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Based on interview and record review, the facility failed to provide a safe patient environment for one (1) of ten (10) patients, Patient #1. Patient #1 was brought to the Emergency Department (ED) on 12/04/13 at 2:28 PM for evaluation of cellulitis to his/her right foot. Patient #1, who the facility was aware was at risk for elopement, walked away from the ED after being seen by the ED physician.

The findings include:

Interview with the Patient Care Manager of the ED on 12/11/13 at 4:20 PM, revealed the facility did not have a policy specific to elopement.

Review of the Transfer Summary from the long term care facility, where Patient #1 resided, revealed the patient had diagnoses which included Psychic Factor with other Disorders, Psychosis, Paranoid Schizophrenia Unspecified, Hallucinations and Psychophysic Visual Disturbances. Further review of the long term care facility's Transfer Summary documents revealed Patient #1 was to wear a Code Alert Bracelet (a device
used to protect people when they are at risk for wandering) at all times.

Review of the ED Patient Care Timeline (Patient #1's ED record) dated 12/04/13 at 2:28 PM revealed Patient #1 arrived at the ED for evaluation of Cellulitis (a skin infection usually caused by bacteria) to his/her right foot/leg. Continued review of the ED Patient Care Timeline from 2:28 PM to 5:51 PM revealed Nurse's Notes indicated Patient was alert and oriented to self.

Review of a Nurse's Note timed 3:52 PM revealed documentationi which indicated the ED had been notified by the long term care facility that Patient #1 was a "high flight risk" and had a history of wandering. Continued review revealed Charge Nurse #1, who was in charge of Patient #1's side of the ED, was notified by Patient #1's nurse, Registered Nurse (RN) #2, of the patient's flight risk status. Review of the Nurse's Note timed 4:10 PM, revealed Patient #1's sister, who was his/her Medical Power of Attorney, was contacted for consent to treat the patient. The Note revealed Patient #1's sister informed ED staff Patient #1 was usually on 1:1 supervision when in the hospital. Further review of the Nurse's Notes revealed at 4:15 PM, Patient #1 requested a drink; and, at 4:19 PM the nurse returned with a drink for Patient #1 and observed the patient was no longer in the ED exam room. Review of the Nurse's Notes revealed the two (2) ED Charge Nurses (Charge Nurse #1 and Charge Nurse #2) and Security were notified Patient #1 was no longer in the exam room.

Interview with the Director of Quality, and the Accreditation and Regulatory Affairs Director on 12/12/13 at 12:33 PM, revealed they did not believe Patient #1 had required 1:1 supervision based on his/her behavior in the ED. They indicated the behaviors displayed by Patient #1 were cooperative, calm and polite; and, he/she had not had exit seeking behaviors.

Interview, on 12/12/13 at 1:15 PM, with Registered Nurse (RN) #2, who had cared for Patient #1 on 12/04/13, revealed the patient had not exhibited exit seeking or wandering behaviors; and had no confusion. She stated Patient #1's affect was polite, calm and cooperative. RN #2 stated she did not see any device on Patient #1's ankles while performing her assessment. She indicated the term "Code Alert" bracelet was unfamiliar to her. Continued interview revealed, upon being notified of Patient #1's flight risk status by the long term care facility, she notified ED Charge Nurse #1 and the Nurse Practitioner (NP) of this information and requested 1:1 supervision. RN #2 stated the NP did not believe Patient #1 would meet the criteria for 1:1 supervision. RN #2 stated she asked a Certified Medical Technician (CMT) #1, who was already providing 1:1 supervision for another ED patient, to "keep an eye out" for Patient #1.

Observation on 12/12/13 at 1:30 PM, revealed Patient #1's exam room was down the hall and around the corner from where CMT #1 was providing 1:1 supervision with another ED patient on 12/04/13.

Interview with CMT #1, on 12/12/13 at 2:00 PM, revealed RN #2 did ask him to watch out for Patient #1 while she went to get something for the patient. However, he indicated he made no observations of Patient #1.

