient unless they have been deemed a harm to themselves or others." Staff A stated, "Patient #1's court committal papers clearly stated she posed a danger to herself or others. However, she would have to state she would have an intent to harm herself or others in order to meet the "mental health" definition." Review of census sheets for the Psychiatric/Behavioral Health Unit revealed there was 1 adult bed available for admission on the afternoon of 5/7/15.

10. During an interview on 5/17/15 at 2:05 PM, Practitioner C, the Vice President of Medical Affairs stated, "To my knowledge there was nothing implemented immediately following the patient's elopement on 5/7/15 from both the Medical/Surgical Nursing unit and Horizons." He reported Horizons was not set up to keep patients from eloping. He stated, "They would have no way to hold a patient nor do they have security at the campus. When Patient #1 is acutely intoxicated she is a danger to herself or others but when she's sober she wouldn't be."

a. During an interview on 5/12/15 at 11:50 AM, the surveyor asked for an elopement policy. Staff J, the Risk Management/QA Director stated, "We do not have a specific policy for patients that are in the non-behavioral unlocked units."

b. During a follow up interview on 5/14/15 at 8:10 AM, Staff E, the Nurse Director stated, "As a result of Patient #1's elopement, the hospital discovered they lacked an elopement risk policy for detox patients. They had created a policy, however, the policy was in the form of a draft for review and not available for staff."

c. During an interview on 5/18/15 at 2:10 PM, Practitioner D, the Internal Medicine Physician, stated, "I would agree to write an order to commit a patient to their hospital for evaluation and treatment for detox most generally because a family member or doctor feels the patient is a threat or danger to themselves of others due to alcohol abuse. Practitioner D stated, "If a patient who is a danger to themselves or others they are not in any condition to make appropriate judgements and it was their obligation to ensure the patient is safe."


II. Based on review of documents, policies, procedures, patient records, interviews with staff and patients revealed 4 patients eloped from the hospitals Emergency Department (ED) exam rooms between 4/24/15 and 5/10/15. (Patients #2, #3, #4, and #5).

Failure to ensure staff periodically checked on the status of ED patients resulted in 4 patient eloping from the ED before the patients received discharge instructions. The elopements occurred after the plan of correction date through the day prior to the revisit.
The Risk Management/Quality Assurance (QA) Director reported an average daily census of 90 patients in the ED between 4/24/15 and 5/10/15.

Findings include:


1. During an interview on 5/11/15 at 2:00 PM, Staff J, the Risk Management/QA Director, identified 4 patients eloped from the ED exam rooms from 4/24/15 to 5/10/15. In addition, the hospital ED documentation provided by Staff P, ED Director, on 5/13/15, revealed 5 ED patients left without being seen (LWBS) by physician or mid-level practitioner and 6 ED patients left against medical advice (AMA) between 5/1/15 and 5/10/15.


2. Review of documents titled, "Safety Huddle meetings" revealed the staff were aware 4 patients eloped from the ED during 4/24/15 to 5/10/15. Two patients received additional care and services and/or were admitted at different hospitals within 48 hours after they eloped from the ED. The Safety Huddle meeting documents failed to show evidence the Staff prepared an action plan, developed and implemented policies, and procedures to prevent and eliminate the risk of patient elopements. The ED staff also were aware that 4 patients eloped from the ED prior to receiving discharge instructions.

Review of a document titled, "Elopement Guidelines" received from the Vice President of Medical Affairs on 5/12/15. The definition for non-decisional patients stated in part, "...For non-decisional patients, we are obligated to make every reasonable effort to keep them from departing for their own safety. For patients who are non-decisional, not fully characterized regarding decision-making capacity or who are court committed, elopement and LWBS (Left without being seen) must result in efforts to locate the patient and return him/her to the patient care area. This could include notifying security...notifying Waterloo Police Department, and attempting to contact patient and family members. For these patients who are non-decisional or court-committed, elopement potential must be assessed and appropriate elopement prevention precautions put in place."

3. Review of 4 of 5 patients ED records revealed:

a. On 5/1/15 at 7:06 PM, stated in part, "...Patient #2, a 12 month old infant, arrived to the ED..At 8:45 PM Disposition status: ELOPE, it is unclear why the patient left, no other follow up is planned...No other follow up planned..."

During a telephone interview on 5/13/15 at 8:00 PM, Patient #2's mother reported they left the ED because she sat in the examination room with her daughter for 3 hours and no one checked to see how they were. She said the doctor completed his assessment in "maybe"15 minutes and then left, and the nurse came in twice out of the 3 hours they were there. She said her daughter was getting fussy, she needed rest, so they walked out of the ED and all of the nurses and physicians watched and did nothing about it. Prior to conclusion of the interview, Patient #2's mother said, "I don't think they really care one way or another about my little girl or me." She did say her daughter recovered without incident from the event and they did not seek treatment anywhere else.

b. On 5/10/15 at 1:37 PM, stated in part, "...Patient #3 arrived by ambulance to the ED...patient eloped, I did not see her prior to discharge...she may have pulled her IV (intravenous catheter) out...3:42 PM..."

