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Based on observation, document review, review of video, and staff interview, the facility failed to:

(a) Ensure a safe environment for patients who had been placed on elopement precautions due to aggressive behavior, and acute psychiatric condition.

(b) Ensure that its policies and procedures for "Elopement Prevention and Response" and "Levels of Patient Observation" were implemented.

This placed patients at risk for elopement and potential harm.


Findings include:

See citation Tag A 144.

Based on medical record review, document review, video record review, and staff interview, the facility failed to:

(a) Maintain a safe environment for patients on elopement precautions assessed with aggressive, and acute psychotic condition.

(b) Ensure that its policies and procedures on 'Elopement Prevention and Response Protocol', and 'Levels of Patient Observation' were implemented.

These findings were noted in two (2) of six (6) medical records reviewed. (Patient #s 2, and 3).

These failures placed patients at risk for elopement and potential harm.

Findings include:

Review of the facility's "Levels of Observation" Policy and Procedure, Revised Date 10/15, documented the following:
"The purpose of this policy is to define the appropriate level of observation needed by both behavioral and non-behavioral patients, and staff's responsibility in providing that care.

Levels of Observation:
1. Arm's Length-Continuous Observation
2. Continuous Observation Behavioral
3. Continuous Observation Non-Behavioral
4. 15-minute Behavioral Watch
5. Routine/Unit Awareness Rounds

Review of the facility's Elopement Prevention and Response Protocol, Revised Date of 10/15 documented the following:

· "Upon assessment, patients who lack the ability to make relevant decisions and/or are not capable of protecting himself/herself from harm will have elopement protocol activated;

· Elopement Precaution" order will be entered into patient's medical record;

· Elopement Precaution patient will be visually identified by staff by designated ID band and yellow gown;

· Patient's belongings and valuable will be secured;

· Continuous Observation-Non-Behavioral will be ordered if deemed necessary (Refer to Administrative Policy-Levels of Observation)

· Security staff will assist in continuous surveillance and safety monitoring."

Review of medical record (MR) for Patient #2 revealed a 31- year- old male who presented to the Emergency Department (ED) on 1/15/18 from home accompanied by Emergency Medical Services (EMS)/New York Police Department (NYPD).

The ED Triage Nurse documented chief complaint, "patient stated hearing voices, seeing things, acting inappropriately, and used Xanax from the street."
Triage Assessments/Screening documented the patient was placed on elopement precautions.

On 1/15/18 at 10:24 AM, the ED physician ordered "Elopement Precautions."

On 1/15/18 at 10:36 AM, the Physician's Health and Physical Information (HPI) documented initial impression: Erratic behavior with Auditory and Visual Hallucination. The patient requires further psychiatric evaluation in the ED.

The patient was admitted to a Medicine Unit (3 North) on 1/15/18. The patient was evaluated by the psychiatrist who noted that admission was strongly advised.

A Registered Nurse Admission note dated 1/16/18 at 12:19 PM indicated patient was on continued Elopement Precautions and a physician's order for "Elopement Precautions" on 3 North Medicine was documented.

The Nursing Plan of Care dated 1/16/18 at 4:33 PM documented for Safety: the patient was at risk for elopement. Behavior was restless. Short and long-term goals: maintain patient safety. Plan/Interventions: Visual rounding every 15 minutes.

There was no documented evidence that a designated level of observation was ordered.

On 1/17/18 at 1:36 PM, a physician's order for "Elopement Precautions" was documented.

Resident's Patient Care Event Note dated 1/17/18 at 7:05 PM documented, "Time of event: 6:45 PM, the physician was notified by the unit clerk that patient was seen by security downstairs wearing yellow gown in parking lot. Patient eloped without anyone's knowledge. Patient on elopement precautions. Family notified that patient absconded. Confirmed patient reached home."

There was no Level of Observation ordered for Patient # 2 in the Emergency Department, and in 3 North Medical Unit where the patient was admitted. In addition, there was no documentation in the medical record that indicates the frequency at which the patient was monitored.

The review of video surveillance for 1/17/18 showed that at 6:31 PM, the patient was observed walking past the concierge/information desk, walking from the inside of the hospital out to the lobby. Staff Y, Security Officer (SO) was observed following the patient. In the middle of the lobby, Staff Y was interacting with the patient, looked at the patient's ID band, and then left the patient.

At 6:33 PM, as soon as Staff Y left the patient, the patient was observed walking toward the lobby's entrance/exit door.

On 4/16/18 at 10:00 AM, Staff J, a Post Graduate III (Resident) from Medicine was interviewed regarding the elopement of Patient #2.
Staff J stated that Patient #2 was on Elopement Precautions on 3 North. The unit clerk received a call from a Security Guard that this patient was in the lobby wearing a yellow gown. The Officer had checked the patient's identification band. The Guard was instructed to get this patient back to the floor, however, this patient did not want to return to his unit. The Guard was unable to prevent the patient's exit from the Hospital.
Staff J explained that a patient search was conducted, but the patient was not located. Staff J stated this patient was on Elopement Precautions. Patients on Elopement Precautions wear a yellow gown. The physicians must write orders for Elopement Precautions and the Levels of Observation. Staff J acknowledged, the patient did not have a level of observation ordered.

