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Based on findings from document review and interview, the emergency department (ED) quality assurance performance improvement (QAPI) program lacked documentation of its actions to improve measures below goal.

Findings include:

Review of the ED QAPI meeting minutes for first quarter, 2016, revealed numerous quality indicators (e.g., critical lab results reported to provided per policy, intravenous start and stop time documented in the medical record, pediatric medications administered to patients under 12-years-old or under 80 pounds verified by 2 registered nurses, hand hygiene, etc.) The quality indicators had goals identified based on various benchmarks. However, goals that were not met did not have any documented action plans to work towards meeting those goals.

During interview with the Staff A, the Chief Nursing Officer, on 7/28/16 at 11:00 am, he/she acknowledged this finding.

Based on findings from medical record (MR) review, document review and interview, in 1 (Patient #1) of 3 MRs reviewed, the facilty did not effectively integrate coordination and communication between the Emergency Department (ED) and another hospital service (security) to protect the health and safety of a patient. As a result, a patient (Patient #1) eloped from the facility and there was potential of a compromise in his safety. Additionally, an incident report was not completed for this elopement per the facility's policy and procedure (P&P).

Findings include:

1. Review of Patient #1's MR identified the following information: Patient #1, a 15 year old, was brought to the ED on 7/14/16 at 11:44 pm with alcohol intoxication and substance abuse. He was triaged at 11:46 pm as a level 2 acuity out of 5, with 1 being life-threatening. A medical screening exam performed at 11:50 pm determined that the patient drank a large amount of vodka and reportedly smoked 4 grams of synthetic marijuana with a noted clinical impression of alcohol intoxication. Patient #1 admitted to thoughts of self harm. A Pediatric PHQ 9-Suicide screen revealed that Patient #1 was not at risk for suicide. An Elopement Risk Assessment revealed that Patient #1 was an elopement risk and considered to be a danger to self or others. Patient #1 was placed in room #14 closest to the nurse's station for maximum visibility.

Review of security "Shift Activity Report," dated 7/15/16, revealed at 12:00 am a security guard was monitoring 3 rooms in the ED, including Patient #1 in room #14. The next entry, at 12:00 am, indicated "room #14 walk out."

On 7/15/16 at 12:32 am, nursing documentation revealed patient not in room, patient seen leaving by family of next room out ambulance doors. A Request for Law Enforcement Pick-up form dated 7/15/16 was initiated.

During interview of Staff B, the Director of Quality and Safety on 7/28/16 at 12:30 pm, he/she acknowledged the lack of communication between the security guard and ED staff.

2. Review of a security "Shift Activity Report," dated 7/15/16 revealed the following information:

Any of the following items checked yes MUST be followed by an Incident Report:
1. Missing or Defective Equipment
2. Security Breaches
3. Safety hazards
4. Suspicious Activity
5. Client Policy Violations
6. Injuries/Illnesses
7. Property Damage
All the above boxes (1-7) were checked "no". However, during this shift a 15-year-old patient at risk for elopement, did elope and was returned to the hospital by law enforcement.

During interview of Staff C, the Facilities Director, on 7/28/16 at 12:00 pm, he/she indicated he/she supervises contracted security staff at the facility. He/she did not know if a patient elopement would constitute a security breach and therefore require an incident report.

The facility's policy and procedure (P&P) titled "Incident/Event Reporting," dated 10/28/15, indicated that a close call is an event that could have resulted in patient harm.

During interview with Staff B, on 7/28/16 at 12:30 pm, he/she acknowledged that an incident report should have been completed for this elopement.