HospitalInspections.org

Based on review of medical records, observations, interviews, and policy review the hospital failed to ensure patients at risk for elopement were provided the care and services necessary to prevent multiple elopements of cognitively impaired patients. Refer to A0144.

Based on facility policy review, medical record reviews, observations and interviews the hospital failed to ensure care provided to confused patients were provided a safe environment to prevent confused patients from leaving the nursing care area without staff knowledge for 3 (#1, #2 and #4) of 4 sampled patients.

Findings included:

Policy and Procedure title, Nursing Standards of Patient Care, dated 04/18/2023 stated...This policy identifies appropriate nursing care/ interventions that each patient shall receive relative to their needs and individual outcomes... Intervention- Each patient will have nursing care intervention available to meet his or her needs ...individual care based on identified medical needs and physical limitation ...Nursing care. Intervention designed to promote a safe, risk free environment; i.e...reporting of potential and actual risk factors ...

Policy and Procedure title, Patient Leaving the Hospital against Medical Advice (AMA), Wanderers and Elopement, last reviewed 06/05/2024 ...A wanderer is a patient with cognitive impairments (i.e. Alzheimer's or dementia) that strays beyond the view or control of staff without the intent of leaving. An elopement occurs when a cognitively, physically, mentally, emotionally, and/or chemically impaired patient leaves the caregiving environment unsupervised, noticed, and/or prior to their schedule discharge.

A review of Patient #1's medical record nursing notes dated 09/13/2023 at 4:33 PM revealed that the patient was last seen at 2:30 PM resting in bed. An off duty employee witnessed the patient outside of the Emergency room and notified the nurse who in turn notified the police and the patient was brought back to the unit. Patient #1 is alert and oriented to name only.

A review of the medical record for Patient #2 reflected an initial admission date of 9/18/21. The initial History and Physical reflected Patient #2 was a 71 year old with dementia who was discharged after an extensive hospital stay in the care of his nephew who has been unable to care for him at home because he works. There are no acute issues, however, social services was involved as he had no funding source. Assessment and Plan reflected diagnoses of dementia and AMS (altered mental status). His mental status was oriented to self only (not to place, time, or situation).
Further review of the medical record revealed an Incapacity Designation dated 10/4/21, signed by the attending physician.
The Order Determining Total Incapacity, was reviewed, and revealed a court order dated 9/22/22, reflecting Patient #2 was determined to be totally incapacitated and a guardian should be appointed to provide for his welfare and safety. A review of the facesheet in the medical record reflected Patient #2 had a court appointed guardian.
A review of physician and nursing progress notes in Patient #2's medical record revealed the following documentation:
7/5/22 Patient eloped from unit during shift. Patient last seen talking to staff around 4:30 PM. Nurse went to check on patient around 4:35 PM and discovered he was missing. Police found patient at Manatee Health Department around 5:30 PM. Patient brought back to the unit around 6:00 PM. Doctor notified and order received for patient to go back to the ER (emergency room) for re-evaluation.
7/6/22 Eloped last night from 4 Radial North and was picked up by police and brought back to the ED (emergency department). He has been a social admission for the last 9 months with nowhere to discharge and family can not resume care. He is pending guardianship and court date. Admit back to unit with sitter.
7/6/22 1:28 AM Patient arrived to the unit irritable and continues to try to escape from unit.
7/6/22 2:30 AM Continues to sit at front desk speaking incomprehensible English and Spanish. He refuses to stay in his room. Unable to redirect. Will continue to monitor.
7/6/22 3:47 AM patient continues to walk around unit with attempts to get out of front and back doors but easily redirected.
7/8/22 11:35 PM student nurse reported Patient #2 as missing. He was last seen two minutes prior in his room. Security and director (of nursing on unit) and nursing office, physician notified.
7/8/22 Pt (patient) is an inpatient at Manatee Memorial Hospital (MMH). Found by MSO (manatee county sheriff's office) and taken to an [inpatient behavioral health hospital].
9/22/22 1:25 PM Patient waited until a Physician went down the back stairs and then eloped down them. A former employee saw him and brought him back to the front entrance. Security helped patient calm down and come back to room. House supervisor and director notified. Patient upset after interview with judge yesterday, and doctor visit today.
10/1/22 Patient was trying to leave the floor through the emergency exit and was stopped by staff. Patient went to his room and closed the door. Around 10:20 AM security called and said they found the patient next to the loading dock. Security brought pt back to his room. Patient did not sustain any injuries. When asked why he left, he said he wanted to sit under the sun because his room was cold. Now sitting in his room. Opened the window slightly open stating the room is cold and he gets warm air. Slamming the door closed. Denies his door to remain open, Maintenance requested yesterday. Room is still cold this morning. Maintenance ordered right now to adjust temperature in patient's room.
10/3/22 8:27 AM patient is not in room. Escaped through emergency exit. Security called. Later saw patient walking by river. Patient sat at bus station. Security updated. Went to bus station to get patient back inside. Security at the bus stop as well. Patient refused to go back to hospital under any circumstances. States he is ready to go home. Tired of being at the hospital. Tried to stop patient taking the bus. Patient got agitated at 9:40 AM. Patient took the bus that was going toward downtown.
10/23/22 6:55 AM Patient has been growing increasingly agitated this shift. Pt just ran to the hallway screaming obscenities in Spanish. Telling staff "I am going to shoot you". He then tipped over a tray of drinks and said "I am going to stab you", ran back to his room saying he was going to grab a knife. Patient was secured in his room while we waited for security to arrive.
6:04 PM A/O (alert and oriented) times 2. Able to communicate needs. Patient is a high risk for elopement. Today he went to the first floor and security was called. Patient verbally aggressive, and he is seen pacing from side to side.
10/30/22 3:00 PM Patient eloped at 10:00. Found wandering in hallway near 4 South Tower. Code gray overhead paged. He was reoriented and redirected to room.
Patient discovered missing from unit around 1200. Notified security and nursing office. At 1 PM security called and states they are still looking for the patient. BPD (Bradenton Police Department) called and around 2 PM he was found at a bar. He was sent to ER for evaluation and transferred back to unit. He arrived to the ER around 3:01 PM. Continues to be closely monitored.
3/6/23 3:55 PM Received a call from security asking if patient was on the unit. Stating main lobby thought they saw him exit the building towards Route 42 attempting to cross into incoming traffic. Patient sat behind the sign and refused to go back to the building. Security was dispatched. Patient became agitated and physically struck the writer in the back. Security gave patient a ride to front entrance and then he refused to enter the building. Nurse manager and supervisor notified of patient's elopement. Patient was returned to the floor by direct care staff and security.
12/27/23: End of shift notes: Patient has not been found after elopement last night.
A review of the case management documentation dated 12/27/23 reflected the court appointed guardian was contacted regarding patient elopement 12/26/23. At this time and date patient has not been found.
A review of the hospital Discharge Summary dated 12/27/23, revealed the following:
74 year old who eloped from MMH after 424 days. Hospitalized for prolonged period due to his dementia and family not participating in care. He was assigned a legal guardian. He has eloped from the hospital on several occasions and is usually found by police and brought back. He eloped and Bradenton PD was notified. Supervisor, DON (director of nursing), PD all informed.

