HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 14 medical records reviewed, the facility failed to (a) consistently assess patients for elopement risk and implement measures to prevent patient elopement, (b) ensure 1:1 Constant Observation was fully implemented in accordance with the facility's policy after a patient elopement.(Patient #1)

This failure may result in serious adverse outcome to patients at risk for elopement.

Findings include:

Review of the medical record for Patient #1 identified: a 27-year-old, male with past medical history of Traumatic Brain Injury, Mood Disorder, Expressive Aphasia, and Seizure Disorder, who presented to the Emergency Department (ED) on 1/15/2023 for medical and psychiatric evaluation.

The patient was in CPEP from 1/15/2023 to 1/20/2023 when the patient was transferred to in-patient Psychiatry.

On 4/16/2023, at 8:58 PM, the patient had a second seizure, was medicated and at 9:55 was transferred to floor 11 (med/surg) unit and was placed on 1:1 for Fall Risk.

On 4/18/2023, the patient was medically and psychiatrically cleared for discharge but remained in the facility for long term placement at a Traumatic Brain Injury facility.

On 6/5/2023 at 2:25 PM, the medical record revealed that after the patient had eloped and returned to the facility the physician ordered 1:1 Constant Observations for the patient.

On 6/29/2023 physician note by Staff H (MD) revealed a second elopement of this patient.


See Tag A-144

Based on medical record review, document review and interview, in one (1) of 14 medical records reviewed, the facility failed to consistently assess a patient for elopement risk and implement measures to prevent patient elopement, (b) ensure 1:1 Constant Observation was fully implemented in accordance with the facility's policy after a patient elopement. (Patient #1)


Findings include:

The facility Policy and Procedure titled Elopement Prevention, last revised 02/22/2023, Section V Procedures, Titled Elopement Assessment, states, "All patients will be assessed for the risk for elopement at the following times:
a) During their ED evaluation, at time of triage by the RN.
b) If they are direct admissions, at the time of initial assessment on the inpatient unit by the
RN.
c) For patients deemed at high risk for elopement, the attending physician in consultation with
the other treatment team members will assess patients daily for changes in risk status and
evaluate the clinical justification for continuing elopement risk precautions.

In the section, "Management of Patients at Risk of Elopement" states,
c) All patients will be taken out of their personal clothing and given a yellow gown, which identifies them as patients at risk for elopement.


Review of the medical record for Patient #1 identified: a 27-year-old, male with past medical history of Traumatic Brain Injury, Mood Disorder, Expressive Aphasia, and Seizure Disorder, who presented to the Emergency Department (ED) on 1/15/2023 for medical and psychiatric evaluation. Elopement assessment was documented in the Emergency Room during Triage.

The patient was in CPEP from 1/15/2023 to 1/20/2023 when the patient was transferred to in-patient Psychiatry.

On 2/8/2023 the patient suffered a breakthrough seizure; was medicated and placed on 1:1 Constant Observation for safety.

On 4/16/2023, at 8:58 PM,the patient had a second seizure, was medicated and at 9:55 was transferred to floor 11 (med/surg) unit and was placed on 1:1 for Fall Risk.

On 4/18/2023, the patient was medically and psychiatrically cleared for discharge. The plan was for this patient to be discharged to his next level of care, Acute Rehab with Traumatic Brain Injury facility (TBI) accommodations. The patient is pending placement in a TBI facility.

On 6/5/2023 at 2:25 PM, Social Work Note, by Staff G (Social Worker), details a call received from the patient's mother, reporting patient is at home in her apartment complex in the lobby. The medical record revealed that after the patient had eloped and returned to the hospital, the physician, Staff H (MD) ordered 1:1 Constant Observation for this patient..

On 6/29/2023 at 4:45 PM, Physician Note, by Staff H (MD), revealed a second elopement of this patient. Per MD, "I couldn't see the patient this morning, he was not on his bed".

There was no documented evidence that the patient was reassessed for elopement by the physician and other treatment team members and that strategies were fully implemented per hospital policy.

There was no documentation in the medical record of having the patient wear the yellow gown even after elopement on 6/5/2023.

On 10/17/2023, at 10:17, AM during interview with Staff A (RN), Staff stated that the patient does not like to wear the yellow gown or the blue armband and that the staff are aware and do not enforce the policy with the patient.


The facility Policy and Procedure titled Observation Level Policy, Acute Care, Section B. Implementation Process for Constant Observation, Special Observation and Two to One Monitoring, last revised 6/2018, states, 1. A physician shall write an order for both constant, special and Two to One observation. The physician's order is good for 24 hours.

As per medical record, after the patient eloped on 6/5/2023, there was an order for 1:1 for elopement risk. Renewal of 1:1 elopement risk every 24 hrs orders for elopement risk within 24 hours was not documented.

Based on document review and interview, the facility failed to utilize its Quality Assessment and Performance Improvement Program (QAPI) to ensure that all patient Incidents/Occurrences were quantified, analyzed and corrective actions implemented and monitored.

