HospitalInspections.org

Based on observation, staff interview, medical record review, and review of facility documents, it was determined that the facility failed to ensure policies and procedures for patients that elope are implemented for two (2) out of three (3) medical records reviewed (Patient (P) 8 and P21).

Findings include:

Facility policy titled, "Discharge Without Order (Against Medical Advice, Elopement)," effective 11/8/24, stated, " ...IX. Definitions: ...3. Elopement A patient that leaves the hospital without knowledge of staff or an Emergency Department patient who leaves without knowledge after receiving medical screening. ...XI. Procedure: ...B. Elopement i. Notify Nurse Leader or Administrative Supervisor that the patient has eloped. ii. Attempt to locate the patient. Depending upon each elopement, different mechanisms may be employed to attempt to locate patient, which may include notification of security and police. iii. Notify attending LP [licensed provider] of elopement. iv. Document in the medical record the individuals called and the activity undertaken to locate the patient including final disposition, e.g., police found patient at home. v. Complete an Occurrence Report. ..."

Patient (P) 8, a 16-year-old presented to the Emergency Department (ED) on 1/6/25 at 1:51 PM, by ambulance unaccompanied by a guardian with a chief complaint of assault victim and vomiting. At 2:18 PM, the ED Triage Note stated, "Patient had altercation with [father/mother] Patient started feeling sick and vomiting yesterday while at a friends last night ...[Father/Mother] was arguing with patient Patient reports [father/mother] was hitting [him/her] with a broom and trying to strangle [him/her] ...Patient was fearful for this [sic] safety and picked up a knife to defend [himself/herself] ...Patient states [he/she] feels safe at home most of the time and that [stepmother/stepfather] is the issue ..."

At 3:51 PM, P8's Medical Screening Examination was completed. At 4:36 PM, the Registered Nurse (RN) ED Note stated, "[Mother/father] arrived ..." At 6:35 PM, P8's ED Disposition was set to Elopement. At 6:45 PM, the RN ED Note stated, "Parent eloped with patient Attempted to get family back [Father/Mother] refused Psych NP [Nurse Practitioner] to file DCPP [Division Child Protection and Permanency] Dr. [name] aware ..."

On 1/31/25 at 11:29 AM, S1, Risk Safety Manager, confirmed there was no occurrence report completed when P8 eloped with his/her parent.


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On 1/30/25 at 11:26 AM, P21's medical record was reviewed in the presence of S33, Advance Nurse Clinician. P21, a 24-year-old patient who was 37 weeks pregnant presented to OB-triage (Obstetrics) on 9/3/24 at 12:59 PM, via a private vehicle with reported contractions every 15 minutes and membranes intact. The triage RN and Provider performed an assessment together at 2:33 PM. An order for observation was placed by the provider at 2:33 PM. At 3:55 PM, the medical record lists P21's disposition as "Left AMA or elopement." The medical record lacked evidence of provider notification of P21's elopement. S33 confirmed that P21's medical record did not include provider notification of her elopement.

On 1/31/24 at 1:38 PM, S1 confirmed that there was no occurrence report submitted when P21 eloped.