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Based on observation, interview, and record review, the facility failed to provide care in a safe setting for two of thirty patients (P2, P8) when these patients eloped from the facility at different times resulting in risk of serious injury, serious harm, serious impairment, or death. P2 eloped from the emergency department (ED) on 9/7/24 between 7:10 p.m. and 7:20 p.m. and was found and brought back to the ED at 10:29 p.m. P8 eloped from a medical unit floor on 11/10/24 at 9:52 p.m. and was never found.

As a result, the hospital was found out of compliance with the Condition of Participation Patietn Rights at 42 CFR 482.13.

An immediate jeopards was issued at A-0144. See A-0144 for additional information.

Based on observation, interview, and record review, the facility failed to provide care in a safe setting for two of thirty patients (P2, P8) when both patients eloped from the facility on separate occasions, resulting in risk of serious injury, serious harm, serious impairment, or death. P2 eloped from the emergency department (ED) on 9/7/24, between 7:10 p.m. and 7:20 p.m. was found and brought back to the ED at 10:29 p.m. P8 eloped from a medical unit floor on 11/10/24 at 9:52 p.m. and was never found.

The immediate jeopardy began on 9/7/24 when hospital staff did not assess P8 and P2 for elopement risks from the hospital. P2 eloped from the hospital on 9/7/24 and was found in a parking garage. P8 eloped from the hospital on 11/10/24 and was not found. The IJ was identified on 5/22/25. The Regulatory and Accreditation System Program Manager and Chief Nursing Officer was informed of the immediate jeopardy on 5/22/25 at 10:22 a.m. The immediate jeopardy was removed on 5/23/25 at 11:14 a.m. but noncompliance remained at a condition level.

Findings include:

During an observation of the emergency department (ED) on 5/19/25 at 10:00 a.m., writer observed hospital staff were required to badge into the ED unit through their employee badge, but did not have to badge out of the ED. When a patient is exiting the ED, they do not have any security measures prior to leaving the hospital.

P2's medical records indicated P2 arrived at the emergency department (ED) on 9/7/24 at 6:18 p.m. via ambulance from an assisted living memory care facility for complaints of chest pain, nausea, vomiting, and diarrhea. P2 had a history of dementia and could not remember why she was in the ED.

P2's ED triage notes dated 9/7/24 at 6:26 p.m. indicated P2 was put in room ED 19, for her cares. P2 did not have an elopement assessment completed. P2 had her vital signs checked at 6:27 p.m., Registered nurse (RN)-A started a peripheral intravenous (IV) at 6:40 p.m., and nursing assistant (NA)-A completed an electrocardiogram (EKG) at 6:51 p.m. P2 had automatic vital signs completed at 6:30 p.m., 6:40 p.m., 6:50 p.m., 7:00 p.m.., and 7:10 p.m.

P2's progress note dated 9/7/24 at 7:35 p.m., indicated RN-B was notified by NA-A that P2 was not in her assigned ED room. RN-B stated she thought P2 had gotten herself dressed and removed her IV. RN-B stated she looked throughout the ED, notified security, and the police department (PD) were called.

P2's progress note dated 9/7/24 at 8:11 p.m., indicated P2 was still missing at that time. PD was assisting in the patient's missing persons case. A Code Missing Adult was paged throughout the hospital "earlier" and continued to be active. Security was rounding the hospital grounds.

P2's progress note dated 9/7/24 at 10:37 p.m. indicated P2 was found by a staff member hiding underneath a stairwell in a parking ramp across from the hospital. P2 was cooperative when she was brought back to the ED.

P2's interventions dated 9/7/24 at 10:38 p.m. indicated P2 was put in a Health Officer Authority to Detain (HOA) hold.

P2's provider progress note dated 9/8/24 at 1:16 a.m. indicated P2 had a history of dementia and was seen in the ED earlier for an episode of check pain, nausea, and vomiting. The progress note indicated the patient eloped from the ED and made it outside of the hospital and was across the street in a parking ramp underneath the stairwell and was brought back to the ED. P2 did not know why she was in the ED. P2 indicated she wanted to go "home".

P2's hospital incident report indicated on 9/7/24 a debrief was completed by administrative nursing supervisor (ANS). On 9/9/24, an event debriefs, and learnings were discussed during a hospital-wide safety huddle. On 9/10/24, a fact-finding meeting was held with ED leaders and risk management. On 10/8/24 an elopement prevention tip sheet was developed and was sent to all hospital leaders.

