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Based on interview and document review, the hospital failed to ensure 1 of 1 patients (P1) with known, cognitive impairment was assessed for safety and/or supervision needs to prevent elopement from the hospital setting. These findings constituted an immediate jeopardy (IJ) for P1. 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 1 of 1 patients (P1) with known, cognitive impairment was assessed for safety and/or supervision needs, and had appropriate interventions placed to ensure safety and prevent elopement from the hospital setting. P1 eloped while waiting for care in the emergency department (ED) and was found walking the city sidewalk several days later, by the local police department. P1 was subsequently hospitalized with aspiration pneumonia. These findings constituted an immediate jeopardy (IJ) for P1. These findings constituted an immediate jeopardy (IJ) situation for P1.

Based on interview and document review, the hospital failed to ensure 1 of 1 patients (P1) with known, cognitive impairment was assessed for safety and/or supervision needs, and had appropriate interventions placed to ensure safety and prevent elopement from the hospital setting. P1 eloped while waiting for care in the emergency department (ED) and was found walking the city sidewalk several days later, by the local police department. P1 was subsequently hospitalized with aspiration pneumonia. These findings constituted an immediate jeopardy (IJ) for P1.

The IJ began on 9/25/23, when P1 presented unaccompanied from a skilled nursing facility (SNF) to the ED via emergency medical services (EMS) with identifying medical paperwork from the SNF. The hospital misplaced P1's SNF paperwork which identified cognitive impairment, and did not provide proper supervision of P1 in the ED who left the hospital unattended. P1's whereabouts were unknown for five days, until he had been found by the local police department on the street. On 10/18/23 at 1:25 p.m. the manager of regulatory quality department (MRQD)-A and the manager of the emergency department (MED) were notified of the IJ. The IJ was removed on 10/19/23 at 3:30 p.m. when an acceptable removal plan was verified as being implemented; however, condition-level non-compliance remained.

Findings include:

On 9/26/23, a facility reported incident indicated P1 had been sent to the hospital on 9/25/23 to have a leaking gastrostomy tube (G-tube) replacement. P1 resided at a skilled nursing facility (SNF) and had been transported by ambulance to the hospital ED. The report indicated on 9/26/23, P1 had not returned from the hospital. The SNF staff called the hospital staff on 9/26/23 to check on P1, and was told he had been discharged on 9/25/23. The SNF staff did not know where P1 had been discharged to, and notified law enforcement of a missing person.

On 10/16/23 at 10:33 a.m. the SNF director of nursing (DON) was interviewed. The DON stated on 9/25/23 at 9:00 a.m. P1 was sent by ambulance to the hospital ED to be evaluated for a leaking G-tube. The DON stated P1's medical information had been given to the ambulance personnel. The paperwork included the name of the SNF, P1's diagnosis of a decline in cognition, P1's medication list, P1's power of attorney (POA) and his resuscitation code status. The DON stated when P1 had not returned back to the SNF the following day on 9/26/23, she phoned the hospital to get an update. The DON stated the hospital staff told her P1 had been discharged on 9/25/23, but refused to give out further information. The DON stated she then phoned the local police department to report a missing person. The DON stated she received a phone call from the police department on 9/29/23, four days after the event, stating they had found P1 walking down a sidewalk (unknown location) and would be transferring him to a hospital to be medically cleared to return to the SNF. The DON stated P1 had been treated for aspiration pneumonia and returned to the SNF on 10/4/23.

On 10/16/23 at 11:25 a.m. family member (FM)-A stated on 9/26/23 at around 2:00 p.m. she went to the SNF to visit P1. FM-A stated P1 was not at the SNF, and when she asked the facility staff where P1 was, she was informed he was still at the hospital. FM-A stated the facility staff phoned the hospital to inquire on P1's condition, and she was told the hospital had discharged P1 on 9/25/23 but would not give out any further information. FM-A stated the facility staff notified the police to assist with P1's whereabouts. FM-A stated the police did not find P1 for approximately 5 days and they were unsure where he had been. P1 had been found walking down a sidewalk somewhere in the city. FM-A stated P1 had confusion and had a feeding tube in place for nutrition, and he was not able to eat food. FM-A stated the SNF later told her P1 would be admitted to a hospital and treated for aspiration pneumonia.

