HospitalInspections.org

The hospital failed to protect and promote each patient's rights to receive care in a safe setting for 1 of 5 sampled patients (#1) who had dementia, eloped from the hospital, was hit by an automobile, and died.

The Immediate Jeopardy began on 11/17/2021. The Immediate Jeopardy was removed on 12/10/2021 after verification of the hospital's implementation of immediate actions to remove the serious threat.

Findings:

Cross Reference A0144 - Based on observations, walking tour of route taken by patient #1, interview, and review of patient records, video recording, police report, and hospital policies, the hospital failed to ensure the protection and promotion of the right to receive care in a safe setting for patients with a dementia diagnosis, history of elopement and classification as an elopement risk for 1 of 5 sampled patients (#1). Patient #1 eloped from the hospital on 11/17/2021 and was hit by an automobile. Patient #1 was taken back to the hospital's Emergency Department (ED) by Emergency Medical Services (EMS), where she later died.

Cross Reference A0145 - Based on observations, walking tour of route taken by patient #1, interview and review of patient records, video recording, police report, and hospital policies, the hospital failed to protect 1 of 5 sampled patients from neglect (#1). The hospital failed to provide the necessary supervision for patient #1 with a dementia diagnosis, who was classified as an elopement risk, and had a history of elopement. Patient #1 eloped from the hospital on 11/17/2021 and was hit by an automobile. Patient #1 was taken back to the hospital's Emergency Department (ED) by Emergency Medical Services (EMS), where she later died.



The implementation of the Hospital's Removal Plan for Serious Threat, effective December 9th, 2021, to remove the Immediate Jeopardy was verified by the survey team and included the following immediate actions:

On December 9th, 2021, all current in patients and newly admitted patient will be screened with the new Elopement Risk Decision Tree tool.

On December 9th, 2021, the Elopement Risk assessment process was reviewed with Nursing Administrators and shift leaders.

On December 10th, 2021, initiatives utilized for patients screening positive for elopement risk includes a Icon sign (Picture of a runner) and location near the nurse's station.

Beginning December 10th, 2021, Safety Sitters supervision will be provided (24/7) of all elopement Risk patients.

Re-education of all team members related to visitor arm banding requirements. Date completed December 10th, 2021 at 1000.

Daily Safety Briefing to communicate the patients who are elopement risks, initiated December 10th, 2021.

Role specific education on the Elopement Risk process has been provided to 100% of all active team members on shift beginning December 9th 2021 at 1900. Education will be on going every shift till 100% of team members have completed the training.

Based on observations, walking tour of route taken by patient #1, interview, and review of patient records, video recording, police report, and hospital policies, the hospital failed to ensure the protection and promotion of the right to receive care in a safe setting for patients with a dementia diagnosis, history of elopement and classification as an elopement risk for 1 of 5 sampled patients (#1). Patient #1 eloped from the hospital on 11/17/2021 and was hit by an automobile. Patient #1 was taken back to the hospital's Emergency Department (ED) by Emergency Medical Services (EMS), where she later died.

Findings:

Cross Reference to A0115.

On 11/13/2021, patient #1 was brought to the ED via ambulance. At 2:07 PM, Advance Practice Registered Nurse (APRN) C note read, "[a description of patient #1] . . . presents to emergency department with complaints of substernal non-radiating chest pain that started intermittently over the last 3 months . . . states she had some shortness of breath which concerned her which made her come to the emergency department today . . . Mental status . . . alert . . . disoriented. Comments: Alert and oriented to person only."

On 11/13/2021 at 10 PM in the ED, patient #1 removed telemetry and refused to have the nurse place it back on her. A At 4:38 AM on 11/14/2021, the nurse wrote that the patient refused blood draw on the night of 11/13/2021 and again in the AM on 11/14/2021, and was "verbally aggressive". Patient #1 patient 's record reflected that she attempted to elope while under the Baker Act.

A Baker Act (Florida involuntary psychiatric examination and admission) was ordered by ED physician F on 11/13/2021 at 3:23 PM. ED phsycian F wrote, "Baker Act. Patient safety attendant at bedside. Continuous observation, 1:1 (one to one) patient."

The hospital's "Baker Act and Marchman Act Patient Safety Guidelines" included to "Maintain 1:1 continuous visual observation even if visitors are present: Uninterrupted direct visual observation of the patient by a team member trained to care for the Baker Act . . . patient . . . who is immediately able to intervene with the patient."

ED physician F's notes on 11/13/2021 from 3:07 PM through 4:31 PM read, "Does not appear to have capacity to make her own medical decisions at this time given her inability to answer simple questions with appropriate responses . . . Spoke with patient's son. Discussed my concern for altered mental status. They state that she has been showing signs of dementia recently. They state that she got into a vehicle and drove to South Florida and ran into another vehicle. They agree that the patient does not appear to have capacity to make her own medical decisions and her mental state is overall worsening. Patient will be Baker Acted . . . ."

On 11/13/2021 at 3:30 PM, The "Certificate of Professional Initiating Involuntary Examination", completed by the physician read, "Diagnosis of mental illness is: Acute psychosis . . . Patient confused. Physically abusive to staff. Unable to make own medical decisions. Without prompt care patient likely to suffer self-harm/death without evaluation."

On 11/13/2021 at 4:10 PM, Security Officer D wrote, "On arrival . . . clinical staff informed them that . . . [patient #1 name] was attempting to leave. Clinical staff also informed Security that (patient #1) is currently under a Baker Act hold. Security Officer [E] stated he was called by two registered nurses to stop [patient #1's name] from leaving the hospital . . . We walked with [patient #1's name] back to her room . . . of the emergency department without incident."

The History and Physical of 11/13/2021 at 4:08 PM written by physician G, a hospitalist, read, "brought to hospital via ambulance for chest pain . . . the patient . . . shows signs of aggression, and was Baker Acted by the emergency team, she was given Geodon . . . She deviates from the conversation asking for her purse and saying that she needs to go home . . . Assessment/Plan . . . Concerns for behavioral disturbance, possible dementia, the patient has been Baker Acted in the emergency room, will have psychiatry evaluation."

