HospitalInspections.org

Based on surveyor review of the patient's medical record, the hospital's missing persons alert log, hospital policies and procedures, and staff interviews, the facility failed to ensure a nursing care plan was developed and kept current that addressed the safety needs of patients with dementia or other cognitive impairments.


The findings include:

~Patient #19 had a diagnosis of dementia upon admission.

~Patient #19 had a previous admission to the facility that documented potential risky behavior.

~On 7/15/21 at 0945, case management staff documented, "History in the email, pt [patient] was brought to ER [emergency room] back in March due to pt [patient] running red lights and was disoriented to month and time-Acute psychosis, advancing dementia.
Another time, [the patient] was brought in due to family concerns with self-care deficits and [having a] altercation with her grandson.
Could be why pt [patient] was placed at the [assisted living] and family has taken control of her car."

~Patient #19 eloped two previous times on 7/15/21 & on 7/16/21] before the elopement incident on 7/19/21.

~Staff member #2 stated that" The nursing staff used fall precautions [a yellow wrist band and yellow socks] to deter patient #19 from other elopements" attempts.

~on 7/19/21, patient #19 was able to elope from the hospital. Patient #19 was missing for approximately seven hours. Patient #19 was found by a bystander approximately four miles from the hospital.

~The facility failed to present the surveyor with a policy regarding the safety of and risk reduction procedures for inpatients admitted to the facility with a high risk for elopement due to mental incapacity.

Validated findings with staff #1. Staff #1 stated, "Yes, there should be something in place. We are waiting to have our RCA [root cause analysis] before changes to policy and procedures are made. This happened so recently we haven't had a chance to talk about it in a quality meeting. "