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Based on medical record (MR) review, document review, and interview, in three (3) of four (4) MR reviewed, the facility failed to implement physician orders for observation of patients identified as an elopement risk.


Findings:

The facility failed to ensure nursing staff implement physician orders for constant observation [1:1] of patients identified as an elopement risk.


See Tag A-0144

Based on medical record (MR) review, document review, and interview, in three (3) of four (4) MR reviewed, the facility failed to implement physician orders for observation of patients identified as an elopement risk.

Findings:

A) Review of Patient #9's MR identified the following: Emergency Department (ED) nursing triage note on 09/07/2023 at 3:21AM, revealed the patient was brought in by staff from a psychiatric hospital for a wound check. The RN risk assessment at 3:25AM, identified the patient as "At Risk" for elopement. "At Risk" for elopement prompted the following prevention strategies: (1) Implement visual cues- safety gown, arm band, epic banner, and secure clothing; (2) notify physician the first time the patient is screened "At Risk" (3) Continue to "Hight Risk" elopement questions".

ED Physician History and Physical (H&P) note at 3:41AM, documented that the patient eloped from an inpatient psychiatric facility and the family brought the patient to another CPEP (Comprehensive Psychiatric Emergency Program) facility to resume psychiatric care. This facility brought the patient in for a wound check.

The ED Registered Nurse (RN) note on 09/07/2023 at 7:21AM, revealed that the patient was admitted to the medical- surgical unit.

The provider (MD) note on 09/07/2023 at 3:28PM, documented that they spoke with the patients family, who stated that the patient has a history of elopement from 2 (two) other facilities. The MD order on 09/07/2023 at 6:12PM, stated the following: "Observation Constant- Distant for Unpredictable Behavior" [1:1].

The MD noted on 09/07/2023 at 11:11PM, the patient eloped.

There was no documented evidence that the constant observation [1:1] was implemented.

The facility P&P titled "Levels of Observation," last reviewed on 03/14/2023, directed nursing staff conducting constant [1:1] observations to remain within 6 (six) to 10 (ten) from the patient with constant and direct visualization at all times ... and document every hour.

During interview of Staff J, Clinical Informatics on 03/04/2024 at 10:53AM, Staff J confirmed that there was no documented evidence that the constant observation [1:1] documentation was present in this chart.

During interview of Staff P, Director of Critical Care Services and Staff M, Clinical Nurse Manager on 03/05/2024 at 11:23AM, Staff P and M stated that Staff R, PCA was assigned to a section which included 16 patients, but not as a constant observation [1:1] as ordered.


B) Review of Patient #10's MR identified: This 52-year-old presented to the ED on 9/14/2023 at 3:00 PM, reported she felt headache, dizzy, then collapsed. She denied any injuries from the fall. The ED provider documented that the patient "has poor focus and is difficult to examine. She provides little history. She states she is on Aspirin and Plavix but denies any other blood thinners. Patient stated having right sided numbness and tingling."
Stroke evaluation was immediately started.

On 9/14/2023 at 7:15 PM, the ED physician documented, the patient verbalized the desire to go home, however the patient was deemed to lack capacity to refuse admission. For further management, Psychiatry consult was initiated.

On 9/14/2023 at 7:30 PM, the ED physician ordered, "Observation Constant-Distant for Unpredictable Behavior" [1:1] to start at 7:31 PM.

On 9/14/2023 at 7:42 PM, the ED RN acknowledged the orders.

On 9/14/2023 at 7:50 PM, the ED Physician documented that the patient was in the area after shift change; the patient was not found in her bed, and neighboring patients reported patient walked out.

On 9/14/2023 at 10:07 PM, Psychiatry documented, consults to evaluate capacity for patient to leave against medical advice in the context of severe headache and brain aneurysm. The psychiatry team was unable to locate patient, who was not in her designated bed. The psychiatrist spoke to ED physician who confirmed that the patient had eloped from the ED.

There was no documented evidence in the MR that the constant observation [1:1] was implemented.

The facility policy and procedure (P&P) titled "Elopement/ AMA [Against Medical Advice]," last reviewed 09/19/2023, directed nursing staff to complete the elopement risk assessment tool and implement risk prevention strategies as appropriate based on answers to the screening questions.