"Geodon (ziprasidone) is an antipsychotic medication . . . Geodon is used to treat schizophrenia and the manic symptoms of bipolar disorder (manic depression) in adults . . . ." (retreived 12/16/2021 www.drugs.com).

The patient went to the Surgical Care Unit (SCU) on the 5th floor at 5:17 PM on 11/13/2021.

On 11/14/2021 at 10 AM, an Internal Medicine note by physician H read, "Assessment/Plan . . . Patient has needed Haldol. This morning patient was extremely agitated requiring security and patient was put on four-point restraints for aggressive behavior and hitting . . . Patient seen and examined at bedside. Patient was very agitated this morning requiring security out to come to bedside. Patient was also hitting, attempting to pull out IV."

"Haldol is an antipsychotic medicine that is used to treat schizophrenia." (retrieved 12/16/2021 www.drugs.com).

On 11/14/2021 at 11:53 AM, Physician Assistant (PA) I's Psychiatry Consultation note read, "Impaired insight and judgment."

On 11/16/21 at 9:24 AM, PA I's note read, "Patient states she does not want to make life complicated and is focused on going home. She states it would make it easier for the doctors if she went home . . . Insight and judgment impaired. Assessment: Adjustment disorder, anxious mood. Rule out dementia with behavioral disturbances . . . Patient appears to have some dementia and is unlikely to benefit from inpatient psychiatry. Will consult neurology as son has expressed concerns regarding memory impairment . . . Son . . . is noting concerns that patient will become more forgetful and is concerned that patient does not have a good understanding of her medical care."

On 11/16/2021 at 12 PM, physician J wrote, "Psychiatry has discussed with Son who has mentioned some memory impairment, concern for dementia and in that case Psychiatric admission may not be helpful and consulted Neuro for evaluation. Neurology suspects cognitive impairment with dementia . . . Discussed with Psych, recommend Neuro eval for dementia since her behavioral disturbance likely due to dementia and may not benefit with Psych admission."

On 11/16/2021 at 3:15 PM, Neurology consultation note of by physician L read, "Her family noted memory impairment. Her son thinks that she may have lost some language . . . While at the hospital she wanted to leave and fought with security and she was Baker Acted . . . Active problems: Cognitive impairment possibly dementia."

A Commuted Tomography (CT) Scan of the Head without contrast, done on 11/16/2021 at 7:07 PM by physician W read, "Findings: Old right hemispheric infarct. Chronic deep white matter ischemic changes." Infarct is "an area of necrosis from a sudden insufficiency of arterial or venous blood supply." (retrieved 12/16/2021 https://medical-dictionary.the freedictionary.com).

On 11/17/2021 at 1:12 PM, PA I's Psychiatry note read, "Patient seen with son present at bedside . . . Will rescind Baker Act as a less strict alternative is available. Patient appears to have some dementia and is unlikely to benefit from inpatient psychiatry . . . Family in agreement and would like transfer to ALF (Assisted Living Facility) instead."

On 11/17/2021 at 3:09 PM, physician J ordered, "Discharged/Transferred to a facility that provides custodial or supportive care."

The Discharge Summary of 11/17/2021 at 3:19 PM by physician J read, "Disposition: Assisted living facility . . . You were also evaluated by psychiatry and neurology. You have dementia and you are recommended to start Aricept 5 MG (milligrams) every night. You do not have the capacity to make your medical decisions and your family/son will have to make medical decisions for you . . . You will be discharged to assisted living facility . . . Discharge diagnosis . . . Dementia . . . Admitted for evaluation . . . Psychiatry has discussed with son who has mentioned some memory impairment, concern for dementia and in that case Psychiatric admission may not be helpful and consulted Neuro for Evaluation. Neurology suspects cognitive impairment with dementia . . . Discussed with Psychiatry, patient has dementia, behavioral disturbances are related to dementia and would not benefit with psychiatric admission. Recommend alternate environment. Discussed with son regarding discharge planning patient is not safe to stay by herself due to dementia case she does not have any insight in her medical condition and her disease, recommend assisted living facility or memory care unit, does not need nursing home since she is able to ambulate independently. Does not have capacity to make her own decisions. Baker act is rescinded . . . Patient is medically stable for discharge home . . . Exam day of discharge: Sitter at bedside. Patient was sitting up in bed and wants to go home . . . Patient is only oriented to place and person. She does not know the date and time. She does not know the name of the president. She is unable to count backwards from 10-1 . . . Apparently, patient has been living by herself which is not safe for her since she does not have the capacity for insight into her medical conditions. Son is agreeable for her memory care placement . . . Has advised the son that patient does not have capacity to make medical decisions."

"Donepezil, sold as the trade name Aricept among others, is a medication used to treat Alzheimer's disease." (retrieved 12/16/2021 https://en.wikipedia.org).

On 11/17/2021 at 3:40 PM, Social Worker (SW) T's note read, "DC (discharge) order placed 11/17 [2021]. Patient was initially Baker Acted but it is now rescinded. Son wants patient to DC to ALF. Son found ALF near his home . . . SW called admissions [name of person at the ALF] . . . who is still reviewing case and will most likely accept patient. Son is not able to take patient home due to safety concerns. Patient is independent but has dementia. 1823 [Resident Health Assessment for Assisted Living Facilities form] on chart . . . D.O.N. (Director of Nursing) accepted case. Admissions from ALF will call nurse to complete a phone assessment."

On 11/17/2021 at 4:01 PM, physician L's neurology note read, "CT showed an old RMCA (right mid cerebral artery) - frontal lobe. I spoke with her son, and he has observed some episodic confusion with the patient. Impression: Dementia either vascular or Alzheimer related."

The Resident Health Assessment for ALFs 1823 assessment form, dated and signed physician J on 11/17/2021, and written by licensed practical nurse (LPN) U read, "Able to ambulate on her own . . . Forgetful and leave her room wants to go home . . . Wanders. Elopement Risk: yes."

