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Based on review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to ensure safety for one patient (P) (P#1) of eight sampled patients (P#2, P#3, P#4, P#5, P#6, P#7, P#8, and P#10). Specifically, on 8/4/25, P#1 failed to have a sitter as ordered by the provider and subsequently eloped from the hospital grounds, placing P#1 at risk for harm.


Findings included:


P#1 was admitted to the facility on 7/31/25 with the diagnosis of dementia (decline in memory, thinking, and judgement) in Alzheimer's disease (type of dementia).


A review of a provider order dated 7/31/25 at 5:22 p.m. revealed an order for patient monitoring one staff: one patient (1:1). Frequency was routine until discontinued. The order was discontinued on 8/4/25 at 11:21 p.m.


Review of nurse note for P#1 revealed note from Registered Nurse (RN) BB on 8/4/25 at 6:42 p.m. narrated that around 4:00 p.m., RN BB was notified by Patient Care Technician (PCT) CC that P#1 was not in her room. and wanted to know if P#1 went for a test. RN BB explained to PCT CC that P#1 did not have any test ordered. RN BB notified security about P#1's absence from her room. RN BB and other staff members checked the rooms on 4 north. Facility security was notified at 4:13 p.m. along with nursing supervisor, director and other leadership team members. A message was sent to medical doctor (MD) GG regarding P#1, MD GG called back at 5:52 p.m. and spoke with RN BB for more report. RN BB gave update with information received from Director of Medical Services (DMS) FF that P#1 was located at her old apartment a mile away from the facility and was transported back to the facility emergency department by an ambulance service.


A review of the "Sitter Assignment List," revealed that P#1 was not assigned a sitter for the 7:00 a.m. to 7:00 p.m. shift on 8/4/25.


A review of the facility's "Safety/Security Event," for P#1 revealed that RN BB described that P#1 had dementia and wandered off. RN BB reported that she called security to report the incident and that P#1 was last seen at around 3:35 p.m.


A review of the facility's policy titled "Sitters Policy," policy #17436766, last revised 3/31/21, revealed that the sitter shall ensure the patient's safety and care.


A review of the facility's policy titled "Rights and Responsibilities of Patients Policy," policy #16455823, last revised 8/22/24, revealed that the patient had a right to the provision of care in a safe setting.


A telephone interview was conducted with RN AA on 9/3/25 at 10:30 a.m. RN AA stated that she had a clear recollection of P#1 whom she cared for during her shift. RN AA said that P#1 was identified as both an elopement risk and a fall risk during her oncoming shift report. RN AA explained that if sitters were unavailable through the float pool, the unit may assign patient care technicians (PCTs) or other staff to sit with the patient.


An interview was conducted with PCT CC on 9/3/25 at 11:40 a.m. in the unit nurse manager's office. PCT CC explained that she was assigned to P#1 on 8/4/25, the day of P#1's elopement. She stated that when she entered P#1's room that morning, no sitter was present at the bedside. She recalled that P#1 appeared somewhat confused and had difficulty maintaining her train of thought during conversation. PCT CC added that while assisting P#1 with a bath, she continued to observe signs of confusion.
PCT CC further revealed that at approximately 3:00 p.m., the nurse assigned to P#1 made rounds and confirmed that the patient was in her room. Around 3:30 p.m., PCT CC returned to the room and discovered that P#1 was no longer present. At approximately 4:30 p.m., the Director of the Medical-Surgical Unit (DMS) FF, informed staff that P#1 had been located at her former residence.
PCT CC explained that, according to report from the previous night shift PCT, P#1 was confused, a fall risk, and an elopement risk. PCT CC said there was no 1:1 sitter available for P#1 during day shift on 8/4/25.


During an interview conducted on 9/3/25 at 12:00 p.m. in the manager's office, RN BB confirmed that she was assigned to P#1 on the day that P#1 eloped. RN BB stated that P#1 had a sitter the previous day but did not have one the day of the incident (8/4/25).
RN BB reported that she had spoken with P#1 shortly before she was discovered missing. RN BB then received a call from PCT CC reporting that P#1 was missing. RN BB stated that she alerted security personnel that P#1 was missing and then informed the charge nurse.
RN BB stated that she questioned the reporting shift nurse as to why P#1 did not have a sitter, and the reporting shift nurse responded that she did not know. RN BB explained that she was busy, having just starting her shift, and was unaware that P#1 had an order for a sitter.


An interview was conducted with the Director of the Medical-Surgical Unit (DMS) FF on 9/3/25 at 3:34 p.m. in the facility conference room. DMS FF reported that he was not familiar with P#1 but was notified of the elopement event on Monday, 8/4/25. DMS FF stated that he was informed by the charge nurse that a 1:1 sitter order had been in place for P#1; however, no sitter was available that day. DMS FF explained that when sitters were not available for float pool assigners to give to patients, units were expected to pull unit staff to provide 1:1 monitoring as needed.
DMS FF acknowledged that the elopement could have been avoided if a PCT staff member had been pulled to sit with P#1.


An interview was conducted with the Unit Nurse Manager (NM) HH on 9/3/25 at 3:45 p.m. in the facility conference room. NM HH stated that she was off on the day of P#1's elopement event and was informed of the incident when she returned to work. She explained that when a provider ordered a 1:1 sitter for a patient, the hospital's Clinical Staffing Office (CSO) was responsible for assigning sitters daily. If a sitter was unavailable, CSO notified the charge nurse, who may then implement other safety measures.
According to NM HH, alternative options included placing the patient on a bed or chair alarm (if they met fall-risk criteria), moving the patient to a room closer to the nurses' station, or assigning available staff to provide sitter coverage, depending on staffing levels.
NM HH confirmed that P#1 did not have a sitter assigned on the day of the elopement. She further stated that CSO was aware of this and that the unit charge nurse did not assign staff to provide 1:1 observation for P#1.