HospitalInspections.org

Based on policy review, document review, medical record review, video review, and interviews, the hospital failed to protect and promote the rights of all patients. Specifically, clinical and security staff failed to identify Patient #1 was at risk for elopement/absconding and potential self-harm and/or harm to others and did not implement safety measures to monitor Patient #1.

Reference:
482.13(c)(2): The patient has the right to receive care in a safe setting.

Based on policy review, medical record review, video review, and interviews, the hospital failed to meet the emergency needs of patient's accordance with acceptable standards of practice. Specifically, the hospital failed to ensure the emergency department clinical staff filed an incident report and notify the night shift supervisor of Patient #1's elopement in a timely manner.

Reference:
482.55(a)(3): Emergency Services Policies.

Based on policy review, document review, medical record review, video review, and interviews, the hospital failed to protect and promote the rights of all patients and ensure care was received in a safe setting. Specifically, clinical and security staff failed to identify Patient #1 was at risk for elopement/absconding and potential self-harm and/or harm to others; the registered nurse did not triage and/or conduct a suicide assessment for Patient #1, police refused to stay and monitor Patient #1; and measures to safely monitor Patient #1 were not implemented. The hospital failed to implement constant or close observation measures despite the patient's history of violence, suicidal/homicidal risk, and being placed in a yellow gown (indicating elopement risk); the noncompliance resulted in Patient #1 eloping/absconding from the Emergency Department while still medically and psychiatrically uncleared, necessitating a hospital lockdown and a subsequent police search, which directly jeopardized the patient's safety and the security of the hospital environment.

Findings include:

Review of the policy "Identification, Assessment and Planning Care for Individuals at Risk for Suicide," revised February 2024, revealed patients at risk of suicide include patients who are diagnosed with a primary or secondary emotional or behavioral illness; patients admitted after a suicide attempt; patients admitted with an injury that appears to be self-inflicted or unexplained origin; patients expressing or demonstrating symptoms of severe depression or mania; and patients at identified at risk after completion of suicide screen. The ultimate goal is to ensure the safety of patients in the hospital. Patients who present for medical stabilization after a suicide attempt or express intent to harm themselves may need to be assessed by psychiatry or transferred to another facility for psychiatric evaluation. Patients who present at risk of harming themselves are placed in a safe environment with continuous observation, until a physician deems the patient is no longer at risk. All patients 13 years old and older entering the ED who present at risk for intentional harm to themselves or others, will receive an age-appropriate psycho-behavioral and suicide screening. The ED provider will assess the patient in more detail and determine any necessary interventions needed to mitigate any potential patient self-harm risks and place an order for the appropriate level of monitoring. All patients and circumstances are unique. In the event there are individualized patient care concerns, a care conference should be held with the care team to discuss the situation and plan for the patient. (No policy was found specifically addressing criteria for a risk assessment for violence and/or homicidal).

Review of the policy "Security Risk Observation Policy for Patient Care," effective May 2024, revealed the purpose of this policy is to provide the appropriate observation and safety measures and to ensure a safe environment to all patients, staff and visitors. Clinical assessments for potential disruptive behaviors will be made by the physician or nurse, who may request assistance from security personnel when necessary. For patients who are under constant observation in the ED, the registered nurse (RN) will evaluate each patient during the triage assessment for any potential security risks. Security will be notified and be present to search for harmful objects, as well as to provide aid in observation until released by the RN in the ED.