On 5/10/15 at 4:08 PM, stated in part, "...Primary Diagnosis...Chest Pain...Disposition Status...Elope...Condition at discharge...Stable...Physician I..."

Staff V, ED RN documentation stated in part,"...3:34 PM......patient was walking in the hall holding her hand where the IV was. States she was going home. I asked if she had been discharged and she said yes. I walked the patient out to the lobby...consent/release form not signed because the patient left without notice...it is unclear why the patient left..."

During a telephone interview on 5/13/15 at 8:16 PM, Patient #3 reported she walked out of the ED that day after calling her family to come and pick her up, because they were not telling her what was happening. She said in the 3 hours that she was in the examination room she seen a nurse one time and a doctor examined her for "maybe" 5 minutes. She reported no one came back to check on her to see how she was doing or if the chest pain was getting worse. Patient #3 reported she went to another hospital the next day and was hospitalized currently. She reported the doctors were concerned with her arteries being "plugged." Prior to conclusion of the interview Patient #3 stated, "The doctors and nurses watched me go and it meant nothing to them."

c. On 5/5/15 at 11:20 PM, Patient #4 presented to the ED. with complaints of visual field disturbances. The patient was examined by a Physician G. On 5/6/15 at 04:49 AM Physician G documented the following in part, "...Visual field disturbances...Primary diagnosis bilateral headache...Disposition Status: Elope..."

During a telephone interview on 5/13/15 at 8:35 PM, Patient #4 reported she waited an hour that day to be seen by a nurse and another hour to be examined by a physician for approximately 10 minutes. She reported she told the doctor she was having pain in her right side but he told her it was a migraine and some pain medication along with an anti-anxiety medication would help. Patient #4 reported the pain medication worked but not for a long period of time, so she sought treatment from another doctor within 48 hours after being seen at Covenant's ED. She reported the doctors at the other hospital completed radiological and laboratory tests and determined her appendix was inflamed and she would have to undergo additional tests to determine if her gallbladder needed to be removed. Patient #4 reported she had to walk down a long corridor in order to exit the ER on 5/6/15 and a lot of nurses and doctors watched her leave and none of them approached her to ask if where she was going or why she was leaving. She said she was there for 5 hours and saw a nurse and doctor for a combined total of 15 minutes. Prior to conclusion of the interview the patient said, "They watched me leave and just ignored it."

d. On 5/10/15 at 4:58 PM, Patient #5 presented to the ED. on 5/10/15 at 4:58 PM with multiple complaints including but not limited to intermittent lower flank and abdominal pain and cramping. Practitioner H, ARNP, documentation stated in part, "...Patient is concerned this cramping might be a miscarriage...Denies vaginal bleeding...patient left the department prior to release..cannot verify intrauterine pregnancy, ectopic pregnancy, or spontaneous abortion...will leave message with charge nurse in the morning." The documentation was completed by Staff H, an ARNP.

4. During an interview on 5/13/15 at 9:35 AM, Staff J, the Risk Management/QA Director said if patients are not court ordered, they can leave voluntarily from their ED anytime they want to because they are capable of making that decision. Staff J said they currently don't monitor elopements in the ED and were not monitoring it in quality.

During an interview on 5/14/15 at 7:30 AM, Practitioner C, Vice President of Medical Affairs, reported if patients are decisional then in his opinion they have a choice of either staying or leaving the ED at any time and that they could not hold them against their will. He reported if they have the opportunity to explain the risks/benefits to them prior to leaving patients and have them sign an Against Medical Advise (AMA) form. If they leave prior to their visit being complete they would attempt to contact that individual or a family member to see if they would consider returning to the ED to finish treatment, ask how they are feeling or if they have been seen elsewhere.

Documentation revealed On 5/11/15 at 9:49 AM Staff attempted to call Patient #5 at the telephone numbers on the patient's contact list. However, both telephone numbers had been disconnected and no longer in service.

5. Review of facility document titled, "Elopement Guidelines" received from the Vice President of Medical Affairs on 5/12/15 stated in part, "For patients deemed decisional, we are obliged to let them depart. For non-decisional patients, we are obligated to make every reasonable effort to keep them from departing for their own safety. For patients who are non-decisional, not fully characterized regarding decision-making capacity or who are court committed, elopement and LWBS (Left without being seen) must result in efforts to locate the patient and return him/her to the patient care area. This could include notifying security...notifying Waterloo Police Department, and attempting to contact patient and family members. For these patients who are non-decisional or court-committed, elopement potential must be assessed and appropriate elopement prevention precautions put in place."

6. During a telephone interview on 5/14/15 at 9:05 AM, Staff P, RN/ED Director reported she had not contacted the 4 patients. She reported in her opinion it was very common in any ED throughout the United States for patients to elope without discharge instructions. She stated, "We review all records of patients who elope from our ED but I don't feel that 4 elopements in 10 days was a high number." Staff P reported patients had the right to leave and if they are decisional, the ED staff could not stop them from leaving.