Review of Patient #4's medical records nurse progress notes dated 03/24/2024 at 1:58 AM revealed that patient is hallucinating and severely confused, with impulsive behaviors noted. Nurse progress note on 3/24/24 at 3:04 AM stated that the patient changed into her street clothes attempting to depart the facility. Another nurse progress note on 3/24/24 at 5:31 AM reflected that the patient had been placed on elopement precautions since 3:04 AM event. Nurse progress note dated 03/24/2024 at 4:39 PM revealed that patient #4 had impulsive behavior and confused and she had ambulated off the unit and refused to come back, security and the supervisor assisted with bringing her back. Sitter was previous requested during the shift.

T
he Quality Director, Staff B was interviewed on 9/5/24 at 2:02 PM, and stated the traffic out there never lets up. It gets really backed up starting around 3:30 PM. They are going to be adding two more lanes. (see photographic evidence of vicinity surrounding hospital)

An interview was conducted with Staff P, Nursing Manager for 4 North Tower on 9/6/24 at 9:24 AM. Staff P said she started in that role November first of last year. She was not initially aware Patient #2 was an elopement risk, but became aware shortly after because he was ambulatory. "We didn't do anything formal to prevent him from eloping because he wasn't actively trying to elope when I was with him. He walked around the unit and he liked to sit in the lobby by the window. We haven't had any wanderers/elopers on the unit. He eloped at night on a Tuesday, around 8:00 PM. I was made aware at 8:51 PM. I was informed that Bradenton Police Department was looking for him. I was still new in my role so the director did most everything." She was not aware of any meeting with management after the elopement. "I don't think we put anything formal in place. But we made an effort to keep those patients in smaller units because our unit is so big. Our unit is spread out and has 32 beds. The rooms that are close to the nurses' station are also close to the elevator. If they are confused and an elopement risk we keep them at the nurses' station so we can keep an eye on them. If they were on isolation then we would have a sitter. Call the supervisor, security and administration. They would probably get a sitter. We don't have a problem getting a sitter. There is not an elopement assessment risk. We have a psychosocial assessment."

On 9/5/24 at 2:40 PM Staff D, Quality Coordinator was interviewed. She was asked about the nursing flowsheet where it was documented that Patient #2 was on elopement precautions. She said she was not sure what that means. Staff B, Quality Director was also interviewed at that time, and she said she thinks they check 'elopement precautions in place'. He was agitated, restless, confused. "All kinds of notes about that."

On 9/6/24 at 9:50 AM Staff Q, Charge RN (Registered Nurse) was interviewed. She has cared for Patient #2 before. He had dementia. He was confused. He had been here for a long time. He could be impulsive at times. Alert and oriented times two [aware of who he was and where he was at]. He knew where he was. He had a history of eloping when he was on other units. "It's a larger unit. He was on our unit during the last elopement. I had him the day he eloped. He eloped at night. He was near the nurses' station. He was visible. Frequent monitoring. It was expressed at all our huddles he was at risk for elopement. He never eloped while he was on our unit. He had been on our unit for many months. He would frequently sit in the waiting area by the elevators. Anybody could get on the elevators. The whole team on the floor was supervising him and the primary nurse. The nurses have six patients. As charge, I typically have two. Usually, we have at least two techs and one unit secretary. 32 beds. We do not always have two techs. I think it would be pretty hard to watch him with the patient assignments. He was assigned to the charge." Yes, the charge can watch him. "The night charge typically takes two, but on nights it could be more. We talked about the elopement in huddles after. We needed to have high visibility on any patients that are at risk for elopement, and to make sure the director and manager were aware. He was incapacitated. I believe he had a court appointed guardian."

On 9/6/24 at 10:26 AM, an interview was held with Staff N, APRN (Advanced Practice Registered Nurse). She said she saw Patient #2 off and on throughout his stay here. He was here for awhile."I was notified of the elopements if I was on call, or the next day when I came in. I reached out to case management and asked what happened or where did he go, and I asked the nurses on the floor." She said she doesn't recall if they did any medication changes for his elopements. "I am not really involved in what they do for a patient after they have eloped. He was cognitively impaired. I did put orders in for a sitter. I don't now if they provided him a sitter. The majority of the time he didn't have a sitter. If he did it might have been at the very early stages of his admission."

On 9/6/24 at 10:42 AM a telephone interview was conducted with Staff R, Security. He said he recalls one elopement he participated in. "Patient #2 was outside. He was across the street by the water at the bus stop by the hospital. It was sometime last year. I was told there was a missing patient. I was told he took off from the back door of the unit. We went on search and I found him across the street with a staff member. We tried to talk him into coming back. The bus came and he got on. The staff member who was with him was trying to take him off the bus. I think it was a nurse. She wanted me to intervene but I told her I am not allowed to touch a patient like that. Then the bus left with the patient. The Director of Risk told me I should've gotten on the bus with him so I could relay where he was at. I told her that was not my job to do that. I am security for the hospital. The police were called and they searched and found him down town at a bus area in Bradenton." He said he was not sure how far way it is. "It's near the courthouse." He thinks it's about three miles away. "There have been several times in the hospital where we found him in the hall. I recall three different times responding to him. One time he was sitting on the floor by the ice machine and I talked him into returning to the unit. Another time I found him by the Labor and Delivery unit around the corner from his unit and talked him into returning. I went to 4 North Tower where he was right before he took off. He was right outside in the hallway near his room a couple doors down on 4 North Tower. I talked him into to going back to his room. He said he wanted to leave the hospital. He wanted to go to Miami to see his daughter. He was very agitated and [angry] about being there. I would say he was high risk for eloping, yes. We had a security guard who worked with us who wanted to put a cheap door alarm on the back door of the unit. He was told we couldn't because that wasn't allowed." Staff R said he has responded to other patients who eloped. "We look at the cameras and have other security looking for the patient. There are cameras on all exits and there is security watching it at all times. We have one security guard posted at the ER. We have an older lady who works at the lobby desk who checks visitors in and calls if she sees something, like a patient with a gown and IV pole trying to leave. I think it could be worked on better personally."

On 09/05/2024 at 9:51 AM an observation was conducted of the T Elevators which open in the lobby and go to 4th North Tower. From the main entrance, Highway 41 could be seen to the left as you exit the main lobby, and the river to the right. (photo evidence #2 obtained).

During an interview on 09/05/2024 at 10:22 AM with the Staff H, Clinical Leader, 3 Main, Staff H disclosed that her area of concern is elopement risk, and she had addressed it with administration. She disclosed that about a year ago the police had to bring Patient #1 back to the hospital.

On 09/05/2024 at 1:02 PM a tour was conducted on the 4th floor North Tower with escort with Staff E. Observed a stairwell exit down the hallway which required a badge to access, or an alarm would go off. Upon entering the stairwell, and taking the stairs down, you arrive at the first floor where there was an exit door (not requiring a badge to exit). The door opens to the left side of the lobby entrance and locks after closing, with no way to re-enter the stair well. The right side of the exit door is the loading dock. Photo evidence obtained (photo evidence #3).

During an interview on 09/05/2024 at 2:00 PM with Staff C, Risk Manager, she disclosed that she was not aware of Patient #4's elopement.

During an interview on 09/05/2024 at 3:00 PM with the Director of Quality. The Director of Quality disclosed that she was sure that Patient #4 had a sitter in the past, prior to the incident where he was found in the lobby. The Director of Quality confirmed the progress note revealed a sitter had been previously requested.