P8's medical records indicated P8 arrived at the ED on 10/31/24 at 2:28 p.m. P8 arrived by walking to the ED.

P8's progress note dated 10/31/24 at 2:35 p.m., indicated while P8 was being triaged, P8 was saying that he was going to leave the hospital and get on a plane.

P8's progress note dated 10/31/24 at 3:01 p.m., indicated while P8 was being triaged, P8 was stating he was not going back to his group home, was going to go on a plane and fly to Florida.

P8's ED provider note dated 10/31/24 at 4:53 p.m., indicated P8 presented to the ED for a psychiatric evaluation. P8 had been brought to the ED by a group home staff member who was concerned about increasing psychosis, paranoia, and being emotionally labile. P8 had been receiving messages through the TV and was on a mission from God. P8 was placed on a HOA hold. The provider had recommended P8 be admitted for inpatient mental health admission, and P8 agreed. P8 was then placed on a 72-hour hold.

P8's provider progress note dated 11/1/24 at 12:22 a.m. indicated for P8 to go to any mental health unit in the state, P8 had to take a COVID-19 test. The COVID-19 test came back positive. P8 was then unable to go to a mental health bed/unit until the COVID-19 was cleared.

P8's progress note dated 11/1/24 at 7:01 a.m., indicated P8 had stated he needed to be out of the hospital by 11/3/24.

P8's provider progress note dated 11/2/24 at 6:21 p.m., indicated P8 was at the hospital due to psychosis and the plan was to pursue mental health commitment due to medication noncompliance. P8 tested positive for COVID-19 so he was unable to be admitted to an inpatient mental health unit.

P8's progress note dated 11/10/24 at 4:32 a.m., indicated P8 had been making several phone calls to a casino and stated he was worried his friends would not be able to find transportation from the casino to get home. Staff assisted with phone calls and the door alarm remained on P8's door.

P8's progress note dated 11/10/24 at 11:00 p.m., indicated RN-V went into P8's room to give him his bedtime medication. P8 grabbed his guitar, bag, and went out the door stating he was leaving. A code was called, and hospital staff searched for P8. PD was called.

P8's progress not dated 11/10/24 at 11:15 p.m., indicated P8 was on a court hold with a door alarm on his door. Social worker and psychiatry were following P8.

P8's progress note dated 11/10/24 at 11:32 p.m. indicated the writer had been called to a missing patient code in a stairwell. Upon the writers arrival, the unit staff directed her to the stairwell stating P8 had left with his guitar, clothing, duffle bag, and hospital tablet down the stairwell. P8 was under a full mental health commitment with Jarvis order and was awaiting placement at an outside mental health facility once he recovered from COVID-19. P8 did not have a 1:1 at the time of his elopement. P8 eloped from his room when an RN entered to administer his evening medication. After P8 eloped from the hospital, hospital staff completed an extensive search of the hospital, and P8 was never located.

P8's progress not dated 11/10/24 at 11:58 p.m., indicated P8 eloped from the hospital around 9:52 p.m. A code was called, PD was called, and the hospital staff searched for P8.

P8's progress note dated 11/11/24 at 12:17 a.m. indicated P8 had been discharged due to P8 eloping from the hospital on 11/10/24 at 10:52 p.m. P8's nurse was giving him his nighttime medications when the patient eloped. P8 had a door alarm on his door during his admission and never attempted to leave prior to this incident. A code was called, PD was called, and hospital staff attempted to look for the patient.

P8's hospital incident report indicated P8 eloped from the hospital on 11/10/24 at 9:54 p.m. P8 was observed exiting his room during a medication administration interaction in P8's room. P8 was on a court hold and he had a door alarm in place. P8 left his room with his belongings and departed the unit via the stairwell. Staff followed P8 to the stairwell but did not proceed into the stairwell per hospital policy.

During an interview on 5/19/25 at 10:58 a.m., RN-E stated if a patient were brought to the ED with cognitive impairments, they would put the patient on an EKG monitor, so that if the patient attempted to elope, she would be alerted when the patient took their EKG leads off.

