HospitalInspections.org

Based on record review, interview, and policy review, the provider failed to provide interventions for one of two sampled (1) patients who had eloped. Findings include.

1. Review of patient 1's medical record for her 1/13/16 through 3/9/16 admission included:
*She had been a resident at a long-term care facility having been admitted there on 11/20/15 and had left against medical advice on 1/11/16.
*She had been admitted on 1/13/16 after having been found unresponsive in a park.
*Her diagnoses included: dementia associated with alcoholism, seizure disorder, urinary tract infection, metabolic acidosis, lactic acidosis, and hypothermia.
*Was initially unable to elope as was on a ventilator and had soft wrist restraints.
*A neuropsychiatric assessment had been completed on 1/20/16, and she had been deemed unable to make her own legal and medical decisions. It was recommended she have twenty-four supervision.
*A 2/3/16 case manager note revealed patient 1's sister was pursing guardianship.
*A 2/11/16 physical therapy note stated she could ambulate 130 meters.
*A 2/18/16 case manager note the patient had requested to be discharged.
*A 2/19/16 case manager note from the sister revealed "If she takes pt. [patient] home she will just run away again."
*On 2/24/16 "Patient upset and wanting to leave."
*On 3/1/16 "Pt out of room without informing staff."
*On 3/5/16 Patient 1 eloped out of room. Had been last seen at 11:00 a.m. when her lunch tray had been delivered. Her sister had called the hospital and had stated she had received a phone call from her and had not recognized the number. Was found at 12:00 p.m. not to be in her room and had not eaten her lunch. Was found at approximately 12:30 p.m. at a clinic 0.6 miles away. A hospital employee had also called and stated she had observed the patient at the clinic location.

The care plan interventions for elopement risk had included:
*Keeping patient close to nurses station for close observation.
*Assessment of the elopement risk every twelve hours.
*Shift-to-shift reports of patient's elopement risk.

Interview on 4/20/16 at 2:50 p.m. with the director of the orthopedics, neurology, and surgical nursing department regarding patient 1 revealed:
*She was fixated on a plan for discharge.
*She was dressed in street clothes on a daily basis.
*She independently used a wheelchair for mobility.
*She had been deemed incompetent after a neuropsychiatric evaluation on 1/20/16.

Interview on 4/21/16 at 9:35 a.m. with patient 1's assigned case manager and the lead case manager revealed:
*They agreed patient 1 was an elopement risk.
*She always wanted to leave to get money from the bank, so she could get to Sioux Falls.
*Agreed the elopement interventions had not been individualized for patient 1.
*There was no process in place to evaluate the documentation of a high elopement risk patient and interventions put in place.

Review of the provider's revised May 2013 Assessment of Patient Elopement Risk policy revealed:
*"In many cases of elopement, the patient may have a decreased mental capacity related to dementia or temporary delirium, or intermittent mental status changes related to medication, disease, or traumatic injury."
*"The patient who elopes is often at risk for serious harm, including death."
*"The goal of this policy is to attempt to prevent elopement through patient assessment and implementing interventions to help mitigate the risk of elopement."
*All patients would be assessed for the potential for elopement during the admission assessment and reassessed every twelve hours or as the patient condition changed as part of the safety assessment.
*"Elopement can be a planed or totally impulsive act. Some risk factors to evaluate to determine whether a patient is at risk an requires very close supervision."
*The patient exhibits confusion related to one or more physical issues that included: dementia, history of current alcohol abuse, a history of elopement, and lacks the cognitive ability to make relevant decisions.
*If the patient was found to be at risk for elopement an elopement care plan was to have been initiated. Interventions to consider for the patient at risk for elopement might include: place the patient close to the nurses' station, request family or volunteer to stay with the patient, patient location checks frequently, place under constant supervision if at high risk, shift-to-shift report would have included identification of the patient at risk for elopement.