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Based on observation, interview, and document review, the hospital failed to ensure 1 of 10 patients reviewed (P1) was provided adequate assessment and supervision to prevent elopement. P1 subsequently eloped from the hospital in below-freezing temperature(s) and was found approximately five blocks away from the hospital campus with skin abrasions due to falling. As a result, the hospital was found out of compliance with the Condition of Participation - Patient Rights at 42 CFR 482.13.

A condition-level deficiency was issued.

Findings include:

See A-0144; The hospital failed to ensure demonstrated behaviors of potential elopement were assessed, and safety interventions provided, to reduce the risk of elopement for 1 of 1 patients (P1) reviewed who eloped from the hospital and was outside for an extended period of time. This resulted in an immediate jeopardy (IJ) situation for P1.

See A-0145; The hospital failed to ensure an allegation of potential neglect was reported to the State Agency (SA) and addressed in accordance with established policies and procedures for 1 of 1 patients (P1) who eloped from the hospital.

Based on observation, interview, and document review, the hospital failed to ensure demonstrated behaviors of potential elopement were acted upon and safety interventions provided to reduce the risk of elopement for 1 of 1 patients (P1) reviewed who eloped from the hospital while infected with COVID-19 and was outside for an extended period of time. This resulted in an immediate jeopardy (IJ) situation for P1 who sustained skin abrasions, fall(s) and was exposed to below-freezing temperatures when he eloped.

The IJ began on 11/16/20, when P1 repeatedly voiced he wanted to leave the hospital, and attempted to walk-out with his belongings. This action was not assessed or acted upon to ensure adequate supervision or safety of P1 to help prevent elopement. The following day, on 11/17/20, P1 was returned to his room after his discharged was abruptly canceled, but his bed-exit alarm was not activated at the nurses' direction which allowed him to leave the unit unsupervised. P1 subsequently eloped from the hospital. P1 was found approximately five (5) blocks away nearly two hours later and returned to the hospital with several skin abrasions and early signs of hypothermia. The regulatory officer (RO)-A, chief nursing officer (CNO) and administrative assistant (AA)-A were notified of the IJ on 12/1/20, at 9:36 a.m. The IJ was removed on 12/3/20, at 10:28 a.m. when an abatement plan was successfully implemented; however, condition-level non-compliance remained.

Findings include:

P1's family member (FM)-A was interviewed on 11/30/20, at 8:20 a.m. P1 admitted to the hospital in early October 2020, due to being struck by a bicycle while out walking, which caused P1 to strike his head and have a traumatic brain injury which required surgery. P1 had the surgery, and progressed to eventually being transferred to the rehabilitation unit for care. P1 remained on the rehabilitation unit until he was actually set to discharge from the hospital; however, he then tested positive for COVID-19. P1 was then moved do a different unit for further care until 11/17/20, when FM-A voiced P1 "went missing" from the unit, and subsequently left the hospital unsupervised. FM-A verified P1 was actively infected with COVID-19 when he eloped from the hospital, and explained she learned of the incident when P1 had called her yelling about falling down "over and over again in the snow banks" on the night of 11/17/20. P1 had left the hospital unsupervised, and was found several blocks away from the hospital campus which FM-A stated was upsetting to her as the weather had been "icy cold" and P1 could have suffered frostbite or been seriously injured being outside unsupervised for multiple hours. FM-A continued and explained P1 had been found outside by a passing hospital staff member who then returned him to the hospital. P1 was then complaining about severe back pain, and some x-rays were completed. FM-A stated P1 voiced to her that he "thought [he] was going to die out there." FM-A again reiterated the entire situation was frustrating and upsetting to her as, prior to 11/17/20, P1 had often times verbalized wanting to leave the hospital and "they knew that," so FM-A questioned why the hospital wasn't monitoring him or supervising him to prevent him leaving. FM-A added, "That's terrible."

A provided CAD (Computer Aided Dispatch) Operations Report, dated 11/17/20, identified the local police department's record of the incident described by FM-A. The department received a call from registered nurse (RN)-C on 11/17/20, at 4:24 p.m. who reported P1 as missing. The initial correspondence outlined P1 as being unable to make his own decisions, and being COVID-19 positive. P1 had left the hospital on foot sometime after 2:45 p.m. according to the dictation. Further, the later correspondence of the report identified the officer arrived to the hospital at 5:25 p.m. and was told the patient had been found, and returned with complaints of back pain. Further, a Preliminary Local Climatological Data report dated 11/2020, identified the area's weather for the month of November. The report identified 11/17/20, as having a maximum temperature recorded of 31 degrees (F).