During an interview on 09/06/2024 at 11:03 AM with Staff C, Risk Manager,she said the Patient #1 eloped one time and the police returned the patient. The second time he wandered and was found in the medical office building on 3 Main, and confirmed there were no notes in his medical record for the incident on 11/20/2023.

At 1:07 PM on 9/6/24 a telephone interview was conducted with Staff F, Charge Nurse, night shift, 4 North Tower. Staff F said she usually has two patients. "I don't remember how many patients I had when I had Patient #2. I think it was only two patients. He was one of the patients who was assigned to the charge nurse because he was medically stable, so we could help the other staff. He was on my unit close to a year I think. He had not eloped before on night shift. I think he might have on day shift. It's a big unit. It's connected to another one. I guess he would go to the other unit and walk around. He would come out of his room and go to the nurses' station, or sit in the waiting room by the nurses' station. If we were busy and no one was around he would go back to his room and wait for his meds. I was aware he was an elopement risk. It was around 8 something. I saw him in the waiting room and I told him too go to his room and I was going to give him his meds. We don't have a secretary on nights so I have to answer call lights. A supervisor called me to ask a nurse something about telemetry for a specific patient. I went and told the nurse, then I went to get Patient #2's medications and came in his room and he wasn't there. So I went to the waiting room and the nurses' station and he wasn't there. I looked in other patients' rooms because he was found in other patients' rooms sometimes, but I didn't find him so I went back to the nurses' station and I called security and the supervisor. They started searching for the patient. I had to take care of the unit and call the police. The police came and asked me some questions. In the morning I went in my car and searched for him. Then the police called and said they found him in Miami a couple days later. We try to use sitters and more staff." It was a time when there was a staffing challenge. "Transfer them to a smaller unit. He was close to the nurses' station and most of the time, he wasn't on a fall alarm because he was steady on his feet. Pretty much just close supervision. Most people knew he was a risk and kept a close eye on him. He was wearing a hospital gown. He would wear a sweater and we found some scrub pants for him. I saw him a few times that night. I was in shock. He was very often in the waiting room. In my mind he was planning it, because he knew exactly what to do. The last time I saw him was between 8PM and 9 PM. It was the time when everybody is passing meds. He was waiting until it was clear. The lights go off at that time too. He probably went down in the elevator. I don't think he had any street clothes. Only a sweater. I gave him some sandals because he would walk around, and pajama pants that are like scrub bottoms for males, so they don't walk around exposed. He was delusional. You could have a whole conversation with him. He could remember my name and other nurses' names. He would say he owned his own business, and the doctors were trying to keep him here. You would think he was normal if you sat in the waiting room and talked to him. I didn't know he had a guardian. I was told he didn't have anybody. He spoke in Spanish primarily and some English. There were times he was very upset that he was in the hospital and said we were retaining him for money. He was very delusional."

At 2:29 PM on 9/6/24 Staff S, House Supervisor, night shift was interviewed. Patient #2 eloped one time on her shift. December of 2023. "If it's big enough to involve us, they will bring it to our attention so we are aware. I was aware he had eloped before. We all knew Patient #2 because he had been here a long time. He was close to the nurses' station and he was always in the day room, so when we were doing rounds, we would actually go check on him and make sure he was doing ok. I got a call just before 9:00 PM from the Charge[ Nurse], Staff F. She said she had seen him and I asked her to go get some patients off telemetry (heart monitors). We were looking at triaging patients off telemetry if they didn't meet telemetry criteria. Staff F was caring for him. They got him some food and then he asked for a drink. She went to get him a drink and that's when they found he was missing. I contacted security and discussed with them how to locate the patient. I looked for the patient. We also contacted law enforcement. It was around 9:00 PM that I contacted security. Patient #2 was not found. Security went around hospital property and stairwells. They also went around the hospital in their truck looking for him. The police were notified he was a missing person. I had conversations with my leadership, but I didn't have a meeting with management. We had discussions after about what we could do to prevent this. We had eyes on him just before he went missing. We did everything we could to keep it from happening, to the best of our ability. The only thing that could have made a difference was a true lock down unit, which we don't have. They tried to give him some ability to have some freedom. They were closely monitoring him because they all knew he was a risk. I don't know what else we could have done to make a difference. We do use sitters when necessary. I couldn't tell you if and when he had a sitter."

During an interview on 09/06/2024 at approximately 3:03 PM with Staff M, Director, Staff M disclosed that Patient #2 was in room 433 and the majority of his time in the hospital he was in this unit. She disclosed that he eloped several times from here and was found in the loading dock. She is unsure how he left the unit because you need a badge to exit in the stairwell.


On 09/05/2024 at 9:51 AM an observation was conducted of the T Elevators, which open in the lobby and go to 4th North Tower. Observation of the main entrance showed Highway 41 to the left when you exit the main lobby and the river to the right. (Photographic evidence obtained).

On 09/05/2024 at 1:02 PM a tour was conducted on the 4th floor North Tower with escort from Staff E. Down the hallway was a stairwell door requiring a badge access, or an alarm would go off. Exiting through the stairwell down to the 1st floor was an exit door (not requiring a badge to exit). The door opened to the left side of the main lobby entrance, and locked upon closing, leaving no way to re-enter the stairwell. To the right side of the exit door was the loading dock. Photo evidence obtained (photo evidence #3).

On 09/06/2024 3:03 PM a tour was conducted of 4 Radial North with escort from Staff M. The stairwell access door on unit 4 Radial North was observed and required badge access to enter into the stairwell. Staff M utilized her badge to open the door. Upon taking the stairs to the first floor through the stairwell, there was no badge access required to exit the door which exited into the cafeteria seating area. There was also a door on ground level, marked G, with no badge access required to open it. The door led into a hallway where there was a door on the right that exited to the loading dock. (Photographic evidence obtained)

Based on review of medical records, observations, interviews, and policy reviews the hospital failed to ensure the QAPI (Quality Assurancce Performance Improvement) plan was implemented in response to patient elopement events after three (#1, #2, and #4) patients of four sampled had multiple elopement events.
Refer to A0286.

Based on record review, interviews, observations, and policy review the hospital failed to ensure an investigation, analysis, and action plan were developed and implemented to prevent further elopements from occurring, after multiple elopement events occurred for three patients (#1, #2, and #4) of four sampled patients.

Findings included:

A. Review of Patient #1's medical record revealed a nurse progress note dated 09/13/2023 4:33 PM; Patient #1 was last seen at 2:30 PM resting in bed. An off-duty employee witnessed the patient outside of the Emergency Room and notified the nurse, who in turn notified the police and the patient was brought back to the unit. Patient #1 is alert and oriented to name only.

B. A review of the medical record for Patient #2 reflected an initial admission date of 9/18/21. Patient #2 was a 71-year-old with dementia who was discharged after an extensive hospital stay in the care of his nephew who has been unable to care for him at home because he works. There are no acute issues, however, social services are involved as he has no funding source. Assessment and Plan reflected diagnoses of dementia and AMS (altered mental status). His mental status was oriented to self only (not to place, time, or situation). The medical record revealed an Incapacity Designation dated 10/4/21, signed by the attending physician. The Order Determining Total Incapacity was reviewed, and revealed a court order dated 9/22/22, reflecting Patient #2 was determined to be totally incapacitated and a guardian should be appointed to provide for his welfare and safety. The patient had a court appointed guardian.

