HospitalInspections.org

Based on document review, and interview, it was determined that the Hospital failed to protect and promote each patient's rights. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure care in a safe setting by failing to prevent patient elopement. A 144.

Based on document review and interview, it was determined that for 1 of 3 (Pt #1) clinical records reviewed for elopement, the Hospital failed to ensure the patients right to receive care in a safe setting by failing to prevent physically and mentally vulnerable patients from eloping. Subsequently, Pt. #1 eloped from the Emergency Department and was found deceased in a nearby pond on the Hospital property.

Findings include:

1. On 8/29/2022, the Hospital's policy titled, "Patient Rights and Responsibilities" revised by the Hospital 12/12/2019, was reviewed. The policy required, "...E Patient Safety...2. Team members will follow current standards of practice and existing policies and procedures for patient...security, and will protect vulnerable patients...These protections include patient's emotional health and safety as well as his/her physical safety."

2. On 8/29/2022, Pt. #1's clinical record was reviewed. Pt. #1 presented to the Emergency Department [ED] on 7/18/2022 at 1735 (5:35 PM). Pt. #1 presented with a complaint of head injury. Pt. #1's ED disposition on 7/18/2022 at 8:33 PM was "eloped".

-The Emergency Department triage note written by an ED Registered Nurse (RN) (E #1), dated 7/18/2022 at 5:42 PM, included, "Patient was trying to get away from husband ...Patient here with husband. Patient would like to call the cops on him. Patient was in the bushes and hit head. Patient stated that she was shoved into a wall."

-The ED Provider note written by an ED Physician (MD #1), dated 7/18/2022 at 5:57 PM, included, " ...Patient active problem list ...Huntington's chorea [rare neurological disease that affects patients mental and physical health] ...depression ...hallucinations, delusional disorder, memory loss, accidental fall ...adjustment reaction with anxiety and depression, presents today for reported head injury. Patient states that she fell in bushes and was told if she ever hit her head to get a CT of her head. Patient states that she told the nurse that she has been abused by her husband routinely ...patient was offered to stay in the Hospital until we know she is safe ... Mental Status: She is alert and oriented to person, place, and time."

-The ED note written by a Social Worker (E #5), dated 7/18/2022 at 6:30 PM and electronically signed 7/19/2022 at 12:58 AM, included, "Met with patient at bedside at request of MD. Pt. reporting domestic violence at home. She states the police were at her house earlier when her husband was abusing her and they would not do anything because they believe it's her Huntingtons. Discussed this with MD. Unknown if patient is currently able to care for herself. Disposition to bring inpatient at hospital for further evaluation and treatment of altered mental status by psychiatry and neurology. During meeting, patient was brought to CT with RN. Shortly after, patient eloped."

-The ED note written by an ED RN (E #4), dated 7/18/2022 at 7:04 PM, included, "RN was wheeling pt. back from CT [computed tomography] scan, stopped to open a set of double doors near pt.'s room, pt. stood up abruptly from wheelchair and started running in the opposite direction from RN. Pt. stated to RN "I want to go home, I need to get out of here right now." RN offered verbal understanding and emotional support of pt.'s anxiety, pt. continued to run in different directions looking for the hospital exit...[Physician] and ED manager notified pt. status. Public Safety also notified."

-The ED note written by an ED RN (E #2), dated 7/18/2022 at 7:23 PM, included, " ...police department called to do a well-being check due to domestic abuse allegation..."

The clinical record included documentation of a 2nd ED visit, dated 7/18/2022 at 11:26 PM. Pt. #1 was transported to ER via the local Fire Department. The ED provider notes written by a Physician (MD #2) dated 7/18/2022 at 11:45 PM, included, " ...Patient was evaluated. No signs of life. No neurologic respiratory or cardiac function ...Found in pond here at hospital per triage information ...Death pronounced ..."
The ED care timeline dated 7/18/2022, included the following:
-At 11:26 PM - Patient arrived in ED
-At 11:26:50 PM - unresponsive
-At 11:30:44 PM - Cardiac arrest
-At 11:30:45 PM - "[local county] Sheriff never left hospital campus since elopement occurred. Made aware of multiple law enforcement and EMS [emergency medical services] agencies on hospital campus. Dredged the pond because friend of the patient found shoes and driver's license next to reeds/shore of the pond. Patient triple zero [no pulse, no respirations, no blood pressure] when pulled from the pond. All of the patient's clothing have been removed by the patient herself. Patient placed in room 7 - the body only has toe tagged to conserve any evidence that may be needed."
-At 11:43:23 PM - Disposition "Expired"

3. On 8/29/2022 at approximately 1:35 PM, videotape footage, dated 7/18/2022, of Pt. #1 leaving the ED was viewed.
-At 6:53:21 - Pt. #1 rushed through the ED hall with an ED RN (E #5) following closely behind her.
-At 6:53:40 - Pt. #1 was walking down ED hall
-At 6:53:43 - ED RN (E #5) followed Pt. #1 through the ED hall
-At 6:54:06 - ED RN (E #5) and Pt. #1 talking in ED hall
-At 6:54:17 - Pt. #1 walks away and ED RN (E #5) tries to stop Pt. #1, but Pt. #1 quickly steps around E #5 and rushes through the ED hall.
-At 6:54:41 - Pt. #1 exits the ED alone.
-At 6:54:54 - Pt. #1 walks down exterior stairs and disappears from camera view.