On 10/17/23 at 9:30 a.m. a tour of the hospital ED department with the ED nursing manager (NM)-A present was conducted. NM-A explained the ED had over 30 patient beds, and the average volume of patients handled each day were approximately 160 to 200 patients. The registration desk and security desk were located just inside the main front ED entrance/exit door. The patient waiting room was located several feet from the registration and security desk and within eyesight of the registration staff. NM-A stated patients brought in via EMS were directed to the waiting room if the ED was at capacity and had no beds immediately available, or if they were unable to be seen immediately. NM-A stated when a patient from an outside facility arrived per EMS, usually EMS provided health information from the facility. The EMS would give a report and hand off the patient to the registration nurse, along with their medical information paperwork. NM-A stated this information was then put in a file area to be sent with the patient when triaged. NM-A stated at the end of the ED visit, the paperwork was scanned to the patient's hospital medical file. NM-A stated if a patient was identified to be at risk for elopement they were provided a 1:1. NM-A stated the hospital did not have a protocol to assess a patient for being at risk for elopement if not identified on the receiving paperwork. Further observation noted an exit door to the main hospital located at the end of a hallway in the ED.

Review of a hospital internal investigation dated 9/26/23 indicated they initiated an investigation into P1's elopement after being informed of a local news broadcast aired on 9/26/23. The broadcast identified P1 was a missing vulnerable adult (VA) and last seen at the hospital. The internal investigation included staff interviews and document review and included the hospital had been aware P1 was a SNF resident upon admission. The hospital investigation also indicated EMS had provided P1's medical information to the registration nurse and this included P1's diagnosis of dysphagia, P1's neurocognitive impairment, and P1 had a clogged G-tube. The hospital investigation also indicated P1's medical information from the SNF had been lost and did not get into his medical file. The investigation indicated a visitor reported to the ED staff when P1 left the facility grounds, and informed the staff P1 appeared confused. P1 told ED staff on a couple of occasions he was homeless and did not know where he was going to go after he left the facility. The report included at one point, P1 had been missing from the ED waiting room, and he wandered to the 3rd floor of the hospital, and required security to assist him back to the ED. The investigation concluded P1 had not been identified as an elopement risk, and he had left the hospital against medical advice (AMA).

On 10/17/23 at 12:00 p.m. the manager of quality and safety (QS)-B confirmed an investigation had been initiated after seeing the news coverage P1 was a missing vulnerable adult (VA). QS-B stated the investigative process was for each department to gather and collect information related to the identified concern and that information is then received and reviewed. QS-B indicated all staff involved in the incident may not be interviewed, unless it was determined to conduct a more extensive investigation. This incident did not require a more extensive investigation. QS-B stated after reviewing the investigative information which included staff interviews and record reviews, it was determined by the hospital safety committee to be an unannounced discharge AMA. This was determined due to having no information related to P1 being at risk for elopement, and the provider had P1 sign a patient consent form, determining he was competent. QS-B further stated even though P1 left the ED waiting room, wandered up to 3rd floor and was confused to his whereabouts, this was not uncommon for patients to do who were not confused. QA-B did confirm EMS provided medical paperwork to the facility staff, and this paperwork was lost so it was not in P1's medical record. QA-B stated she thought the ED nurse manager was going to follow through with checking on this, but had been unsure if had been.

