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Based on medical record review, document review and interview, the facility failed to protect patients at risk of elopement. Specifically, the facility failed to conduct patient assessment for risk of elopement, identify patients at risk for elopement, and implement appropriate preventive measures for elopement.

A serious adverse outcome occurred as a result of this failure and may result in serious adverse outcome to other patients.

This was identified in one (1) of 30 medical records reviewed. (Patient #1)


Findings include:

Review of the Medical Record for Patient #1 identified: 69-year-old patient who was brought into the ED by ambulance from the nursing home on 1/14/2022 at 11:01 PM, for complaint of abdominal pain for three days. The patient was triaged at 11:08 PM. A Columbia-Suicide Severity Scale (CSSR) Initial Screening revealed no risk. There was no documented evidence the patient was assessed for risk of elopement.

The patient received physician evaluation and medical work-up was done and on 1/15/2022 at 6:58 AM, the physician discharged the patient back to the nursing home. The patient remained in the ED awaiting transportation. At 1:00 PM, ED nurse's note revealed the patient was not on bed and a search, and notification of charge nurse and security done.

A review of the Security Department video review report, noted on 1/15/2022, the patient was found twice leaving the Main ED area to the Waiting Area and Security Officer escorted the patient back into the emergency room. The Video review report validated the patient left the facility on 1/15/2022 at 12:36 PM.

A media report indicated an automobile accident on 1/15/2022. The pedestrian was attempting to cross the Brooklyn-Queens Expressway and was hit by a car. Subsequently, the victim was sent to another hospital and expired on the same day.

The survey team validated this information and confirmed the pedestrian victim was Patient #1.

See Tag A 144.

Based on medical record review, document review and interview, the facility failed to protect patients at risk of elopement. Specifically, the facility failed to conduct patient assessment for risk of elopement, identify patients at risk for elopement, and implement appropriate preventive measures for elopement.

A serious adverse outcome occurred as a result of this failure and may result in serious adverse outcome to other patients.
This was identified in one (1) of 30 medical records reviewed. (Patient #1)


Findings include:

Review of the facility's policy, "Elopement and Leaving Against Medical Advice (AMA) by Adult Inpatients," original effective date 09/2021 states:
"The Registered Nurse (RN) will assess all patients for risk of elopement and leaving against medical advice (AMA) at certain intervals including:
At any time during a patient's stay if staff is concerned that the patient is exhibiting behavior indicating risk for elopement/AMA.
The RN will assess all patients for risk of elopement upon admission to the Emergency Department (ED)."


Review of the Medical Record for Patient #1 identified: 69-year-old patient who was brought into the ED by ambulance from the nursing home on 1/14/2022 at 11:01PM, for complaint of abdominal pain for three days. The patient was triaged at 11:08PM. A Columbia-Suicide Severity Scale (CSSR) Initial Screening revealed no risk.

There was no documented evidence the patient was assessed for risk of elopement.

The patient was evaluated by the ED physician at 11:15 PM. Lab work and assessments were completed at 5:00 AM, 1/15/2022. The patient's diagnoses included Bipolar disorder, Depression, Hypertension and Schizoaffective Disorder, of which the patient was on medication (Risperdal 2 mg by mouth two times a day). Patient was re-evaluated by the physician at 5:18 AM with plan to be discharged back to the nursing home. On 1/15/2022 at 6:59 AM, the physician documented the patient for discharge and completed the transportation form request, untimed. On 1/15/2022 at 10:50 AM, the ED nurse's note documented patient was waiting for transportation. On 1/15/2022 at 1:00 PM, ED nurse's note revealed the patient was not on bed and a search and notification of charge nurse and security done.

A review of the Security Department video review report, noted, on 1/15/2022 at 11:30 AM, a Security Officer was seen talking to the patient to go back to the ED and escorted patient back into the emergency room (Elopement attempt #1). A second attempt, untimed, the patient attempted to leave again, and the same Security Officer escorted the patient back into the emergency room. The patient was relocated from Asthma Bed #2 to Bed #16. Video review report validated the patient left the facility on 1/15/2022 at 12:36 PM.

There was no documented evidence patient's elopement behavior was reported or escalated.
There was no documented evidence the patient was reassessed for risk for elopement and measures to prevent elopement were put in place when the patient demonstrated elopement behavior.

During interview with Staff H, Triage Nurse, on 4/29/2022 at 11:30 AM, after review of the record, Staff H stated she was not sure if she did the elopement assessment. Staff H stated elopement assessment was not on her triage notes and cannot recall if Patient #1 was at risk for elopement.

During interview with Staff A, Director of Security on 5/2/2022 at 9:45 AM, staff stated the patient was found twice leaving the Main ED area to the Waiting Area.

During interview with Staff A, Director of Security, Staff B, ED Charge Nurse, and Staff C, ED Chairman on 5/2/2022, staff stated the patient's elopement attempts should have been reported to ED nursing staff by security.

On 4/29/2022 at 1:32 PM, during interview with Staff D, Director of Risk Management, staff stated per media report, patient was killed on that night and did not know exactly what happened.

The survey team validated this information from a media report which indicated an automobile accident on 1/15/2022. The pedestrian was attempting to cross the Brooklyn-Queens Expressway and was hit by a car. Subsequently, the victim was sent to another hospital.

Contact with the other hospital confirmed the person in the automobile incident report was Patient #1. The patient was transported to this facility on 1/15/2022 and expired the same day.


During interview with Staff T, facility's Administrator, Staff S, Director of QA, and Staff U, Director of Nursing, on 4/28/2022, 4/29/2022 and 5/2/2022 AM, the following information was obtained:

-Staff was requested for QA minutes, any QA review of the case, including a root-cause-analysis, and/or any room for improvement identified? Staff stated there was no QA review conducted for Patient #1.

-Staff was requested for documented evidence of re-training on elopement for the ED clinical staff in response to the elopement event. Staff stated the ED clinical staff (Nursing and Licensed Independent Practitioners-LIPs) were re-trained.
Staff was asked for documented evidence as proof of completed elopement training for ED Licensed Independent Practitioners (LIPs). Staff stated the person in charge, ED Chairman for the ED LIPs elopement training was out on leave. The case was discussed including elopement education during the Physician QA meeting of January 19, 2022.

-Staff was requested for in-patient clinical staff re-training in response to the elopement event. Staff stated the in-patient clinical staff were trained on September 2021 during the roll out of elopement process in EPIC (electronic medical record system), and there was no re-training in response to the elopement event.

-Staff was also requested for proof of completed elopement training for security officers in response to the event. Staff responded there was no elopement training for security officers in response to the event.


An Immediate jeopardy was called on 5/5/2022 at 1:00 PM and the facility's administrator and leadership were notified. The facility failed to (a) assess all ED patients for risk for elopement, identify at risk for elopement, and implement measures to prevent elopement as per facility protocol, (b) ensure elopement education was provided to all ED applicable staff, including security officers and (c) re-training of all In-patient RNs in response to the elopement event.


The facility provided an IJ Removal Plan to survey staff on 05/05/2022 at 7:30 PM. The plan included:
(a) Elopement Education for all Security Officers and Inpatient RNs to be completed 5/9/22 and 6/4/22 respectively. Staff who had not completed training will not be allowed to return to work until such time that they complete the training on elopement.
(b) Training Security Officers on "Security Escalation to the Charge Nurse and Security Supervisor for Identification of Elopement Behavior by Patients." Training is to be completed by 5/9/22. Security Officers will not be allowed to return to work until such time that they completed the training by 5/9/22.


On 5/6/2022 at 4:00 PM, IJ was removed as confirmed by an onsite verification by survey staff.