A Security Incident Report of 11/17/2021 by Security Officer Q read, "On 11/17/2021 at approximately 9:40 PM, I [Security Officer Q's name] . . . was posted at the Emergency Department security desk when I observed a female patient (which turned out to be patient #1) being treated in room . . . I overheard two EMS providers . . . speaking about the patient, stating that they observed the patient laying in the roadway at the intersection . . . in front of the hospital after being struck by a vehicle . . . I identified the patient by sight from a previous contact where she had been Baker Acted in the emergency room days prior, wearing the same clothing as she was while in room . . . At approximately 9:50 PM I was notified along with additional security staff by overhead announcement of a Code Echo (Alert code used for patient eleopement) for room . . . Patient was missing was described as a [physical description was documented] and was last seen by staff on the 5th floor approximately 15 minutes prior . . . I immediately recognized the description matched the patient being treated in room . . . for injuries suffered from a vehicle versus pedestrian accident . . . I responded to room . . . to successfully identify the patient . . . The patient was also successfully identified by her hospital band on her wrist which she was still wearing."

An ED physician's note of 11/17/2021 at 11:40 PM by physician R read, "Patient presented to ED as a trauma code via EMS. Patient was found by EMS pulseless on the side of the road. Patient had no spontaneous respirations and no pulse on arrival to the ED . . . Based on EMS story and physical exam patient is most likely struck by an automobile . . . Patient was brought to the hospital within 5 minutes of being found pulseless on the side of the road unknown when the trauma occurred ....EMS found her laying pulseless on the side of the road after what appears to be an auto versus pedestrian. They had no further information . . . Patient was pronounced dead at 9:49 PM. I spoke to family and expressed my condolences and answered all questions."

A written statement by Nursing Assistant II (NA) N on 11/19/2021 at 12 AM read, "At approximately 9 PM, my coworker and I saw her in her doorway and we asked her to go back to her room as I offered her snacks but she didn't want any because she didn't want it to upset her stomach so she went back in her room and we went to see the next patient as that was the last time I saw her. By 9:40 the nurse made me aware the patient was not in the room . . . ." The above-mentioned "9 PM" was the last time the patient had been seen alive by staff per record review and a review of statements.

A written statement by RN P on 11/19/2021 at 1:10 AM read, "I [RN P's name] arrived at the hospital at 6:40 PM [note: this would be on 11/17/21] to start my shift . . . I then went into [patient #1's name] room with the day shift nurse to complete bedside shift report, this was approximately 7:50 PM . . . The patient was in her hospital gown sitting on the side of the bed, she seemed content and happy at this time . . . I then continued to get report on the rest of my patients. At approximately 8:30 PM on the way to greet a new admission I passed by the patient's room and visually assessed the patient sitting on her bed in her hospital gown with no apparent distress. I greeted my new admission. I then was called into another patient's room in which I handled the situation and returned to assess [patient #1's name] as soon as I could. I walked into [patient #1's name] room at approximately 9:30 PM and did not see her I looked around the room, and thought the patient was in the bathroom. I opened the bathroom door to find the patient's hospital gown, socks, and an empty patient belongings bag lying on the floor. I then approached the nurse's station and asked the secretary and tech did they see the patient and they stated no. The secretary told the supervisor that the patient was not in her room, and a code ECHO was called and all team members on the floor were looking for the patient. At this time, I notified the patient's son [name of son] at 9:50 PM to let him know that his mother was not in the room and the nursing staff is looking for her . . . I heard over the intercom that the code ECHO was cleared at approximately 10:00 PM."

A written statement by the NA I Sitter M on 11/20/2021 at 1:07 PM read, "On Wednesday November 17, I was at Health Central Hospital from 7 AM to 7 PM and I was a sitter at room . . . with a BA [Baker Acted] patient. At the end of the shift, I've been informed by the nurse who was assigned to the room that I can leave, there is no releave [relief] cause the patient is no longer BA [Baker Acted]." Sitter services ended near the end of the 7 AM to 7 PM shift on 11/17/2021.

On 12/07/2021 at 11:34 AM, the Chief Operating Officer (COO) stated that after the incident, they reviewed available video. She stated that they saw her go to the stairwell exit on her floor and enter it, exit onto the third floor, and find another stairwell on the third floor, and enter it. She stated that since the patient did not exit this stairwell on any other floor, she only could have exited on the first floor. She stated that the first floor exited to the outside of the building, near the ED entrance. She stated that the camera corresponding to this exit was broken.

On 12/08/2021 at 10:20 AM, physician F stated that the APRN had seen the patient first. He confirmed that the patient had attempted to leave but was stopped by staff. He stated that the reason for the Baker Act was a lack of capacity and a failure to understand risks/benefits. He stated that due to self-neglect, she had a risk of self harm. He stated that the patient did not have the capacity to refuse. He stated that the placement of sitters is part of Baker Act protocol. He had stated that the son related a recent event where the patient had driven her car to Miami and wrecked it. He stated that the son had also voiced concern with the patient having worsening dementia symptoms. The physician was aware of the patient's prior trip to South Florida and that there was an attempt by the patient to leave the ED during her 11/13/2021 admission. The medical record did not reveal any evidence that the 5th floor patient unit staff, where patient #1 was being admitted, were informed about the elopement event that occured in the ED.

On 12/08/2021 at 10:40 AM, APRN C stated that the patient had been combative with staff prior to her eventual placement on a Baker Act on 11/13/2021. She confirmed that the patient attempted to leave the ED during her stay on 11/13/2021 and that she was returned to her assigned ED room.

On 12/08/2021 at 10:59 AM, RN B stated that the patient was originally reluctant to talk. He stated that during her stay in the ED, she removed her intravenous line. She said she was leaving the ED. He stated he followed her down the hall, but she was unable to exit because the door required badge access.

On 12/08/2021 at 12:01 PM, NA I Sitter M stated that she began work at 7 AM on 11/17/2021 and was called off her sitting assignment with the patient around 6:55 PM on 11/17/2021. She stated that around four times that day the patient asked to go to the nurses' station to call her son.

On 12/08/2021 at 12:35 PM, RN P confirmed that the day shift sitter had been released due to the cancellation of the Baker Act.

On 12/08/2021 at approximately 1:05 PM, SW T stated that, in her opinion, the patient was more appropriate for a memory care unit which was a secure or locked unit.

