HospitalInspections.org

Based on a review of medical records, policy and procedures, interviews and observations, it was determined that the facility failed to have an effective Governing Body:

That ensured that Patient #1's rights to receive care in a safe environment were protected;
That nursing care was delivered in a safe manner;
That sufficient staffing was provided for the facility's needs;
That prevented a system failure that resulted in the elopement of a patient with an altered mental status (Patient #1). This failure resulted in serious harm to Patient #1 who wandered off the hospital premises in an altered mental state, was missing for several days, and eventually found in a weakened and dehydrated state after five days.

Cross-reference A0115 as it relates to the failure of the facility to maintain Patient #1's right to receive care in a safe setting, which resulted in Patient #1's elopement from the facility while under a physician's order for continuous monitoring.

Cross-reference A385 Nursing Services as it relates to the failure of the facility to ensure that nursing services followed doctor's orders and facility's policies for continuous monitoring for a patient with dementia who was a known flight risk (Patient #1). This failure resulted in serious harm to Patient #1 who eloped from the facility and was found several days later in a weak and dehydrated state.

Specifically:

The governing body failed to ensure Patient #1's right to be protected from neglect; Patient #1, who was mentally impaired and an identified elopement risk under a continuous monitoring order, was left to wander around unmonitored due to lack of staff to watch him.
The governing body failed to ensure that nursing staff were educated in the facility's procedure when a patient with an altered mental status eloped from the facility.
Nursing staff:
Failed to provide patient safety monitoring as ordered by the physician for Patient #1.
Failed to follow facility's policy 'Patient Safety Observation Policy' for monitoring a patient who was without decision-making ability, was unable to follow commands, and was an elopement risk, by failing to provide continuous monitoring as ordered by MD.
Failed to follow the facility's policy 'Patient Safety Observation Policy' for ensuring that a patient with a PSM (sitter - personal safety monitor) order must not be left unattended without a replacement sitter.
Failed to follow the facility's policy 'Patient Safety Observation Policy' for ensuring that the sitter will always accompany the patient and assures visibility; the sitter should maintain constant attendance and not leave the assignment.
Failed to document patient observations every 15 minutes for Patient #1 and Patient #3.
Failed to ensure that their 'Elopement/Walkaway Policy' was followed as evidenced by failing to notify Nurse Manager/Supervisor or designee immediately after Patient #1 went missing. The clinical manager was notified 3 hours after Patient #1 went missing; the Director of Unit 7A was not notified until 6:32 pm , 7.5 hours after Patient #1 went missing. There was no documentation in the medical record to indicate the the hospital's GHS operator was paged to ask the patient to return to the unit as stated in the facility's policy. The City Police Department was not notified by Security that the patient was missing until 5 hours later.
Failed to notify the family member of Patient #1 of Patient #1's elopement in a timely manner.
Failed to notify the attending physician of Patient #1's elopement in a timely manner.
Failed to follow facility's 'Absent without leave/Elopement/Walk Away and AMA Policy' to notify the patient's physician after the patient did not return within one hour, to alert him/her of the incident.
The governing body failed to initiate mitigating actions to correct the system failures that led to the elopement of Patient #1 to prevent a recurrence.

Findings included:

Review of Patient #1's medical record revealed that he had been brought to the facility's Emergency Department (ED) by his wife on 7/16/19 at 10:26 a.m. A medical screening examination (MSE) performed by an ED physician on 7/16/19 at 12.08 p.m. revealed a history of dementia (a severe decline in memory and thinking skills that reduces a person's ability to perform everyday activities) and threats of violence as reported by Patient #1's wife. Further review of the ED physician's notes revealed that Patient #1 was confused, agitated and oriented only to self (patient only knows his own name). Review of the ED physician notes revealed that Patient #1 often wandered throughout the ED, was difficult to redirect, was not aware of his current circumstances, and lacked independent decision-making ability. The decision was made to admit Patient #1 to the medical-surgical unit of the hospital for further placement.

While Patient #1 was still in the ED on 7/16/19, at 5:54 p.m., MD MM, an internal medicine physician performed a history and physical (H and P) examination on Patient #1. Review of the H and P revealed that Patient #1's wife was unable to provide round-the-clock care for Patient #1 and reported being afraid of him. Patient #1 refused to answer the physician's questions and voiced that he wanted to leave the hospital. During the examination, Patient #1 became physically confrontational with the physician and security had to be called. Further review of the history and physical revealed that Patient #1 would be admitted as an in-patient, receive medications, and social services would attempt to find placement for discharge. The admission diagnosis on the history and physical was homicidal ideations. A signed 1013 (an order to hold a patient involuntarily due to potential harm to self or others) was placed on the record on 7/16/19 at 5:34 p.m. that would need to be renewed in 48 hours. MD MM further noted that Patient #1 was exhibiting homicidal/aggressive behavior. Additionally, MD MM noted as follows:
- The patient was refusing to get an EKG;
- Order for Haldol (an antipsychotic drug that decreases excitement in the brain) 2 mg IV every 6 hours PRN (as needed) for agitation;
- Social work consult for placement
- Patient placed on 1: 1 observation and needs to be in an isolation room. He is an elopement risk and may not sign out AMA
- Form 1013 signed and placed in the chart.
Review of orders revealed that a Patient Safety Monitor (PSM - also called a sitter, a facility employee assigned to provide continuous observation and supervision of a patient) was ordered due to the signed 1013 on 7/16/19 at 5:24 p.m. This order expired on 7/18/19 at 5:23 p.m.
Patient #1 was transferred from the ED to an in-patient medical-surgical unit on 7/17/19 at 7:58 p.m.
A progress note that was written by MD LL on 7/18/19 at 1:29 p.m. revealed that Patient #1 was agitated and restless. Patient #1 was oriented to self and knew his wife's name. A PSM was present at the bedside. The medical record revealed that the plan was to have psychiatry evaluate Patient #1 and continue to search for placement as his wife could not care for him.

A psychiatric evaluation conducted 7/18/19 at 1:42 p.m. revealed that Patient #1 had symptoms consistent with dementia. The evaluation revealed that Patient #1 had impaired insight (the capacity to gain an accurate and deep intuitive understanding of a person or thing), impaired judgment, poor attention span, impaired concentration, poor recent memory, and fair remote memory. Further review of the psychiatric evaluation revealed recommendations including elopement precautions and constant monitoring by a PSM (sitter).
Further review of the medical record included a physician's order at 7:50 p.m. on 7/18/19 for direct observation with a bedside sitter.

Despite Patient #1 not being on an involuntary status hold on 7/18/2019 at 7:50 p.m., the patient's physician wrote an order for Direct Observation with a bedside sitter. On 7/22/2019, the facility failed to ensure that Direct Observation with a sitter was maintained by failing to utilize Patient Safety Monitor (PSM) employees, which may include assistants, nurse externs, paramedics, PCT's, public safety officers, or other licensed staff who meet eligibility criteria. There was no indication that the facility utilized other PSM employees within the hospital to sit with Patient #1 on 7/22/2019 due to short-staffing on Unit 7A.