During an interview on 5/19/25 at 11:34 a.m. RN-F stated if a patient were brought into the ED with cognitive impairments, they would assess whether the patient was ambulatory or not. If the patient is ambulatory, he would worry about the patient being a fall risk. RN-F would use a bed alarm on the patient for patients who have cognitive impairments. He would also try to put a patient on a 1:1. RN-F stated they may not always have the staff to provide the patient a 1:1.

During an interview on 5/19/25 at 11:53 a.m., RN-G stated if a patient came to the ED that had cognitive impairments, she would put a yellow band on the patient indicating the patient is a fall risk, she would have the patient wear yellow grippy socks, attach a fall risk sign to the outside of the door, and she would keep the curtain in their room open at all times, so everyone could observe the patient who walked past the patient's room. RN-G stated if she knew a patient would have a history of dementia, she would put the patient in a room near the nurses station and put the patient on a 1:1.

During an email correspondence on 5/19/25 at 3:42 p.m., the regulatory and accreditation system program manager (RASM) stated NA-A was unavailable for an interview.

During an interview on 5/19/25 at 4:07 p.m., RN-J stated shortly after 7:25 p.m., he was notified by RN-B that P2 was not in her room. RN-J attempted to located P2 by looking for P2 in the ED as well as the exterior of the hospital. Around 7:25 p.m., RN-J notified the ED staff, ED providers, ED supervisor, the memory care facility, and P2's family and called a code throughout the hospital. RN-J had all charge nurses throughout the hospital floors notify staff to look on their units for P2. About 7:45 p.m. p.m., RN-J called PD and filed a missing person's report. RN-J stated RN-M left her shift and found P2 under the stairwell in the parking ramp. P2 had been gone for about two and a half hours. Once P2 was found, RN-J alerted the security team, ED nurses, and the ED supervisor.

During an interview on 5/20/25 at 7:31 a.m., RN-H stated she did not care for P2 while she was in the ED but knew that she had a history of dementia. RN-H was alerted that P2 was missing from the ED. RN-H talked with RN-J about what steps he was taking in the elopement process. RN-H stated P2 was found in a parking ramp underneath the stairwell by RN-M.

During an interview on 5/20/25 at 8:11 a.m., RN-B stated she started her shift at 7:00 p.m. on 9/7/24. P2 did not have a 1:1 at that time. RN-B was alerted by NA-A that P2 was not in her room in the ED. RN-B stated she looked around the ED for the patient but could not find her. RN-B alerted the security staff who had watched the cameras. RN-M left the hospital after her shift and while she was exiting the parking ramp, she found P2. After she was found, P2 was brought back to the ED by RN-J. RN-B had suggested P2 was put in an ED room with a camera. RN-B stated the hospital does not have an elopement assessment that clinical staff can document on. RN-B would look to see if a patient has had any falls recently or if the patient came to the hospital from a memory care unit, and if that were the case, she would make an "internal" judgment if they are an elopement risk. RN-B stated she does not document whether a patient is an elopement risk or not. RN-B stated if she deemed a patient was an elopement risk, she would put the patient on a bed alarm, EKG monitor, or move the patient to an ED room near the nurse's station.

During an interview on 5/20/25 at 8:19 a.m., RN-D stated when a patient comes to the ED with cognitive impairments, the clinical staff would attempt to put the patient on a nurse's hold and put the patient on a HOA hold and ensure the patient is on a 1:1. If the patient could not be put on a HOA hold, clinical staff would utilize a bed alarm so that it could alert the nurse if the patient attempted to get out of bed. RN-D stated she received a call on 9/7/24 around 8:00 p.m. from RN-J stating P2 had eloped. P2 has been in an ED room near the nurse's station. RN-D stated P2 eloped from the ED during shift change. RN-D stated P2 was not on a HOA hold at the time of her elopement nor had a 1:1, but if she did, she "didn't think P2 would have been able to elope.".

During an interview on 5/20/25 at 10:45 a.m., RN-M stated when she was leaving her shift, she was in the parking ramp and there was a line of cars to get to the road. RN-M looked over and saw a person underneath the stairwell that looked like the patient who had been missing from the ED. RN-M approached P2 and asked if she was ok and if she needed help. RN-M asked for P2's name and it matched the patient's name who had eloped from the ED. P2 had been sitting on the ground and had her knees to her chest. RN-M stated P2 had been shaking because "she was cold". P2 had been wearing her "street" clothing.

