HospitalInspections.org

Based on interview, record and policy review the facility failed to honor 1 (SP#1) out of 3 sample patient's (SP) rights to receive care in a safe setting by not providing appropriate supervision for a confused patient who eloped from hospital.


Findings include:

Review of sample patient (SP) #1 Emergency Provider Notes dated 03/13/2020 at 9:02 AM documented the Chief Complaint: Patient presented to emergency room via fire rescue from home with complaints of weakness since the day before not able to ambulate. Patient told fire rescue had chest pain. Patient denies pain upon arrival to emergency room and has history of dementia per family.


Review of SP#1 Patient Care Timeline dated 03/13/2020 at 11:10 AM documented patient was admitted as observation.

Review of SP #1 ED to Hospital Admission Notes dated 03/13/2020 09:00 AM documented Cardiac/Telemetry Monitor on, audible: yes, alarm set: yes.

Review of SP#1 Emergency Department Nursing Notes dated 03/13/2020 at 14:30 PM documented patient was found to have eloped without notifying any staff.

Review of the Emergency Department Timeline notes dated 03/13/2020 at 14:37 PM documented spoke with [named] from security cameras he stated would check cameras to see if he could find patient (SP #1). At 15:02 PM spoke with 911 dispatcher to report patient has eloped.

Review of SP#1 Emergency Department Nursing Notes dated 03/13/2020 at 15:39 PM documented patient was found and brought back to room with no acute distress noted. Patient placed with 1:1 sitter.

Review of Emergency Department Physician Notes dated 03/13/2020 at 20:35 PM documented patient seen by prior emergency department physician and admitted to medicine service however ran from room, agitated, screaming, danger to self and others. Requiring chemical sedation. Haldol, Ativan, Benadryl ordered. Patient placed back in bed. Will make admitting team aware.

Review of the Emergency Department Timeline notes dated 03/13/2020 at 23:22 PM, no sitter at bedside at this time, sitter went home. Charge Nurse aware.

Interview with Registered Nurse Emergency Room- Staff A on 09/04/2020 at 10:38 AM revealed staff A verified emergency department nursing notes documented on 03/13/2020. Stated passed patient room and saw patient's gown on the bed but did not see patient. Stated that there was no notification of the telemetry monitor alarm going off. Stated patient eloped. Stated called the number on file to see if patient went back to home. Stated family member who answered the phone was not identified. Stated informed that the patient left the hospital. Stated notified physician, charge nurse and called security. Stated knew patient was confused. Stated called the police and asked security camera guy if seen patient leave but could not tell where or when. Stated wife brought patient back and nurse was told that patient was found in the street walking towards the house. Stated person who brought back patient clarified was wife who had answered the phone. Stated placed patient back in room. Stated notified the police that patient was found. Stated placed patient back on the telemetry monitor and notified Charge Nurse. Stated emergency room technician was placed as 1:1 sitter to watch patient. Stated does not remember if an incident report was completed.


Review of the policy (PolicyStat ID: 4217329), "Patient Rights and Responsibilities"; Last revised : 11/2017, states the facility will recognize, protect, and respect the rights of patients, individually and collectively. Attachments: Patient Bill of Rights #2: The right to be treated with courtesy and respect, appreciation of individual dignity. #20. The right to receive care in a safe setting. The facility failed to follow its policy.

Interview with Executive Director Risk Management on 09/03/2020 at 11:04 AM revealed that there is no incident report (Elopement in ED) for SP#1 during the period of February 2020 to March 2020.

Review of PolicyStat ID: 7569122 - Incident Reporting; Last revised: 04/2020; II. Policy: Event reporting is initiated by any staff member with knowledge of an Incident/Event on the Event Reporting System. In addition to the reporting requirements, all incident/events will be investigated with a focus on identifying opportunities for improvement. Actions/follow-up may be taken (when appropriate) with efforts to reduce re-occurrence of the event and minimize potential risk. All staff will report adverse incidents to Risk Management for review within three business days of the occurrence. III. Definition: A Reportable Event is an event that is not consistent with the routine operation of the facility or the routine care of a patient and caused or has potential to cause harm/injury. An example of what to report includes: 10. Patients leaving against medical advice (AMA/elopement/AWOL).

Facility failed to provide evidence of an incident report, and evidence of an investigation with a focus on identifying opportunities for improvement, and with actions/follow-up taken to reduce re-occurrence.