A progress note that was written by MD LL on 7/19/19 at 8:14 a.m. revealed that Patient #1 was much calmer and easier to redirect. Patient #1 continued to be fidgety. Patient #1 denied having suicidal or homicidal ideations. A sitter (PSM) was at Patient #1's bedside. MD LL documented that the plan was to find a long-term care facility for Patient #1. The involuntary hold had lapsed and would not be renewed as behavior was due to dementia and not an acute psychiatric illness.
MD LL documented that Patient #1 could walk around the unit with a sitter but could not be left alone.

A progress note that written by MD LL on 7/20/19 at 8:23 a.m. revealed that Patient #1 continued to remain calm and requested to walk around the unit with the sitter. Patient #1 denied having suicidal or homicidal ideations. A sitter was at Patient #1's bedside. MD LL documented that the plan was to find a long-term care facility for Patient #1. MD LL documented that Patient #1 was permitted to walk around the unit accompanied by the sitter but could not be left alone.

A progress note written by MD LL on 7/21/19 at 8:07 a.m. revealed that Patient #1 was calm, and symptoms of aggression had significantly improved. Patient #1 denied having suicidal or homicidal ideations. A sitter was at Patient #1's bedside. The plan of care remained unchanged.

Review of a psychiatric progress note on 7/22/19 at 9:38 a.m. revealed that Patient #1 denied having any suicidal or homicidal ideations. Patient #1 was alert and oriented to self. The psychiatric progress notes further revealed that Patient #1 was wearing civilian clothing per his wife's request. Patient #1 exhibited impaired insight and judgment and no reported aggressive behavior overnight. The note revealed that Patient #1 was a moderate imminent risk of wandering that led to safety concerns. Patient #1 did not meet the criteria for in-patient psychiatry hospitalization.

Review of progress notes by RN FF on 7/22/19 at 7:45 a.m. revealed that Patient #1 was awake and in no distress.

RN FF's progress notes at 11:00 a.m. revealed that Patient #1 was not found on the unit. The nurse had been in Patient #1's room since 9:30 a.m. and Patient #1 had been going in and out of the room independently. Patient #1 did not return for about ten minutes and RN FF searched the unit but could not locate Patient #1. Security was notified, and the physician was updated further about Patient #1's elopement. Further review of the note revealed that security returned to the unit at 3:30 p.m. and reported that they had continued to search for Patient #1. The Unit Manager, Patient #1's wife, and physician were called at 3:30 p.m. Further review of the note revealed that Patient #1's wife came to the unit. Time was not noted. Physician and security were called and came to speak to Patient #1's wife. The chaplain was notified and came to speak to Patient #1's wife.

A discharge summary written by MD LL on 7/22/19 revealed that MD LL received a notification from the nursing staff at 3:30 p.m. that Patient #1 had not been in his room since 11:00 a.m. Due to a staffing shortage, Patient #1 did not have a sitter with him on 7/22/19. MD LL documented that she had not been notified that sitter was unavailable but she (MD LL) had repeatedly discussed with staff during morning rounds, Patient #1's high potential to wander and get lost. MD LL instructed the nursing staff to notify Patient #1's wife. MD LL documented that she called security and was told that the protocol for a missing person with dementia was being followed. Further review of the discharge note revealed that security spoke to Patient #1's wife at 5:30 p.m. At this time, security informed MD LL that the City Police Department had not been called yet. A detective with the City Police Department arrived and took statements from Patient #1's wife, the nurse, and MD LL. The City Police Department was given a picture and description of Patient #1. Patient #1 did not have any identification or a cell phone with him. Patient #1 had the capacity to walk well and did not appear as sick as he was. Patient #1 remained extremely confused on 7/22/19, at the time he eloped.
Review of Flowsheets included but was not limited to the following:

Patient Safety Observations on 7/18/19 at 12:00 p.m., 4:00 p.m., 8:00 p.m., and 11:00 p.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside.
Patient Safety Observations on 7/19/19 at 12:00 a.m., 4:00 a.m. 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside.
Patient Safety Observations on 7/20/19 at 12:00 a.m., 4:00 a.m. 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside.
Patient Safety Observations on 7/21/19 at 12:00 a.m., 4:00 a.m. 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside.
Patient Safety Observations on 7/22/19 at 12:00 a.m. and 4:00 a.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside. There was no further documentation in Patient 1 #'s medical record of any Patient Safety Observations from 4:00 a.m. on 7/22/19 up until the time that the facility discovered that Patient #1 was missing at approximately 11:00 a.m. on 7/22/19.

Other Facility Documentation reviewed included:

A review of the staffing sheet for unit 7A on 7/22/19 revealed that there were seven (7) RNs and three (3) assistants scheduled from 7:00 a.m. until 3:00 p.m. Facility did not provide the number of patients present on the unit.

A review of a timeline of events that occurred on 7/22/19 that was provided by the facility revealed the following:

10:00 a.m. - RN FF stated that after he was done with morning medication at about 9:30 a.m. he went to Patient #1's room to document while watching the patient. Patient #1 had been going in and out of the room while RN FF was watching him.
11:00 a.m. - Unit Clerk notified RN FF that Patient #1 may have left the unit. RN FF and for security to be called; RN FF searched the 7th floor and down to the ground floor.
11:30 a.m. - Security officers spoke to RN FF.
2:00 p.m. - RN FF returned from searching for Patient #1 and notified MD LL.
2:00 p.m. - Unit Charge Nurse was notified that Patient #1 was missing.
2:15 p.m. - 2:30 p.m.- Charge Nurse notified the Unit 7A Clinical Staff Manager (Manager GG) that Patient #1 was missing.
3:00 p.m. RN FF notified Patient #1's family that Patient #1 was missing.
4:00 p.m. - Family arrived on the unit. MD LL and security arrived on the unit to speak to the family. City Police Department officer arrived at the unit to take the report.
6.32 p.m. - The Unit Director of 7A (Director EE) was notified that Patient #1 was missing.

3. Review of a Public Safety Incident report revealed that on 7/22/19 at approximately 11:25 a.m., a public safety officer was dispatched to unit 7A to investigate a walk-a-way patient. RN FF informed the officer that Patient #1 was not on a 1013 hold or one-on-one care. The officer received a physical description of Patient #1. The officer put out a description of Patient #1 to other officers and searched the perimeter and common areas of the facility. At 3:00 p.m., RN FF contacted Patient #1's wife. At 5:30 p.m., Patient #1's wife arrived and requested to speak to a public safety officer. The officer notified the City Police Department who arrived on the unit at 5:50 p.m. Video surveillance cameras were viewed that showed Patient #1 exiting the main doors of Unit 7A at 10:56 a.m. Patient #1 took the elevators to the atrium lobby at 11:08 a.m. and exited the building. Patient #1 was last captured on video walking north on Jesse Hill Jr. Drive. At 6:30 p.m., about 7 hours after Patient #1 disappeared, two security officers searched the perimeter of the facility, the atrium, and the ED waiting area.