A review of physician and nursing progress notes in Patient #2's medical record revealed the following documentation:
1. On 7/5/22 Patient #2 eloped from unit. Patient was last seen talking to staff around 4:30 PM. Nurse went to check on patient around 4:35 PM and discovered the patient was missing. Police found patient at around 5:30 PM and brought him back to the unit around 6:00 PM. The Doctor was notified, and order received for patient to go back to the ER (emergency room) for evaluation.
2. On 7/8/22 at 11:35 PM student nurse reported Patient #2 as missing. He was last seen two minutes prior in his room. Security and director (of nursing on unit) and nursing office, physician notified. Patient was found by the Sheriff's Office and taken to an [inpatient behavioral health hospital].
3. On 9/22/22 1:25 PM Pt waited until a PCP (primary care physician) went down the back stairs and then eloped down them. A former employee saw him and brought him back to the front entrance. Security helped patient calm down and come back to room. House supervisor and director notified. Patient upset after interview with judge yesterday, and doctor visit today.
4. On 10/1/22 Pt was trying to leave the floor through the emergency exit and was stopped by staff. Pt went to his room and closed the door. Around 10:20 AM security called and said they found the patient next to the loading dock. Security brought pt back to his room. Pt did not sustain any injuries. When asked why he left, he said he wanted to sit under the sun because his room was cold.
5. On 10/3/22 8:27 AM patient is not in room. Escaped through emergency exit. Security called. Later saw patient walking by river. Patient sat at bus station. Security updated. Went to bus station to get patient back inside. Security at the bus stop as well. Patient refused to go back to hospital under any circumstances. States he is ready to go home. Tired of being at the hospital. Tried to stop patient from taking the bus. Patient got agitated at 9:40 AM. Patient took the bus that was going toward downtown.
6. On 10/23/22 6:55 AM patient has been growing increasingly agitated this shift. The patient just ran to the hallway screaming obscenities in Spanish. Telling staff "I am going to shoot you". He then tipped over a tray of drinks and said, "I am going to stab you", ran back to his room saying he was going to grab a knife. Patient was secured in his room while we waited for security to arrive. A note at 6:04 PM A/O (alert and oriented) times two. Able to communicate needs. Patient is a high risk for elopement. Today he went to the first floor and security was called. Patient verbally aggressive, and he is seen pacing from side to side.
7. On 10/30/22 patient eloped at 10:00 AM. The patient was found wandering in hallway near 4 south tower. Code gray (a security concern) overhead paged, He was reoriented and redirected to room.
8. On 10/30/22 patient discovered missing from unit around 1200. Notified security and nursing office. At 1 PM security called and states they are still looking for the patient. BPD (Bradenton police department) called and around 2 PM he was found at a bar. He was sent to ER for evaluation and transferred back to unit. He arrived to the ER around 3:01 PM.
9. On 3/6/23 at 3:55 PM received a call from security asking if pt was on the unit, stating main lobby thought they saw him exit the building towards Route 42 attempting to cross into incoming traffic. Patient sat behind the sign and refused to go back to the building. Security was dispatched. Pt became agitated and physically struck the writer in the back. Security gave patient a ride to front entrance and then he refused to enter the building. Nurse manager and supervisor notified of patient's elopement. Patient was returned to the floor by direct care staff and security.
10. On 12/27/23: End of shift notes: Pt has not been found after elopement last night. A review of the case management documentation dated 12/27/23 reflected the court appointed guardian was contacted regarding patient elopement 12/26/23. At this time and date patient has not been found.
A review of the hospital Discharge Summary dated 12/27/23, revealed the following:
74-year-old who eloped from MMH after 424 days. Hospitalized for prolonged period due to his dementia and family not participating in care. He was assigned a legal guardian. He has eloped from the hospital on several occasions and is usually found by police and brought back. He eloped and Bradenton PD (Police Department) was notified. Supervisor, DON (Director of Nursing) informed.

C. Review of Patient #4's nurses progress notes dated 03/24/2024 at 1:58 AM revealed that patient is hallucinating and severely confused, with impulsive behaviors noted. Nurse progress note timed 3:04 AM stated that the patient changed into her street clothes attempting to depart the facility. Another nurse progress note timed 5:31 AM showed the patient had been placed on elopement precautions since 3:04 AM event. The Nurse progress note dated 03/24/2024 at 4:39 PM revealed that patient #4 had impulsive behavior and confused and had ambulated off the unit and refused to come back. Security and the supervisor assisted with bringing her back. Sitter was previous requested during the shift.

D. On 09/05/2024 at 9:51 AM an observation was conducted of the T Elevators, which open in the lobby and go to 4th North Tower. Observation of the main entrance showed Highway 41 to the left when you exit the main lobby and the river to the right. (Photographic evidence obtained).

On 09/05/2024 at 1:02 PM a tour was conducted on the 4th floor North Tower with escort from Staff E. Down the hallway was a stairwell door requiring a badge access, or an alarm would go off. Exiting through the stairwell down to the 1st floor was an exit door (not requiring a badge to exit). The door opened to the left side of the main lobby entrance, and locked upon closing, leaving no way to re-enter the stairwell. To the right side of the exit door was the loading dock. Photo evidence obtained (photo evidence #3).

On 09/06/2024 3:03 PM a tour was conducted of 4 Radial North with escort from Staff M. The stairwell access door on unit 4 Radial North was observed and required badge access to enter into the stairwell. Staff M utilized her badge to open the door. Upon taking the stairs to the first floor through the stairwell, there was no badge access required to exit the door which exited into the cafeteria seating area. There was also a door on ground level, marked G, with no badge access required to open it. The door led into a hallway where there was a door on the right that exited to the loading dock. (Photographic evidence obtained)

E. At 1:22 PM on 9/5/24 Staff O, information services/clinical analyst (a previous director of nursing for one of the units where Patient #2 resided), was interviewed. Staff O said she was the interim Director over two units until August 2022. She agreed wandering behavior is a safety issue. "We always had somebody at the desk who was watching him. He was sneaky. He was allowed to walk around the unit. Everybody knew he wandered. They all kept on eye on him. He was confused. I think he had underlying liver or kidney issues that caused it. We brought him back to the unit and stepped it up a little bit. Probably had someone watch him more closely. They may have gotten him a sitter. Reinforced to anyone floating into the unit that you had to keep an eye on him. It was a small unit. It is a circular unit. There is only one door out. He had a bed by the nurses' station. It was pretty secure for an elopement risk."