Review of the policy "Emergency Medicine Unit Structure Standard," last revised August 2024, revealed the triage/nurse inputs the patient's chief complaint, documents significant physical, relevant recent medical and surgical, psychological history in the triage note related to the chief complaint. The triage/nurse will complete relevant/required screening tools to facilitate rapid staff awareness and expedite patient care. The triage/nurse determines the priority for treatment based upon the initial assessment and classifies the patient per the "Emergency Severity Index-ESI." The triage/nurse communicates priority needs of Category ESI 1 and 2 to the Clinical Nurse Leader (CNL), charge nurse and/or provider. The triage/nurse will assign in collaboration with the CNL/charge nurse the patient to an open room and/or send the patient with a nurse or patient care technician (PCT) to the clinical area for placement. The role of Emergency Medical Services (EMS) triage in the adult ED is to collaborate with ED provider team to flow psychiatric patients to the Crisis Intervention Unit (CIU) in an expeditious manner while maintaining client and staff safety. Triage in conjunction with CNL or charge nurse initiates crisis intervention when warranted. The hospital will provide a safe and secure environment for all patients presenting with psychiatric emergencies. Any patient expressing lethality issues or in acute psychiatric distress are to be immediately escorted to an appropriate bed either in the psychiatric area or CIU, or to a medical bed. The ED shall take custody of these patients from the moment of contact by requiring a 1:1 observation by a staff member or placed on close observation as necessary. This may include security, a technician, or nursing staff. The ED provider evaluates all psychiatric or behavioral health patients in order to medically screen and medically clear the patient prior to the patient being seen by a psychiatrist or their designee. (No policy was found specifically addressing criteria for a risk assessment for absconding/elopement).

Review of the policy "Comprehensive Emergency Management Plan Annex 8 Missing Patient Plan," reviewed January 2025, revealed patient elopement can be defined as the unauthorized absence of an admitted patient from the boundaries of the care unit, including the Emergency Center, without staff knowledge. An appropriate plan includes mitigation activities to reduce the potential for elopement and actions to improve the prospect for a quick resolution to a missing patient incident. Criteria for patients with elopement potential include those with a previous history of elopement, attempted elopement, wandering, patients who are resistant to admission, or those that develop wandering tendencies. Once a patient has been identified as being high risk for elopement, appropriate interventions will be implemented. In the ED, all attempts are made to place them in a room that they can't leave without being seen. If additional supervision is necessary, they are put on 1:1 for safety.

Review of the policy "Incarcerated Patient," revised May 2025, revealed hospital patients, who by nature of their incarceration in any jail or prison, are considered potentially dangerous will be accompanied by law enforcement officers at all times during their stay. The law enforcement officer is expected to sit inside the patient's room, except when patient is in isolation, in the operating room or during the birth of an infant. Should the law enforcement officer need a personal relief break, the officer must obtain their own coverage. No Rochester Regional Health personnel are to ever replace a law enforcement officer.