Findings include:

Review of the medical record for Patient #1 identified: a 27-year-old, male with past medical history of Traumatic Brain Injury, Mood Disorder, Expressive Aphasia, and Seizure Disorder, who presented to the Emergency Department (ED) on 1/15/2023 for medical and psychiatric evaluation.

Review of medical record revealed that on 6/5/2023 and on 6/29/2023, the patient had eloped from the facility.

Review of QAPI minutes for March 2023 to July 2023 revealed "Elopement" as a quality indicator.

Data for March 2023 to July 2023 revealed that 5 (five) elopements in the Emergency Department were documented and investigated. However, 1 (one) in-patient elopement was not documented. (Patient #1).

Review of QAPI Meeting Minutes for March 2023 through July 2023 shows no documented evidence of a discussion/review of the 6/5/23 or the 6/29/2023 elopements of Patient #1.

During interview with Staff D (VP Clinical Risk Management and Clinical Administrator) on 10/18/2023, Staff confirmed that no formal investigation was performed or documented for either date of elopement because the patient came back to the hospital.

There was no documented evidence in the QAPI minutes that the in-patient elopement, was investigated, analyzed and a plan developed and implemented to improve patient outcome.

Per the facility organization Quality Improvement Plan, dated 2023 -2024, the "OBH objectives are to Identify opportunities to improve patient care and organizational performance and reduce potential risks to patients."

During interview on 10/18/2023 at 9:35 AM, Staff D, (VP Clinical Risk Management and Clinical Administrator) acknowledged these findings.

The facility Quality Assessment and Performance Improvement plan lacks specific instructions to include the review of patient Complaints, Grievance, or Incidents.

Based on medical record review, document review and interview, in 1 (one) of 14, the facility failed to ensure that a nursing care plan and safety strategies, as outlined in the hospital policy for elopement, were maintained for a patient who eloped from the facility. (Patient #1)

As a result, Patient #1 was able to elope from the facility on two occasions, 6/5/2023 and 6/29/2023.

Findings:

Review of the medical record for Patient #1 identified: a 27-year-old, male with past medical history of Traumatic Brain Injury, Mood Disorder, Expressive Aphasia, and Seizure Disorder, who presented to the Emergency Department (ED) on 1/15/2023 for medical and psychiatric evaluation.

Patient #1 eloped from the facility on two occasions, 6/5/2023 and 6/29/2023.

The facility Policy and Procedure titled "Elopement Prevention", last revised 02/22/2023 V Procedures, C. 1. instructs that "all patients will be taken out of their personal clothes and given a yellow gown, which identifies them as a patient at risk of elopement.

During interview with Staff A (RN) on 10/17/2023 at 10:17 AM, Staff stated that the patient does not like to wear the yellow gown or the blue armband and that the staff are aware and do not enforce the policy with the patient.

The facility Policy and Procedure titled "Nursing Process", last revised 8/2020 indicates the minimum time frame for patient assessment/reassessment for patients admitted to Medical/Surgical Patients is within 2 hours of start of each shift.

The facility Policy and Procedure titled Elopement Prevention, last revised 9/18/2023, section C b. The patient will be placed on increased observation status for Elopement. This could be up to a 2:1 ratio depending on the ability of staff to have close proximity to patient. c. All patients will be taken out of their personal clothing and given a yellow gown which idetifies them as patients at risk for elopement.

The medical record lacked documented evidence of consistent reassessment for elopement risk and documentation of "every 15-minute check of patient on 1:1 for elopement", as per hospital policy.

As per medical record, Nursing Care Plans were not consistently updated, for example, on 7/20/2023 at 9:14 PM, the Nursing Care Plan was updated and included the following notation, "Problem: IP Elopement Prevention, Goal: Elopement Prevention, Outcome: Progressing". On 7/24/2023 at 6:34 PM the Nursing Care Plan was again updated. The Nursing Care Plan was not updated again until 7/28/2023 at 7:56 PM.

There was no documented evidence of elopement reassessments and no 1:1 constant observation was fully implemented. There was minimal documentation of elopement risk and monitoring and 1:1 assessment for this patient. There was documentation for the 1:1 on 6/29/2023 only between 2:00 and 3:00 AM. The patient eloped at 4:45 PM on 6/29/2023.

There was no documentation in the medical record of having the patient wear the yellow gown even after elopement on 6/5/2023.

On 10/17/2023, at 10:17, AM during interview with Staff A (RN) , Staff stated that the patient does not like to wear the yellow gown or the blue armband and that the staff are aware and do not enforce the policy with the patient.

This was included in the documentation after the initial elopement on 6/5/2023 and 6/29/2023. For example the nursing care plan was updated On 6/9/2023 at 12:16 PM, Staff K (RN) wrote the addition of Problem: IP Elopement Prevention, Goal: Elopement Prevention, and Outcome, updated on 7/20/2023 & 7/24/2023.


See Tag A-0115