HospitalInspections.org

Based on observation, document review, review of video recording and staff interview,
The facility failed to:

(a) Ensure a safe environment for patients who are at risk for elopement and for patients who are tagged with an anti- wandering device (Prosec) for elopement prevention.

(b) Develop a comprehensive policy to prevent patient elopement from all patient care areas.

This placed patients at risk for potential harm.

Findings include:

See citation TAG A 144.

Based on medical record review, document review, video record review and staff interview, the facility failed to: (a) maintain a safe and protective environment for patients who are at risk for elopement and are tagged with an anti - wandering device, (b) develop a comprehensive policy concerning patient elopements from all patient care areas.
This was noted in two (2) of 16 medical records reviewed. (Patient #1, Patient #2)

Findings include:


Review of Medical Record #1 revealed that an 81-year-old male presented to the ED on 11/30/17 at 4:15 AM, status post fall at home.

The ED RN Triage Note dated 11/30/17 at 4:37 AM, noted that the patient could not remember all the events leading to the fall and after the fall.

An ED Attending Note dated 11/30/17 at 6:30 AM, documented patient's assessment. The physician's exam noted a very limited history from the patient. Impression/Plan: possible fall, unsure of etiology ...close monitoring. Patient likely had dementia, possible Alzheimer's. Need to confirm baseline mental status ... Need to track down next of kin/HCP (Health Care Proxy).

Review of the Nursing Flowsheet dated 11/30/17 at 2300 (11:30 PM), documented patient was at risk for elopement and Prosec was applied. (The Prosec is an electronic alarm system with an anti wandering tag).

From 11/30/17 through 12/4/17, the Nursing Flowsheets documented the patient was on Elopement Precautions.

There was no documented evidence in the Nursing Flowsheets that the patient had the Prosec device on dates 12/1, 12/2, and 12/4/17 to prevent elopement.

The RN Progress Note dated 12/4/17 at 1947 (7:47 PM) documented, "Upon doing hourly rounds, noticed patient was not in his room. Nurse did a thorough check on the unit. MD supervisor and hospital police made aware. No Medlock on patient." (Medlock is a device for peripheral intravenous access).

Review of the RN Assistant Director note, dated 12/5/17 at 1454 (2:54 PM) revealed, that the patient's Prosec was observed missing at the time of the elopement.


During interview on 1/12/17 at 1:38 PM, Staff D, RN (who took care of the patient on 12/2, and 12/3/17) stated, "The patient did not have a Prosec device on my time. I did not know patient had the Prosec device for two days. I received a handoff, and patient was not on elopement precautions. I could not remember what was reported in the huddle."

During interview on 1/11/18 at 2:15 p.m. Staff F & Staff G, Registered Nurses on Unit B6, stated Patient #1 successfully removed the device on two occasions. On the first occasion, 12/1/17, at 7:00PM, the device was found in the bed, therefore no alarm went off. On the second occasion, 12/1/17 at 9:00PM, the Prosec device was found in the bathroom. After each removal of the Prosec device, the staff stated that they redirected the patient.



A review of the facility's video recording dated 12/4/17 B6 Unit, 6th Floor, showed the following sequence of events:

At 14:56 (2:56 PM), Patient #1 walked out from his room B32, to hallway, and continued to walk toward the unit exit/entrance door. The patient was observed wearing street clothes, black jacket, and black shoe with his hat on.
At 14:59 (2:59 PM), Patient #1 walked past the unit double doors toward the elevator.

The patient was off camera from 14:59 (2:59 PM) to 15:02 (3:02 PM). Staff C, Hospital Police Director (who was present at the time of the video review), stated that the patient exited the 6th floor using the nearby staircase to the ground floor.

At 15:02 (3:02 PM), Patient #1 was observed on the East Wing, First Floor, Radiology Area towards the Exit at the clinic side.
At 15:03 (3:03 PM), Patient #1 was observed walking outside Annex G towards the street.


