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Based on record review and staff interviews, it was determined the facility failed to provide a safe environment for one (1) patient who was allowed to walk off the hospital ' s nursing unit (Washington Hospital Center, WHC), out of the hospital ' s front door, and entered neighboring hospital facility ' s lobby all while accompanied by a staff nurse; and was subsequently apprehended by hospital security sustaining injury while returning to the hospital.


According to the nursing progress notes and the the nursing assessment, Patient #1 was mildly agitated and confused on the morning of September 29, 2015. The bed alarm went off several times and reportedly s/he wanted to walk. The unit clerk was asked to contact Protective Services (security guards) because the patient was " loud at times; frustrated " . In addition, the staff was concerned that s/he might try to leave the unit. When Protective Services arrived on the unit, s/he went back to the room.

During an interview with Employee #1 on October 5, 2015 at 3:00 PM and Employee #3 on November 10, 2015 at 2:00 PM, facility staff stated the patient wanted to go for a walk. Patient #1 was allowed to walk while the nurse accompanied him/her. S/he walked out pass the waiting area of the nursing unit and towards the elevators. The door to one of the elevators opened and the patient and nurse entered the elevator. They went down to the first floor and both exited the elevator and made their way through and out the hospital ' s main entrance towards a neighboring hospital; which is located across from WHC.

Upon arrival to the other hospital, the WHC staff nurse asked the security guard from the other hospital for assistance in guiding the patient back to WHC. S/he also called the unit clerk at WHC to contact Protective Services for assistance. The neighboring hospital ' s security guard guided the patient out of the lobby and the patient and staff nurse headed back towards WHC. While on the way back, they were met by officer (s) from WHC Protective Services and an altercation ensued. The patient was brought to the ground by two (2) Protective Services ' members. Allegedly, the two (2) Protective Services ' members were lying on top of patient when the nurse heard noises coming from Patient #1. S/he asked the two (2) officers to get off the patient. The staff nurse proceeded to check the patient ' s pulse because s/he looked unconscious; the pulse was absent. The nurse asked someone to call a ' code blue ' and initiated cardio-pulmonary resuscitation (CPR) on the Patient #1 until the code blue team arrived. The patient was taken to the emergency room.

The facility failed to provide a safe environment for Patient #1. The record and policy review was conducted on October 5, 2015. Staff interviews were conducted with Employee #1 on October 5, 2015 and Employee #3 on November 10, 2015.