Review of the facility's educational training related to elopement focused on the overhead page code announcement of the elopement of a patient who was under the Baker Act or Marchman Act [emergency assistance and temporary detention for individuals requiring substance abuse evaluation and treatment in the state of Florida] or who was in medical peril. The code for elopement was called code ECHO. The facility failed to ensure that staff members were trained on recognizing the elopement risks of Alzheimer's and dementia related diseases and how to act on the elopement risks if identified. On 12/08/2021 at 3:05 PM, the Corporate Risk Manager and Hospital Learning Specialist acknowledged that no such training was part of the hospital's required staff at hire and at annual trainings.

On 12/09/2021 at 11:34 AM, LPN U stated that the 1823 assessment (ALF Resident Health Assessment) was completed with RN S at approximately 5:30 PM on 11/17/2021. She confirmed the entries she had made. She stated that during her shift, the patient was anxious to go home. She told the next shift to "keep an eye on her." She stated that she did not explicitly voice to the next shift that the patient was an elopement risk. She was aware of the diagnosis of dementia, the departures of the patient in and out of her room, and her voiced desire to go home which contributed to the patient being deemed an elopement risk.

On 12/09/2021 at 1:52 PM, PA I stated that she was not aware of the facility's practice to automatically remove sitters once Baker Acts are cancelled.

On 12/09/2021 at 2:28 PM, the Operations Manager of Corporate Risk Services stated that the practice with Baker Acts is to remove sitter coverage if the Baker Act is rescinded. She stated that the exception to this would be when the physician writes an order to continue sitter coverage.

On 12/09/2021 at approximately 3 PM, the surveyors reviewed the hospital video of the patient's eleopement. The times as shown on the video, as well as the observed settings, corresponded to what the hospital staff had written in their timeline. The only place where staff members were seen in the proximity of the patient was when the patient approached the third-floor nurses' station (a staff member crossed her path while on the way to a patient's room). Two staff members were seen at the nurse's station, but it could not be concluded that they saw the patient as she passed by. The patient walked at a normal pace and did not exhibit any abnormal behavior. She was dressed in a black long-sleeve top and black pants.

On 12/09/2021 at 3:39 PM, the Risk Manager and the Corporate Risk Manager confirmed that the facility was aware of patient #1 having attempted to elope from the ED on 11/13/2021, was aware that family had reported a recent event with the patient where she drove to South Florida and crashed her car, was aware that the patient had a dementia diagnosis prior to her 11/17/2021 elopement, and was aware that the patient had been deemed an elopement risk in the 1823 assessment form for at least one and one half hours prior to the termination of sitter services, around 7 PM on 11/17/2021. She also confirmed that the facility did not have measures or staff training in place on 11/17/2021 to identify and assess patients at risk for elopement and the steps to take with such patients. She also confirmed that no new measures with respect to elopement had been initiated with the patient upon termination of sitter services on 11/17/2021. She confirmed that the patient eloped in the evening of 11/17/2021, made her way outside of the hospital and walked to a nearby road and was hit by a vehicle and ultimately died upon return to the ED that evening.

The facility produced the following video timeline which corresponded to what the surveyors saw in the video:
08:57:51 PM - seen walking toward the 5th floor SCU (surgical care unit) stairwell which was closest to her room
08:58:07 PM - enters SCU stairwell
08:59:18 PM - exits stairwell on 3rd floor Adult Medical Unit
09:01:14 PM - seen walking on 3rd floor new tower (camera #5)
09:01:53 PM- seen walking north on 3rd floor
09:02:15 PM - enters stairwell.

On 12/09/21 at 9:30 AM, the Director of Security stated that the distance from the hopsital building door, which the patient was thought by hospital staff to have exited, was as follows: 675 feet from the door then across a grassy area to Colonial Drive, then to the intersection; and 830 feet along the most convenient paved path to Kelton Avenue and then to the intersection with West Colonial Drive.

On 12/10/2021 at 1:10 PM, the surveyor and hospital Risk Manager walked the route which the hospital video indicated patient #1 took. The route began at the patient's room on the fifth floor. This room was not visible from the nurses' station, unless a person in the nurses' station was to lean over the counter and look down the hall. There were three patient rooms between patient #1's room and the nurses' station. The route lead away from the nurse's station eastward to a stairway door located to the right at the termination of this path. The stairs were taken to the third floor. Upon exiting on the third floor, the path, which had a gradual turn to the northwest, was followed. The path went by two nurses' stations. At the end, stairwell #5 was observed. These stairs were taken to the first floor which led to the hospital building exterior.

There was no evidence in patient #1's medical record that the Social Work staff and Nursing staff had informed other staff on 11/17/2021 of the determination that the patient was an elopement risk in the general time vicinity of the cessation of sitter coverage. SW T was aware of the termination of the Baker Act at least by 3:40 PM on 11/17/2021.

There was no evidence that the hospital had initiated any actions while the patient remained in-house which pertained to elopement risks upon cessation of the Baker Act at approximately 3:40 PM on 11/17/2021 and the discontinuation of a sitter which occurred shortly thereafter. There was no evidence that the hospital initiated any actions on 11/17/2021 to prevent the risk of elopement while the patient remained in-house after sitter discontinuation. There was no evidence that the hospital addressed combined factors of the patient's dementia diagnosis, her attempted elopement while in the ED, and the determination that she was an Elopement risk, as documented on the 1823 ALF Resident Health Assessment form.

The facility did not have a process to assess patients for their elopement risk. On 12/08/2021 at 2:35 PM, the Chief Nursing Officer acknowledged that the hospital did not have an elopement risk process. Hospital documentation indicated that patient #1 was an elopement risk.

The hospital policy "Patients' Rights and Responsibilities", revised 11/2019, read, "The patient has a right to expect reasonable safety insofar as the hospital practices and environment are concerned."

Based on observations, walking tour of route taken by patient #1, interview and review of patient records, video recording, police report, and hospital policies, the hospital failed to protect 1 of 5 sampled patients from neglect (#1). The hospital failed to provide the necessary supervision for patient #1 with a dementia diagnosis, who was classified as an elopement risk, and had a history of elopement. Patient #1 eloped from the hospital on 11/17/2021 and was hit by an automobile. Patient #1 was taken back to the hospital's Emergency Department (ED) by Emergency Medical Services (EMS), where she later died.

Findings:

Cross Reference to A0115.