4. Review of a Public Safety Incident Report dated 7/27/19 revealed that Patient #1 was brought to the ED via ambulance on 7/27/19 at 2:00 a.m. At this time, Patient #1's wife, Risk Management, Legal Services, and the City Police Department were notified that Patient #1 was in the facility's ED.

The following interviews were conducted:

An interview took place on 8/1/19 at 9:00 a.m. in a conference room with the Director of Risk Management (Director AA) in the presence of Senior Vice President DD. Director AA explained that Patient #1 had been a patient for approximately one week at the time of the incident. She explained that Patient #1 had been brought to the facility for increased aggression and agitation by his wife. Patient #1 had been on an involuntary hold when he was admitted but the involuntary status expired after 24 hours. She stated that sitters had been assigned to be with Patient #1, but on the day of the incident, a sitter was not available. Director AA explained that on the day of the incident, Patient #1 had been ambulating the hallways and returning to his room. Patient #1's nurse was in the patient's room when the patient left the room to walk around the unit, and after about ten minutes, the RN went to look for the patient. Patient #1 could not be located. Patient #1 was brought back to the facility on 7/27/19 at 2:00 a.m. in a weakened and dehydrated state.

An interview with RN FF (Registered Nurse responsible for Patient #1 at the time of Patient #1's elopement on 7/22/19 during the day shift) took place on 8/1/19 at 10:00 a.m. in a conference room. RN FF recalled that Patient #1 had an order to have Patient Safety Monitors (PSM), but on this day the staffing office did not have a sitter available. RN FF explained that he and the Patient Care Technicians (PCT) took turns sitting in Patient #1's room. RN FF stated that 7/22/19 was the first time that he had taken care of Patient #1. Patient #1 spoke English, but French was his native language. RN FF's native language is also French. RN FF recalled he had a conversation in French with Patient #1 that morning. RN FF recalled that Patient #1 had been alert and oriented and did not express a desire to leave the facility. RN FF recalled that the 1013 order for Patient #1 had expired and Patient #1 was being watched carefully. RN FF explained that the facility's staffing office assigned PSMs (sitters) and that patients with current 1013s took priority. RN FF recalled that he went to Patient #1's bedside and relieved a PCT who had been at the bedside. Patient #1 had been walking around the unit and returning to his room. RN FF recalled that on 7/22/19, the unit clerk came into Patient #1's room accompanied by a physician who spoke French. The staff had requested that this physician speak with Patient #1. RN FF told the Unit Clerk that Patient #1 was ambulating on the unit. The Unit Clerk searched the unit for Patient #1 and was unable to locate him. RN FF recalled that Patient #1 had been out of his room for less than ten minutes. RN FF recalled that he called security and searched the unit, the stairwells, the ground floor and outside the perimeter of the facility. RN FF recalled that he followed up with the security office later to get an update and did a second search of the facility. RN FF then notified MD LL. RN FF explained that Patient #1's family arrived at approximately 4:00 p.m. and met with MD LL, security, and the City Police Department. RN FF explained that a chaplain came to the unit to speak to the family and was still meeting with the family when RN FF got off work at approximately 7:00 p.m.

An interview with Physician, MD LL took place on 8/1/19 at 12:10 p.m. in an administrative office. MD LL was an internal medicine physician and had been on staff at this facility since October 2018. MD LL was Patient #1's attending physician from 7/17/19 through 7/22/19. MD LL explained that Patient #1's wife told MD LL that Patient #1 had been diagnosed with dementia prior to this admission. Patient #1's wife informed MD LL that Patient #1 had become more aggressive and agitated recently and would wander from home and get lost during the day while she was at work. MD LL explained that Patient #1 had been under a 1013 (order for involuntary admission due to potential to harm self or others) upon admission due to the reports of increased aggression and dementia. MD LL stated that she had ordered various tests to ensure that Patient #1's behavior was not due to a cause other than dementia. MD LL stated that psychiatry services had assessed Patient #1 and determined that Patient #1 did not have a psychiatric diagnosis; he had dementia. The 1013 order expired after 24 hours and was not extended due to the outcome of the psychiatric evaluation. MD LL explained that she ordered Patient #1 to have constant monitoring by sitters. MD LL recalled that a sitter had been present each morning that she made rounds and recalled reminding the sitters that Patient #1 needed to be watched constantly. MD LL also told the sitters that Patient #1 was able to walk around and encouraged the sitters to walk with Patient #1. On the morning that Patient #1 eloped, MD LL recalled that there were no sitters available and the staff on the unit were taking turns sitting with Patient #1. MD LL recalled that on 7/22/19 she received a call from RN FF that Patient #1 had left the unit at approximately 11:00 a.m. and had not been found. MD LL recalled that RN FF informed her that Patient #1's family had not been notified. MD LL recalled that she instructed RN FF to inform the family. MD LL recalled that after speaking with RN FF, she called the security office and inquired what was being done to locate Patient #1. She was informed by the security staff that the protocol was being followed. MD LL arrived on the unit at approximately 5:30 p.m. MD LL met with Patient #1's family, along with a security staff member and RN FF. MD LL explained that she had had patients leave the facility against medical advice in the past but had not had a patient leave who had diminished mental capacity. MD LL assessed Patient #1 when he was transported back to the facility via ambulance a few days later. MD LL stated that Patient #1 was not hurt physically except that he was dehydrated and tired.

An interview with the Director of Unit 7A (Director EE) took place on 8/1/19 at 9:30 a.m. in a conference room. Director EE had been the Unit Director of 7A for approximately two years. Director EE explained that Unit 7A was a general medical and surgical unit and it was not unusual to have patients with various diagnoses that caused an altered mental status. Director EE stated that Unit 7A was not a locked unit but did require badge access to enter the main entrance. Anyone could freely exit through the main entrance. Director EE recalled that RN FF had been sitting in Patient #1's room on 7/22/19. Director EE further explained that Patient #1 had been ambulating from his room into the hallways of the unit all morning. Patient #1 had always returned to his room with some re-direction. On 7/22/19, RN FF reported that Patient #1 had been gone about ten (10) minutes when he could not be located. Director EE explained that the security office had been notified as well as the patient's family and the City Police Department. Director EE explained that she had personally assisted in searching for Patient #1 throughout the facility and areas around the facility. Director EE explained that after this incident, staff were made aware during shift huddles. Director EE explained that the staff had a 'heightened' awareness of patient observation after this incident. Director EE explained that all staff participate in shift huddles, therefore the schedule was reflective of participation in huddles. Topics discussed at huddles included specific issues or problems with patients and ways to address them differently. Director EE explained that either patient care technicians (PCTs) or nurses check on patients every hour. After the incident, security staff assessed the unit for potential areas of improvement regarding security. The security department made recommendations for changes to the entrance doors and installation of additional cameras. Director EE explained that price quotes had been obtained for the recommendations and changes would be implemented. At the time of the of the initial date of entry of the survey on 8/1/2019, the facility failed to present any evidence that any changes had been made to the entrance doors or that additional cameras had been installed in Unit 7A, to protect and promote patients rights to receive care in a safe setting for patients who were on continuous observation in the facility.