Review of the medical record progress notes and sequence of events dated 9/25/23, for P1 included:
At 10:07 a.m. P1 arrived to the ED by ambulance.
At 10:11 a.m. P1 was handed off to the registration nurse, who indicated paperwork had been provided by EMS stating P1 came from a SNF to be assessed for a G-tube replacement concern.
At 11:15 a.m. P1 was seen by triage staff and sent back to the patient lobby until he could be seen by the provider
At 1:03 p.m. nursing staff located on the 3rd floor medical surgical unit of the hospital reported to security an ED patient had been wandering in the hallway, and was unable to tell staff what he was doing or where he was going. Security was called and assisted P1 back to the ED waiting room area. The nursing staff identified P1 as an ED patient by his hospital wrist band.
At 1:25 p.m. P1 was seen by the provider. The provider note indicated P1 was unable to provide his medical history. The provider indicated he was able to retrieve information from another local hospital. This history included neurocognitive disorder, dysphagia, aspiration pneumonia, anxiety, depression, alcohol abuse and psychoactive dependence. The provider note indicated P1 was awake and alert, and his speech and motor exam were normal. P1 had clear lung sounds. The provider assessed P1's G-tube and ordered a replacement, after P1 signed a consent.
At 1:50 p.m. P1 had his G-tube replaced and he was assisted back to the ED lobby to wait for provider clearance to discharge.
At 2:18 p.m. a visitor informed the ED staff she observed P1 leaving the hospital through the ED exit doors. The visitor indicated P1 appeared confused.
At 2:45 p.m. the hospital discharged P1 and identified the discharge as AMA

On 10/17/23 at 11:30 a.m. NM-A was interviewed again. NM-A stated she became aware of P1 identified as a missing VA person a few days ago. NM-A stated she started interviewing ED staff who provided care for P1. After interviewing staff, NM-A stated it had been determined facility staff had been given P1's medical information, but it did not get included in P1's medical record. NM-A stated P1's medical information had been lost prior to him receiving care in the ED. NM-A stated the investigation identified P1 exhibited signs of confusion during his care at the ED, which included wandering up to the 3rd floor of the hospital from the ED waiting room, informing staff he did not know where he was going to go after leaving the hospital, his known cognitive impairment history and a visitor informing staff P1 left the facility and appeared confused. NM-A stated when interviewing staff who cared for P1 in the ED, their assessments of P1 indicated he had been alert/oriented and able to answer most of their question. Also, she stated without P1's medical history from the SNF related to P1's risk for elopement, the staff were not aware of the risk. NM-A further stated most of the staff who cared for P1 had not been informed he resided at a SNF. NM-A stated if the staff were aware a patient was an elopement risk, the hospital would implement 1:1 supervision. NM-A stated the hospital had not implemented interventions due to the decision of risk management, as they believed this incident did not fall under the requirement of being a reported.

On 10/17/23 at 12:00 p.m. registered nurse (RN)-B stated she triaged P1 in the ED on 9/25/23. RN-B confirmed P1's medical file did not included any medical information. RN-B stated she had been informed P1 was presented to the ED with a leaking G-tube and which needed to be replaced. RN-B had not been aware P1 had been admitted to the ED from a SNF. RN-B stated during her assessment, P1 was alert, able to answer most of her questions, and did not seem confused at the time. RN-B stated P1 had been directed to sit in the ED lobby waiting room after she had assessed him in triage, because there were no open rooms in the ED. RN-B stated P1 had been alone and unsupervised. RN-B further added if staff were aware a patient was from a SNF and were an elopement risk, they were assigned a 1:1 for observation, or placed in a room in the ED with close supervision.

On 10/17/23 at 12:30 p.m. registered nurse (RN)-A stated P1 had wandered up to the 3rd medical surgical floor on 9/25/23 at approximately 1:00 p.m. RN-A stated she had been working at the nurse's station when P1 was observed walking up and down the patient hallways. RN-A stated P1 did not have a visitor badge on so she asked him what he was doing. RN-A stated P1 was unable to tell her why he was there or what he was doing. RN-A noticed a hospital wrist band on P1's wrist, and noted he was a ED patient. RN-A stated she called security to assist P1 back to the ED as he was confused on where to go.

On 10/17/23, at 1:00 p.m. the ED medical director (MD)-A stated he had not been included on the investigation for P1 and did not know the results of the investigation. MD-A stated he did not want to elaborate or comment on the incident with P1, because he had not been totally aware of the situation or the findings.