Patient #1's record reflected an admission to the hospital on 11/13/2021 after being brought to the ED via EMS for complaint of chest pains. Patient #1's ED and physician records, dated 11/13/2021, included that she was confused, disoriented, oriented to person only, physically abusive to staff, and unable to make her own medical decisions. Patient #1 was Baker Acted (Florida involuntary psychiatric examination and admission) in the ED and then attempted to elope from the ED. The record contained physician interviews with patient #1's son, who was concerned about her increasing signs of dementia, one of which was she got into a vehicle, drove to South Florida, and ran into another vehicle.

Advance Practice Registered Nurse (APRN) C's note in the ED, dated 11/13/2021 at 2:07 PM, read, "[a description of patient #1] who presents in emergency department with complaints of substernal non-radiating chest pain that started intermittently over the last 3 months . . . states . . . had some shortness of breath which concerned her which made her come to the emergency department today . . . Mental status . . . alert disoriented . . . .Alert and oriented to person only."

On 11/13/2021 at 3:23 PM, ED physician F ordered, "Baker Act. Patient safety attendant at bedside. Continuous observation, 1:1 (one to one) patient." Patient #1's record reflected that she attempted to elope from the ED. The "Certificate of Professional Initiating Involuntary Examination", completed by ED physician F on 11/13/2021 at 3:30 PM read, "Diagnosis of mental illness is: Acute psychosis . . . Patient confused. Physically abusive to staff. Unable to make own medical decisions. Without prompt care patient likely to suffer self-harm/death without evaluation."

On 11/13/2021 at 4:10 PM, Security Officer D wrote, "On arrival . . . clinical staff informed them that .... [patient #1's name] was attempting to leave. Clinical staff also informed Security that [patient #1's name] is currently under a Baker Act hold. Security Officer . . . stated he was called by two registered nurses to stop [patient #1's name] from leaving the hospital . . . We walked with [patient #1's name] back to her room in . . . of the emergency department without incident."

ED physician F's notes on 11/13/2021 from 3:07 PM through 4:31 PM read, "Does not appear to have capacity to make her own medical decisions at this time given her inability to answer simple questions with appropriate responses . . . Spoke with patient's son. Discussed my concern for altered mental status. They state that she has been showing signs of dementia recently. They state that she got into a vehicle and drove to South Florida and ran into another vehicle. They agree that the patient does not appear to have capacity to make her own medical decisions and her mental state is overall worsening. Patient will be Baker Acted . . . ."

The History and Physical of 11/13/2021 at 4:08 PM, written by hospitalist physician G, read, "brought to hospital via ambulance for chest pain . . . patient . . . shows signs of aggression, and was Baker Acted by the emergency team, she was given Geodon . . . She deviates from the conversation asking for her purse and saying that she needs to go home . . . Assessment/Plan . . . Concerns for behavioral disturbance, possible dementia, the patient has been Baker Acted in the emergency room, will have psychiatry evaluation."

"Geodon (ziprasidone) is an antipsychotic medication . . . Geodon is used to treat schizophrenia and the manic symptoms of bipolar disorder (manic depression) in adults . . . ." (retreived 12/16/2021 www.drugs.com).

Patient #1 was later admitted to the hospital's 5th floor Surgical Care Unit (SCU) on 11/13/2021 at 5:17 PM. The Baker Act order and a one-to one Baker Act sitter order continued until the Baker Act was rescinded in the afternoon of 11/17/2021. The medical record did not reveal any evidence that the 5th floor patient unit staff, where patient #1 was admitted, were informed about the elopement attempt and combative events which occurred in the ED prior to patient #1's admission to the fifth floor. However, patient #1's medical record contained documentation of signs and symptoms of dementia behavior.

An Internal Medicine note by physician H, dated 11/14/2021 at 10 AM, read, "Assessment/Plan . . . Patient has needed Haldol. This morning patient was extremely agitated requiring security and patient was put on four-point restraints for aggressive behavior and hitting . . . Patient seen and examined at bedside. Patient was very agitated this morning requiring security . . . to come to bedside. Patient was also hitting, attempting to pull out IV."

"Haldol is an antipsychotic medicine that is used to treat schizophrenia." (retrieved 12/16/2021 www.drugs.com).

On 11/14/2021 at 11:53 AM, Physician Assistant (PA) I's Psychiatry Consultation note, "Impaired insight and judgment." On 11/16/2021 at 9:24 AM, PA I's note read, "Patient states she does not want to make life complicated and is focused on going home. She states it would make it easier for the doctors if she went home . . . Insight and judgment impaired. Assessment: Adjustment disorder, anxious mood. Rule out dementia with behavioral disturbances . . . Patient appears to have some dementia and is unlikely to benefit from inpatient psychiatry. Will consult neurology as son has expressed concerns regarding memory impairment . . . son . . . is noting concerns that patient will become more forgetful and is concerned that patient does not have a good understanding of her medical care."

On 11/16/2021 at 12 PM, hospitalist physician J wrote, "Psychiatry has discussed with son who has mentioned some memory impairment, concern for dementia and in that case Psychiatric admission may not be helpful and consulted Neuro for evaluation. Neurology suspects cognitive impairment with dementia . . . Discussed with Psych, recommend Neuro eval for dementia since her behavioral disturbance likely due to dementia and may not benefit with Psych admission."

Neurology consultation note by physician L, dated 11/16/2021 at 3:15 PM, read, "Her family noted memory impairment. Her son thinks that she may have lost some language . . . While at the hospital she wanted to leave and fought with security and she was baker acted . . . Active problems: Cognitive impairment possibly dementia."

A Commuted Tomography (CT) scan of the Head without contrast confirmed that patient #1 had dementia. The CT scan was done on 11/16/2021 at 7:07 PM and physician W's findings read, "Findings: Old right hemispheric infarct. Chronic deep white matter ischemic changes." "A stroke or cerebral (brain) infarct . . . is when there is a blockage to blood flow to one or more areas of the brain." (retrieved 12/16/2021 https://www.newhealthadvisor.org).

PA I's Psychiatry note dated 11/17/2021 at 1:12 PM read, "Patient seen with son present at bedside . . . Will rescind Baker Act as a less strict alternative is available. Patient appears to have some dementia and is unlikely to benefit from inpatient psychiatry . . . Family in agreement and would like transfer to ALF (Assisted Living Facility) instead."