On 9/5/24 at 2:04 PM Staff C, Risk Manager (RM) was interviewed. Staff C took the RM position on 7/17/23. She reviewed the elopement events for Patient #2 and said on 7/27 he was wandering around and was brought to his room from another unit on the same floor. 9/22/22 the event type was a wanderer. He was on 4 radial north, left down the back stairs when it was opened by a provider. He left three times and was brought back three times. We have not had this problem in a long time. His angst was because he had a judge interview the day before and a doctor visit that day. Staff C said there wasn't any intervention documented in the event report for those. 10/1/22 wanderer event. He was found next to the loading dock. When asked why he left he said he wanted to sit in the sun because his room is cold. A doorbell was added so staff can hear it ring before the patient leaves the unit. On 10/3/22 elopement event, security got a call that the patient was across the street at a bus stop. Security and the nurse tried to bring him back. Police were notified. The bus came and the patient hopped on. The nurse also hopped on. Security found the patient downtown getting off the Manatee bus, and the patient was escorted back to the nursing unit. A doorbell was added so staff can hear it. 10/23/22 wanderer event. Patient left the unit. He was trying to get in the kitchen. The nurse was with the patient and security was called and escorted the patient back to the unit. No interventions were documented in the report. 3/6/23 wanderer event. Patient left the unit. Security got a call from the main lobby saying they thought they saw the patient exit the building. The nurse located the patient outside the building walking towards route 41, attempting to cross into oncoming traffic. Patient refused to go back to the building. Security arrived. He became agitated and hit the nurse in the back. They gave the patient a ride to the front entrance, and he was brought back to the unit. No documented interventions in the report. 12/26/23 Security was notified the patient eloped from his room. The nurse stated he was not wearing a hospital gown, but green pants and a sweater. Police notified and filed a missing person's report. He was subsequently found in Hialeah. He was Baker Acted (a Baker Act is an involuntary admission for a examination by a psychiatrist) and went to a facility there. "I was on vacation at the time. The Quality Director, Staff B was covering. It was escalated to the CNOs (Chief Nursing Officer), supervisors, Administrator on call. Staff B called me. Risk made sure we followed our policy, so all steps were completed as they should be; notifying security and the police and filing a missing person's report. He didn't have any family. Local hospitals were called. The case was assigned to detectives. Because of the missing person's report, when the police down there picked him up, that's when they contacted us to let us know. I feel we could have done better. I wasn't here at the time. The other RM no longer works here. I would have called the Manager and Director and asked what we were going to do to prevent this. Escalated up to upper management and involved the CEO (Chief Executive Officer), who is my direct report. None of upper management are still here. The only person who is still here is the ACNO (Assistant Chief Nursing Officer). She wasn't the ACNO at the time. It's all brand-new people." Yes, he was diagnosed with dementia. "I would say Risk and the Director of the unit are responsible for preventing him from eloping again. I would have put him with a sitter. I would have moved him off the tower to a radial unit. I would have had the nurse sitting outside the door to document. Made sure he was kept in a gown and not clothes. I would have made sure the leaders were doing daily audits to make sure everything was in place."

On 9/5/24 at 3:22 PM a telephone interview was held with Staff A, former Risk Manager. She said she left in August of 2023. She said she was aware of his elopements. "I am sure we discussed it as a group. We would have discussed it with department directors, but I don't recall. I didn't speak to administration. Directors and Risk Managers do it as a group. Whatever we need to do at the time." She doesn't recall if a doctor was involved. "At one point we put a floor alarm mat, so when he stepped out of the room the floor alarm would go off."

On 9/5/224 at 4:12 PM an interview was held with Staff B, Director of Quality. She said they have not had a QAPI (Quality Assurance Performance Improvement) for elopement in the last year. "When we do our risk assessments we discharge 2,000 patients a month, 18 elopements for a year out of 24,000 discharges doesn't meet the criteria to develop a QAPI. "The RM, Staff C was also interviewed. She said "We look at several hundred event reports every month. We didn't see a trend. Most of those elopements were patients who were alert and oriented so it's even less than 18 in a year. I wasn't here when most of his (Patient #2) elopements happened. If I was, I would have looked at it more in depth."

At 9:20 AM on 9/6/24 Staff B, Director of Quality was interviewed. "I asked the staff to put them close to the nurses' station, move them away from exit doors, try to keep them where they can keep an eye on them."

An interview was conducted with Staff P, Nursing Manager for 4 North Tower on 9/6/24 at 9:24 AM. Staff P said she started in that role November first of last year. She was not initially aware he was an elopement risk but became aware shortly after because he was ambulatory. "We didn't do anything formal to prevent him from eloping because he wasn't actively trying to elope when I was with him. He walked around the unit, and he liked to sit in the lobby by the window. We haven't had any wanderers/elopers on the unit. He eloped at night on a Tuesday, around 8:00. I was made aware at 8:51 PM. I was informed that Bradenton PD (police department) was looking for him. I was still new in my role so the director did most everything." She was not aware of any meeting with management after the elopement. "I don't think we put anything formal in place. But we made an effort to keep those patients in smaller units because our unit is so big. Our unit is spread out and has 32 beds. The rooms that are close to the nurses' station are also close to the elevator. If they are confused and an elopement risk, we keep them at the nurses' station so we can keep an eye on them. If they were on isolation, then we would have a sitter. Call the supervisor, security and administration. They would probably get a sitter. We don't have a problem getting a sitter. There is not an elopement assessment risk. We have a psychosocial assessment."

On 9/6/24 at 11:00 AM Staff I, CNO (Chief Nursing Officer) was interviewed. "I got the phone call from the house supervisor notifying me of what happened. They explained that during shift change he asked to have his food heated and asked for a drink. Then they went to do vitals about ten minutes later and he was gone. Then they called security to start looking for him. I looked at the policy and used it as a check list. They went and searched for him by vehicle. They searched the hospital and started looking at video and were looking outside. Eventually they found the (video)footage and drove to those areas to see if they could find him. He was not found. He did not have an IV (Intravenous)[line] . I asked if he was a Baker Act. I was told no at the time, but they were looking at that to see what his mental status was and if he was a Baker Act or Marchman (involuntary admission for substance/alcohol abuse). I was not aware at the time he had a history of eloping. As we started the investigation, the Manager on the unit shared with me that he had done this before. The police department and risk were notified as well. We put in a missing person's report. He was checked into a hospital in Miami. He had a nephew here in town. We think he drove him. He had family in Miami who brought him to the hospital there. We got a call from the hospital there. We saw the video. The manger went to a gas station down the road who said they had seen him. That was around 9:20 PM. I don't have anything in writing. I reviewed the policy and discussed it with the leaders and risk, that was about as far as we went. I have been working with Facilities, and we have made some requests to put some alarms on some doors."

On 9/6/24 at 11:09 AM an interview was conducted with Staff E, Director for 4 North tower, 4 South Tower, 5 Radial South and 3 Main, (since April 22, 2024). "There is a Manager on every unit. I have three managers and one clinical leader. They would look to see if the patient has a history of elopement before they came to the facility. That starts on admission. Looking at the history. Looking to see if they are a frequent flyer. There is not an assessment tool specifically for elopement. When they are doing their assessments and getting to know their patients, if they identify a concern they bring it to the clinical leader on 3 Main, and myself. We trouble shoot with the staff what we can do to avoid an elopement. We moved that patient down the hallway not so close to the doors. 3 Main is a very small unit. It's only 12 beds. We don't have anything formally in response to an elopement. We search the unit, we alert security, and we alert the police department. There isn't anything else in place. One of the things we do is make sure all the doors are closed because it's badge access only. I have one near my office and one at the end of the hall. Those are the only doors on 4 North Tower. When the charge makes her rounds on night shift, they look to make sure the door is always closed. It could be left open because it's a slow-moving automatic door. We met in a safety committee discussing an AMA (against medical advice), but we haven't had an elopement to my knowledge. There has been no discussion of elopements or any elopement drills. Since I have been here there was a potential elopement, and we met and discussed it. We discussed that we call security and the police. She was found in an office on 3 Main. That was late April, early May. That's why the staff on 3 Main are very vigilant about discussing any patients that can get out the doors. Most of the patients on 3 Main are bed bound. We do use sitters around the clock. We have a sitter department. If we do not have a sitter, then the tech on the unit is the sitter."