During an interview on 5/20/25 at 1:23 p.m., RN-A stated she knew P2 had come from an assisted living facility but did not know what unit she resided in. P2 had come into the ED for chest pain. Once RN-A triaged P2, P2 continued to state she wanted to leave the hospital. RN-A had P2 change into a hospital gown, she started an IV on P2 and drew labs. RN-A had put cardiac monitoring on P2. Around 6:50 p.m., P2 had to use the restroom, so RN-A had NA-A assist P2 on the commode in her room. RN-A stated that was the last time she had an interaction about P2. RN-A stated if she knew a patient was cognitively impaired, she would put the patient in a room closest to the nurses station, put the patient on continuous cardiac monitoring, and place a bed alarm on the patient's bed. RN-A would alert the staff at her nurses station that the patient was cognitively impaired so other staff could watch for the patient.

During an interview on 5/20/25 at 2:29 p.m., RN-N stated the only patient situations that would require a patient to have a 1:1 is if the patient is talking about leaving, attempting to leave, packing their personal belongings, calling for rides, or if the patient had cognitive impairments and was ambulatory. RN-N stated if a patient that was cognitively impaired was "content" with being in the ED and were not attempting to elope, they were not a high risk for eloping. If a patient with cognitive impairments was not "content" with being in the ED, clinical staff "may" increase supervision, but it may not be a 1:1.

During an interview on 5/20/25 at 3:18 p.m., RASM stated an elopement assessment was not available in Epic. It would be an expectation that clinical staff would "think though" an assessment to ensure patient safety. After this incident involving P2, the hospital created a tip sheet that circulated system wide. RASM clarified that the tip sheet was not created just for this incident with P2 but had identified "webs" that needed to be cleared up in the policies and procedures regarding elopements.

During an interview on 5/20/25 at 4:18 p.m., RASM stated currently, the hospital "asks" clinical staff to think about elopement risks and patient safety. The hospital does not require nurses to formally document if they completed an internal elopement assessment. After the elopement tip sheet was created, the tip sheet was sent to leaders at all sites and those leaders were expected to share this information with employees for the first week. This tip sheet was then emailed to all staff. If the staff did not work during the week that leaders were sharing this tip sheet, it was expected that leaders would still review the tip sheet with the staff when they returned to work and the staff would be required to review the tip sheet that was sent in their work emails.

During an interview on 5/21/25 at 1:36 p.m., RASM stated the incident regarding P2 was part of the reason the tip sheet was created. The hospital did not keep a list of staff who was educated about the elopement tip sheet. The hospital did not make any changes to the elopement policy and procedure because they thought the policy and procedure looked "fine". The hospital did not feel as though there was a lack of competency, but that staff did not use the same resources and the same process with cognitively impaired patients.

During an interview on 5/21/25 at 2:17 p.m., RN-O stated if a patient came to the ED that was cognitively impaired, she would ensure the patient is in a room closest to the nurses station. She would communicate with the other nurses and ED techs about the patient's situation so that everyone could "watch" for the patient. RN-O stated she does not document elopement assessments. RN-O was unaware of the elopement tip sheet.

During an interview on 2/21/25 at 2:20 p.m., RN-P stated if he took care of a patient who was cognitively impaired, he would utilize a bed alarm and "maybe" put the patient on a continuous cardiac monitor. RN-P stated he does not document elopement assessments but will document if the patient is stating they want to leave or attempting to elope. RN-P stated there is not an elopement assessment in the computer system. RN-P stated he would do a mental assessment in his own mind on the risk of elopement.

During an interview on 5/21/25 at 2:29 p.m., RN-Q stated if she cared for a patient that was cognitively impaired, she would put the patient on a 1:1, change the patient into yellow slippers alerting a fall risk, and put a wristband on the patient alerting fall risk. RN-Q stated any patient who comes from a memory care facility to the ED was an elopement risk. RN-Q stated she did not think she had any formal training on elopement and could not recall if there was an elopement tip sheet.

During an interview on 5/21/25 at 2:38 p.m., RN-R stated the hospital did not have an elopement tool, but he would assess the patient for safety risks. If RN-R thought the patient had increased safety risks, he would "maybe" put the patient on a HOA hold. If the patient were put on a HOA hold, he would document that in the computer system. RN-R was unaware of an elopement tip sheet.