Review of the emergency department medical record for Patient #1 revealed the following:
On 09/15/25:
-The "Emergency Medical Service-EMS," document revealed at 10:30 PM, EMS arrived at a local police department to find Patient #1 in a holding cell. Police requested a 9.41 mental health transport ((New York State Mental Hygiene Law that allows police/peace officers to take into custody a person who appears to be mentally ill and likely to cause serious harm to themselves or others) for evaluation. The police officer advised EMS that Patient #1 had over 20 pending charges and was acting "bizarre" earlier in the day. This "bizarre" behavior resulted in police having to tase Patient #1 multiple times. The only complaint that Patient #1 reported to EMS was pain and swelling to the right hand. Police officers reported that the injury to the right hand could have been caused by Patient #1 banging their hand on glass windows (in the jail cell). At 10:43 PM, Patient #1 was transported to the hospital with their left hand secured to the gurney via handcuffs. The EMS examination revealed Patient #1 was alert, with no neurological deficits noted. A review of body systems were within expected limits, except for swelling and pain noted to the right hand. At 10:45 PM, EMS documented Patient #1's vital signs as a temperature of 98.1 degrees (normal range 96-99 degrees) Fahrenheit, a heart rate of 66 (normal range 60-100) beats per minute, respirations of 16 (normal range 12-20) breaths per minute, a blood pressure of 152/96 (normal range 90-140/60-90) millimeters of mercury, an oxygen saturation of 99 (normal range 93-100) percent, and a pain level of 10/10 (0-no pain, 10-worst pain ever). At 11:01 PM, EMS arrived at hospital with Patient #1. Patient #1 was registered and triaged. At 11:15 PM, Patient #1 was moved to room #18 by EMS, but there was no bed in the room. At 11:30 PM, a bed arrived in the room. The handcuffs were removed by police. Patient #1 moved over to the hospital bed and patient care was transferred from EMS to hospital staff.
-At 10:53 PM, the "Mental Health Transport 9.41," paperwork documented by police revealed at 09:00 PM, police officers arrived at the residence of Patient #1 for a follow-up visit. Patient #1 became manic and would not listen to police officers' commands. Patient #1 grabbed a large knife in their vehicle, threatened the police officers, before running through an apartment complex, and into the woods. Once police officers located Patient #1, they would not follow verbal commands and kept yelling for police officers to "shoot" them. Patient #1 was then tased and taken into police custody. Patient #1 was manic the entire time and was not making any sense. Patient #1 placed themselves in a dangerous situation, was unable to care for self, made verbal and physical threats, attempted to hurt/kill self/others, and had a weapon (butcher knife).
-At 11:05 PM, Patient #1 arrived in the ED via ambulance and police escort for a 9.41 mental hygiene law evaluation and complaints of right-hand pain.
-At 11:06 PM, Staff (M), RN documented a triage note indicating EMS reported Patient #1 was placed under a mental health evaluation by police for acting strange and punching the glass in their cell with right fist. EMS reported Patient #1 would remain in police custody.
-At 11:08 PM, vital signs were a temperature of 98.1 degrees (normal range 96-99 degrees) Fahrenheit, heart rate of 66 (normal range 60-100) beats per minute, respirations of 16 (normal range 12-20) breaths per minute, blood pressure of 152/96 (normal range 90-140/60-90) millimeters of mercury an oxygen saturation of 99 (normal range 93-100) percent, and a pain score of 10 (scale 0-10, 0= no pain-10= worst pain ever). (The vital signs documented are the same vital signs taken by EMS at 10:45 PM).
-At 11:09 PM, triage documentation by Staff (M), RN, revealed Patient #1's airway, breathing, circulation and disability were all "within defined limits (met all established criteria for what is considered normal or acceptable)." The triage suicide screen (assess the severity of suicide risk) was performed. Patient #1 denied feeling down, depressed, or hopeless over the past two weeks. Patient #1 denied having thoughts of killing themselves and harming others in the last two weeks. Patient #1 denied ever attempted to kill themselves. An emergency severity index (assesses patient acuity, needed resources, and level of urgency) score of 2 (high-risk). (Staff (M) verified that they did not interview Patient #1 for triage or the suicide screening stating information was received from EMS).
-At 11:16 PM, Patient #1 was moved to ED Room #A17 located across the hallway, in direct view of the nurse's station.
-At 11:19 PM, Staff (P), Secretary documented "please contact [local police department] police sergeant prior to release."
-At 11:20 PM, Staff (N), Physician, documented a medical screening examination that indicated Patient #1 presented to the ED under arrest by police. Patient #1 was a former police officer who had prepared a list of individuals they intended to kill. Patient had confronted someone and was subsequently arrested. Patient #1 was brought to the ED after they reportedly voiced homicidal and suicidal thoughts. It was also reported that Patient #1 had been hitting their hand against glass. Patient #1 reported they did not know why they were arrested. Patient #1 was not hallucinating, was not delusional, and did not appear to be intoxicated. Patient #1 denied having suicidal or homicidal thoughts. Patient #1 was not psychotic, manic, delusional, or responding to internal stimuli (experiences, thoughts, and physiological changes that originate within an individual). There were abrasions noted on the head of Patient #1, which Patient #1 was unaware of how they occurred. Patient #1's only complaint was pain to the right hand.
-At 11:26 PM, Staff (N), Physician, ordered laboratory tests and imaging (procedure that creates detailed images of internal structures in the body) of the right hand and head.
(At approximately 11:45 PM, police leave the hospital per security report).
-At 11:58 PM, Staff (O), RN, documented a psychosocial assessment that revealed Patient #1 appeared disheveled, fearful, and exhibiting anxious behaviors. Patient #1 was alert and oriented to person, place, time, and their affect (immediate expression of emotion) was appropriate for the circumstances. However, Patient #1 was also restless and had a rapid speech pattern.
On 09/16/25:
-At 12:05 AM, Staff (O), RN, documented Patient #1 was calm and cooperative. Patient #1 was resting in bed with monitoring ongoing.
-At 12:33 AM, the urine drug and cannabinoid screens resulted negative.
-At 01:08 AM, Staff (O), RN, documented Patient #1 was not in their room. Patient #1 was observed by nearby staff following the emergency exit signs. There was an ongoing search for Patient #1 with security.
(There is no documentation of when police left the hospital, no interventions were ordered/implemented to monitor Patient #1 due to the absconding risk and/or risk for harm to self or others).