On 11/30/20, at 12:20 p.m. the hospital's Neuroscience and Spine unit was toured with registered charge nurse (RN)-A present. The unit consisted of several corridors which RN-A described as having "no real shape" and lacking video recording systems. RN-A was interviewed and voiced she had been working the day P1 eloped from the hospital, but had just left the hospital and returned home when she received a notification on her phone about the elopement. RN-A recalled P1 as impulsive who required a sitter "on and off" as a result. RN-A stated P1 was planning to discharge the hospital on the day he eloped; however, the family had appealed the discharge so P1 was returned to his room and then was not found when staff returned. RN-A stated she was unsure how P1 was able to leave the unit unnoticed; however, voiced he did make comments about wanting to leave and go home "all the time," and used a bed-exit alarm for the entirety of his admission to the unit from her recall. RN-A explained P1's "back and forth" of discharging, and then having the discharges stopped, may have contributed to him eloping.

P1's Occupational Therapy Progress Note dated 11/17/20, identified P1 as demonstrating independence with ambulation in his patient room and bathroom; however, the note continued and P1 was recorded as having decreased strength, coordination, balance and activity tolerance coupled with impulsiveness, and decreased safety awareness. The note lacked any recommendations for safety interventions despite the identified impulsiveness and decreased safety awareness.

P1's Social Worker Progress note dated 11/17/20, identified P1 was stable for discharge from the hospital to a local skilled nursing facility (SNF) at 2:30 p.m. However, an insurance appeal was filed and the discharge was canceled as a result. A subsequent Care Plan note dated 11/17/20, identified P1 as having an infection (COVID-19) with occasional dry cough. P1 was listed as having no neurological changes, being independent with his mobility, and discharging to a local SNF with transportation planned for 2:30 p.m. However, an addendum was completed for the note which identified discharge was not possible on 11/17/20, and care management was following P1 for his discharge needs.

P1's Flowsheets dated 11/15/20 to 11/18/20, identified several assessed aspects of P1's care including activity, behaviors and used safety devices. P1 was assessed by the nurses as being a "High Fall with Injury Risk" on 11/17/20, at 7:51 a.m. along with several interventions which included universal fall precautions and, "Alert systems (bed-exit, string monitor, chair pad, bed pad)." These flowsheets recorded P1 as using the bed-exit alarm on 11/15/20, and 11/16/20, with the last dictation being recorded as 11/16/20, at 7:00 a.m. There was recorded dictation on 11/17/20, at 2:38 p.m. which identified P1 as up ad lib and independent with his assistance level.

P1's subsequent Nursing Note dated 11/17/20, at 6:30 p.m. was authored by registered nurse (RN)-C and outlined, "Event: Elopement." The note described staff entered P1's room at 3:30 p.m. and he was not present. The hospital security team, along with the local police department, were notified and a missing person alert was placed. The note continued, "Per security camera, patient is found to be walking out of a hospital door at [3:15 p.m.]. Patient is brought back to his hospital, accompanied by bystanders that ambulated with him ... It was reported that patient fell to his knees at some point during the walk." The note outlined a skin check was completed which found reddened areas on his bilateral knees with gravel present and his fingers were cold with dried blood on his right hand nail beds. Further, the note outlined P1 voiced back pain, so an x-ray was obtained and P1's family had been updated on the event.