An interview with the Executive Director of Public Safety (Director CC) took place on 8/1/19 at 1:15 p.m. in an Administrative Office. Director CC explained that RN FF had notified security dispatch that a patient was missing. A security officer was dispatched to the unit and spoke with RN FF. RN FF informed the responding officer that Patient #1 did not have a current 1013 but did not inform the security officer that Patient #1 had diminished mental capacity. The security officer responded to the incident as if the patient had left against medical advice (AMA). Director CC explained that when a patient with a 1013 elopes, the City Police Department was notified immediately. Furthermore, if a patient with any type of diminished mental capacity was missing, the incident was treated with the same steps as an elopement of a 1013 patient. Director CC explained that it was hours later that his office learned of Patient #1's diagnosis, at which time the city Police Department was immediately notified. In response to this incident, his department made recommendations for some structural changes to Unit 7A. One of the recommendations was to install a delayed-release door on the entrance door of the unit. This type of door will not release immediately; there is a delay after the door is pushed. A fixed video camera is positioned to enable a monitor view who is about to exit through the door. This mechanism allows the person to be stopped from leaving if warranted. The door will open after a set number of seconds. The door will continue to require badge access to enter and a badge access exit will be available to staff. At the time of the of the initial date of entry of the survey on 8/1/2019, there was no evidence that the foregoing security recommendations had been implemented by the facility.

An interview with the Clinical Staff Manager of Unit 7A (Manager GG) took place in a conference room on 8/1/19 at 11:00 a.m. Manager GG explained that she arrived at work each morning prior to shift change at 7:00 a.m. All incoming staff attend huddle as well as the off-going charge nurse. Manager GG facilitates the morning huddle and the day shift charge nurse facilitates the night shift huddle. Agenda items discussed at huddle included safety issues, quality issues, and specific patient concerns. Manager GG explained that information that needed to be shared with staff immediately was shared at huddles. Manager GG stated that staff sign in at huddle.

A follow-up interview with Manager GG took place on 8/1/19 at 1:15 p.m. in a conference room. Manager GG explained that RN FF received verbal counseling after the incident with Patient #1. She explained that the policy on Patient Elopement had been revised and would be presented to all staff 'soon'. At the time of the initial date of entry of the survey on 8/1/2019, the facility failed to present evidence that the revised policy on Patient Elopement had been presented to all staff on Unit 7A.

During the supervisory review of the complaint, additional information was received via a telephone interview with Patient #1's wife (Family Member A) on 8/14/2019 10:30 a.m. The telephone interview revealed that Familiy Member A got a call from RN FF on 7/22/19 at 3:43 p.m. She could not recall RN FF's name, but he identified himself as her husband's nurse. RN FF asked Family Member A if her husband was home. She stated that she exclaimed that how could he be home? He was in the hospital! RN FF then told Family Member A that her husband was missing and hung up. Family Member A stated that she got to the hospital within 45 minutes after the call from RN FF. She said she got to the front desk and was kept waiting for about 20 minutes. She then told the front desk that she was the wife of Patient #1 and that somebody had called her that her husband was missing. The front desk attendant said she had to talk to Patient #1's nurse. RN FF then appeared in the lobby at that time. RN FF told Family Member A to sit there and wait for him. Family Member A stated that she went instead to the 7th floor where Patient #1 was housed. On the 7th floor, Family Member A was told to sit in a corner near Patient #1's room. Family Member A saw someone cleaning out Patient #1's room and immediately thought Patient #1 was dead, had killed himself or someone had killed him. No one told her anything for several minutes and she began to cry. Family Member A then I heard someone say that 'they need to tell these people something'. At that point, Family Member A stated she asked for someone to help her and tell her something.
The doctor and RN FF came, and Family Member A asked what had happened to her husband? RN FF told Family Member A that Patient #1 left the unit that morning and had not been found. Family Member A asked if they had called the police? And why had they not called her since he went missing several hours ago?
Family Member A stated that after this that the hospital security came to talk to her and called the Police. Family Member A stated that it was she who insisted that the police should be called.
Family Member A stated that RN FF apologized to her.
Family Member A stated that she heard nothing from the hospital the 5 days that Patient #1 was missing. She and other family members made flyers, went to the Internet and went to the media to ensure that Patient #1 would be found. She worked closely with the police, informing them of sightings of Patient #1 from the public.

Family Member A stated that she was called immediately Patient #1 was found. She stated that Patient #1 was very weak, could not stand and was very dirty when found. He could not remember where he had been in those five days. Family member A stated that Patient #1 has since been re-admitted to the hospital and always had a sitter whenever she has visited every other day.
Family Member A stated finally that the hospital should have called her and the police sooner, and that the hospital should not have waited for her to insist that they call the police before they did.

Policy reviews included:

Review of the facility's policy titled 'Absent without leave/Elopement/Walk Away and AMA Policy', last reviewed 04/15 delineated that the facility staff made every effort to locate patients who left, walked away, or eloped and attempted to get them to return for care. The purpose of the policy was to identify the appropriate documentation and procedures to follow when a patient was discovered missing or eloped without hospital staff permission to leave or against medical advice (AMA). Such policy also covered infants and code PINK definition.
Further review of the policy revealed that for patients who left the Emergency Care Center (EEC) without permission, left without being seen (LWBS) or without notifying EEC staff, the event was documented in the patient's medical record. When in the waiting room, staff made at least three (3) attempts to call for the patient to be seen. This was documented as 'did not answer' (DNA) in the medical record. After the third attempt to call the patient, note the disposition as LWBS in the electronic medical record. If the patient returned, the patient was instructed to go through the arrival process again.
Further review of the policy on 'Elopement/ AWOL/Walk Away (For In-patient Care Areas) delineated the following:
The following steps were taken by staff when an in-patient

Based on review of medical records, review of policy and procedure, interviews and observations it was determined that the facility failed to protect and promote Patient #1's right to receive care in a safe setting, which resulted in Patient #1's elopement from the facility while under while under a physician's order for continuous monitoring.

Specifically:
The facility:
Failed to ensure Patient #1's right to be protected from neglect; Patient #1, who was mentally impaired and an identified elopement risk under a continuous monitoring order, was left to wander around unmonitored due to lack of staff to watch him.
Failed to ensure that nursing staff were educated in the facility's procedure when a patient with an altered mental status eloped from the facility.
Failed to provide patient safety monitoring as ordered by the physician for Patient #1.
Failed to follow the facility's policy 'Patient Safety Observation Policy' for ensuring that the sitter will always accompany the patient and assures visibility; the sitter should maintain constant attendance and not leave the assignment.
Failed to notify the family member of Patient #1 of Patient #1's elopement in a timely manner.
Failed to notify the attending physician of Patient #1's elopement in a timely manner.
Failed to follow facility's 'Absent without leave/Elopement/Walk Away and AMA Policy' to notify the patient's physician after the patient did not return within one hour, to alert him/her of the incident.

