HospitalInspections.org

Based on medical record (MR) review, document review, observation, and interview, in one (1) of three (3) observations revealed, the facility did not utilize its Quality Assessment and Performance Improvement Program to identify all the problems that contributed to patient's elopement and implement all corrective actions to prevent recurrence (Patient #1).

The failure place patients at risk for potential harm.

Findings include:

Review of Patient #1's MR identified the following information: This 72-year-old was transferred from a Nursing Home to the Emergency Department on 5/25/2022 at 6:22 PM. Her chief complaint was "refusing to take Haldol injection." Her past medical history included Bipolar Disorder, Schizophrenia, HTN, Asthma. At 7:12 PM, the Psychiatrist's Note documented "this is a 72-year-old woman who is chronically mentally ill. She is poorly organized and unable to live unsupervised. Her dress was "dilapidated, thought process illogical and loose associations, delusions grandiose, insight poor, judgment poor, impulse control poor" and is an elopement risk. The plan included Haldol administration and that she could be returned to nursing home after she was medicated. At 7:13 PM Haldol 50 mg IM was administered, and the patient was discharge awaiting the ambulance. At 9:15 PM when the ambulance arrived, the patient could not be located. A search of the hospital and review of the ED video was unproductive. The NYPD was notified.

On 06/3/22 at 3:20 AM - 8:45 PM, the Supervising Nurse's Note documented "as per NYPD on Saturday at 1:00 AM, patient was found; she called a family member not listed on her chart who notified the authorities. The patient went to Mount Sinai Brooklyn Hospital without injury."

The facility policy and procedure (P&P) titled "2022 Quality and Patient Safety Plan," approved 12/16/2021, stated the following: "The scope of the Quality Patient Safety Program includes identification of actual and potential problems concerning patient care and clinical performance; assessment of cause and scope of problems identified; development and recommendation of proposed causes of action to address identified problems; use of information gathered regarding problems for review in and making revisions to hospital policies and procedures; use of established mechanisms to implement corrective actions to identified problems; monitoring and evaluation of actions taken and implementation of remedial actions to confirm effectiveness; and documentation of measures outlined above."

Review of the hospital's investigation of patient #1's elopement revealed the following problems were not identified and corrective actions implemented to prevent recurrence.

1. The (P&P) titled" Elopement Risk Screening and Management was not updated to reflect that patient identified as an elopement risk will be changed into a purple gown in accordance with the facility's elopement protocol observed in the Emergency Department.

The facility policy and procedure (P&P) titled" Elopement Risk Screening and Management," last revised 12/2020, stated the following: "d. The following elopement precautions will be implemented for patients determined to be at risk for elopement: Change patient into an appropriate hospital attire/gown..."

Per interview with Staff F (Director of Quality Assurance) on 8/25/2022 at 11:25 PM, the Elopement policy and procedure was not updated to reflect patients identified as an elopement risk will be changed into a purple gown. Staff F could not offer a reason why the policy was not updated.

2. The hospital could not provide documented evidence that the Emergency Department staff received education regarding "Purple huddles," which was one of the corrective actions implemented for elopements.

Per interview with Staff F (Director of Quality Assurance) on 8/25/2022 at 2:15 PM, and Staff J (Chief Medical Officer) and Staff K (Psychiatry Manager of Quality Assurance) on 08/26/2022 at 1:46 PM, some staff received "Purple huddles" education during ED huddles or via email however there was no documented evidence of staff attendance or staff attestation confirming they read the information.

3. The elopement investigation did not identify that Staff Q (Triage ED Nurse) failed to review the Nursing Home Transfer paperwork for Patient #1 when determining the patient's elopement risk.

The Nursing Home Transfer Form dated 5/25/2022, documented the following: altered mental status, current episodes manic without psychotic features, occasional confusion, and ambulatory.

Per interview with Staff G (Emergency Department Nurse) on 8/25/2022 at 1:00 PM, there was no place to document that the nursing home paperwork was reviewed by the triage nurse. "You can't tell if she reviewed it." After reading the nursing home paperwork "I would have placed her on elopement precautions. I would have put her in a purple gown, secured her belongings and put her on a 1:1."

4. The facility policy and procedure (P&P) titled" Elopement Risk Screening and Management," was not effectively implemented by the ED staff.

Observations and review of the ED census with Staff A (ED Assistant Charge Nurse) on 08/26/2022 at 10:15 AM revealed Patient #2, Patient #3 and Patient #4 were identified as elopement risks. Patient #2 was in cubicle 25 L. She was on a stretcher, in her street clothes and had her purse on her lap. Patient #2 was not placed in a purple gown and the patient did not have her possessions removed.

The facility policy and procedure (P&P) titled" Elopement Risk Screening and Management," last revised 12/2020, stated the following: "d. The following elopement precautions will be implemented for patients determined to be at risk for elopement: Change patient into an appropriate hospital attire/gown...; and secure belongings away from patient..."

Per interview of Staff A, at the time of the observation, she triaged Patient #2 today at 9:30 AM. The triage nurse does the elopement risk assessment during triage. Once the patient is identified as an elopement risk, the precautions should be immediately implemented. She stated, " I should have done it faster."