HospitalInspections.org

Based on interview and record review the hospital failed to ensure an incident report was created and investigated for 1 of 1 patient (Patient #1) a pregnant patient who eloped from the ED (emergency department) after presenting to the department with complaints of suicidal ideation.

Findings included:

A review of Patient #1's ED Physician's notes reflected at 6:00 PM Patient #1 presented to the hospital's ED on 02/16/17 with complaints of suicidal thoughts. Patient #1 was a 27 year-old female who was 36 weeks pregnant. She presented to the ED for a psychiatric evaluation referred by her OB-GYN physician. Patient #1 stated she woke up that morning and felt like she would "rather be dead than be pregnant." Patient #1 stated the pregnancy had been difficult from the beginning and she started having suicidal thoughts that morning. She had a history of depression and was currently on Prozac. Patient #1 had attempted to commit suicide once before in the past but denied having a current plan of self-harm, homicide ideation's, or hallucinations. There were no other symptoms or complaints at that time.

On 09/17/17 at 12:28 AM Physician #6 went to update Patient #1 on her plan of care. The patient was concerned about being admitted as an inpatient to a different facility. The physician had been called away to an emergency and had told Patient #1 he would be back shortly to answer her questions. After leaving, Patient #1 eloped with her husband. "I am concerned pt is a risk to herself and her fetus. Police have been called for further evaluation due to this concern.

ED Disposition. Elopement. AMA. "The condition of the patient at this time is not stable."

ED Nurses' Notes
Patient #1's last vital signs were taken at 11:30 PM on 09/16/17. Personnel #7 discovered the patient was missing at 12:10 AM on 09/17/17.
Patient #1 was called by Personnel #8 and asked to return at 12:30 AM (40 minutes after she was found to be missing, 1 hours since her last vital signs). Patient #1 refused. It was learned Patient #1 spoke with the police and they allowed her to contact her Obstetrician. After speaking with her doctor she agreed to go to a hospital for treatment. Patient #1' husband took the patient to a local hospital for treatment.

A review of the hospital's incident reports reflected that Patient #1's incident wasn't listed.

During an interview with Personnel #5 on 08/30/17 at 12:45 PM she was asked by the surveyor if an incident report had been filled out for Patient #1's incident. She said there was not an incident report, but there should have been one. There was no investigation.

A review of the hospital's policy, "Event Reporting" dated 08/18/17 indicated that all members of the workforce were to report safety events and near misses using The Reliability Learning tool. Patient elopement was an event that was listed in the Reliability Learning tool Event Types.