On 11/17/2021 at 3:09 PM, hospitalist physician J ordered "Discharge/Transfer to a facility that provides custodial or supportive care."

On 11/17/21 at 3:19 PM, physician J's Discharge Summary included, "Disposition: Assisted living facility . . . You were also evaluated by psychiatry and neurology. You have dementia and you are recommended to start Aricept 5 MG (milligrams) every night. You do not have the capacity to make your medical decisions and your family/son will have to make medical decisions for you . . . You will be discharged to assisted living facility . . . Discharge diagnosis . . . Dementia . . . Admitted for evaluation . . . Psychiatry has discussed with son who has mentioned some memory impairment, concern for dementia and in that case Psychiatric admission may not be helpful and consulted Neuro for Evaluation. Neurology suspects cognitive impairment with dementia .... Discussed with Psychiatry, patient has dementia, behavioral disturbances are related to dementia and would not benefit with psychiatric admission. Recommend alternate environment. Discussed with son regarding discharge planning patient is not safe to stay by herself due to dementia case, she does not have any insight in her medical condition and her disease, recommend assisted living facility or memory care unit, does not need nursing home since she is able to ambulate independently. Does not have capacity to make her own decisions. Baker act is rescinded . . . Patient is medically stable for discharge home . . . Exam Day of discharge: Sitter at bedside. Patient was sitting up in bed and wants to go home .... Patient is only oriented to place and person. She does not know the date and time. She does not know the name of the president. She is unable to count backwards from 10 . . . Apparently, patient has been living by herself which is not safe for her since she does not have the capacity for insight into her medical conditions. Son is agreeable for her memory care [locked unit] placement . . . Has advised the son that patient does not have capacity to make medical decisions."

"Donepezil, sold as the trade name Aricept among others, is a medication used to treat Alzheimer's disease." (retrieved 12/16/2021 https://en.wikipedia.org).

On 11/17/2021 at 3:40 PM, Social Worker (SW) T's note for patient #1 read, "DC (discharge) order placed 11/17 [2021]. Patient was initially Baker Acted but it is now rescinded. Son wants patient to DC to ALF. Son found ALF near his home . . . SW called admissions [name of person at the ALF] . . . who is still reviewing case and will most likely accept patient. Son is not able to take patient home due to safety concerns. Patient is independent but has dementia. 1823 [Resident Health Assessment for Assisted Living Facilities form] on chart . . . D.O.N. (Director of Nursing) accepted case. Admissions from ALF will call nurse to complete a phone assessment."

The Resident Health Assessment for ALFs 1823 assessment form, filled out by licensed practical nurse (LPN) U under the supervision of RN S, included, "Able to ambulate on her own . . . Forgetful and leave her room, wants to go home . . . Wanders. Elopement Risk: yes." The assessment form was dated 11/17/2021 and signed physician J.

Neurology physician L's, note dated 11/17/2021 at 4:01 PM, read, "CT showed an old RMCA (right mid cerebral artery) - frontal lobe. I spoke with her son, and he has observed some episodic confusion with the patient. Impression: Dementia either vascular or Alzheimer related."

At approximately 9 PM on 11/17/2021, patient #1 was last seen by nursing staff on her 5th floor unit and made her way out of the hospital to Colonial Drive, a busy 6 lane State Highway, where she was hit by a automobile at approximately 9:22 PM, sent by EMS to the ED, and died in the ED.

On 11/17/2021, Security Officer Q's report read, "On 11/17/2021 at approximately 9:40 PM, I [Security Officer Q's name] . . . was posted at the Emergency Department security desk when I observed a female patient (which turned out to be patient #1) being treated in room . . . I overheard two EMS providers . . . speaking about the patient, stating that they observed the patient laying in the roadway at the intersection of West Colonial Drive and Kelton Avenue in front of the hospital after being struck by a vehicle . . . I identified the patient by sight from a previous contact where she had been Baker Acted in the emergency room days prior, wearing the same clothing as she was while in room . . . At approximately 9:50 PM I was notified along with additional security staff by overhead announcement of a Code Echo for room . . . Patient was missing . . . and was last seen by staff on the 5th floor approximately 15 minutes prior . . . I immediately recognized the description matched the patient being treated in room . . . for injuries suffered from a vehicle versus pedestrian accident . . . I responded to room . . . to successfully identify the patient . . . The patient was also successfully identified by her hospital band on her wrist which she was still wearing."

ED physician R's note of 11/17/2021 at 11:40 PM read, "Patient presented to ED as a trauma code via EMS. Patient was found by EMS pulseless on the side of the road. Patient had no spontaneous respirations and no pulse on arrival to the ED . . . Based on EMS story and physical exam patient is most likely struck by an automobile . . . Patient was brought to the hospital within 5 minutes of being found pulseless on the side of the road unknown when the trauma occurred . . . EMS found her laying pulseless on the side of the road after what appears to be an auto versus pedestrian. They had no further information . . . Patient was pronounced dead at 9:49 PM. I spoke to family and expressed my condolences and answered all questions."

A police report, dated 11/18/2021, read, "On November 17, 2021, at approximately 2122 hours [9:22 PM], I . . . responded to the area of West Colonial Drive and Kelton Avenue in reference to a traffic crash with injuries. Upon arrival, I observed . . . female, later identified as [patient #1's name] . . . laying in the roadway in the right straight thru lane westbound on West Colonial Drive just north of Kelton Avenue. I observed a . . . truck . . . just north of the female laying on the roadway. I made contact with the driver of the . . . truck . . . [Patient #1's name] was treated by Ocoee Fire Department. [Patient #1's name] was transported by Ocoee Rescue to Health Central. [Patient #1's name] was pronounced deceased at 2149 [9:39 PM] by . . . [physician] at Health Central. [Driver of truck] . . . advised . . . traveling westbound on West Colonial Drive and something appeared in the roadway in front his . . . truck. [Driver of truck] then called police and waited until police arrived on scene . . . Contact with a witness . . . advised . . . traveling westbound on West Colonial Drive in the right lane behind [truck] . . . [witness] observed something fly into the street . . . advised the fire department arrived on scene immediately and began attending the pedestrian. [Witness] stayed on scene until police arrived . . . . "

Review of a written statement by Nursing Assistant II (NA) N on 11/19/2021 at 12 AM read, "At approximately 9 PM, my coworker and I saw her in her doorway and we asked her to go back to her room as I offered her snacks but she didn't want any because she didn't want it to upset her stomach so she went back in her room and we went to see the next patient as that was the last time I saw her. By 9:40 the nurse made me aware the patient was not in the room . . . ." The above-mentioned "approximately 9 PM" was the last time the patient was seen alive by staff per record review and a review of staff statements.