There was a seven-minute timeframe when the patient eloped from B6 Unit to the facility's street exit.
The Hospital's Security Tape dated 12/4/17 indicated that the patient exited B6 on 12/4/17 at 14:56 or (2:56 p.m.) via the unit's main exit door. There was no evidence that an alarm was activated.

This video event of the patient's elopement, was verified by Staff C, HP Director and Staff M, Associate Director QA, who were present during the review of the video, on 1/11/18 at 3:00PM.


The facility's Prosec Alarm System was tested by the surveyors on 1/12/18 at approximately 2:30 p.m. The system was found to be functional at the time of the check. Visual and audio alarms sounded when the staff, holding the Prosec device, approached B6's exit door.
When the tag approached the pre set perimeter, the audio and visual alarms sounded and the unit's exit doors locked.




Review of Medical Record for Patient #2, identified that this 31-year-old male presented to the hospital Emergency Room (ED) via ambulance on 1/2/18 at 8:26 PM. The Prehospital Care Report Summary (PCRS) indicated the patient stated that he had been drinking and that he expressed suicidal thoughts. The PCRS was signed by a registered nurse (RN) at 8:52 PM.


An Occurrence Report dated 1/2/18 at 9:20 PM, indicated "unable to find patient in the ED."
The ED discharge disposition documented on 1/3/18 indicated that the patient left without being seen (LWBS) before triage.


Review of the facility's Occurrence Report dated 1/2/18 at 9:20 PM, indicated that "the patient could not be found in the ED, triage PCAs (Patient Care Associate) made aware multiple times that patient is on suicidal status and to be watched. Emergency Operator (911) was called. At 9:45 PM emergency operator (911) reported that patient was not found at his house."

During interview on 1/16/18 at 5:45 PM, Staff K and Staff L (triage PCAs), they both denied that they were assigned to watch Patient #2.

There was no documentation that a suicidal risk assessment was performed by the triage nurse for this patient, arriving by ambulance with suicidal thoughts and that suicide watch was ordered.


This patient was not found at the close of the facility's investigation.


During interview on 1/12/87 at approximately 3:45 PM, Staff N, VP Quality Assessment, Performance Improvement and Staff I, ADN, acknowledged the patient elopements.








09995

Based on document review, medical record review and staff interview, the facility did not ensure that (a) incidents of patient elopement was adequately investigated and analyzed, and (b) corrective actions were developed and implemented to maintain patient safety and prevent future elopements.
This was noted in four (1) of four (4) medical records reviewed.

Findings include:

A review of Medical Record #1, identified the following events:

On 12/4/17, Patient #1 eloped from the facility. The patient was admitted to the Medical Unit B6 on 11/30/17, status post fall, with likely Dementia, possible Alzheimer's. Patient was assessed to be at risk for elopement and Prosec device was applied. (The Prosec is an electronic alarm system with an anti wandering tag).

During interview on 1/11/18 at 2:15 p.m. Staff F & Staff G, Registered Nurses on Unit B6, stated Patient #1 successfully removed the device on two occasions. On the first occasion, 12/1/17, at 7:00PM, the device was found in the bed, therefore no alarm went off. On the second occasion, 12/1/17 at 9:00PM, the Prosec device was found in the bathroom. After each removal of the Prosec device, the staff stated that they redirected the patient.

The Hospital's Security Tape dated 12/4/17 indicated that the patient exited B6 on 12/4/17 at 14:56 or (2:56 p.m.) via the unit's main exit door wearing street clothes and appropriate outerwear.


During interview on 1/12/87 at approximately 3:45 PM, Staff N, VP Quality Assessment, Performance Improvement and Staff I, ADN, acknowledged the patient elopement.


There was no documented evidence that the elopement was adequately investigated and analyzed, or that the circumstances of the event was analyzed.


An interview with the Staff O, the Risk Manager on 1/11/18 at 11:45 a.m. was conducted. The Staff O related that an investigation of an occurrence is performed only if there is patient harm.