At 2:57 PM at 9/6/24 Staff B, Director of Quality and Staff C, RM confirmed in an interview there wasn't any documentation of an investigation and RCA (root cause analysis) for each elopement.

F. Policy and Procedure title, "Patient Leaving the Hospital against Medical Advice (AMA), Wanderers and Elopement", RR816, reviewed 06/05/2024 ...A wanderer is a patient with cognitive impairments (i.e. Alzheimer's or dementia) that strays beyond the view or control of staff without the intent of leaving. An elopement occurs when a cognitively, physically, mentally, emotionally, and/or chemically impaired patient leaves the caregiving environment unsupervised, noticed, and/or prior to their schedule discharge.

Review of the policy, Scope of Service for the Quality Department, last revision date, 6/2024, reflected the following:
1. Primary services
a) Implementation of the Hospital's Quality Plan, which is evaluated and updated annually.
b) Facilitation all patient safety efforts, including reporting and investigating any concerns.
c) Providing leadership for all necessary education, tracers, audits, and case reviews to facilitate compliance with all State, Federal, and Regulatory requirements.
d) Abstracting, validating, and submitting all required publicly reported quality data.
e) Concurrent review of potential quality of care concerns. This includes, but is not limited to Core Measures, PSI-90 indicators, and high priority regulatory requirements.
f) Helping to identify, track, and trend any patient complications or safety events.
g) Working closely with the Risk Management Department to assist in facilitation of Root Cause Analyses and case reviews after any identified events, variations from best practice, or near miss incidents.

Policy and Procedure title, "Risk Management Patient Safety Plan", # LD170, reviewed 05/24/2024. Manatee Memorial Hospital (MMH) endorses an integrated, system wide patient safety program designed to improve patient safety and reduce risk to patients.
Patient safely is a cornerstone of quality care and is a leadership priority ...Most patient safety events are due to a failure of systems therefore a systems analysis approaches mainly utilized in evaluations. The goal is to identify and track errors, deficiencies, and problematic trends in order to continuously improve the underlying systems and to intervene as necessary to improve system processes ...to support, maintain and enhance the quality of patient care delivered by: Systematic and objective monitoring and evaluation of reports of injuries , accidents, patient safety issues ...identification and assessment of general areas of actual or potential risk in the clinical aspect of the delivery of patient care and safety ...

Based on record reviews, observations, interviews, and policy review the hospital failed to ensure adequate assessmments and reassessments identified patients at risk for elopement, and implemented effective interventions to ensure appropriate supervison to prevent further elopements for three patients (#1, #2, and #4).
Refer to A0392

Based on medical record reviews, observations, interviews, and facility policy review the hospital failed to ensure the nursing care process was used to effectively prevent confused patients from wandering and eloping for 3 (#1, #2 and #4) of 4 sampled patients.

Findings included:

Review of Patient #1's medical record nurse progress notes dated 09/13/2023 at 4:33 PM revealed that Patient #1 was last seen at 2:30 PM resting in bed. An off duty employee witnessed the patient outside of the Emergency Room and notified the nurse, who in turn notified the police and the patient was brought back to the unit. Patient #1 was alert and oriented to name only.

A review of the medical record for Patient #2 reflected an initial admission date of 9/18/21. The History and Physical reflected Patient #2 was a 71 year old with dementia who was discharged after an extensive hospital stay in the care of his nephew who has been unable to care for him at home because he works. There are no acute issues, however, social services is involved as he has no funding source. Assessment and Plan reflected diagnoses of dementia and AMS (altered mental status). His mental status was oriented to self only (not to place, time, or situation).

Further review of the medical record revealed an Incapacity Designation dated 10/4/21, signed by the attending physician.
The Order Determining Total Incapacity, was reviewed, and revealed a court order dated 9/22/22, reflecting Patient #2 was determined to be totally incapacitated and a guardian should be appointed to provide for his welfare and safety.
A review of the facesheet in the medical record reflected Patient #2 had a court appointed guardian.
A review of physician and nursing progress notes in Patient #2's medical record revealed the following documentation:
7/5/22 Patient eloped from unit during shift. Patient last seen talking to staff around 4:30 PM. Nurse went to check on patient around 4:35 PM and discovered he was missing. Police found patient at Manatee Health Department around 5:30 PM. Patient brought back to the unit around 6:00 PM. Doctor notified and order received for patient to go back to the ER (emergency room) for re-evaluation.
7/6/22 Eloped last night from 4 Radial North and was picked up by police and brought back to the ED (emergency department). He has been a social admission for the last 9 months with nowhere to discharge and family can not resume care. He is pending guardianship and court date. Admit back to unit with sitter.
7/6/22 1:28 AM Patient arrived to the unit irritable and continues to try to escape from unit.
2:30 AM Continues to sit at front desk speaking incomprehensible English and Spanish. He refuses to stay in his room. Unable to redirect. Will continue to monitor.
3:47 AM patient continues to walk around unit with attempts to get out of front and back doors but easily redirected.
7/8/22 At 11:35 PM student nurse reported Patient #2 as missing. He was last seen two minutes prior in his room. Security and director (of nursing on unit) and nursing office, physician notified.
7/8/22 Pt (patient) is an inpatient at Manatee Memorial Hospital (MMH). Found by MSO (manatee county sheriff's office) and taken to an [inpatient behavioral health hospital].
9/22/22 1:25 PM Pt waited until a PCP (primary care physician) went down the back stairs and then eloped down them. A former employee saw him and brought him back to the front entrance. Security helped patient calm down and come back to room. House supervisor and director notified. Patient upset after interview with judge yesterday, and doctor visit today.
10/1/22 Pt was trying to leave the floor through the emergency exit and was stopped by staff. Pt went to his room and closed the door. Around 10:20 AM security called and said they found the patient next to the loading dock. Security brought pt back to his room. Pt did not sustain any injuries. When asked why he left, he said he wanted to sit under the sun because his room was cold. Now sitting in his room. Opened the window slightly open stating the room is cold and he gets warm air. Slamming the door closed. Denies his door to remain open, Maintenance requested yesterday. Room is still cold this morning. Maintenance ordered right now to adjust temperature in patient's room.
10/3/22 8:27 AM patient is not in room. Escaped through emergency exit. Security called. Later saw pt walking by riverwalk. Patient sat at bus station. Security updated. Went to bus station to get patient back inside. Security at the bus stop as well. Patient refused to go back to hospital under any circumstances. States he is ready to go home. Tired of being at the hospital. Tried to stop pt taking the bus. Pt got agitated at 9:40 AM. Pt took the bus that was going toward downtown.
10/23/22 6:55 AM pt has been growing increasingly agitated this shift. Pt just ran to the hallway screaming obscenities in Spanish. Telling staff "I am going to shoot you". He then tipped over a tray of drinks and said "I am going to stab you", ran back to his room saying he was going to grab a knife. Pt was secured in his room while we waited for security to arrive.
6:04 PM A/O (alert and oriented) times 2. Able to communicate needs. Pt is a high risk for elopement. Today he went to the first floor and security was called. Pt verbally aggressive, and he is seen pacing from side to side.
10/30/22 3:00 PM Pt eloped at 10:00. Found wandering in hallway near 4 south tower. Code gray overhead paged, He was reoriented and redirected to room.
Pt discovered missing from unit around 1200. Notified security and nursing office. At 1 PM security called and states they are still looking for the patient. BPD (Bradenton police department) called and around 2 PM he was found at a bar. He was sent to ER for evaluation and transferred back to unit. He arrived to the ER around 3:01 PM. Continues to be closely monitored.
3/6/23 3:55 PM received a call from security asking if pt was on the unit. Stating main lobby thought they saw him exit the building towards Route 42 attempting to cross into incoming traffic. Patient sat behind the sign and refused to go back to the building. Security was dispatched. Pt became agitated and physically struck the writer in the back. Security gave patient a ride to front entrance and then he refused to enter the building. Nurse manager and supervisor notified of patient's elopement. Patient was returned to the floor by direct care staff and security.
12/27/23: End of shift notes: Pt has not been found after elopement last night.
A review of the case management documentation dated 12/27/23 reflected the court appointed guardian was contacted regarding patient elopement 12/26/23. At this time and date patient has not been found.
A review of the hospital Discharge Summary dated 12/27/23, revealed the following:
74 year old who eloped from MMH after 424 days. Hospitalized for prolonged period due to his dementia and family not participating in care. He was assigned a legal guardian. He has eloped from the hospital on several occasions and is usually found by police and brought back. He eloped and Bradenton PD (police department) was notified. Supervisor, DON (director of nursing) informed.