On 11/30/20, at 1:11 p.m. RN-C was interviewed and verified she was the nurse assigned to care for P1 on 11/17/20, when he eloped from the hospital. RN-C recalled the incident, and explained P1 was admitted to the unit on the COVID-19 dedicated hallway. P1 was actually set to discharge from the hospital and was dressed and ready to depart in the wheelchair when they were notified the discharge was canceled. RN-C stated she directed the nursing assistant (NA)-A to take P1 back to his room, help him back into bed and activate his bed-exit alarm. However, the shift change then happened and a new NA assigned to care for P1. NA-B, entered his room, and P1 was "nowhere to be found." NA-B notified RN-C and a "quick search" for him was started, along with commencing an overheard page for a missing person. The hospital security team then reviewed video camera footage, and identified a person matching P1's description leaving the hospital doors. RN-C explained P1's room was located down at the end of the corridor with an unalarmed stairwell next to it, so her thought process was he must have left the unit through the stairwell since the door locks after you go through it, and a person would be unable to re-open it. RN-C stated P1's bed-exit alarm must not have gotten re-activated "since it didn't go off," and explained the bed-exit alarm system was "a foggy area" for P1 as, at times, he would use it, and other times would be able to be up in his room without it. RN-C stated they used a fall risk assessment tool to help determine safety needs, and added she was unaware of any formal elopement risk assessment process used on the unit. RN-C voiced using the bed-exit alarm was more at the individual nurses' discretion; however, reiterated she wanted it placed on P1 after his abruptly canceled discharge as likely "would have been antsy to leave." RN-C then reiterated she directed NA-A to activate the bed-exit alarm when P1 was returned to his room prior to this elopement on 11/17/20. RN-C expressed P1 was located outside the hospital several blocks away by a physical therapist who recognized him from his gait. They contacted the unit, and then remained with P1 while directing him back to the hospital. Upon his return, RN-A stated P1 had gravel on his knees and his hands were "scuffed up" with dried blood present on them. RN-A stated a set of vital signs were obtained, and she recalled it was "hard to get a temp[erature]" on P1 as "he was pretty chilly" when he returned from being outside. RN-C voiced P1's abruptly canceled discharge was "so out of the ordinary" that she felt it contributed to the incident given he was ready to go, and then was told he couldn't and had to stay. Further, RN-C stated she was unaware what actions the hospital had taken to help prevent further like-incidents since P1's elopement, and added nobody from the hospital administration or management team had even visited with her directly about the incident or circumstances surrounding it.

On 11/30/20, at 1:58 p.m. a phone message was left for NA-A. A return call was provided on 11/30/20, at 2:09 p.m. and NA-A was interviewed. NA-A verified she had been working on P1's unit the day he eloped, and recalled he was going to discharge when it was abruptly canceled. NA-A stated that process "got him kind of confused" as she recalled. NA-A voiced she could not recall anyone directing her to activate his bed-exit alarm when she helped him back to his room; however, acknowledged P1 had verbalized wanting to leave and get to his vehicle. NA-A stated bed-exit alarms were used often on the unit, and the nurses typically directed who used them and when during their hand-off reports with staff. Further, NA-A expressed she could not remember if she activated P1's bed-exit alarm or not when she left him, and questioned how he had eloped adding, "How does nobody see that [him leaving the unit]?"

When interviewed on 11/30/20, at 2:00 p.m. NA-B stated she recalled P1 and the incident of his elopement on 11/17/20. NA-B explained she received verbal report at approximately 3:15 p.m., and had been told P1's discharge was canceled at the "last minute." NA-B stated she entered P1's room to help get him changed back into a hospital gown and make sure he was safe and comfortable; however, when she entered his room he was not there. NA-B stated they had just discussed using his bed-exit alarm "that day" to help keep him safe; however, she verified when she entered his room and discovered he was not there that the alarm had not been activated. NA-B stated P1 was a "bit of a bed jumper" and, at times, had tried to leave the hospital. NA-B explained they had attempted to remove and discontinue the bed-exit alarm from P1 the night prior to his elopement; however, the staff then caught him coming down the hallway with his bag and wanting to leave the hospital. NA-C stated the nurses were aware of this to her knowledge.

P1's medical record was reviewed, and lacked evidence of P1 attempting to leave the hospital unit on 11/16/20, despite staff witness to the event. There was no evidence his repeated verbalizations about wanting to leave, nor his subsequent physical attempt to leave on 11/16/20, had been assessed or acted upon to ensure interventions (including use of a bed-exit alarm) were consistently implemented to help prevent potential elopement. Further, the record lacked evidence or rationale demonstrating why a bed-exit alarm was not used on 11/17/20, despite the intervention being assessed as potentially appropriate earlier on the same date prior to his elopement.

