HospitalInspections.org

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Based on medical record review, document review and interview, the facility failed to protect patients at risk for elopement. Specifically, the facility failed to implement its policy and procedure titled "Elopement" to identify patients at risk for elopement in the Emergency Department and implement measures to prevent elopement. This failure was identified in five (5) of 15 medical records reviewed (Patient #s 1, 2, 5, 7, and 9).

This failure may result in serious adverse outcome to patients.

Findings include:

Review of medical records identified five patients at high risk for elopement who were not assessed for elopement risk. There was no documented evidence of measures implement to ensure the safety of these patients. Consequently, Patient #s 1, 2, 5, 7, and 9 eloped from the ED without a safe discharge plan.

See Tag A144.
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Based on medical record review, document review and interview, the facility failed to protect patients at risk for elopement. Specifically, the facility did not have a policy for "Elopement" in the Emergency Department to identify patients at risk for elopement and implement measures to prevent elopement (Patient #s 1, 2, 5, 7, and 9).

This failure may result in serious adverse outcome to patients.

Findings include:

Patient #1 is a 63-year-old patient who was brought into the ED by ambulance from a supervised residential home on 9/04/2020 for complaint of back pain and body rash. The patient's psychiatric history was significant for schizophrenia. It was noted in the Patient's Rights documents that the patient was unable to acknowledge the document due to altered mental status. The patient was evaluated by the ED physician with an impression of body rash and was discharged from the ED at approximately 10:26 pm.
The patient eloped from the ED while waiting for transportation back to the residential facility.
The Security Department verified from video surveillance that the patient left the ED on 9/05/20 at 12:02 am.

There was no documented evidence the patient was assessed for risk of elopement.

On June 25, 2021, at approximately 2:00 pm, during an over the phone conversation with the Director of Nursing of the patient's residential facility, she stated that the patient never returned, and she is not aware of the patient's whereabouts.

Patient #2: 58-year-old patient arrived in the ED by ambulance from a Nursing Home (NH) for complaint of headache from being hit in the head by another resident at the NH. The patient had a psychiatric history of bipolar disorder. Diagnostic tests were negative for bleed and injury. At 3:00 pm, nurse documented the patient refused all assessments and the doctor was informed that the patient was attempting to elope from the ED. Patient's intravenous access was removed. At 4:21 pm, nurse noted the following: patient was yelling at staff and was attempting to walk out of the Ambulance Bay entrance. The patient departed the ED ambulating with a steady gait. The provider was made aware.

There was no documented evidence that the patient was assessed for risk of elopement. There were no preventive measures implemented when the nurse observed that the patient was attempting to elope.

On June 28, 2021, at approximately 12 pm, during an over the phone conversation with the Director of Nursing of the patient's residential facility, she stated that currently, the patient is in the residential facility.


Patient #5: 59-year-old patient who was undergoing evaluation and treatment in the ED for Drug overdose. Assessment by a resident physician at 3:03 pm noted the patient was alert, disoriented x 3 and lethargic. At 3:15 pm, nurse noted the patient was not in his room. At 5:41 pm, the nurse documented "patient stated he had business to tend to."

There was no elopement risk assessment conducted and measures implemented to ensure the safety of the patient.

The status of the patient is unknown.

Patient #7: 23-year-old with history of bipolar disorder and marijuana use was brought to the ED on 9/7/20 at 11:34 am for evaluation post suicide attempt. Triage nurse at 11:38 am, noted the patient became tearful when the patient was informed that she would be admitted. The nurse documented the patient was not a high risk for elopement. On 9/08/20 at 3:00 pm, nurse documented the patient is requesting to go home and the resident physician was paged. A physician order for 1:1 observation was written at 3:50 pm. At 4:08 pm, New York Police Department (NYPD) called to report that the patient left the ED with intravenous port in place. The time of departure of the patient was unknown. The patient's mother was contacted and instructed to call the facility when the patient gets home.

There was no reassessment of the patient's elopement risk when the patient requested to go
home. The physician order for 1:1 was not immediately implemented to prevent elopement of a patient with suicidal attempt.

The status of the patient is unknown.

Patient #9: 26-year-old patient arrived in the ED on 10/21/20 at 15:20 pm with a chief complaint of laceration to left wrist. The patient's medical history was significant for bipolar disorder, Post Traumatic Stress Syndrome, drug overdose and suicidal ideation. The previous day on 10/20/20, the patient reported she overdosed on Seroquel and Risperdal (doses unknown). Suicide Risk Assessment on 10/21/20 at 3:20 pm was negative. The patient reported she sustained the left wrist laceration when she stuck her hand in a drawer that had a knife. However, at 3:30 pm, the Physician Assistant (PA) suspected suicide attempt when he observed a linear cut during assessment and suturing of the left wrist laceration. 4:04 pm, case discussed with the Social Worker and a decision made to transfer the patient to the psychiatric ED for further evaluation. 5:10 pm, nurse noted the patient was missing from the medical ED treatment area. 5:20 pm, the nurse contacted the patient via cell phone, the patient stated she was not coming back to the ED.

There was no documented evidence that the patient was assessed for elopement and appropriate measures implemented to ensure the patient's safety.

The patient was returned to the facility's Psychiatric ED on 10/22/20 escorted by officers from the New York State Police Department.

Review of facility's policy titled Elopement Prevention and Management last reviewed 11/15/20 noted the following under 'Assessment/Prevention' "All patients will be assessed for risk for elopement on admission to inpatient units using the screening tool. Routine daily assignments of all patients will monitor for changes in mental status and prompt this documentation and utilization of the elopement screening tool ..."

There was no indication that this elopement policy was implemented in the ED. Patient #s 1, 2, 5, and 9 were not assessed for elopement. Patient #7 was not assessed using the elopement screening tool.

Interviews with Triage nurses and ED nurses during tour of the ED on 6/23/21 between 11:30 am to 11:45 am, staff reported that elopement risk assessment was not routinely done for ED patients.

The facility's failure to conduct an elopement risk assessment resulted in the failure to identify patients at risk for elopement.

On 06/23/21 at approximately 4:00 PM these findings were brought the attention of Staff A, Vice President of Quality Affairs, Staff C, Assistant Vice President, and Staff D, Emergency Department Chairman.
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Based on medical record review, document review and interview, in five (5) of fifteen medical records reviewed, the facility failed to ensure that elopements from the Emergency Department (ED) were investigated and corrective actions implemented to prevent elopement.

Findings include:

Review of Emergency Department logs for the year 2020 and 2021 identified several elopements from the ED. The number of elopements from the ED was not quantified.

Review of a sample of 15 elopements in 2020 and 2021 identified five patients who eloped from the ED without as safe discharge plan. Two patients (Patient #s 1 and 2) were from a supervised residential facility; two patient (Patient #s 7 and 9) presented with suicidal ideation and Patient #5 was assessed by a physician as being disoriented to place, persons and time shortly before the patient eloped.

Review of the facility's 2020-2021 Quality Assessment, Performance Improvement & Patient Safety Plan revealed no documented evidence of monitoring and assessment activities and corrective action plans for ED elopements.

On 06/23/20 at approximately 11:30 AM, these findings were brought to the attention of Staff C, Assistant Vice President.