Findings included:

Cross reference A0043 as it relates to the failure of the governing body to ensure that Patient #1's rights were protected and nursing care was delivered in a safe manner. This failure resulted in Patient #1's elopement from the facility while under a doctor's order for continuous monitoring.

Cross-reference A385 Nursing Services as it relates to the failure of the facility to ensure that nursing services followed doctor's orders and facility's policies for continuous monitoring for a patient with dementia who was a known flight risk (Patient #1). This failure resulted in serious harm to Patient #1 who eloped from the facility and was found several days later in a weakened and dehydrated state.

Based on a review of medical records, policy and procedures, interviews and observations, it was determined that the facility failed to ensure that nursing services followed doctor's orders and facility's policies for continuous monitoring for a patient with dementia who was a known flight risk (Patient #1). This failure resulted in serious harm to Patient #1 who eloped from the facility and was not found for several days.

Specifically, the facility's nursing services:

Failed to provide patient safety monitoring as ordered by the physician for Patient #1.
Failed to follow facility's policy 'Patient Safety Observation Policy' for monitoring a patient who was without decision-making ability, was unable to follow commands, and was an elopement risk, by failing to provide continuous monitoring as ordered by MD.
Failed to follow the facility's policy 'Patient Safety Observation Policy' for ensuring that a patient with a PSM (sitter - personal safety monitor) order must not be left unattended without a replacement sitter.
Failed to follow the facility's policy 'Patient Safety Observation Policy' for ensuring that the sitter will always accompany the patient and assures visibility; the sitter should maintain constant attendance and not leave the assignment.
Failed to document patient observations every 15 minutes for Patient #1 and Patient #3.
Failed to follow facility's procedure per 'Absent without leave/Elopement/Walk Away and AMA Policy' for the elopement of a patient with AMS (altered mental status) by informing hospital security of the patient's mental status. As a result of this failure, security failed to alert the City Police Department in a timely manner of Patient #1's elopement.
Failed to notify the family member of Patient #1 of Patient #1's elopement in a timely manner.
Failed to notify the attending physician of Patient #1's elopement in a timely manner.
Failed to follow facility's policy to notify the patient's physician after the patient did not return within one hour, to alert him/her of the incident.

Findings included:

Cross-reference A0043 Governing Body - as it relates to the failure of the facility to have an effective Governing Body:
That ensured that Patient #1's rights to receive care in a safe environment were protected
That nursing care was delivered in a safe manner;
That sufficient staffing was provided for the facility's needs;
That ensured the prevention of a system failure that resulted in the elopement of a patient with an altered mental status (Patient #1).
This failure resulted in serious harm to Patient #1 who wandered off the hospital premises in an altered mental status, was missing for 5 days, and was eventually found an returned to the facility in via ambulance in a weakened and dehydrated state.

This failure resulted in serious harm to Patient #1who wandered off the hospital premises in an altered mental status, and was brought back to the hospital via ambulance after being missing for 5 days, and was eventually found in a weakened and dehydrated state.

Cross-reference A0115 Patient Rights - as it relates to the failure of the facility to maintain Patient #1's right to receive care in a safe setting, which resulted in Patient #1's elopement from the facility while under a physician's order for continuous monitoring.

Review of Patient #1's medical record revealed that he had been brought to the facility's Emergency Department (ED) by his wife on 7/16/19 at 10:26 a.m. A medical screening examination (MSE) performed by an ED physician on 7/16/19 at 12.08 p.m. revealed a history of dementia (a severe decline in memory and thinking skills that reduces a person's ability to perform everyday activities) and threats of violence as reported by Patient #1's wife. Further review of the ED physician's notes revealed that Patient #1 was confused, agitated and oriented only to self (patient only knows his own name). Review of the ED physician notes revealed that Patient #1 often wandered throughout the ED, was difficult to redirect, was not aware of his current circumstances, and lacked independent decision-making ability. The decision was made to admit Patient #1 to the medical-surgical unit of the hospital for further placement.

While Patient #1 was still in the ED on 7/16/19, at 5:54 p.m., MD MM, an internal medicine physician performed a history and physical (H and P) examination on Patient #1. Review of the H and P revealed that Patient #1's wife was unable to provide round-the-clock care for Patient #1 and reported being afraid of him. Patient #1 refused to answer the physician's questions and voiced that he wanted to leave the hospital. During the examination, Patient #1 became physically confrontational with the physician and security had to be called. Further review of the history and physical revealed that Patient #1 would be admitted as an in-patient, receive medications, and social services would attempt to find placement for discharge. The admission diagnosis on the history and physical was homicidal ideations. A signed 1013 (an order to hold a patient involuntarily due to potential harm to self or others) was placed on the record on 7/16/19 at 5:34 p.m. that would need to be renewed in 48 hours. MD MM further noted that Patient #1 was exhibiting homicidal/aggressive behavior. Additionally, MD MM noted as follows:
- The patient was refusing to get an EKG;
- Order for Haldol (an antipsychotic drug that decreases excitement in the brain) 2 mg IV every 6 hours PRN (as needed) for agitation;
- Social work consult for placement
- Patient placed on 1: 1 observation and needs to be in an isolation room. He is an elopement risk and may not sign out AMA
- Form 1013 signed and placed in the chart.
Review of orders revealed that a Patient Safety Monitor (PSM - also called a sitter, a facility employee assigned to provide continuous observation and supervision of a patient) was ordered due to the signed 1013 on 7/16/19 at 5:24 p.m. This order expired on 7/18/19 at 5:23 p.m.
Patient #1 was transferred from the ED to an in-patient medical-surgical unit on 7/17/19 at 7:58 p.m.
A progress note that was written by MD LL on 7/18/19 at 1:29 p.m. revealed that Patient #1 was agitated and restless. Patient #1 was oriented to self and knew his wife's name. A PSM was present at the bedside. The medical record revealed that the plan was to have psychiatry evaluate Patient #1 and continue to search for placement as his wife could not care for him.

A psychiatric evaluation conducted 7/18/19 at 1:42 p.m. revealed that Patient #1 had symptoms consistent with dementia. The evaluation revealed that Patient #1 had impaired insight (the capacity to gain an accurate and deep intuitive understanding of a person or thing), impaired judgment, poor attention span, impaired concentration, poor recent memory, and fair remote memory. Further review of the psychiatric evaluation revealed recommendations including elopement precautions and constant monitoring by a PSM (sitter).
Further review of the medical record included a physician's order at 7:50 p.m. on 7/18/19 for direct observation with a bedside sitter.