4.. On 8/29/2022 at approximately 2:04 PM, an interview was conducted with an ED Physician (MD #1). MD #1 stated that she was the ED Physician providing care for Pt. #1. MD #1 stated that she spoke with Pt. #1 briefly and Pt. #1 stated that she hit her head during a fall and her neurologist instructed her (Pt. #1) to have a CT scan. MD #1 stated that Pt. #1 reported that her husband was abusive and she (MD #1) offered to admit Pt. #1 as an inpatient until a determination about Pt. #1's safety could be made. MD #1 stated that Pt. #1 agreed to an inpatient status. MD #1 stated that a behavioral health consultation was ordered to help Pt. #1 with the domestic violence situation. MD #1 stated that the main concern was to get Pt. #1 medically cleared and to keep her safe from abuse. MD #1 stated that she does not recall speaking to Pt. #1 about the suicide, depression, hallucinations or delusional disorders that were listed in Pt. #1's diagnosis history that were present in electronic record from previous admissions. MD #1 stated that Pt. #1 had a weird demeanor but that was typical of patients with Huntington's. MD #1 stated that she did not feel that Pt. #1 was a danger to herself.

5. On 8/29/2022 at approximately 2:19 PM, an interview was conducted with a Public Safety Officer (E #6). E #6 stated on 7/18/2022, he was aware of Pt. #1 because his team removed Pt. #1's husband from the Hospital premises due to an abuse allegation. E #6 stated an elopement was called for Pt. #1 on 7/18/2022 just after 7:00 PM. E #6 stated that the Public Safety team conducted an interior and exterior property search for Pt. #1, but did not locate Pt. #1. E #6 stated that a search was conducted for Pt. #1 because there was a previous report of abuse and the Clinical Nurse Manager (E #2) reported that Pt. #1 was not petitioned but the ED staff was working on it.

6. On 8/29/2022 at approximately 2:40 PM, an interview was conducted with an ED RN (E #4). E #4 stated that Pt. #1 was placed in an exam room immediately after being triaged, in order to keep Pt. #1 safe. E #4 stated that Pt. #1 was placed in a recliner in the room because there was not a bed in the exam room. E #4 stated that Pt. #1 was seen by the Physician and the Social Worker within 20 minutes of being placed in the exam room. E #4 stated that Pt. #1 was taken to have a CT scan before Pt. #1 could change into a Hospital gown and had the CT scan while wearing her street clothes. E #4 stated that she (E #4) accompanied Pt. #1 to CT scan and noticed that Pt. #1 became fidgety following the CT scan. E #4 stated that Pt. #1 tried standing while she (E #4) was pushing Pt. #1 in the wheelchair. E #4 stated that Pt. #1 eventually stood and walked through the ED looking for an exit. E #4 stated that Pt. #1 seemed anxious and said 'I have to leave right now'. E #4 stated that she tried to stop Pt. #1 from leaving, but Pt. #1 was insistent upon leaving the Hospital. E #4 stated that she let Pt. #1 leave and immediately notified the ED Physician (MD #1) and ED Clinical Nurse Manager (E #2). E #4 stated that Public Safety was notified of Pt. #1's elopement.

7. On 8/29/2022 at approximately 12:19 PM, an interview was conducted with the ED Clinical Nurse Manager (E #2). E #2 stated that she worked in the ED on 7/18/2022, when Pt. #1 eloped. E #2 stated that the ED RN (E #4) informed her (E #2) that Pt. #1 had eloped from the ED. E #2 stated that the ED Physician and Public Safety was notified immediately. E #2 stated that the local police department was also notified and asked to do a well-being check on Pt. #1. E#2 stated that public safety reported seeing Pt. #1 getting in a car after eloping from the ED. E#2 stated that Public Safety then reported that they had made a mistake and Pt. #1 was not seen getting into a car. E #2 stated that the County police department conducted a grounds search after Pt. #1's friend located Pt. #1's personal items near the outside of the hospital. E #2 stated that Pt. #1's body was recovered from the pond by the police department on 7/18/2022. E #2 stated that Pt. #1 was found without a heart rate, blood pressure or respirations. E #2 stated that since the incident with Pt. #1, the ED staff are required to follow an elopement patient keeping them in line of sight until Public Safety or the Police department arrives. E #2 stated that Public Safety has increased their ED rounding activity.