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Based on observation, document review and interview, it was determined that the Hospital failed to protect and promote patient rights to ensure the patient's emotional health and safety as well as his/her physical safety. Therefore, the Condition of Participation 42 CFR 482.13, Patient Rights was NOT met, as evidenced by:

Findings Include:

1. The Hospital failed to ensure that an elopement risk assessment was completed and failed to monitor a cognitively impaired patient to prevent patient elopement from the Emergency Department (ED). See A-0144

An immediate jeopardy (IJ) investigation was conducted on 04/20/2021 through 04/22/2021 for Complaint #IL 00131683/211086. An immediate jeopardy was identified. The IJ began on 04/22/2021, due to the Hospital's failure to: ensure that an elopement risk assessment was completed and failed to monitor a cognitively impaired patient to prevent patient elopement from the Emergency Department (ED). Subsequently, Pt #1, only in an undergarment, eloped from the ED and was not found. Pt #2 eloped outside and was brought back by the police department. The IJ event was identified on 02/01/2021, at 42 CFR 482.13, Patient Rights, and was announced on 04/22/2021 at 11:05 AM, during a meeting with the Chief Nursing Officer (E #5), Quality Assurance (E #1) and Director of Quality (E #6). The IJ was not removed by the survey exit date of 04/23/2021.

Based on document review and interview, it was determined for 2 of 2 patient's (Pt #1 and Pt #2) clinical records reviewed for Emergency Department elopements, the Hospital failed to ensure an elopement risk assessment was completed and failed to monitor a cognitively impaired patient to prevent patient elopement. This has the potential to affect all patients, staff, and community at large.

Findings include:

1. On 04/21/21 at approximately 10:00 AM the "SMD Sitter Policy" was reviewed. The policy stated "Sitter Responsibilities.... 2. Cognitively impaired patients a. 1:1 observation - initiated when patient is severely cognitively impaired with the mobility and capacity for elopement. 1) Designated staff member must be positioned within proximity of the patient at all times. 2) Documentation of continuous observation is required every 15 minutes."

2. The clinical record of Pt #1 was reviewed on 04/20/21 at approximately 1:00 PM. Pt #1 was brought to the Emergency Department (ED) by police department with a court order to detain and evaluate on 01/31/21 at 11:55 AM. The admitting complaint was behavioral problem. The chart noted:
a. ED MD (MD #2) noted at 12:02 PM "Patient can give no good history. He is alert, but obviously has tangential thoughts and response to internal stimuli. ... Patient cannot maintain a rational conversation."
b. Nursing note at 2:04 PM stated "Writer explained several times why patient is here and why patient cannot leave at this time. Patient grows increasingly agitated and angry. Patient states 'You can't keep me here! I am leaving. See ya! There's the door I'm outta here!' Security called at this time."
c. At 3:00 PM a nursing psychosocial assessment stated "Thought Process: Coherency: Flight of ideas; incoherent Content: Delusions; Delusions: Paranoid.
d. At 3:51 PM Pt #1 was given Haldol 10 milligram (mg) and Ativan 2 mg intramuscularly.
e. Pt #1 was determined to be an involuntary admission by a Psychiatry Specialist (MD #1) at 6:10 PM.
f. At 6:40 PM ED notes stated "Paperwork faxed to (receiving hospital)" for possible admission.
g. On 02/01/21 at 10:27 AM a nursing note stated "Patient stood outside room stated (Pt #1) was leaving. Writer requested patient return to room. Patient continued to walk to door. Patient exited building security notified."
h. At 10:30 AM a nursing note stated "Patient continued to ambulate with only a pair of blue boxers on outside hospital and began running down entrance to hospital. Writer notified (Police Department)."
i. At 7:09 PM an ED MD note stated, "Patient ran out of the building in (pt) underwear. (Pt) was chased by police, but never found."
j. The record lacked documentation of an elopement risk assessment and lacked documentation to indicate the presence of a sitter or continuous observation of Pt #1.