Despite Patient #1 not being on an involuntary status hold on 7/18/2019 at 7:50 p.m., the patient's physician wrote an order for Direct Observation with a bedside sitter. On 7/22/2019, the facility failed to ensure that Direct Observation with a sitter was maintained by failing to utilize Patient Safety Monitor (PSM) employees, which may include assistants, nurse externs, paramedics, PCT's, public safety officers, or other licensed staff who meet eligibility criteria. There was no indication that the facility utilized other PSM employees within the hospital to sit with Patient #1 on 7/22/2019 due to short-staffing on Unit 7A.

A progress note that was written by MD LL on 7/19/19 at 8:14 a.m. revealed that Patient #1 was much calmer and easier to redirect. Patient #1 continued to be fidgety. Patient #1 denied having suicidal or homicidal ideations. A sitter (PSM) was at Patient #1's bedside. MD LL documented that the plan was to find a long-term care facility for Patient #1. The involuntary hold had lapsed and would not be renewed as behavior was due to dementia and not an acute psychiatric illness.
MD LL documented that Patient #1 could walk around the unit with a sitter but could not be left alone.

A progress note that written by MD LL on 7/20/19 at 8:23 a.m. revealed that Patient #1 continued to remain calm and requested to walk around the unit with the sitter. Patient #1 denied having suicidal or homicidal ideations. A sitter was at Patient #1's bedside. MD LL documented that the plan was to find a long-term care facility for Patient #1. MD LL documented that Patient #1 was permitted to walk around the unit accompanied by the sitter but could not be left alone.

A progress note written by MD LL on 7/21/19 at 8:07 a.m. revealed that Patient #1 was calm, and symptoms of aggression had significantly improved. Patient #1 denied having suicidal or homicidal ideations. A sitter was at Patient #1's bedside. The plan of care remained unchanged.

Review of a psychiatric progress note on 7/22/19 at 9:38 a.m. revealed that Patient #1 denied having any suicidal or homicidal ideations. Patient #1 was alert and oriented to self. The psychiatric progress notes further revealed that Patient #1 was wearing civilian clothing per his wife's request. Patient #1 exhibited impaired insight and judgment and no reported aggressive behavior overnight. The note revealed that Patient #1 was a moderate imminent risk of wandering that led to safety concerns. Patient #1 did not meet the criteria for in-patient psychiatry hospitalization.

Review of progress notes by RN FF on 7/22/19 at 7:45 a.m. revealed that Patient #1 was awake and in no distress.

RN FF's progress notes at 11:00 a.m. revealed that Patient #1 was not found on the unit. The nurse had been in Patient #1's room since 9:30 a.m. and Patient #1 had been going in and out of the room independently. Patient #1 did not return for about ten minutes and RN FF searched the unit but could not locate Patient #1. Security was notified, and the physician was updated further about Patient #1's elopement. Further review of the note revealed that security returned to the unit at 3:30 p.m. and reported that they had continued to search for Patient #1. The Unit Manager, Patient #1's wife, and physician were called at 3:30 p.m. Further review of the note revealed that Patient #1's wife came to the unit. Time was not noted. Physician and security were called and came to speak to Patient #1's wife. The chaplain was notified and came to speak to Patient #1's wife.

A discharge summary written by MD LL on 7/22/19 revealed that MD LL received a notification from the nursing staff at 3:30 p.m. that Patient #1 had not been in his room since 11:00 a.m. Due to a staffing shortage, Patient #1 did not have a sitter with him on 7/22/19. MD LL documented that she had not been notified that sitter was unavailable but she (MD LL) had repeatedly discussed with staff during morning rounds, Patient #1's high potential to wander and get lost. MD LL instructed the nursing staff to notify Patient #1's wife. MD LL documented that she called security and was told that the protocol for a missing person with dementia was being followed. Further review of the discharge note revealed that security spoke to Patient #1's wife at 5:30 p.m. At this time, security informed MD LL that the City Police Department had not been called yet. A detective with the City Police Department arrived and took statements from Patient #1's wife, the nurse, and MD LL. The City Police Department was given a picture and description of Patient #1. Patient #1 did not have any identification or a cell phone with him. Patient #1 had the capacity to walk well and did not appear as sick as he was. Patient #1 remained extremely confused on 7/22/19, at the time he eloped.
Review of Flowsheets included but was not limited to the following:

Patient Safety Observations on 7/18/19 at 12:00 p.m., 4:00 p.m., 8:00 p.m., and 11:00 p.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside.
Patient Safety Observations on 7/19/19 at 12:00 a.m., 4:00 a.m. 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside.
Patient Safety Observations on 7/20/19 at 12:00 a.m., 4:00 a.m. 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside.
Patient Safety Observations on 7/21/19 at 12:00 a.m., 4:00 a.m. 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside.
Patient Safety Observations on 7/22/19 at 12:00 a.m. and 4:00 a.m. revealed that the Patient Safety Monitor (PSM) Protocol was in effect. PSM was present at the bedside. There was no further documentation in Patient 1 #'s medical record of any Patient Safety Observations from 4:00 a.m. on 7/22/19 up until the time that the facility discovered that Patient #1 was missing at approximately 11:00 a.m. on 7/22/19.

Other Facility Documentation reviewed included:

A review of the staffing sheet for unit 7A on 7/22/19 revealed that there were seven (7) RNs and three (3) assistants scheduled from 7:00 a.m. until 3:00 p.m. Facility did not provide the number of patients present on the unit.

A review of a timeline of events that occurred on 7/22/19 that was provided by the facility revealed the following:

10:00 a.m. - RN FF stated that after he was done with morning medication at about 9:30 a.m. he went to Patient #1's room to document while watching the patient. Patient #1 had been going in and out of the room while RN FF was watching him.
11:00 a.m. - Unit Clerk notified RN FF that Patient #1 may have left the unit. RN FF and for security to be called; RN FF searched the 7th floor and down to the ground floor.
11:30 a.m. - Security officers spoke to RN FF.
2:00 p.m. - RN FF returned from searching for Patient #1 and notified MD LL.
2:00 p.m. - Unit Charge Nurse was notified that Patient #1 was missing.
2:15 p.m. - 2:30 p.m.- Charge Nurse notified the Unit 7A Clinical Staff Manager (Manager GG) that Patient #1 was missing.
3:00 p.m. RN FF notified Patient #1's family that Patient #1 was missing.
4:00 p.m. - Family arrived on the unit. MD LL and security arrived on the unit to speak to the family. City Police Department officer arrived at the unit to take the report.
6.32 p.m. - The Unit Director of 7A (Director EE) was notified that Patient #1 was missing.

