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Based on record review, staff interview and policy review, the facility failed to enusre a confused patient did not leave the hospital unattended. Patient #4 left the hospital unattended and did not return to the unit. Patient #4 was found by a passing ambulance crew, wandering the sidewalk wearing a hospital gown. He was taken to another area hospital and admitted with a chief complaint of altered mental status.

See A144.

Based on record review, interview and policy review, the hospital failed to notify a patient's emergency contact when he left the nursing unit and did not return. This affected one (Patient #4) of ten patients reviewed. The hospital census was 954.

Findings include:

Review of the medical record of Patient #4 revealed the patient presented to an outside hospital on 10/06/23 after a syncopal event at home. The decision was made to transfer the patient to a tertiary facility for further care.

Nursing notes documented on 10/09/23 at 5:19 PM, Patient #4 left the nursing unit to "get some air". After more than an hour, the patient did not return and a staff nurse was unable to locate him. The patient was discharged against medical advice (AMA).

Review of the medical record from another hospital revealed Patient #4 was found by a paramedic crew on 10/09/23 at 6:09 PM, wandering the streets wearing only a hospital gown. . Paramedics transported the patient to another hospital where he was admitted with a chief complaint of altered mental status and diagnoses including encephalopathy, alcohol withdrawal, hyponatremia and substance use disorder. A physician's progress note on admission stated the patient reported he and his wife going to a hotel to celebrate their anniversary. They had an argument and while he was in the shower, his wife took all of his belongings leaving only a hospital gown on the hotel bed. The patient reported that he put the gown on and was walking around outside when the paramedics found him. According to the outside record, the patient was placed on medical hold. The physician from the outside hospital stated in a progress note, that the patient had an altered recollection as the patient still believed he was in a hotel as opposed to the hospital. He remained inpatient until 10/13/23.

During an interview on 11/29/23 at 1:00 PM, Staff P confirmed that the medical record lacked documentation the patient's emergency was contacted regarding the patient not returning from leaving the unit.

The facility policy titled "Patients Leaving Units Independently (03-53)", effective 03/01/21 documented if the patient does not return within the agreed upon timeframe and/or there is a concern for the safety of the patient, unit staff shall attempt to locate the patient, staff shall also notify the manager and/or nursing supervisor who will continue to contact the patient and/or the emergency contact, unit staff shall attempt to contact the emergency contact if unable to locate the patient.

Based on record review, staff interview and policy review, the facility failed to ensure a confused patient did not heave the hospital unattended. Patient #4 left the hospital unattended and did not return to the unit. Patient #4 was found by a passing ambulance crew, wandering the sidewalk wearing on a hospital gown. He was taken to another area hospital and admitted with a chief complaint of altered mental status. This affected Patient #4. The hospital census was 954.

Findings include:

Review of the medical record of Patient #4 revealed the patient presented to an outside hospital on 10/06/23 after a syncopal event at home. The patient had a tonic-clonic seizure (a type of seizure that involves violent muscle contractions) and was transferred to the current hospital for further care. Diagnoses included seizure and alcoholism.

Patient #4 arrived at the hospital on 10/07/23 at 6:29 AM. A progress note on admission revealed the patient was tremulous, diaphoretic, and anxious. Although the patient was able to state his name and the year, he had to be told it was October and was unable to report his current city. A physician stated, in her history and physical, that the patient was evaluated at an outside hospital in March 2023 after a motor vehicle accident where he suffered numerous fractures and his alcohol level was elevated on initial evaluation. The physician also stated she suspected the seizures were related to alcohol withdrawal.