During an interview on 5/21/25 at 3:09 p.m., RN-S stated if she cared for a patient who had cognitive impairments, she would document if the patient was confused or refusing treatments. Those indicators would determine if the patient were at a high risk for eloping. RN-S was unaware of an elopement tip sheet.

During an interview on 5/22/25 at 12:58 p.m., RASM stated RN-V no longer worked at the hospital and would be unavailable for an interview.

During an interview on 5/22/25 at 1:48 p.m., RN-U stated on 11/11/24, she was working with another clinical staff when she heard loud yelling coming from the hallway. She asked what happened and was told P8 had eloped through the back door. RN-U stated clinical staff called a code on P8's elopement but was unsure what clinical staff member called the code. P8 had a door alarm on his door. RN-U stated she did not hear P8's door alarm going off, so she thought P8's door was already open when he eloped. RN-U stated P8 had been an elopement risk prior to the incident because he was on a 72-hour hold.

During an interview on 5/22/25 at 2:01 p.m., RN-T stated she cared for P8 on 11/8/24. RN-T stated P8 had a door alarm on his door so that if P8 opened his door, he would alert the staff that P8 was coming out of his room. P8 did not have a door alarm because he had COVID-19. RN-T was unaware of an elopement tip sheet.

Hospital's Peace Officer or Health Officer Authority to Detain a Person Against the Person's Will for Assessment and-or Transport policy dated 8/30/20 indicated peace officer (PO) or health officer (HO) had the authority to detain a person of any age if the PO/HO has reason to believe, either through direct observation of the person's behavior or upon reliable information of the person's recent behavior and, if available, knowledge of reliable information concerning the person's past behavior or treatment if that person has a mental illness or developmental disability and was in danger of harming themselves or others if the PO/HO does not immediately detain the patient.

Hospital's Patient Elopement policy dated 10/21/21 indicated the assessment of patient for elopement risk would be done upon arrival to the hospital care setting, the patient would be assessed to determine whether they are at risk of patient elopement and what types of precautions and interventions may be necessary to ensure patient safety. Questions that could be helpful in the assessment may include if the patient has a commitment order, if the patient lacks the cognitive ability to make relevant decisions, if the patient has a history of elopement, and if the patient has physical or mental impairments that increase their risk of harm to themselves or others. '

The hospital's Elopement Prevention tip sheet dated 9/30/24 indicated patients would be considered an elopement if the patient leaves the patient care area without the consent of their authorized decision maker for adult patients who lack decisional capacity and any patient on a legal hold, court hold, or court commitment.

Hospital's Increased Patient Supervision policy dated 2/4/25 indicated a patient would require continuous observation via 1:1 monitoring if the patient were physically able to elope and exhibiting high-risk behaviors for elopement.

The immediate jeopardy that began on 9/7/24 was removed on 5/23/25, when it was verified by observation, interview, and document review the facility completed review of the Patient Elopement policy, the facility's assessment guidance in the Patient Elopement policy in procedure section 1b was added to Elopement Risk questions in the computer system for staff to have framework for assessing a patients elopement risk. The facility ensured required documentation on elopement risk assessment was added to the computer system for RN's to complete in the ED during triage and applicable inpatient admission. These questions ask if the patient is an elopement risk. The Patient Elopement policy is in the row details of the question to help the RN's in the assessment. If the first question an RN responds "yes" to, then there is a question that cascades down asking what elopement risk interventions were put into place. That question has a drop-down box with the options door alarm, close to nurses station, telemetry leads on, bed alarm, 1:1, free test, locked environment, and camera. The goal for the questions in the computer system was implemented on 5/23/25. The facility required RN's to document interventions in the computer system if an elopement risk assessment is selected and is visible to all members of the care team. Patients that have been assessed for being at risk for elopement will have a best practice alert visible in the computer system. The alert will be automatic if the elopement risk assessment was selected as "yes". This alert will "go live" in the computer system on 5/31/25. The facility's patient safety alert was issued on 5/23/25 at 8:30 a.m. The hospital-wide safety huddle was observed starting day shift on 5/23/25, RN's must attest via e-learning during their shift that they received and understood the alert. RN's complete this attestation during their first scheduled shift. This alert included information on the computer system updates and the Patient Elopement policy.