3. Review of a Public Safety Incident report revealed that on 7/22/19 at approximately 11:25 a.m., a public safety officer was dispatched to unit 7A to investigate a walk-a-way patient. RN FF informed the officer that Patient #1 was not on a 1013 hold or one-on-one care. The officer received a physical description of Patient #1. The officer put out a description of Patient #1 to other officers and searched the perimeter and common areas of the facility. At 3:00 p.m., RN FF contacted Patient #1's wife. At 5:30 p.m., Patient #1's wife arrived and requested to speak to a public safety officer. The officer notified the City Police Department who arrived on the unit at 5:50 p.m. Video surveillance cameras were viewed that showed Patient #1 exiting the main doors of Unit 7A at 10:56 a.m. Patient #1 took the elevators to the atrium lobby at 11:08 a.m. and exited the building. Patient #1 was last captured on video walking north on Jesse Hill Jr. Drive. At 6:30 p.m., about 7 hours after Patient #1 disappeared, two security officers searched the perimeter of the facility, the atrium, and the ED waiting area.

4. Review of a Public Safety Incident Report dated 7/27/19 revealed that Patient #1 was brought to the ED via ambulance on 7/27/19 at 2:00 a.m. At this time, Patient #1's wife, Risk Management, Legal Services, and the City Police Department were notified that Patient #1 was in the facility's ED.

The following interviews were conducted:

An interview took place on 8/1/19 at 9:00 a.m. in a conference room with the Director of Risk Management (Director AA) in the presence of Senior Vice President DD. Director AA explained that Patient #1 had been a patient for approximately one week at the time of the incident. She explained that Patient #1 had been brought to the facility for increased aggression and agitation by his wife. Patient #1 had been on an involuntary hold when he was admitted but the involuntary status expired after 24 hours. She stated that sitters had been assigned to be with Patient #1, but on the day of the incident, a sitter was not available. Director AA explained that on the day of the incident, Patient #1 had been ambulating the hallways and returning to his room. Patient #1's nurse was in the patient's room when the patient left the room to walk around the unit, and after about ten minutes, the RN went to look for the patient. Patient #1 could not be located. Patient #1 was brought back to the facility on 7/27/19 at 2:00 a.m. in a weakened and dehydrated state.

An interview with RN FF (Registered Nurse responsible for Patient #1 at the time of Patient #1's elopement on 7/22/19 during the day shift) took place on 8/1/19 at 10:00 a.m. in a conference room. RN FF recalled that Patient #1 had an order to have Patient Safety Monitors (PSM), but on this day the staffing office did not have a sitter available. RN FF explained that he and the Patient Care Technicians (PCT) took turns sitting in Patient #1's room. RN FF stated that 7/22/19 was the first time that he had taken care of Patient #1. Patient #1 spoke English, but French was his native language. RN FF's native language is also French. RN FF recalled he had a conversation in French with Patient #1 that morning. RN FF recalled that Patient #1 had been alert and oriented and did not express a desire to leave the facility. RN FF recalled that the 1013 order for Patient #1 had expired and Patient #1 was being watched carefully. RN FF explained that the facility's staffing office assigned PSMs (sitters) and that patients with current 1013s took priority. RN FF recalled that he went to Patient #1's bedside and relieved a PCT who had been at the bedside. Patient #1 had been walking around the unit and returning to his room. RN FF recalled that on 7/22/19, the unit clerk came into Patient #1's room accompanied by a physician who spoke French. The staff had requested that this physician speak with Patient #1. RN FF told the Unit Clerk that Patient #1 was ambulating on the unit. The Unit Clerk searched the unit for Patient #1 and was unable to locate him. RN FF recalled that Patient #1 had been out of his room for less than ten minutes. RN FF recalled that he called security and searched the unit, the stairwells, the ground floor and outside the perimeter of the facility. RN FF recalled that he followed up with the security office later to get an update and did a second search of the facility. RN FF then notified MD LL. RN FF explained that Patient #1's family arrived at approximately 4:00 p.m. and met with MD LL, security, and the City Police Department. RN FF explained that a chaplain came to the unit to speak to the family and was still meeting with the family when RN FF got off work at approximately 7:00 p.m.

An interview with Physician, MD LL took place on 8/1/19 at 12:10 p.m. in an administrative office. MD LL was an internal medicine physician and had been on staff at this facility since October 2018. MD LL was Patient #1's attending physician from 7/17/19 through 7/22/19. MD LL explained that Patient #1's wife told MD LL that Patient #1 had been diagnosed with dementia prior to this admission. Patient #1's wife informed MD LL that Patient #1 had become more aggressive and agitated recently and would wander from home and get lost during the day while she was at work. MD LL explained that Patient #1 had been under a 1013 (order for involuntary admission due to potential to harm self or others) upon admission due to the reports of increased aggression and dementia. MD LL stated that she had ordered various tests to ensure that Patient #1's behavior was not due to a cause other than dementia. MD LL stated that psychiatry services had assessed Patient #1 and determined that Patient #1 did not have a psychiatric diagnosis; he had dementia. The 1013 order expired after 24 hours and was not extended due to the outcome of the psychiatric evaluation. MD LL explained that she ordered Patient #1 to have constant monitoring by sitters. MD LL recalled that a sitter had been present each morning that she made rounds and recalled reminding the sitters that Patient #1 needed to be watched constantly. MD LL also told the sitters that Patient #1 was able to walk around and encouraged the sitters to walk with Patient #1. On the morning that Patient #1 eloped, MD LL recalled that there were no sitters available and the staff on the unit were taking turns sitting with Patient #1. MD LL recalled that on 7/22/19 she received a call from RN FF that Patient #1 had left the unit at approximately 11:00 a.m. and had not been found. MD LL recalled that RN FF informed her that Patient #1's family had not been notified. MD LL recalled that she instructed RN FF to inform the family. MD LL recalled that after speaking with RN FF, she called the security office and inquired what was being done to locate Patient #1. She was informed by the security staff that the protocol was being followed. MD LL arrived on the unit at approximately 5:30 p.m. MD LL met with Patient #1's family, along with a security staff member and RN FF. MD LL explained that she had had patients leave the facility against medical advice in the past but had not had a patient leave who had diminished mental capacity. MD LL assessed Patient #1 when he was transported back to the facility via ambulance a few days later. MD LL stated that Patient #1 was not hurt physically except that he was dehydrated and tired.

An interview with the Director of Unit 7A (Director EE) took place on 8/1/19 at 9:30 a.m. in a conference room. Director EE had been the Unit Director of 7A for approximately two years. Director EE explained that Unit 7A was a general medical and surgical unit and it was not unusual to have patients with various diagnoses that caused an altered mental status. Director EE stated that Unit 7A was not a locked unit but did require badge access to enter the main entrance. Anyone could freely exit through the main entrance. Director EE recalled that RN FF had been sitting in Patient #1's room on 7/22/19. Director EE further explained that Patient #1 had been ambulating from his room into the hallways of the unit all morning. Patient #1 had always returned to his room with some re-direction. On 7/22/19, RN FF reported that Patient #1 had been gone about ten (10) minutes when he could not be located. Director EE explained that the security office had been notified as well as the patient's family and the City Police Department. Director EE explained that she had personally assisted in searching for Patient #1 throughout the facility and areas around the facility. Director EE explained that after this incident, staff were made aware during shift huddles. Director EE explained that the staff had a 'heightened' awareness of patient observation after this incident. Director EE explained that all staff participate in shift huddles, therefore the schedule was reflective of participation in huddles. Topics discussed at huddles included specific issues or problems with patients and ways to address them differently. Director EE explained that either patient care technicians (PCTs) or nurses check on patients every hour. After the incident, security staff assessed the unit for potential areas of improvement regarding security. The security department made recommendations for changes to the entrance doors and installation of additional cameras. Director EE explained that price quotes had been obtained for the recommendations and changes would be implemented. At the time of the of the initial date of entry of the survey on 8/1/2019, the facility failed to present any evidence that any changes had been made to the entrance doors or that additional cameras had been installed in Unit 7A, to protect and promote patients rights to receive care in a safe setting for patients who were on continuous observation in the facility.