Interview with the NP on 12/12/13 at 5:10 PM, revealed she did not recall being notified of Patient #1's flight risk or need for 1:1 supervision while in the hospital. She stated if she had known of Patient #1's flight risk status, she would have ordered 1:1 supervision until he/she had been seen by herself or the Physician. Continued interview revealed she had gone to Patient #1's exam room at least twice to examine the patient; however, he/she was not in exam room at those times.

Interview with the Ombudsman on 12/13/13 at 9:44 AM, revealed she saw Patient #1 outside the facility on a street corner nearby. Continued interview revealed she observed Patient #1 had a Code Alert Bracelet on his/her ankle; and observed the patient had sock on and no shoes on his/her feet. She indicated she was unaware Patient #1 had been to the ED and she transported the patient back to the long term care facility.
The Ombudsman stated Patient #1 told her someone had robbed him/her and stolen his/her shoes. The Ombudsman further stated Patient #1 would be lucid one moment and confused the next.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure Registered Nurses (RNs) supervised and evaluated nursing care for one (1) of ten (10) sampled patients (Patient #1). Patient #1 was brought to the Emergency Department (ED) on 12/04/13 at 2:28 PM for evaluation of cellulitis (a bacterial skin infection) to his/her right foot. The RN, caring for Patient #1, was aware the patient was at risk for elopement. The RN left the patient unsupervised and Patient #1 eloped from the Emergency Department (ED).

The findings include:

Review of the facility policy titled, "Management of Medically Unstable and Behavioral Patients Requiring 1:1 Observation", Section: I(F-3), dated December 2011, revealed a Nursing Supervisor would evaluate the patient and document the findings and actions in the patient Electronic Medical Record (EMR). Interview on 12/12/13 at 12:33 PM with the Accreditation and Regulatory Affairs Director revealed this policy would also be pertinent to the ED.

Review of the Transfer Summary from the long term care facility, where Patient #1 resided, revealed the patient had diagnoses which included Psychic Factor with other Disorders, Psychosis, Paranoid Schizophrenia Unspecified, Hallucinations, Psychophysic Visual Disturbances.

Review of the ED Nurse's Notes revealed the facility was notified Patient #1 was a "high flight (elopement) risk" and had a history of wandering. Continued review revealed RN #2 notified Charge Nurse #1, who was in charge of Patient #1's side of the ED of the patient's elopement risk status. Review revealed Patient #1's sister, who was his/her Medical Power of Attorney (POA), was contacted and she informed ED staff that the patient required 1:1 supervision when in the hospital. Additional review of the Nurse's Notes revealed no documented evidence Patient #1 was placed on increased supervision related to his/her elopement risk. Further review of the Nurse's Notes revealed documentation which indicated at 4:15 PM, Patient #1 requested a drink which the nurse obtained and returned to the patient's exam room. Review revealed Patient #1 was no longer in the ED exam room when the nurse returned. In addition, review of the Nurse's Notes revealed the two (2) ED Charge Nurses (Charge Nurse #1 and Charge Nurse #2) and Security were notified Patient #1 had not remained in the exam room.

Interview, on 12/12/13 at 12:33 PM, with the ED Patient Care Manager, who was an RN, revealed based on the behaviors Patient #1 displayed in the ED on 12/04/13, he had not required increased supervision, such as, 1:1 (one on one) supervision as indicated by his Medical POA.

Interview, on 12/12/13 at 1:15 PM, with RN #2, who was assigned to Patient #1's care on 12/04/13, revealed the patient had been cooperative and had not exhibited exit seeking behaviors. RN #2 stated she had been notified by the long term care facility the patient was an elopement risk; and, by Patient #1's Medical POA that he/she required 1:1 supervision when in the hospital. She indicated she had notified the Nurse Practitioner who didn't believe Patient #1 met requirements for 1:1 supervision. She stated Patient #1 requested a drink and she needed to obtain intravenous (IV) supplies, so she exited the patient's exam room, leaving Patient #1 unsupervised.