Review of the video surveillance, dated 09/15/25 to 09/16/25, revealed the following:
-At 11:03:59 PM, Patient #1 was wheeled into the ED through the EMS entrance on a stretcher, with their left wrist handcuffed to the side rail of the stretcher with two EMS providers, five security officers, and one police officer, to the triage area.
-From 12:44:16 AM to 12:47:22, Patient #1 was pacing in the hallway, on a cell phone, in a yellow gown with a blanket in his arms across from the nurse's station.
-At 12:47:22 AM, Patient #1 hung up the phone and started walking down the hallway. There were no staff in the hallway. Two staff members in the nurse's station across from Patient #1's room, both had their backs facing Patient #1's room as Patient #1 walked down the hallway.
-From 12:47:37 AM to 12:51:13, Patient #1 leaves the area of their room and was seen walking down hallways until they opened an exterior door of the hospital next to a parking garage in their yellow gown and a blanket draped over their shoulders and exited the hospital, walking down the sidewalk, and exiting the parking garage.

Review of the emergency department medical record for Patient #1 dated 09/16/25 (visit #2-returned to the ED after absconding) revealed at 01:28 PM, Patient #1 arrived at the ED in the custody of police officers for a mental health examination. A suicide assessment indicated Patient #1 was at high risk, and a psychiatric consult was ordered and performed at 02:47 PM. Patient #1 was placed on 9.37 mental hygiene law (involuntary inpatient admission of an individual at substantial risk of harm to themselves of others) status and was transferred to an outside, secure inpatient psychiatric facility at 08:30 PM. Police stayed with Patient #1 the entire time.

Review of the "Department of Safety and Security Report," by Staff (AA), Security Officer, dated 09/15/25 at 11:35 PM, revealed at around 11:00 PM, security was made aware that Patient #1, a mental health transport, was arriving with a police officer. At about 11:06 PM security met Patient #1 at the emergency medical services triage area. Patient #1 was handcuffed to the stretcher and was cooperative with medical staff and security. Patient #1 was assigned to Room #17 and the handcuffs were removed. Patient #1 was changed into a yellow gown. Staff (AA) asked the police officer if they were going to stay with Patient #1 as there were 15 pending charges stemming from the encounter that led to the mental health transport. The police officer stated that they would not be staying due to not having enough police officers that night. Extra rounds were conducted to check on Patient #1 periodically. The last rounding was on 09/16/25 at 12:40 AM.