Patient #4 was admitted to the facility's East Tower unit (ET 7), a medical surgical unit. A physician ordered seizure precautions, continuous telemetry monitoring, Clinical Institute Withdrawal Assessment (CIWA) for alcohol withdrawal, and as needed Ativan, an anti-anxiety medication. The CIWA protocol for alcohol withdrawal is a questionnaire that measures the severity of an individual's alcohol withdrawal symptoms. A score less than 8 requires vital signs and CIWA scoring frequency every 4 hours, times six. If the score remains less than 8, nurses can stop the vital signs and CIWA scoring and no Ativan is administered. If the score is between 8-14, vital signs and CIWA scoring is required every two hours and Ativan 1 milligram (mg) is administered intravenously. If the score is between 15-20, vital signs and CIWA scoring is required hourly and Ativan 2 mg is administered. A score between 21 and 30 requires nurses are required to assess vital signs and CIWA scoring hourly and Ativan 3 mg is administered. A score between 31 and 45 requires vital signs and CIWA scoring every hourly and Ativan 4 mg is administered.

A nurses note on 10/07/23 at 6:45 AM stated a pre-fall huddle, performed by two staff nurses on admission, noted that the patient had fall risk factors including a history of falls and an altered mobility and/or gait. A bed exit alarm was initiated as an intervention to prevent the patient from falling.

Review of the toxicity assessment dated 10/07/23 at 6:45 AM, revealed the patient received a CIWA score of an 11 which included the highest possible score of a 4 for orientation as the patient was disoriented to place and/or person. At 8:31 AM, Patient #4 received an orientation score of a 0 as the patient was oriented and able to complete serial additions. The total CIWA score was an 8 at this time. At 10:00 AM and 11:48 AM, the patient continued to be oriented and able to complete serial additions. The total CIWA scores were 8 and 4 respectively. At 4:00 PM, the toxicity assessment revealed the patient was again disoriented to place and/or person. A nurse's note at this time stated the patient turned the bed alarm off and was found wandering the halls, trying to leave the unit. A video sitter was initiated. At 6:12 PM, the CIWA score was 16 which included an orientation score of a 4 as the patient remained disoriented. A nurse's note at 6:58 PM revealed the patient fell on his bottom attempting to get out of bed as he had become increasingly confused and restless. Bilateral soft wrist restraints and an in-person sitter were initiated at 7:31 PM as ordered by a physician. An emergency response team physician called to the bedside to assess the patient post fall stated in a progress note that a medical hold would be placed to prevent elopement and potential injury. The medical hold was ordered and the patient was placed in a purple hospital gown to differentiate him from other patients. A phenobarbital taper was also ordered. The patient was transferred to the facility's Progressive Care Unit at 8:33 PM where Phenobarbital was initiated. A sitter remained in constant attendance, the patient remained in restraints, and CIWA scoring and seizure precautions continued. The patient remained disoriented to place and/or person receiving a 4 on the orientation of the CIWA scoring on 10/07/23 at 9:40 PM and on 10/08/23 at 12:09 AM, 3:45 AM, 8:50 AM, 12:20 PM, 4:00 PM, 6:00 PM, and 7:40 PM. Patient #4 remained disoriented to place and/or person through the night, however, on 10/09/23 by 10:20 AM, the patient received an orientation score of a 0 as the patient was oriented and able to complete serial additions.

The attending physician's progress note on 10/09/23 at 10:24 AM stated the patient was doing much better on phenobarbital taper which was scheduled to be completed two days later. The physician documented the sitter and the restraints would be discontinued.

The restraints were discontinued on 10/08/23 at 9:00 PM and the sitter was discontinued on 10/09/23 at 9:49 AM. At 11:11 AM, an addiction physician noted the patient's risk of serious withdrawal complications was severe and staff should continue monitoring the CIWA with the phenobarbital taper.

On 10/09/23 at 5:19 PM, a nursing note documented Patient #4 left the unit to "get some air". After more than an hour, Patient #4 did not return and a staff nurse was unable to locate him. The patient was discharged against medical advice (AMA). Review of the medical record revealed no physician order to leave the unit and no documentation staff accompanied Patient #4 off the unit.

