HospitalInspections.org

Based on interview, and document review, the hospital failed to ensure a safe setting for patients in that a patient with a Peace Officer Emergency Commitment (POEC) was permitted to elope out of the hospital Adult Emergency Department.

Findings included:

Review of patient #1's Adult Emergency Department medical record revealed documentation by registered nurses, Licensed Master Social Workers (LMSWs), and security officers that provided care to patient #1 during his stay in the ED revealed no documentation that patient #1 had been placed in a purple gown as per hospital policy for elopement precautions. Review of the triage RN staff #11 notes stated "06/23/17 at 1734 Risk for elopement? Y"

Review of ED RN, Staff #7 nurse notes stated "6/24/17 at 1345 - "Unable to find the patient. Security has no answer why patient eloped" Security #5 at bedside. Let the pt. go he thought pt. was discharged. "Amended by RN staff #7 on 06/24/17 at 1408" "Charge nurse and security supervisor is aware and they are unable to find the patient. Social worker called police and bystander out in the parking lot who saw the pt. called 911."
Review of the Adult ED Licensed Master Social Worker (LMSW), Staff #14 documentation dated "6/24/17 at 0017 stated that at 23:45 an APD Peace Officer, Staff #13, "placed patient on POEC in order to keep patient hospitalized for decompensation for his own safety. POEC #171741354."
Review of a hospital document titled "Suicide /Violent Patient Initial Safe Environment Checklist For Patients Identified as Imminent or High Risk for Suicide and/or Violence" stated in part "1. Place patient in purple gown .... #14. Assign staff to monitor patient per the physician order. Utilize the Patient Monitoring Form as indicated." The ED RN, staff #7 signed and dated the form on 6/24/17 at 0800.

Review of a facility document titled "Psychiatric Checklist" stated in part: "Initial Tasks: ___Inform Social Worker of patient's arrival,
___Equipment removed from room -cables, monitors, and call lights, remove cart if in room 1-4,
___Red/Purple gown, red/purple socks

The Patient Monitoring form dated 6/23/17 stated in part "Line of Sight Level 2" revealed initialed 15 minute monitoring of patient that started at 1728 through 2345. The Patient Monitoring form dated 6/24/17 stated in part "Line of Sight Level 2" revealed initialed 15 minute monitoring of patient that started at 0000 through 1245. The 1245 time slot was initialed by Security Officer, staff #5 with a "Behavioral Assessment Code as "Discharged".
Review of the hospital incident report of Patient #1's elopement on 6/24/17 revealed it was created on 6/24/17 at 7:50 pm by the Security Supervisor, staff #12 and contained details of the event's leading up to the patient's elopement. There was also a written report of the elopement incident created by ED RN, staff #7 on 6/24/17.

An interview was conducted the morning of 7/18/17 in a conference room with the, Chief Nursing Officer, Staff #2. Staff #2 was asked by the surveyor if she was on duty the day of Patient #1's elopement. Staff #2 stated that she was not on duty on the day of the incident and that she was notified on Saturday 6/24/17 by a text message and email from the ED Director, Staff #3. Staff #2 stated "The triage nurse saw the patient sitting with the security guard. The security guard went to the bathroom and when he returned the patient was gone. He called the patient's mother. Immediately they started looking over the whole campus for the kid." Staff #2 stated the administrative staff created an immediate Serious Event Analysis (SEA) regarding the patient's elopement. Staff #2 stated the security guard involved was placed on immediate disciplinary action that included suspension and a repeat competency training. There is a plan to roll out training to all of the security guards and ED staff. There will be repeat training of the ED nursing staff to a revised "Code Exit" policy that includes the procedure on when a patient leaves.

Based on interview, and document review, the hospital failed to ensure the nursing care for a patient that had an Emergency Detention order was assessed and evaluated on an ongoing basis while in the Adult Emergency Department.

Findings included:

Review of Patient #1's Adult Emergency Department medical record revealed documentation by the Adult ED registered nurses provided care to Patient #1 during his stay in the ED revealed no documentation that Patient #1 had been placed in a purple gown as per hospital policy for elopement precautions. Review of the triage RN Staff #11 notes stated "06/23/17 at 1734 Risk for elopement? Y"

An interview was conducted with ED RN, Staff #7, at approximately 11:00 am on 7/18/17 in a hospital conference room. When Staff #7 was asked what her ED schedule was on 7/24/17 she stated she worked 7:00am - 7:00 pm. Staff #7 stated that when she first comes on duty if her psychiatric patients are asleep she lets them sleep. She stated that she was told in report that Patient #1 was on a Protective Order of Emergency Custody (POEC) and that she had gotten a purple gown for him to change into but he was asleep when she first checked him so she let him sleep until around 9:00 am and then she did a head to toe assessment. She stated she did vitals around 9:15 am and ordered breakfast and that Patient #1 ate breakfast around 10:30 am. Staff #7 stated that Patient #1 was walking a lot with the security officer, Staff #5 in the ED hallway within the locked doors. Staff #7 stated she was giving report when the charge nurse, Staff #8 told her Patient #1 had eloped around 1:15 pm - 1:20 pm.
An interview was conducted with Security Officer, Staff #5 at approximately 2:55 pm in a facility conference room. When the surveyor asked Staff #5 to explain what happened regarding the elopement incident of Patient #1 on 6/24/17, Staff #5 stated he received Patient #1 wearing a regular gown not a purple gown and that there was no nurse available for approximately 35 minutes. Staff #5 stated the security officer told him in the verbal report that Patient #1 was on a bed watch and could not leave. Staff #5 stated that a purple hospital gown means the patient is on a bed watch and can't leave.

A phone interview was conducted with the Licensed Master Social Worker (LMSW), Staff #9 on 7/19/17 at approximately 8:50 am in a facility conference room. Staff #9 stated that Patient #1 was placed on an Emergency Detention the night before and that the night staff put the Emergency Detention on the chart and notified the nurse desk clerk so it could be changed on the census. She stated when they checked the chart on 6/24/17 the Emergency Detention was on the chart. Staff #9 stated that typically when the ED has a patient on elopement precautions, the mental health clients are placed in a purple gown. She stated that Patient #1 was in a regular gown when she came to work the morning of 6/24/17.

Review of facility policy titled "Elopement Prevention" stated in part "PROCEDURE:
1. Patients will be assessed for elopement risk in the ED and when admitted. All admitted patients will also be assessed with each nursing shift assessment.
2. Immediate notifications regarding patients who are identified as being an elopement risk will be made by the charge nurse to the director/manager over the area the patient is admitted (during business hours), the house supervisor, and security.
3. Elopement risk patients will be placed in a purple patient gown. This elopement risk identifier will remain on the patient throughout their stay or until the patient is no longer deemed an elopement risk.
4. Elopement precautions will be initiated immediately to elopement risk patients.