On 4/26/18 at 11:00 AM, Staff L, Director of Medical/Surgical Nursing on 3 North and 2 North was interviewed. Staff L acknowledged this patient was not on any Level of Observation. The Physician must order the level of observation that is required for each patient.

Review of medical record for Patient #3 documented that this 13-year-old male patient called 911 from home, and was brought to the Emergency Department by NYPD/EMS with a chief complaint of abuse.

The triage note dated 3/27/18 at 6:35 PM documented chief complaint of "some guy assaulted me." Patient complained of right hand pain status post assault by mom's boyfriend.
A physician's order for "Elopement Precautions" was documented.


The patient attempted to leave the ED after five minutes of arrival . The patient ran down the hallway. Security was called for assistance. The patient required restraint by security officers. The patient was transferred back to the ED.

ED Attending Progress Note documented the patient will be closely monitored.

ED Physician Progress Note dated 3/28/18 documented that he was notified by the staff that patient was not in his bed. Search was made, and the patient could not be located.

There was no Level of Observation ordered for Patient # 3 in the Emergency Department and there was no documentation in the medical record that indicates the frequency at which the patient was monitored.

Review of the video surveillance of the elopement event of 3/28/18 revealed the following:
On 3/28/18 at 3:06 AM, a female NYPD (New York Police Department) Officer was observed watching the patient's area/stretcher. The patient was not captured by the camera. Staff X, Assistant Director Hospital Security Officer validated that the patient was behind the curtain.

At 3:17 AM, the female NYPD Officer left the patient in the ED with another male NYPD Officer.
Staff Q, SO was observed on the scene watching the patient area.

At 3:23 AM, a female, and male visitor were observed walking toward the ED, and then toward the patient's bedside. The patient was observed coming out behind the curtain in a yellow gown. The male visitor was holding a transparent plastic bag with clothing in it.

At 3:24 AM, Staff Q, SO was observed interacting with the visitors, and the patient.

At 3:25 AM, during the Staff Q, and visitors' interaction, the patient was observed taking off his yellow gown and getting dressed.

At 3:26 AM, Staff Q, SO was observed walking toward the nursing station.

At 3:27 AM, when Staff Q, SO was at the Nurses' Station, the patient was observed walking briskly from the ED with a sweater in his hand, and walked toward the direction of the ED Entrance/Exit. Staff Q turned to where the patient and visitors were, however, at this time, the patient was no longer seen in the ED. Staff Q, SO was observed looking for the patient. Staff Q walked toward the direction of the ED Entrance/Exit.

The video showed that the patient was not being monitored by the clinical staff.

On 4/20/18 at 3:53 PM, an interview with Staff A, ED Primary RN was conducted. Staff A stated that the patient was placed on Elopement Precautions only, and no level of observation was ordered and therefore, no observation flowsheets were completed.

On 4/23/18 at 10:22 AM, Staff P, Hospital Security Officer (SO) was interviewed . Staff P stated that he was not aware that the patient was on visitor restrictions. He stated that Hospital Security Central Command Office would let them know if there are any restrictions.
Staff P added that pediatric elopement patients are always monitored by the nurse.

On 4/23/18 at 10:46 AM, Q, Hospital SO was interviewed. Staff Q, SO stated, "Two (2) family members came and told me that they received a call that the patient is for discharge. I told the family that the patient is not for discharge. I saw they have a bag of clothing. I went to the doctor in the nurses' station to ask if the patient is for discharge. Before I could tell the doctor, I told my co-worker to watch the patient. I was not sure if he heard me. When I turned around, the patient was gone." Staff Q stated that he immediately called for assistance.

On 4/23/18 at 1:08 PM, an interview with Staff T, RN Director of the ED Nursing was conducted. Staff T confirmed that the patient was on elopement precautions which would mean patient would be on a yellow gown, has ID band, and clothing secured. There was no observation sheet or form because the patient was only on elopement precautions.
Staff T acknowledged that there was no level of observation ordered for the patient. Staff T explained that the elopement and level of observation policies are the same for pediatrics and adults and explained that the level of observation must be ordered by the doctor based on the nurse's and doctor's clinical assessment of the patient.

There was no indication that Patient #2 and #3 had orders for continuous observation and there was no indication that Security Staff conducted continuous surveillance and safety monitoring of patient #3. In addition, staff failed to secure the patient's belongings (clothing) as required the Elopement Prevention and Response Protocol.

Based on document review and staff interview, in one (1) of 6 medical records reviewed for elopement precautions, there was no evidence that the Quality Assessment & Performance Improvement (QAPI) Committee performed a comprehensive review of a patient elopement that occurred on 1/17/18. (Patient #2)

In MR#2, the patient eloped from a Medical Surgical Unit on 1/17/18 while on Elopement Precautions.

The QAPI Committee did not identify that Patient #2, who presented with erratic behavior and visual/auditory hallucinations, did not have an order for a level of observation and was not monitored in accordance with the facility's policies for 'Elopement Prevention and Response" and "Levels of Observation."

In addition, the QAPI Committee did not implement measures to prevent a recurrence of patient elopements.

On 4/26/18 at 10:10 AM, Staff F, Vice President QA/Risk Manager stated that the only investigation of the elopement was from the Security Department.