Review of Patient #4's medical record nurse progress notes dated 03/24/2024 at 1:58 AM revealed that Patient #4 is hallucinating and severely confused, with impulsive behaviors noted. 3:04 AM nurse progress note stated that the patient changed into her street clothes attempting to depart the facility. Another nurse progress note at 5:31 AM reflected that the patient had been placed on elopement precautions since the 3:04 AM event. The nurse progress note dated 03/24/2024 at 16:39 PM revealed that Patient #4 had impulsive behavior and was confused and had ambulated off the unit and refused to come back. Security and the supervisor assisted with bringing her back. Sitter was previously requested during the shift.

The Quality Director, Staff B was interviewed at 2:02 PM on 9/5/24, and stated the traffic out there never lets up. It gets really backed up starting around 3:30 PM. They are going to be adding two more lanes.

At 2:40 PM on 9/5/24 Staff D, quality coordinator was interviewed. She said they documented in the flow sheet Patient #2 was on elopement precautions. She said she was not sure what that means. Staff B, quality director was also interviewed at that time, and she said she thinks they 'check elopement precautions in place'. He was agitated, restless, confused. "All kinds of notes about that."

An interview was conducted with Staff P, nursing manager for 4 North Tower on 9/6/24 at 9:24 AM. Staff P said she started in that role November first of last year. She was not initially aware he was an elopement risk, but became aware shortly after because he was ambulatory. "We didn't do anything formal to prevent him from eloping because he wasn't actively trying to elope when I was with him. He walked around the unit and he liked to sit in the lobby by the window. We haven't had any wanderers/elopers on the unit. He eloped at night on a Tuesday, around 8:00 PM. I was made aware at 8:51 PM. I was informed that Bradenton PD was looking for him. I was still new in my role so the director did most everything." She was not aware of any meeting with management after the elopement. "I don't think we put anything formal in place. But we made an effort to keep those patients in smaller units because our unit is so big. Our unit is spread out and has 32 beds. The rooms that are close to the nurses' station are also close to the elevator. If they are confused and an elopement risk we keep them at the nurses' station so we can keep an eye on them. If they were on isolation then we would have a sitter. Call the supervisor, security and administration. They would probably get a sitter. We don't have a problem getting a sitter. There is not an elopement assessment risk. We have a psychosocial assessment."

On 9/6/24 at 9:50 AM Staff Q, Charge RN (Registered Nurse) was interviewed. She has cared for Patient #2 before. He had dementia. He was confused. He had been here for a long time. He could be impulsive at times. Alert and oriented times two. He knew where he was. He had a history of eloping when he was on other units. "It's a larger unit. He was on our unit during the last elopement. I had him the day he eloped. He eloped at night. He was near the nurses' station. He was visible. Frequent monitoring. It was expressed at all our huddles he was at risk for elopement. He never eloped while he was on our unit. He had been on our unit for many months. He would frequently sit in the waiting area by the elevators. Anybody could get on the elevators. The whole team on the floor was supervising him and the primary nurse. The nurses have six patients. As charge, I typically have two. Usually, we have at least two techs and one unit secretary. 32 beds. We do not always have two techs. I think it would be pretty hard to watch him with the patient assignments. He was assigned to the charge." Yes, the charge can watch him. "The night charge typically takes two, but on nights it could be more. We talked about the elopement in huddles after. We needed to have high visibility on any patients that are at risk for elopement, and to make sure the director and manager were aware. He was incapacitated. I believe he had a court appointed guardian."

At 10:26 on 9/6/24 an interview was held with Staff N, APRN (Advanced Practice Registered Nurse). She said she saw him off and on throughout his stay here. He was here for awhile." I was notified of the elopements if I was on call, or the next day when I came in. I reached out to case management and asked what happened or where did he go, and I asked the nurses on the floor." She said she doesn't recall if they did any medication changes for his elopements. "I am not really involved in what they do for a patient after they have eloped. He was cognitively impaired. I did put orders in for a sitter. I don't now if they provided him a sitter. The majority of the time he didn't have a sitter. If he did it might have been at the very early stages of his admission."

On 9/6/24 at 10:42 AM a telephone interview was conducted with Staff R, Security. He said he recalls one elopement he participated in. "Patient #2 was outside. He was across the street by the water at the bus stop by the hospital. It was sometime last year. I was told there was a missing patient. I was told he took off from the back door of the unit. We went on search and I found him across the street with a staff member. We tried to talk him into coming back. The bus came and he got on. The staff member who was with him was trying to take him off the bus. I think it was a nurse. She wanted me to intervene but I told her I am not allowed to touch a patient like that. Then the bus left with the patient. The director of risk told me I should've gotten on the bus with him so I could relay where he was at. I told her that was not my job to do that. I am security for the hospital. The police were called and they searched and found him down town at a bus area in Bradenton." He said he was not sure how far way it is. "It's near the courthouse." He thinks it's about three miles away. "There have been several times in the hospital where we found him in the hall. I recall three different times responding to him. One time he was sitting on the floor by the ice machine and I talked him into returning to the unit. Another time I found him by the Labor and Delivery unit around the corner from his unit and talked him into returning. I went to 4 North Tower where he was right before he took off. He was right outside in the hallway near his room a couple doors down on 4 North Tower. I talked him into to going back to his room. He said he wanted to leave the hospital. He wanted to go to Miami to see his daughter. He was very agitated and pissed off about being there. I would say he was high risk for eloping, yes. We had a security guard who worked with us who wanted to put a cheap door alarm on the back door of the unit. He was told we couldn't because that wasn't allowed." He said he has responded to other patients who eloped. It was two other times with two different patients. 2 ER (emergency room) patients; one who was baker acted. It was awhile ago. "We look at the cameras and have other security looking for the patient. There are cameras on all exits and there is security watching it at all times. We have one security guard posted at the ER. We have an older lady who works at the lobby desk who checks visitors in and calls if she sees something, like a patient with a gown and IV pole trying to leave. I think it could be worked on better personally."