3. The clinical record of Pt #2 was reviewed on 04/20/21 at approximately 2:00 PM. Pt #2 was involuntarily admitted to the emergency department 02/10/2021 with the diagnosis of psychiatric evaluation, while awaiting in-patient placement at a different facility. The chart noted:

a. At 4:18 PM, Pt #6 was brought to the ED by ambulance. Upon assessment level of consciousness stated, "alert, but mumbling". Columbia Suicide Severity Rating Scale completed, Pt #2 was deemed to be at no risk for harm to self or others.
b. At 4:41 PM nursing note stated "patient stating very scared, feels the government is after (pt). Pt states (pt) uncle is very high up in the government and has explosives in (pt) shoes and someone is spraying (pt's) apartment with acid".
c. At 5:30 PM, a Psychosocial assessment was completed by an ED RN, and stated "Thought Process-- Coherency: loose associations; Content: blaming others/delusions; Judgement: impaired; Confusion: moderate; Delusions: paranoid; Hallucinations: visual".
d. At 7:07 PM nursing note stated, "Patient out of room yelling to turn the damn satellites off ...patient redirected back to room".
e. On 02/11/2021 at 12:30 AM a nursing note stated, "writer in another patient room. Security called to state patient was out front smoking. Patient refusing to come back inside. Multiple attempts made by staff to bring patient back in. (Police Department) notified to pick up patient and bring back". Pt #2 had eloped from the builiding to the parking lot and was returned to the ED by the police department.
f. At 9:27 AM a nursing note stated, "patient requesting to sign form stating ...I need to sign a form I have been here for 5 days".
g. The record lacked documentation of an elopement risk assessment and lacked documentation to indicate the presence of a sitter or continuous observation of Pt #2.

4. An ED elopement list was presented on 04/21/21 at approximately 9:00 AM. The list contained 80 events in which an elopement occurred from the ED.

5. An interview was conducted with Quality Assurance (E #1) and ED Director (E #2) on 04/21/21 at 2:00 PM. E #1 and E #2 reviewed Pt # 1 and Pt #2's clinical record. E #2 stated "There is no elopement risk assessment. There is no documentation of 1:1 observation." E #1 stated "There is no policy related to elopements."

6. An interview was conducted with the Accreditation Manager (E #8), Quality Assurance (E #1), and Director of Quality (E #6) during the IJ announcement. E #8 stated that the "elopement list provided was not accurate and included patients who had left without being seen, left against medical advice, or refused care, etc in addition to elopements." It was unable to be determined the accurate number of ED elopements on the list.

Based on document review and interview, it was determined for 1 of 2 patient's (Pt #8) clinical records reviewed for violent restraints, the Hospital failed to ensure documentation of a one-hour face to face evaluation was completed, as required. This has the potential to affect all patients placed in violent restraints with a monthly average of 10.

Findings include:

1. On 04/20/2021 at approximately 1:30 PM, the Hospital's policy titled "HSHS Restraints and Seclusion Policy" (approved on 12/14/2020) was reviewed and stated, "A face-to-face evaluation of the patient must be performed within one hour of the restraint initiation...can only be initiated by a physician, physician assistance or RN (registered nurse) trained...".

2. The clinical record of Pt #8 was reviewed on 04/21/2021 at approximately 12:00 PM. Pt #8 presented to the Emergency Department (ED) on 01/24/2021 at 5:53 AM with COVID-19 symptoms, altered mental status, and schizophrenia. The following was noted:

Pt #8 was placed in violent restraints on 1/24/2021 at 6:00 AM.
Pt #8 was placed in violent restraints on 2/3/2021 at 1:41 PM.

The clinical record lacked documentation that a face-to-face evaluation was completed within one hour of restraint initiation.

3. An interview was conducted on 4/22/2021 at approximately 2:00 PM with Quality Assurance (E #1) and Director of Behavioral Health (E #7). Both E #1 and E #7 agreed with the above findings.