Review of the "Department of Safety and Security Control Access Lockdown Report," by Staff (W), Security Supervisor, dated 09/16/25 at 02:41 AM, revealed on 09/15/25 at 11:06 PM, Patient #1 arrived at the ED escorted by police officers. At 11:19 PM, Patient #1 was triaged and changed into a yellow gown. Patient #1 was placed in room #17. At 11:35 PM Staff (W) and Staff (Z), Security Officers confirmed the police officer would not be staying with Patient #1. At 11:45 PM, the police officer left. On 09/16/25 at 12:37 AM, a medical incident occurred in Room #18. At 12:40 AM, Staff (AA), Security Officer saw Patient #1 standing in the doorway of room #17 requesting to use the bathroom. Staff (AA) escorted Patient #1 back to room #17 after they used the bathroom. At about 12:46 AM, staff notified security that Patient #1 was missing from their room. At 12:51 AM, video review confirmed Patient #1 exited the building through a door near the parking garage. At 01:20 AM, police were notified and arrived at the hospital at 01:45 AM. At 02:15 AM, Staff (W) ordered a hospital lockdown. At 03:41 AM, the Incident Command Center was formally established to coordinate the response and search operations.

Review of the "Department of Safety and Security Missing Patient/Elopement Attempt Report," by Staff (AA), Security Officer, dated 09/16/25 at 01:05 AM, revealed Patient #1 was a 911 contact (contact the police department when the patient is discharged from the hospital) and was not in their assigned room. Security dispatch was immediately notified and started a camera/video review to locate Patient #1's last known location. Security started searching the immediate area and was unable to locate Patient #1. Police officers arrived to assist in the search for Patient #1 as they had pending charges against Patient #1 and their recent conduct that made them a danger to society. The building was put on lockdown. After video review, it was determined that Patient #1 was last seen heading towards the parking garage at 12:51 AM in their yellow gown and a blanket.

Interview on 09/22/25 at 01:00 PM with Staff (N), Physician, revealed that on 09/15/25, Patient #1 was under arrest for threatening police officers and family. Patient #1 hurt their right hand and needed to be evaluated. The police officers who brought Patient #1 into the hospital did not stay with them and they told staff that he was a 911 contact. Usually, the police officers stay with patients who are a high risk. Constant observation was not ordered as Patient #1 denied homicidal and suicidal ideations and was calm and cooperative. After a long discussion with the psychiatric assessment officer who was aware that Patient #1 was threatening others, it was mutually decided that Patient #1 did not need psychiatric care (no evidence of conversation found in medical record). Patient #1 absconded from the ED while Staff (N) was caring for a critical patient in the room next to Patient #1. Patient #1 was in a yellow hospital gown indicating that they were an elopement risk.

Interview on 09/22/25 at 03:40 PM with Staff (M), Registered Nurse, revealed that they were the triage nurse for Patient #1 on 09/15/25. Patient #1 arrived at the ED handcuffed to the stretcher with emergency medical services (EMS) and a police officer due to a right-hand injury from punching a wall while in jail. All of the information for the triage assessment was from the EMS team. Staff (M) never spoke directly with Patient #1. At the time of triage, the 9.41 paperwork was not available, and Staff (M) did not speak to the police officer. The homicidal and suicidal screen were completed based on information from the EMS team. Security took Patient #1 into the bathroom and did a weapon search and had them change into a yellow gown. Patient #1 was put into Room #17 which was directly across from the nurse's station. Staff (M) thought that the police officer was staying with Patient #1 since they were in custody. Handoff was given to Staff (O), Registered Nurse, who assumed care of Patient #1. When the 9.41 paperwork was available Staff (M) scanned it into Patient #1's chart.