C) Review of the medical record for patient #6 identified: This 36-year-old presented to the ED on 1/13/2024 at 12:03 AM. Patient stated "he took half of his cigarettes from a woman who was a passenger in the back of his taxi ..."
Patient denied suicide or homicide ideations and/or hallucinations. However, patient exhibited manic behavior while telling his story.

The RN triage note on at 12:33AM, indicated the patient was evaluated in the ED appeared calm and cooperative. Elopement risk assessment did not identify any risk factors for elopement.

On 1/13/2024 at 1:49AM, the ED Physician Assistant (PA) assessed the patient and ordered "Observation Constant - visual and distance for unpredictable behavior" [1:1].

The RN's note on 1/13/2024 at 1:55AM documented Staff I, Patient Care Assistant made aware, "patient was placed on close observation [1:1]."

An addendum RN's note on 1/13/2024 at 2:15AM documented, the patient was not in area, inquired technicians and other nurse's whereabouts of the patient and the writer was informed that the patient is in the bathroom. The bathroom was checked, and the patient was not there. The ED PA and supervisor were informed. The patient was not found after a facility wide search.

An addendum RN notes on 1/13/2024 at 5:53AM documented, patient contacted, writer was informed by the patient that he "left the ED because he was really hungry and starving so he ran home to eat. Patient was asked to return to ED and he stated he will return in the morning after he sleeps ..."

There was no documented evidence that the patient was placed on constant - visual and distance observation as ordered by the PA.

Review of PCA assignment sheets from 1/12/2024 night shift (11:00PM to 7:00AM) 1/13/2024, revealed Staff I, PCA was assigned two (2) other patients on the night of 1/12/2024 to AM of 1/13/2024.


During interview on 3/01/2024 at 12:40PM, Staff G, Emergency Department Chairman, confirmed "it was a true elopement."

During interview on 3/4/2024 at 9:10AM with Staff I, Night PCA from 11:00 PM to 7:00 AM, stated that she could not recall the incident. After reviewing the documentation in EMR (Electronic Medical Record), the Staff I was able to recall the incident, but could not provide an explanation for the lack of "close observation 1:1".

This finding was acknowledged by Staff B, Director of ED Nursing, who was present during the interview, confirmed that the patient did not receive constant - visual / distance observation as ordered by the PA.



An Immediate Jeopardy (IJ) situation was identified on 3/6/2024 at 3:12PM, due to the facilities failure to implement physician orders for observation of patients identified as an elopement risk.

The facility provided an IJ removal plan to survey staff on 03/06/2024 at 8:15PM. The IJ removal plan included:

1.Re-education on the Elopement/ AMA [Against Medical Advice] policy to all nursing staff.
2.Initiate education on the updated ED tracker to increase visibility of patient observation status, to all ED nursing and medical staff.

The Facility provided IJ plan was accepted on 03/06/2024 at 8:25PM.

The IJ was removed on 03/07/2024 at 2:20PM based on onsite verification of the facilities implementation of the IJ plan.

100% of staff interviewed on 3/7/2024 received education on the IJ removal plan and verbalized knowledge of elopement/ AMA policy; observation of patients, and staff responsibilities regarding a patient on Constant [1:1] observation.

Based on document review and interview, the facility did not to utilize its Quality Assessment and Performance Improvement (QAPI) Program to ensure that all safety incidents/occurrences were quantified, analyzed and corrective actions implemented.

Findings include:

Review of the facility's Performance Improvement and Patient Safety Council [PIPS] minutes from September 2023 to February 2024 revealed, the facility only report on the top 2 (two) safety events, and top 2 (two) RCAs (Root Cause Analysis) every month.

There was no documented evidence in the PIPS QAPI minutes that elopements were integrated in the safety events for reporting. tracking, analysis and trending of elopement incidents.

During interview on 03/05/2024 at 9:32AM, Staff E, Network Director of Quality, and Staff O, Director for Performance Improvement, confirmed that Risk Management only reports on the top 2(two) safety and RCAs.