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Based on interviews and record review, the hospital failed to keep Patient #5, an elderly man with dementia, from eloping. Patient #5 was able to walk out of the facility and wander to a nearby skilled nursing facility where he was taken in. This failed practice exposed Patient #5 to potential serious physical harm while he wandered the streets. The findings are:

A. Record review of Patient #5's provider progress notes and psychiatry consultation notes indicated the patient had a history of dementia, hypertension and diabetes. Psychiatry was consulted to determine capacity. He was determined to lack capacity (legal and clinical definition of the ability for self-determination). He was also deemed a flight risk and was placed in a camera observed patient room on admission on 07/21/17. A camera room has 24/7 video of the patient's room but was not monitored. The camera room was confirmed during observation on 08/09/17. Patient #5 eloped on 08/04/17.

B. Record review of the History & Physical for Patient #5 indicated he presented to the[Hospital's] Emergency Department (ED) on 07/21/17 via ambulance with confusion and abdominal pain. It was determined the patient was confused and diagnosed with an underlying dementia.

C. During interview on 08/09/17 at 9:45 am, the Nurse Manager of Patient #5's unit, indicated he did not make any notes or incident report of Patient #5's elopement. He stated he called the facility security department to inform them the target patient was missing around 1:30 pm.

1. The Nurse Manager, further indicated approximately 10 minutes or 1:40 pm, he received a phone call from a nearby Skilled Nursing Facility (SNF), stating Patient #5 was found near their facility. At that time, a hospital Certified Nursing Assistant (CNA), was getting off work and volunteered to pick up Patient #5 from the SNF. The patient was returned unharmed to his hospital unit. The SNF staff had to remove some thorns from his socks as he was not wearing shoes.

E. During interview on 08/09/17 at 10:10 am, the Chief Nursing Executive (CNE) stated the target patient was deemed high risk for elopement.

F. During interview on 08/09/17, the Registered Nurse #1 assigned to Patient #5 on the day of the incident, stated she checked the target patient's blood sugar levels at 12:30 pm. This was the last time she saw the patient. She went to lunch at 1:30 pm and received a phone call from another unit nurse, Nurse #2, stating the patient was missing. The patient was seen walking through the parking lot by another patient who reported this to Nurse #2. Nurse #1 stated she did not hear the patient's name called "overhead" as is the usual protocol when a patient cannot be located. She also stated she thought the Charge Nurse, "probably called Security." After lunch, Nurse #1 was advised by security that Patient #5 was found at the local SNF and CNA #1 was going to pick him up.

G. During interview on 08/09/17 at 11:15 am, Patient #5 demonstrated he was not oriented to name, time, date, place, or situation. He was unable to complete thoughts and had clear word finding problems.

H. During interview on 08/09/19 at 1:45 pm, the Security Department Director stated he had no record of a call to local police and could not locate any documentation of this event on this patient. He stated security procedure is to ask how long the person has been missing. If the patient is already gone then local police are called. He also stated the information goes to his boss, the Executive Director of Security Department.

I. During interview on 08/09/17 at 1:00 pm, the CNE and Executive Director of Nursing (EDON), produced an Action Plan for Patient Elopement Root Cause Analysis and stated an emergency mandatory training for all staff is scheduled for Monday, August 14, 2017 at 2:30 pm. The CNE stated the RN manager had also been re-educated on proper hospital protocol.