Interview on 09/22/25 at 04:00 PM with Staff (W), Security Supervisor, revealed that the police officer called the hospital before Patient #1 arrived and requested to meet them upon their arrival. The police officer alerted them that Patient #1 was tased after threatening police officers with a knife and had many other charges pending. Staff (W) had asked the police officer if they were staying with Patient #1 and were told that they were short staffed and could not stay, but to call when Patient #1 was discharged so they could pick them up. Security Officers then escorted Patient #1 to the rest room for Patient #1 to change into a yellow gown and collect personal items. Patients who are in yellow gowns are at risk of wandering or elopement, such as patients with dementia or psychiatric/behavioral problems. Security staff do not sit with patients who are in police custody and the police officer is to stay with the patient. Staff (W) knew Patient #1 was not able to leave the facility as they had not been medically cleared and were there on a 9.41. 911 was called to alert police Patient #1 absconded. A lockdown of the hospital was called. Video footage revealed Patient #1 left the building out of an exit door that led to a parking garage.

Interview on 09/22/25 at 04:26 PM with Staff (A), Senior Director Regulatory Compliance, revealed that all patients of the ED receive a suicidal and homicidal ideation screen. It is a requirement that the RN ask the patient the screening questions directly. If a patient is on a 9.41 and not medically cleared, they cannot leave the hospital. There is not a policy for when a police officer leaves a patient in the ED alone without anyone watching them.

Interview on 09/23/25 at 08:00 AM with Staff (O), Registered Nurse, revealed that they were the nurse assigned to Patient #1 on 09/15/25. Patient #1 was brought in by the police. Patient #1 was in police custody due to being arrested for warrants, threatening police with a knife, and being tased. While in police custody Patient #1 punched the wall in the jail cell and injured their right hand. Security was also with Patient #1 and assisted with a weapon search, changing into a yellow gown, and locking up their belongings. Even though Patient #1 was in police custody, the police officer left Patient #1 alone. Security was not assigned to sit with Patient #1 when the police officer left. If a police officer needs to leave, security would need to delegate a staff member to stay with the patient and collaborate with the charge nurse. Staff (O) and security were checking in on Patient #1 frequently. The patient in the room next to Patient #1's had an emergency. That is when Patient #1 was found to not be in their room. Staff (O) spoke to security, and they immediately began to search for Patient #1.

Interview on 09/23/25 at 09:30 AM with Staff (X), Security Officer, revealed they were working when Patient #1 arrived at the ED on 09/15/25. The police officer called and alerted security that Patient #1 was coming to the ED for evaluation and wanted Staff (W), Security Supervisor, to meet them on arrival. Staff (X) was present when Patient #1 arrived at the ED in handcuffs attached to the gurney. The police officer told security that Patient #1 had 15 charges against them. Patient #1 was calm and cooperative, triaged, searched for weapons, and changed into a yellow gown. Patient #1 was then put into Room #17. The police officer told security that they were not staying with Patient #1 due to being short-staffed and to call when Patient #1 was discharged. Staff (W) told the police officer that they did not have anyone to sit with Patient #1. If a patient is brought into the ED in police custody, they are to have a police officer always stay with them. If a patient goes into the CIU (crisis intervention unit- locked psychiatric area of the emergency department) the police officer can leave the premises. The CIU was full at the time. Patient #1 was brought into the medical ED. Nursing staff called security once when they realized that Patient #1 was missing.

Interview on 09/23/25 at 010:00 AM with Staff (Y), Nurse Supervisor, revealed that they were not told about Patient #1 until 09/16/25 at 02:29 AM when the ED was going on lockdown. Security should have told them about Patient #1 and how the police were refusing to stay with Patient #1. Staff (Y) would have escalated the situation to the police officer's supervisor notifying them an officer would have to stay with Patient #1.

Interview on 09/23/25 at 01:11 PM with Staff (Z), Security Officer, revealed that Patient #1 came into the ED in police custody. When the police officer said that they could not sit with Patient #1 Staff (Z), told the police officer that they needed to stay with the patient. The police officer refused to stay due to them being short staffed. The police officer told Staff (Z) and Staff (W), Security Supervisor to call when Patient #1 was discharged.