Review of the medical record from an outside hospital documented Patient #4 was found by a paramedic crew on 10/09/23 at 6:09 PM, wandering the streets wearing only a hearing only a hospital gown. Patient #4 still had a heparin locked IV access in his arm. Paramedics transported the patient to another hospital. Patient #4 was admitted with a chief complaint of altered mental status and diagnoses including encephalopathy, alcohol withdrawal, hyponatremia and substance use disorder. A physician's progress note on admission stated Patient #4 reported he and his wife were going to a hotel to celebrate their anniversary. They had an argument and while he was in the shower, his wife took all of his belongings leaving only a hospital gown on the hotel bed. The patient reported that he put the gown on and was walking around outside when the paramedics found him. A physician progress note documented Patient #4 had an altered recollection as the patient still believed he was in a hotel as opposed to the hospital. He remained inpatient until 10/13/23.

During an interview on 11/29/23 at 1:00 PM., Staff P, the manager of the Progressive Care Unit, stated patients are required to sign out and in on a log kept at the nurse's station when leaving the floor. Patients should also sign a Safety Agreement prior to leaving the unit. The signed agreement should be part of the patient's permanent medical record. Staff P stated although there is a log kept at the nurse's station, once the log is full, it is discarded. The log where the patient signed out was no longer available.

During an interview on 11/29/23 at 2:00 PM, Staff O, the charge nurse on duty on 10/09/23 when Patient #4 left the hospital, stated she remembered Patient #4 leaving the floor multiple times on 10/09/23. Staff O stated Patient #4 was wearing street clothes all day.

During a telephone interview on 11/30/23 at 12:10 PM, Staff L stated she vaguely remembering caring for Patient #4. She stated that when the patient told her that he was going out to get some fresh air, she reminded him to sign the log but did not physically see him sign out. She stated she remembered the patient wearing a hospital gown when he left the unit.

During interview on 11/30/23 at 3:00 PM., Staff A and Staff B both confirmed Patient #4 was on seizure precautions, was a high risk for a fall, and was on telemetry but was permitted to leave the unit independently wearing only a gown. It was confirmed that the medical record lacked documentation the patient was accompanied by a staff member and lacked documentation a physician ordered that the patient was permitted to leave the unit independently.


Review of the facility policy titled " Patients Leaving Units Independently (03-53)", effective 03/01/21, documented it is in the best interest of patients to remain in their area of care while in the hospital. By patients staying on the nursing unit/area of care, the hospital staff's ability to promote the safety of the patient, and to proceed with treatment plans without unexpected delays or interruptions in enhanced. Nursing should review this expectation with patients and families during the admission process. The patient is expected to stay on the unit. It is normally considered unsafe for patients with certain clinical conditions or treatments to leave the unit unaccompanied by a staff member. Patients with the below medical conditions/equipment should not be given permission to leave the unit unaccompanied by a staff member unless cleared by a physician. If the patient is permitted to leave the unit with one of the conditions listed below, a nursing communication order by an attending is required.

1. Receiving an infusion of a high alert medication or controlled substance.
2. Recently administered medications that may cause clinically significant sedation.
3. Receiving a blood transfusion.
4. On isolation precautions
5. On seizure precautions
6. At high risk for falls or injury
7. On telemetry
8. On supplemental oxygen
9. With unstable vital signs including fluctuating oxygen saturation.
10. And/or any condition in the judgement of the care team may compromise the patient's safety.

The policy further stated if the patient leaves the unit with one of the clinical conditions, staff should document that the patient was counseled on the safety risks of leaving the unit, but left the unit against medical advice. If the patient does not fall into one of the categories, the patient may leave the unit. The patient may leave for 60 minutes. Units will keep a log of patients that leave the unit with the agreed upon location. If the patient does not return within the agreed upon timeframe and/or there is a concern for the safety of the patient, unit staff shall attempt to locate the patient, staff shall also notify the manager and/or nursing supervisor who will continue to contact the patient and/or the emergency contact, unit staff shall attempt to contact the emergency contact if unable to locate the patient.