An interview with the Executive Director of Public Safety (Director CC) took place on 8/1/19 at 1:15 p.m. in an Administrative Office. Director CC explained that RN FF had notified security dispatch that a patient was missing. A security officer was dispatched to the unit and spoke with RN FF. RN FF informed the responding officer that Patient #1 did not have a current 1013 but did not inform the security officer that Patient #1 had diminished mental capacity. The security officer responded to the incident as if the patient had left against medical advice (AMA). Director CC explained that when a patient with a 1013 elopes, the City Police Department was notified immediately. Furthermore, if a patient with any type of diminished mental capacity was missing, the incident was treated with the same steps as an elopement of a 1013 patient. Director CC explained that it was hours later that his office learned of Patient #1's diagnosis, at which time the city Police Department was immediately notified. In response to this incident, his department made recommendations for some structural changes to Unit 7A. One of the recommendations was to install a delayed-release door on the entrance door of the unit. This type of door will not release immediately; there is a delay after the door is pushed. A fixed video camera is positioned to enable a monitor view who is about to exit through the door. This mechanism allows the person to be stopped from leaving if warranted. The door will open after a set number of seconds. The door will continue to require badge access to enter and a badge access exit will be available to staff. At the time of the of the initial date of entry of the survey on 8/1/2019, there was no evidence that the foregoing security recommendations had been implemented by the facility.

An interview with the Clinical Staff Manager of Unit 7A (Manager GG) took place in a conference room on 8/1/19 at 11:00 a.m. Manager GG explained that she arrived at work each morning prior to shift change at 7:00 a.m. All incoming staff attend huddle as well as the off-going charge nurse. Manager GG facilitates the morning huddle and the day shift charge nurse facilitates the night shift huddle. Agenda items discussed at huddle included safety issues, quality issues, and specific patient concerns. Manager GG explained that information that needed to be shared with staff immediately was shared at huddles. Manager GG stated that staff sign in at huddle.

A follow-up interview with Manager GG took place on 8/1/19 at 1:15 p.m. in a conference room. Manager GG explained that RN FF received verbal counseling after the incident with Patient #1. She explained that the policy on Patient Elopement had been revised and would be presented to all staff 'soon'. At the time of the initial date of entry of the survey on 8/1/2019, the facility failed to present evidence that the revised policy on Patient Elopement had been presented to all staff on Unit 7A.

During the supervisory review of the complaint, additional information was received via a telephone interview with Patient #1's wife (Family Member A) on 8/14/2019 10:30 a.m. The telephone interview revealed that Familiy Member A got a call from RN FF on 7/22/19 at 3:43 p.m. She could not recall RN FF's name, but he identified himself as her husband's nurse. RN FF asked Family Member A if her husband was home. She stated that she exclaimed that how could he be home? He was in the hospital! RN FF then told Family Member A that her husband was missing and hung up. Family Member A stated that she got to the hospital within 45 minutes after the call from RN FF. She said she got to the front desk and was kept waiting for about 20 minutes. She then told the front desk that she was the wife of Patient #1 and that somebody had called her that her husband was missing. The front desk attendant said she had to talk to Patient #1's nurse. RN FF then appeared in the lobby at that time. RN FF told Family Member A to sit there and wait for him. Family Member A stated that she went instead to the 7th floor where Patient #1 was housed. On the 7th floor, Family Member A was told to sit in a corner near Patient #1's room. Family Member A saw someone cleaning out Patient #1's room and immediately thought Patient #1 was dead, had killed himself or someone had killed him. No one told her anything for several minutes and she began to cry. Family Member A then I heard someone say that 'they need to tell these people something'. At that point, Family Member A stated she asked for someone to help her and tell her something.
The doctor and RN FF came, and Family Member A asked what had happened to her husband? RN FF told Family Member A that Patient #1 left the unit that morning and had not been found. Family Member A asked if they had called the police? And why had they not called her since he went missing several hours ago?
Family Member A stated that after this that the hospital security came to talk to her and called the Police. Family Member A stated that it was she who insisted that the police should be called.
Family Member A stated that RN FF apologized to her.
Family Member A stated that she heard nothing from the hospital the 5 days that Patient #1 was missing. She and other family members made flyers, went to the Internet and went to the media to ensure that Patient #1 would be found. She worked closely with the police, informing them of sightings of Patient #1 from the public.

Family Member A stated that she was called immediately Patient #1 was found. She stated that Patient #1 was very weak, could not stand and was very dirty when found. He could not remember where he had been in those five days. Family member A stated that Patient #1 has since been re-admitted to the hospital and always had a sitter whenever she has visited every other day.
Family Member A stated finally that the hospital should have called her and the police sooner, and that the hospital should not have waited for her to insist that they call the police before they did.

Policy reviews included:

Review of the facility's policy titled 'Absent without leave/Elopement/Walk Away and AMA Policy', last reviewed 04/15 delineated that the facility staff made every effort to locate patients who left, walked away, or eloped and attempted to get them to return for care. The purpose of the policy was to identify the appropriate documentation and procedures to follow when a patient was discovered missing or eloped without hospital staff permission to leave or against medical advice (AMA). Such policy also covered infants and code PINK definition.
Further review of the policy revealed that for patients who left the Emergency Care Center (EEC) without permission, left without being seen (LWBS) or without notifying EEC staff, the event was documented in the patient's medical record. When in the waiting room, staff made at least three (3) attempts to call for the patient to be seen. This was documented as 'did not answer' (DNA) in the medical record. After the third attempt to call the patient, note the disposition as LWBS in the electronic medical record. If the patient returned, the patient was instructed to go through the arrival process again.
Further review of the policy on 'Elopement/ AWOL/Walk Away (For In-patient Care Areas) delineated the following:
The following steps were taken by staff when an in-patient was discovered missing:
1. Search the general area where the patient was supposed to be
2. Notify the area Manager/Supervisor, the patient's physician and Security (security phone number provided) immediately. Security is given the patient's description including mental status.
3. The facility operator (operator's phone number provided) was called to have the patient paged and instructed to return to the area immediately. This procedure was repeated at least three times and documented in the patient's medical record.
4. The Manager/Supervisor of the area contacted the family/next kin and inquired whe