On 11/30/20, at 2:20 p.m. the hospital's regulatory officer (RO)-A and the Neuroscience and Spine clinical manager (CM)-A were interviewed. They explained P1 admitted to the Neuroscience and Spine unit to reside on their converted medical COVID-19 unit on 11/12/20. P1 demonstrated no acute distress during his admission, and was there for monitoring to ensure no progression of his symptoms. CM-A explained P1 was ready to discharge the unit to a local nursing home on the afternoon of 11/17/20; however, the family appealed the discharge "literally minutes before the driver arrived" to take him, which caused his discharge to be abruptly canceled, with P1 then eloping from the hospital shortly afterwards. P1's medical record was then reviewed with the surveyor. P1's care plan was reviewed which lacked any evidence of P1's assessed elopement risk or interventions to help ensure his safety, despite repeated verbal statements of wanting to leave the hospital, and being witnessed as attempting to leave on 11/16/20. CM-A stated the hospital was currently under "disaster documentation" guidelines given the COVID-19 surge in the area. which explained the lack of care planning on P1's risks and interventions. When questioned on the hospital's process for the assessment of elopement risk, CM-A explained the nurses complete the fall risk flowsheet assessment(s), which then provide several intervention options which could be used to keep patients safe from falls or elopement. However, CM-A stated these identified interventions were not required to be done and the floor nurses were to document which interventions, if any, had been used in their corresponding progress notes. CM-A acknowledged P1's various flowsheet assessments had the bed-exit alarm used on 11/15/20 and 11/16/20; however, there were no assessments or notes outlining the lack of bed-exit alarm use on 11/17/20. CM-A also acknowledged there was no rationale or documented assessment explaining an objective, justified lack of use despite P1 being assessed for falls and injury on 11/17/20, at 7:51 a.m. which outlined a bed-exit alarm may be appropriate. CM-A attributed this to P1's pending discharge, as she felt the nurses tried to keep patients more independent and not use alarm systems when they were ready to leave adding that was "my [her] assessment" of the situation. When questioned on the subsequent assessment and response of the hospital when P1 had been witnessed attempting to physically leave the unit on 11/16/20, CM-A responded she was unaware such an event had occurred; however, reiterated the shift to shift report process along with individual nurses' judgement was used to determine if alarm systems were to be activated or not. CM-A acknowledged the medical record seemed to lack evidence of the interventions and actions the immediate floor staff expressed they took prior to P1's elopement, including the voiced direction of the nurse to the NA to activate and use the bed-exit alarm. Further, CM-A voiced the hospital had just started the internal review process of P1's elopement; however, they were not "at that stage" in the process to send out follow-up, education, or implement systemic stop-gap measures to help prevent subsequent incidents.

On 12/1/20, at 1:33 p.m. provided video footage was reviewed with the hospital's security supervisor (SS)-A. The footage showed P1 coming into view on the ground level of the hospital in a hallway on the West side of the main building. P1 entered the camera' view dressed in a dark-colored coat with pants and tennis shoes, however, no hat or gloves were visible. P1 proceeded to push open the exit door, and walked outside unsupervised. The video clip was time stamped 11/17/20 at 3:14 p.m., and had no recorded sound for the entirety of the footage. SS-A was interviewed at this time and voiced there were no other cameras installed, either on the unit or around the hospital, which would show clear observation of P1 leaving his room and subsequently eloping. SS-A voiced that while there were no cameras installed on P1's unit, they "assume [P1] went down the elevator" upon leaving his room and then went outside when he got to the ground-level. SS-A recalled the incident from 11/17/20, and explained they had off-site officers begin to review footage, and search for a person matching P1's description upon being notified he was missing. They located the provided footage, and then had the nurse verify it was P1. SS-A stated P1 was gone from the hospital for a "little over two hours" by the time he was found and returned.

P1's corresponding Missing Person/Elopement report, dated 11/17/20, identified the security department was notified of a patient who was " ... missing from his room, [room number]." A description of the patient was outlined along with, "The patient was reported as positive for COVID-19." The report continued, and outlined a search of the hospital campus was completed. The local police department was contacted, who started a search for P1. P1 was located on the camera system as leaving the hospital at 3:13 p.m., and was returned to the North entrance by hospital staff members at approximately 5:20 p.m. (over two hours after he eloped).

A St. Cloud Hospital - Missing Person Decision Making Process undated, was provided. This flow chart identified a series of steps to implement, in order, if an adult went missing. This flow chart ended with, "Activate Missing Person Policy and Initiate Facility-Wide Response." A corresponding Missing Person policy, dated 08/2019, defined an elopement as, " ... a patient that departs the health care facility unsupervised, undetected, and has not been informed of the risks associated with early discharge." The policy outlined several steps to be implemented if a missing adult was identified which included beginning a search of the grounds and contacting the security department. The policy lacked direction or guidance on steps to be completed, including any review of the incident, once the missing person is found.