Interview on 09/23/25 at 01:30 PM with Staff (AA), Security Officer, revealed that Patient #1 came in on 09/15/25 in police custody handcuffed to the gurney under a 9.41. The police officer requested to speak to Staff (W), Security Supervisor, as they were not able to stay with Patient #1 and wanted the hospital to call when Patient #1 was discharged. If a patient comes into the ED in police custody with charges pending, they must stay with the patient. A few minutes before Patient #1 eloped from the ED, Staff (AA) assisted Patient #1 to the bathroom and then back to Room #17. At the same time there was a critical patient in the room next to Patient #1. Patient #1 noticed this when walking back to their room. Patient #1 eloped shortly after.

Interview on 09/23/25 at 04:09 PM with Staff (BB), Clinical Nurse Leader, revealed that they did not know Patient #1 was in the ED until Staff (EE), Charge Nurse made them aware that Patient #1 had absconded. Due to the immediate danger, Staff (BB) decided that the hospital needed to go on lockdown for safety.

Interview on 09/23/25 at 05:43 PM with Staff (FF), Psychiatric Assessment Officer, revealed they were alerted by Patient #1's outpatient treatment team that Patient #1 was coming to the hospital for violent behavior toward police officers. Staff (FF) communicate to Staff (W), Security Supervisor, and Staff (N), Physician that Patient #1 was being brought in on a 9.41 due to pulling a knife on police officers, was suicidal and wanted the police officer to shoot and kill him. After Patient #1 was discharged they would be going to jail. Staff (FF) followed up with Staff (N) later in the shift to see if they wanted a psychiatric workup and Staff (N) revealed that Patient #1 was not medically cleared at that time. Staff (FF) did not document any conversations as no consultation was ordered.

Based on policy review, medical record review, video review, and interviews, the hospital failed to ensure the emergency department (ED) staff followed policies and procedures governing the care provided in the ED. Specifically:
1. Clinical staff failed to file an incident report within 24 hours of the adverse elopement event for Patient #1.
2. The Clinical Nurse Leader and Nursing Supervisor were not notified of Patient #1's elopement (12:51 AM) timely, delaying security measures such as a hospital-wide lockdown (controlled access of all entrances/exits) until 02:15 AM, emergency department diversion (notification to Emergency Medical Services (EMS) to not to bring ED patients to the hospital) until 02:55 AM, and notification to leadership until 03:13 AM for the implementation of the incident command center until 03:41 AM.
This noncompliance resulted in a signficant delay in implementing necessary security and emergency protocols, jeopardizing patient safety and hospital operations.

Findings #1:

Review of the "Event Reporting Policy & Procedure," effective November 2023, revealed that all employees and staff are responsible for identification and notification of any errors, close calls or other safety events to their supervisor/manager. Errors, close calls, and other safety events are reported in the on-line event reporting system as soon as possible, but ideally no later than 24 hours after event discovery.

Review of the emergency department (ED) medical record and surveillance video for Patient #1 revealed on 09/15/25 at 11:05 PM, Patient #1 arrived at the ED via ambulance and police escort for a 9.41 mental hygiene transport (New York State Mental Hygiene Law that allows police/peace officers to take into custody a person who appears to be mentally ill and likely to cause serious harm to themselves or others) evaluation and complaints of right-hand pain. On 09/16/25 at approximately 12:51 AM, Patient #1 absconded/eloped from the hospital.

An interview on 09/22/25 at 04:26 PM with Staff (A), Senior Director Regulatory Compliance, revealed that no Safe Connect report (incident report) was filed by staff related to Patient #1's absconding from the facility.

Findings #2:

Review of the policy "Emergency Medicine Unit Structure Standard," last revised August 2024, revealed when a patient is discovered missing, staff must notify the charge nurse and ED attending physician. The charge nurse will inform security and the clinical evaluator, notify the nursing shift supervisor, and enter the information into Safe Connect (incident reporting system). Security will call 911. The clinical evaluator will notify the ED nurse manager and the adult ED medical director. The nursing shift supervisor will notify the administrator on call. If the patient has not been located within four hours, the administrator on call will notify the corporate risk manager and senior leadership, including the chief nursing officer and the president. When the patient is located, the above process should be repeated in reverse order to be sure that all parties are notified.