A written statement by RN P on 11/19/2021 at 1:10 AM read, "I [RN P's name] arrived at the hospital at 6:40 PM [this would be on 11/17/2021] to start my shift . . . I then went into [patient #1's name] room with the day shift nurse to complete bedside shift report, this was approximately 7:50 PM . . . The patient was in her hospital gown sitting on the side of the bed, she seemed content and happy at this time . . . I then continued to get report on the rest of my patients. At approximately 8:30 PM on the way to greet a new admission I passed by the patient's room and visually assessed the patient sitting on her bed in her hospital gown with no apparent distress. I greeted my new admission. I then was called into another patient's room in which I handled the situation and returned to assess [patient #1's name] as soon as I could. I walked into [patient #1's name] room at approximately 9:30 PM and did not see her. I looked around the room, and thought the patient was in the bathroom. I opened the bathroom door to find the patient's hospital gown, socks, and an empty patient belongings bag lying on the floor. I then approached the nurse's station and asked the secretary and tech did they see the patient and they stated no. The secretary told the supervisor that the patient was not in her room, and a code ECHO was called and all team members on the floor were looking for the patient. At this time, I notified the patient's son [son's name] at 9:50 PM to let him know that [patient #1's name] was not in the room and the nursing staff is looking for her . . . I heard over the intercom that the code ECHO was cleared at approximately 10:00 PM."

On 12/07/2021 at 11:34 AM, the Chief Operating Officer (COO) stated that after the incident, they reviewed available video. She stated that they saw her go to the stairwell exit on her floor and enter it, exit onto the third floor, and find another stairwell on the third floor and enter it. She stated that since the patient did not exit this stairwell on any other floor, she only could have exited on the first floor. She stated that the first floor exited to the outside of the building, near the ED entrance. She stated that the camera corresponding to this exit was broken.

On 12/08/2021 at 10:20 AM, ED physician F stated that the APRN had seen the patient first. He confirmed that the patient had attempted to leave but was stopped by staff. He stated that the reason for the Baker Act was a lack of capacity and a failure to understand risks/benefits. He stated that due to self-neglect, she had a risk of self-harm. He stated that the patient did not have the capacity to refuse. He stated that the placement of sitters is part of Baker Act protocol. He had stated that the son related a recent event where the patient drove her car to Miami and wrecked it. He stated that the son had also voiced concern with the patient having worsening dementia symptoms. The physician was aware of the patient's prior trip to South Florida and that there was an attempt by the patient to leave the ED during her 11/13/2021 admission.

On 12/08/2021 at 10:40 AM, APRN C stated that patient #1 had been combative with staff prior to her eventual placement on a Baker Act on 11/13/2021. She confirmed that the patient was confused and attempted to leave the ED during her stay on 11/13/2021 and that she was returned to her assigned ED room.

On 12/08/2021 at 10:59 AM via telephone, RN B stated that patient #1 was originally reluctant to talk. He stated that during her stay in the ED, she ripped out her intravenous line and walked to the exit door. He said the patient ambulated independently and said she was leaving the ED. The nurse said he followed her down the hall, and patient was unable to exit because the EMS entrance door was locked and required badge access. RN B said, "She swung at me. She said just wanted to go home, didn't need to be here. She didn't want to be here. She would not answer questions, couldn't tell us the year, the dates, and could not answer memory related questions." RN B said her son showed up and calmed her.

On 12/08/2021 at approximately 1:05 PM, SW T stated that, in her opinion, the patient was more appropriate for an ALF memory care unit, a secured unit, as opposed to a regular ALF room due to her dementia and the son's concerns about her dementia.

On 12/08/21 at 12:01 PM, NA I Sitter M stated that she began work at 7 AM on 11/17/2021 and was removed from her sitting assignment with patient #1 around 6:55 PM on 11/17/2021. She said she left the patient's room, and the patient was sitting on the edge of her bed. She stated that about four times that day, the patient asked to go to the nurses' station to call her son. She said the son had already visited the patient twice that day.

A written statement by NA I Sitter M, dated 11/20/2021 at 1:07 PM read, "On Wednesday November 17 [2021], I was at Health Central Hospital from 7 AM to 7 PM and I was a sitter at room . . . with a BA [Baker Acted] patient. At the end of the shift, I've been informed by the nurse who was assigned to the room that I can leave, there is no releave [relief] cause the patient is no longer BA." Sitter services ended near the end of the 7 AM to 7 PM shift on 11/17/2021, and elopement risk patient #1 was no longer receiving one to one staff supervision.

On 12/08/2021 at 12:35 PM, RN P confirmed that the day shift sitter had been released due to the cancellation of the Baker Act.

On 12/09/2021 at 9 AM, surveyor observation of West Colonial Drive, State Highway 50 on the stretch of road between the two streets revealed that it was a very busy highly trafficked 6 straight through lane highway with turn lanes and bicycle lanes on both sides of the road. The approximate distance from where patient #1 most likely exited the hospital stairwell door next to the ED entrance was approximately 0.4 miles to Kelton Street and West Colonial Drive, where she was struck by a truck. Kelton Avenue is 0.2 miles from the intersection of West Colonial Drive. This intersection is approximately 0.2 miles away from the ED stairwell exit door.

According to the website Sunrise-Sunset at https://sunrise-sunset.org, the sun set at 5:33 PM on 11/17/2021. It was dark outside when the patient eloped, was hit by a truck, and died.

