HospitalInspections.org

Based on medical record (MR) review, document review, interview and in one (1) of one (1) medical record reviewed, the facility staff did not ensure an incident of elopement was fully investigated and analyzed to identify areas for improvement.


Findings include:

The Medical Record (MR) review for Patient #1 documented a 57 year old male who was brought to the Emergency Department (ED) on 2/20/18 at 7:31 PM. Per Emergency Medical Services (EMS), the patient was found wandering down a street unable to tell where he lived or how he was going to get home, and 911 was called. Per EMS patient had altered mental status. The patient was seen and evaluated in the ED. He received medical screening examination in the ED, and was managed for his elevated elevated blood sugar of 305 (reference range-70-120) with insulin, intravenous fluid, and glucose monitoring. Documentation indicated patient was alert and oriented, and with no acute psychiatric condition including suicidal and homicidal ideations. The patient was admitted to the Second Floor Medical Unit on 2/21/18 at 11:56 AM for further observation and management.


The Occurrence Report Form dated 2/21/18 at 2:15 PM and Security Incident Report dated 2/21/18 documented a telephone call was received from the unit reporting Patient #1 had eloped. The patient was last seen using the bathroom in Room 217-2 at 2:15 PM. The Nurse checked on the patient and patient was missing. Unit staff and security were notified. Search was made. Elopement protocol was in put effect and activated. New York Police Department (NYPD) was notified and son made aware.
Documentation indicated that the facility staff, and NYPD with canine unit, conducted a search which was unsuccessful. The facility staff with the NYPD reviewed the video camera and patient was not seen on video.


During interview on 4/6/18 PM, at 2:00 PM, Staff B, Chief Nursing Officer (CNO) and Staff C, Administrator both explained that the incident reports were forwarded to the Risk Management Department (Mount Sinai Beth Israel Corporate) who does further review of cases. Staff stated that Risk Management determines if an incident is reportable to New York Patient Occurrence Reporting and Tracking System (NYPORTS). Staff reported that this case did not meet reportability criteria.


Interviews were conducted on 5/21/18 at 10:30 AM, with Staff B CNO, Staff Oo, Quality Improvement (QI) Coordinator, and Staff Pp, QI Coordinator. Staff acknowledged that for the elopement of Patient in MR#1, the event was immediately discussed at the huddle with Incident and Security reports completed. The reports were forwarded to Risk Management. Risk Management determined that the case did not meet the requirements for a report to NYPORTS, therefore, the case would not be reviewed individually by Quality Improvement Committee.


There was no documentation that a case analysis for an unwitnessed elopement was conducted to identify areas for improvement.