Review of the policy "Comprehensive Emergency Management Plan Annex 8 Missing Patient Plan," last reviewed January 2025, revealed patient elopement can be defined as the unauthorized absence of an admitted patient from the boundaries of the care unit, including the Emergency Center, without staff knowledge. The staff member who initially becomes aware of the missing patient is responsible for verifying that the patient did not have permission to leave and that staff members are not aware of any other reasons they may be gone. Nursing staff are to search the entire unit thoroughly. The nursing personnel will call security, give a patient description, and when the patient was last seen. Security will begin a search of the facility for the missing patient, issue a "Missing Person Alert" and contact the Administrative Clinical Coordinator, who will contact the Administrator on call. In the event a patient cannot be located, the police department may be notified by security at the discretion of the physician or Director of Nursing. If appropriate, hospital leadership will activate the Incident Command System. If the patient is not located within a reasonable amount of time, the hospital will establish the Hospital Command Center (HCC- an area set up to gather information, direct activities, and provide guidance in an emergency situation) and request appropriate team members to report.

Interview on 09/22/25 at 11:00 AM with Staff (A), Senior Regulatory Compliance Officer, revealed the following timeline: On 09/15/25 at 11:05 PM, Patient #1 arrived via ambulance with police. At 11:35 PM, Patient #1 was moved to Room #17 across from the nurse's station. At 11:45 PM, police leave the hospital. On 09/16/25 at 12:46 AM, security was notified Patient #1 was missing. At 12:51 AM, Patient #1 exited the parking garage. At 01:20 AM, the police are notified. At 01:45 AM, police onsite, assist in searching for Patient #1. At 02:15 AM, security/clinical nurse leader placed the hospital in lockdown (controlled access of all entrances/exits). At 02:29 AM, the charge nurse notified the nursing supervisor. At 02:55 AM, the nursing supervisor called 911 for emergency medical services (EMS) diversion (notification to EMS not to bring ED patients to the hospital). At 02:58 AM, the nursing supervisor contacted the administrator on call. At 03:13 AM, the administrator on call contacted hospital leadership. At 03:41 AM, the Incident Command Center was established, and a media alert was sent. At 04:08 AM, lockdown was ended. At 04:44 AM, diversion was ended. At 07:05 AM, the Incident Command Center was closed.

Interview on 09/23/25 at 10:00 AM with Staff (Y), Nurse Supervisor, revealed that they were not told about Patient #1 until 09/16/25 at 02:29 AM when the ED was going on lockdown. (Patient #1 absconded/eloped at approximately 12:51 AM). They got an update from the charge nurse and security as to the events that occurred, and that Patient #1 had absconded. The decision for lockdown was between security and Staff (BB), Clinical Nurse Leader. The decision was made by Staff (Y) to go on diversion. After the hospital was put on diversion, Staff (Y) called Staff (U), Administrator on call. Staff (Y) had never had to put the hospital on diversion before this event and Staff (U) expressed that they would handle making the appropriate individuals aware. Staff (Y) called 911 to make them aware of the diversion. Security should have told them about Patient #1 and how the police were refusing to stay with Patient #1. Staff (Y) would have escalated the situation to the police officer's supervisor notifying them an officer would have to stay with Patient #1.

Interview on 09/23/25 at 04:09 PM with Staff (BB), Clinical Nurse Leader, revealed that they did not know Patient #1 was in the ED until Staff (EE), Charge Nurse made them aware that Patient #1 had absconded. Due to the immediate danger, Staff (BB) decided that the hospital needed to go on lockdown for safety. Staff (Y), Nurse Supervisor, was informed about Patient #1 absconding and the lockdown.