A provided Nursing Documentation Reduction Strategies During Emergency Response policy dated 5/2020, identified a purpose of guiding the process for nursing documentation for inpatient department(s) in the pandemic. It directed, "All patients in surge areas are high fall and injury risk. Implement available interventions and resources. Fall and injury risk documentation does not need to be completed." A section labeled, "Inpatient Required Documentation," outlined nurses should complete, "Other screenings to be completed if patient presentation warrants." Further, the policy directed focused assessments were to be completed on abnormal findings and identified patient changes as needed, including completing event note(s) for unanticipated situations. However, the policy then outlined, "A care plan note is not required."

A requested policy on the medical-unit elopement assessment and subsequent safety process was requested; however, none was received.

The IJ which began on 11/16/20, was removed on 12/3/20, after the hospital successfully implemented a removal plan which included review and revision of applicable systems to ensure displayed behaviors of potential elopement were identified, assessed and acted upon; developing a wander risk/elopement risk flowsheet for use on the medical unit(s); and providing education to direct care staff to ensure bed-exit alarms were consistently communicated and implemented when needed. On 12/3/20, from 9:00 a.m. to 10:15 a.m. interview(s) were conducted with direct care staff members and administration officials to ensure education had been provided and systems were placed to prevent subsequent patient elopements.

Based on interview and document review, the hospital failed to ensure an allegation of potential neglect was reported to the State Agency (SA) and addressed in accordance with established policies and procedures for 1 of 1 patients (P1) who eloped from the hospital.

Findings include:

See A-0144: The hospital failed to ensure demonstrated behaviors of potential elopement were assessed and safety interventions provided to reduce the risk of elopement for 1 of 1 patients (P1) reviewed who eloped from the hospital, and was outside for an extended period of time. This resulted in an immediate jeopardy (IJ) situation for P1 who sustained skin abrasions, fall(s) and was exposed to below-freezing temperatures when he eloped.

A provided CAD (Computer Aided Dispatch) Operations Report dated 11/17/20, identified the police department received a call from registered nurse (RN)-C on 11/17/20, at 4:24 p.m. who reported P1 as missing. P1 had left the hospital on foot sometime after 2:45 p.m. according to the dictation. Further, the later correspondence of the report identified the officer arrived to the hospital at 5:25 p.m. and was told the patient had been found, and returned with complaints of back pain. Further, a Preliminary Local Climatological Data report dated 11/2020, identified the area's weather for the month of November. The report identified 11/17/20, as having a maximum temperature recorded of 31 degrees (F).

A provided Vulnerable Adult (VA) Maltreatment Policy, dated 5/2020, identified a vulnerable adult as any person over 18 years of age who was an inpatient of the facility. The policy outlined several descriptions which could meet the definition of neglect including:

"The failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is ... reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and ... which is not the result of an accident or therapeutic conduct," and,

"The absence ... of care or services, including but not limited to, food, clothing, shelter, health care, or supervision necessary to maintain the physical and mental health of the vulnerable adult which a reasonable person would deem essential to obtain or maintain the vulnerable adult's health, safety, or comfort considering the physical or mental capacity or dysfunction of the vulnerable adult."

The policy continued and directed all employees must report situations of abuse or "self and caregiver neglect" to the Minnesota Adult Abuse Reporting Center (MAARC). The policy directed this report should be made 'immediately.'

When interviewed on 12/1/20, at 9:16 a.m. regulatory officer (RO)-A stated the hospital's "Quality Resources" team handles and determines which incidents, including elopements, are reported to the SA as potential allegations of neglect. RO-A voiced the decision to report typically included a review of whether or not the patient was harmed by the event, however, stated the incident of P1 eloping on 11/17/20, had not been reported to the SA to her knowledge, but rather was referred to the local Ombudsman for review. At 9:24 a.m. RO-A contacted the Senior Director of Performance Excellence who verified the allegation had not been reported to the SA and, when asked why it had not been reported as a potential allegation of neglect responded, "That's a good question."

During follow-up interview on 12/3/20, at approximately 8:55 a.m. RO-A stated she was unable to locate any further information demonstrating the allegation had been reported to the SA. RO-A added, "It got missed."