On 09/05/2024 at 9:51 AM observed the T Elevators which open in the lobby and goes to the 4th North Tower. Observed the main entrance with Highway 41 to the left when you exit the main lobby and the ocean to the right upon exiting. (photo evidence #2 obtained).

During an interview on 09/05/2024 at 10:22 AM with the Staff H, clinical leader, 3 Main. Staff H disclosed that her area of concern is elopement risk, and she had addressed it with administration. She disclosed that about a year ago the police had to bring a patient back to the hospital (patient #1).

On 09/05/2024 at 1:02 PM a tour was conducted on the 4th floor North Tower with escort from Staff E. continued down the hall to the stairwell which required a badge to access, or an alarm would go off. Went into the stair well down to the 1st floor with the exit door (not requiring a badge to exit) the door opens to the left side of the lobby entrance with no way to reenter the stair well. The right side of the exit door is the loading dock. Photo evidence obtained (photo evidence #3).

During an interview on 09/05/2024 at 2:00 PM with Staff C Risk Manager. Staff C Risk Manager disclosed that she was not aware of Patient #4 elopement.

During an interview on 09/05/2024 at 3:00 PM with the Director of Quality. The Director of Quality disclosed that she was sure that the patient #4 had a sitter before the event of the patient being found in the lobby. The Director of Quality read the progress note that revealed the sitter was previous requested, the director stated they should not write that.

During an interview on 09/06/2024 at 11:03 AM with Staff C, Risk Manager (RM), she said Patient #1 eloped one time and the police returned the patient, and the second time he wandered and was found in the medical office building on 3 Main. The RM confirmed there were no notes found for the 11/20/2023 elopement.

At 1:07 PM on 9/6/24 a telephone interview was conducted with Staff F, Charge Nurse, night shift, 4 North Tower. Staff F said she usually has two patients. "I don't remember how many patients I had when I had Patient #2. I think it was only two patients. He was one of the patients who was assigned to the charge nurse because he was medically stable, so we could help the other staff. He was on my unit close to a year I think. He had not eloped before on night shift. I think he might have on day shift. It's a big unit. It's connected to another one. I guess he would go to the other unit and walk around. He would come out of his room and go to the nurses' station, or sit in the waiting room by the nurses' station. If we were busy and no one was around he would go back to his room and wait for his meds. I was aware he was an elopement risk. It was around 8 something. I saw him in the waiting room and I told him too go to his room and I was going to give him his meds. We don't have a secretary on nights so I have to answer call lights. A supervisor called me to ask a nurse something about telemetry for a specific patient. I went and told the nurse, then I went to get Patient #2's medications and came in his room and he wasn't there. So I went to the waiting room and the nurses' station and he wasn't there. I looked in other patients' rooms because he was found in other patients' rooms sometimes, but I didn't find him so I went back to the nurses' station and I called security and the supervisor. They started searching for the patient. I had to take care of the unit and call the police. The police came and asked me some questions. In the morning I went in my car and searched for him. Then the police called and said they found him in Miami a couple days later. We try to use sitters and more staff." It was a time when there was a staffing challenge. "Transfer them to a smaller unit. He was close to the nurses' station and most of the time, he wasn't on a fall alarm because he was steady on his feet. Pretty much just close supervision. Most people knew he was a risk and kept a close eye on him. He was wearing a hospital gown. He would wear a sweater and we found some scrub pants for him. I saw him a few times that night. I was in shock. He was very often in the waiting room. In my mind he was planning in it, because he knew exactly what to do. The last time I saw him was between 8 and 9. It was the time when everybody is passing meds. He was waiting until it was clear. The lights go off that time too. He probably went down in the elevator. I don't think he had any street clothes. Only a sweater. I gave him some sandals because he would walk around. Pajama pants that are like scrub bottoms for males, so they don't walk around exposed. He was delusional. You could have a whole conversation with him. He could remember my name and other nurses' names. He would say he owned his own business, and the doctors were trying to keep him here. You would think he was normal if you sat in the waiting room and talked to him. I didn't know he had a guardian. I was told he didn't have anybody. He spoke in Spanish primarily and some English. There were times he was very upset that he was in the hospital and said we were retaining him for money. He was very delusional."

At 2:29 PM on 9/6/24 Staff S, House Supervisor, night shift was interviewed. She said Patient #2 eloped one time on her shift. December of 2023. "If it's a big enough to involve us, they will bring it to our attention so we are aware. I was aware he had eloped before. Aware he had eloped in the past. We all knew Patient #2 because he had been here a long time. He was close to the nurses' station and he was always in the day room, so when we were doing rounds, we would actually go check on him and make sure he was doing ok. I got a call just before 9:00 from the charge, Staff F. She said she had seen him and I asked her to go get some patients off telemetry (cardiac monitors). We were looking at triaging patients off telemetry if they didn't meet telemetry criteria. Staff F had him. They got him some food and then he asked for a drink. She went to get him a drink and that's when they found he was missing. I contacted security and discussed with them how to locate the patient. I looked for the patient. We also contacted law enforcement. It was around 9:00 PM that I contacted security. Patient #2 was not found. Security went around hospital property and stairwells. They also went around the hospital in their truck looking for him. The police were notified he was a missing person. I had conversations with my leadership, but I didn't have a meeting with management. We had discussions after about what we could do to prevent this. We had eyes on him just before he went missing. We did everything we could to keep it from happening, to the best of our ability. The only thing that could have made a difference was a true lock down unit, which we don't have. They tried to give him some ability to have some freedom. They were closely monitoring him because they all knew he was a risk. I don't know what else we could have done to make a difference. We do use sitters when necessary. I couldn't tell you if and when he had a sitter.

During an interview on 09/06/2024 at approximately 3:03 PM with Staff M, Director disclosed that patient #1 was in room 433 and the majority of his time in the hospital he was in this unit. She disclosed that he eloped several times from here and was found in the loading dock. She is unsure how he left the unit because you need a badge to exit in the stairwell.

Policy Review of Plan for Patient Assessment and Reassessment, dated 7/5/23, reflected the following:
Purpose:
The goal of patient assessment/is to determine the aspects of care required to meet the patient's initial needs as well as his or her needs as they change in response to care. All clinicians will complete a focused re-assessment related to any change in patient condition, immediately following that change in condition.
Policy:
Each patient's needs for care or treatment is assessed by qualified individuals of appropriate disciplines throughout the organization. This assessment begins at the time of admission and throughout the patient's contact with MMH. Assessment includes the collection and analysis of physiological, psychological, social, environmental information. The patient's care needs and the Individual Plan of Care (IPOC) are also required for diagnosis and treatment of the patient are also assessed. Patient assessment is interdisciplinary in approach. The importance of input from various members of the team is valued and supported at MMH.
Each discipline is responsible for the assessment and re-assessment of patients under there care. Each discipline must consider the importance of integrating information form the various assessments of the patient to identify and assign priorities to the patient's care needs.
Registered nurse: The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care.

Policy and Procedure title, Nursing Standards of Patient Care, was reviewed, dated 04/18/2023 ...This policy identified appropriate nursing care/ interventions that each patient shall receive relative to their needs and individual outcomes... Intervention- Each patient will have nursing care intervention available to meet his or her needs ...individual care based on identified medical needs and physical limitation ...Nursing care. Intervention designed to promote a safe, risk free environment; i.e...reporting of potential and actual risk factors ...