On 10/18/23 at 9:30 a.m., RN-C stated she was the nurse who discharged P1 after he left the hospital. RN-C stated after P1's G-tube was replaced, the radiology staff informed her he would possibly be ready for discharge. RN-C stated P1 was assisted to the ED waiting room to be seen by triage and to assess for discharge. RN-C stated P1 was assisted to the waiting room around 1:50 p.m. RN-C stated P1 told her he probably did not need discharge orders because he lived on the street, and he was not sure where he was going to go after leaving the hospital. RN-C stated at around 2:15 p.m. a visitor informed the ED staff P1 had left the facility and appeared confused. RN-C stated she had not been alarmed as she had not been informed P1 was a SNF resident or an elopement risk. RN-C stated P1 was discharged in the system at 2:18 p.m. as AMA. RN-C confirmed P1's medical file did not have any information to inform the staff of if he was an elopement risk or had a cognitive impairment related to confusion. RN-C stated if a patient was identified to be at risk, they were taken back to an ED room for increased supervision or provided a 1:1, but that day the hospital did not have any beds left in the ED. RN-C also stated she had been aware of P1 wandering to the 3rd floor of the hospital, but it was not unusual for patients to walk around the hospital while waiting in the ED.

On 10/18/23 at 10:00 a.m. registered nurse (RN)-D stated she had been the registration nurse that checked in P1 on 9/25/23. RN-D confirmed she received P1's SNF information from the EMS staff. RN-D stated she recalled seeing a face sheet which included the name of the nursing home, but could not recall what other information was included. RN-D stated she could not remember what she did with the paperwork after registering P1, but was told it had not been placed in his medical file and could not be found. RN-D stated the practice when registering a patient was to place the medical paperwork received in a file, and send it with the patient during the ED visit. RN-D confirmed this had not been done.

On 10/18/23 at 1:00 p.m. paramedic (PA)-A stated P1 had been picked up at the SNF on 9/25/23 at around 9:30 a.m. and transferred to the hospital to have a leaking G-tube replaced. PA-A indicated P1 was independent with ambulating and alert at the time. PA-A stated paperwork had been provided from the SNF which included current physical orders, diagnoses, code status and POA. PA-A stated this information had been handed off to the registration nurse upon arrival to the hospital. P1 had been stable throughout transport.

The hospital policy ED Triage Registration in the ED dated 7/27/23 directed: 1. All patients who arrive by ambulance will be triaged for placement by an RN. Patients arriving by ambulance who are deemed able, will be sent to triage.
2. On arrival, triage nurse will obtain chief complaint and determine triage acuity classification level (ESI level) of customer. Triage RN will follow triage process. Patient registration should occur as soon as safely possible. 5. In the event that no beds are available: Monitor the EPIC trackboard for rooms as they become available.
6. Call the Charge RN if multiple patients present to the triage desk or ED beds are at capacity and patients are waiting for placement. Charge RN will delegate additional backup assistance to Triage to help with patient surge or placement. 7. An ED RN will maintain presence at triage desk. 8. Document if patient has expressed desire to leave the hospital. AMA form is to be signed by patient. If patient refuses to sign or has left, document into EPIC.

The IJ which began on 9/25/23, was removed on 10/19/23, when an acceptable removal plan was verified as being implemented. The plan included mandatory education on revisions of the policies related to the ED registration process that included and ensuring health care information is received on patients coming from outside facilities. This information included: History of confusion, at risk for elopement and legally authorized decision maker name and number. To ensure healthcare information is followed through with the patient through the ED process, a patient label with be attached to the medical information until it is scanned. An assessment tool for triage staff to utilize during the triage process to determine a patients cognitive status and risk for elopement. Policy revisions were completed on 10/18/23. Education was to be completed prior to the hospital employees' next shift, implemented on 10/19/23. These actions were reviewed and verified as being implemented on 10/19/23, through employee interviews and corresponding documentation review.