On 12/09/2021 at 11:34 PM, LPN U stated that the Resident Health Assessment for ALFs 1823 form was completed with RN S at approximately 5:30 PM on 11/17/2021. She confirmed the entries she had made. She stated that during her shift, the patient was anxious to go home. She told the next shift to "keep an eye on her". She stated that she did not explicitly voice to the next shift that the patient was an elopement risk. She was aware of the diagnosis of dementia, the departures of the patient in and out of her room, and her voiced desire to go home, all which contributed to the patient being deemed an elopement risk.

On 12/09/2021 at 1:52 PM, the Psychiatry PA I stated that she was not aware of the facility's practice to automatically remove sitters once Baker Acts are cancelled.

On 12/09/2021 at 2:28 PM, the Corporate Risk Manager stated that the practice with Baker Acts was to remove sitter coverage when the Baker Act is rescinded. She stated that the exception to this would be where the physician writes an order to continue sitter coverage. She acknowledged that there was no order for sitter supervision of patient #1 after her Baker Act was rescinded.

On 12/09/2021 at approximately 3 PM, the surveyors reviewed the hospital's video related to patient #1's elopement. The times as shown on the video, as well as the observed settings, corresponded to what the facility had written in their timeline. The only place where staff members were seen in the proximity of the patient was when the patient approached the third-floor nurses' station. A staff member crossed her path while on the way to a patient's room. Two staff members were seen at the nurses' station, but it could not be concluded that they saw the patient as she passed by. The patient walked at a normal pace and did not exhibit any abnormal behavior. She was dressed in a black long-sleeve top and black pants.

On 12/09/2021 at 3:39 PM, the Risk Manager and the Corporate Risk Manager confirmed that the facility was aware of patient #1 having attempted to elope from the ED on 11/13/2021, was aware that family had reported a recent event with the patient where she drove to South Florida and crashed her car, was aware that the patient had a dementia diagnosis prior to her 11/17/2021 elopement, and was aware that the patient had been deemed an elopement risk in the 1823 assessment form for at least one and one half hours prior to the termination of sitter services, around 7 PM on 11/17/2021. She confirmed that the facility did not have measures and staff training in place on 11/17/2021 to identify and assess patients at risk for elopement and the steps to take with such patients. She confirmed that no new measures with respect to elopement had been initiated with the patient upon termination of sitter services on 11/17/2021. She confirmed that the patient eloped in the evening of 11/17/2021, made her way outside of the hospital and walked to a nearby road and was hit by a vehicle and ultimately died upon return to the ED that evening.

The facility produced the following video timeline which corresponded to what the surveyors saw in the video:
08:57:51 PM - seen walking toward the 5th floor SCU stairwell which was closest to her room
08:58:07 PM - enters SCU stairwell
08:59:18 PM - exits stairwell on 3rd floor Adult Medical Unit
09:01:14 PM - seen walking on 3rd floor new tower (camera #5)
09:01:53 - seen walking north on 3rd floor
09:02:15 PM - enters stairwell.

On 12/10/2021 at 1:10 PM, the surveyor and the hospital Risk manager walked the route that patient #1 most likely took out of the hospital. The route began at the patient's room on the fifth floor. This room was not visible from the nurses' station, unless a person in the nurses' station was to lean over the counter and look down the hall. There were three patient rooms between patient#1's room and the nurses' station. The route lead away from the nurses' station eastward and a stairway door was located to the right at the termination of this path. The stairs were taken by the surveyor and Risk Manager to the third floor. Upon exiting on the 3rd floor, the path which had a gradual turn to the northwest was followed. The path went by two nurses' stations. At the end, stairwell #5 was observed. These stairs were taken by the surveyor and Risk Manager to the 1st floor and found to have exited to the hospital building exterior.

The hospital policy "Patients' Rights and Responsibilities", revised 11/2019, read, "The patient has a right to expect reasonable safety insofar as the hospital practices and environment are concerned." This was the only policy the hospital provided when asked about their policy on abuse/neglect of hospital patients.

A review of the staffing for SCU 5th floor on 11/17/2021, the date of patient #1's elopement, was conducted with the Corporate Risk Manager on 12/09/2021 at 10:03 AM. This unit was where patient #1 resided while in the hospital. The staffing revealed that the patient census on the 5th floor at 6 PM was 35 patients. On the 11/17/21 7 PM-7 AM shift, when patient #1 eloped, there was one nurse manager, 7 nurses and 4 patient technicians. The census plan called for 9 nurses and 5 patient technicians. They attempted to fill the slots but still found themselves short by two nurses and one patient care technician for a census of 35. The Corporate RM acknowledged the facility attempted to fill the slots but still found themselves short by two nurses and one patient care technician for a census of 35.

There was no evidence in patient #1's medical record that the Social Work staff and nursing staff had informed other staff on 11/17/2021 of the determination that the patient was an elopement risk in the general time vicinity of the cessation of sitter coverage at about 6:55 PM. There was no documented evidence that the hospital had initiated any actions while the patient remained in-house which pertained to elopement risks upon cessation of the Baker Act, at approximately 3:40 PM on 11/17/2021, and the discontinuation of a sitter which occurred shortly thereafter. There was no evidence that the hospital initiated any actions on 11/17/2021 to prevent the risk of elopement while the patient remained in-house after sitter discontinuation. There was no evidence that the hospital addressed combined factors of the patient's dementia diagnosis, her attempted elopement while in the ED, and the determination that she was an elopement risk, as documented on the 1823 ALF Resident Health Assessment form, to protect the patient from harm.

The facility did not have an elopement risk process to determine who is at risk for elopement. On 12/08/2021 at 2:35 PM, the Chief Nursing Officer (CNO) acknowledged that the hospital did not have an elopement risk assessment process.

Review of the facility's educational training related to elopement focused on the overhead page code announcement of the elopement of a patient who was under the Baker Act or Marchman Act [emergency assistance and temporary detention for individuals requiring substance abuse evaluation and treatment in the state of Florida] or who was in medical peril. The code for elopement was called code ECHO. The facility failed to ensure that staff members were trained on recognizing the elopement risks of Alzheimer's and dementia related diseases and how to act on the elopement risks if identified. On 12/08/2021 at 3:05 PM, the Corporate Risk Manager and Hospital Learning Specialist acknowledged that no such training was part of the hospital's required staff at hire and at annual trainings.