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Based on medical record review, document review and interview, the facility failed to protect patients at risk for elopement. Specifically, patients that have cognitive and/or mental health impairment were not identified, and appropriate measures implemented to prevent their elopement. This finding was identified in three (3) of 20 medical records reviewed. (Patients #s 1, 2, and 5).

This failure may result in serious adverse outcome to patients at risk for elopement.

Findings include:

Review of the medical record for Patient #1 identified: a 31-year-old male patient who was brought into the Emergency Department (ED) by ambulance from a supervised group home on 02/02/2022 at 2:55 pm with a complaint of testicular pain. The Columbia-Suicide Severity Scale (CSSR) screening and elopement assessment at 3:02 pm revealed patient was not at risk. The patient's medical history was significant for traumatic brain injury, intellectual disability, anxiety, intermittent explosive disorder, and schizoaffective disorder.

On 02/03/21, at approximately 2:58 am the patient was noted have eloped from the ED. The facility searched for the patient and activated 911. The patient was found by the police and was taken to another hospital on 02/03/22 at 1:18 pm.

Patient #2 is an 80-year-old with a history of dementia who wandered away from home and was brought into the ED by EMS on 11/17/21 at 2:59 pm for an assessment. The patient was not assessed for elopement risk and there was no documented evidence that the patient was monitored.

The patient eloped from the ED on 11/17/21 at approximately 5:00 pm. The facility contacted 911 and notified the patient's family. There was no documentation of the patient's status in the medical record.

Patient #5 is a 39-year-old patient who arrived in the ED by ambulance on 9/5/21 at 2:37 am with aggressive behavior.
The physician noted patient was uncooperative, acutely agitated, yelling, and making threatening gesture to staff. Elopement assessment at triage revealed the patient was not at risk for elopement. At approximately 2:50 am, the patient received Haldol 5 mg IM, Versed 2 mg IV Push and Ativan 2 mg IV Push for agitation. The nurse documented that the patient had eloped on 9/5/21 at approximately 5:00 am. The patient was contacted by phone and refused to return to the ED.

The ED assessment tool used to determine patients at risk for elopement did not include cognitive impairment in the ten criteria listed in the tool.

See Tag A 144.

Based on medical record review, document review and interview, the facility failed to protect patients at risk of elopement. Specifically, the facility failed to evaluate patients for risk of elopement, identify patients at risk for elopement, and implement appropriate preventive measures. This finding was identified in three (3) of 20 medical records reviewed. (Patient #1, #2, and #5).

This failure may place patients at risk for harm.

Findings include:

Patient #1 is a 31-year-old patient who was brought into the Emergency Department (ED) by ambulance from a supervised residential home on 2/2/22 at 2:55 pm for complaint of testicular pain. The patient's medical history was significant for Traumatic Brain Injury, Intellectual disability, anxiety, conduct and intermittent explosive disorders, schizophrenia, and schizoaffective disorder. Triage assessment at 3:02 pm revealed the patient was not an elopement risk. The patient was assessed by the physician and treated. On 2/3/22 at 2:01 am, the ED physician noted the patient was given discharge documents and was instructed to wait. At 2:58 am, the patient was noted to have eloped and was not found in the hospital premises. 911 was activated. The patient was found by police officers on the street and was taken to another hospital at 1:18 pm.

There was no documented evidence that this patient who lived in a supervised residential facility with history of cognitive impairment was identified as a risk for elopement.

Patient #2: 80-year-old who arrived in the ED by ambulance on 11/17/21 at 2:59 pm after a bystander found her on the street, sitting on a bench and was confused. Triage assessment at 3:15 pm documented a history of hypertension, Dementia, and multiple ED visits. The patient was alert and oriented to persons and place. 3:40 pm, MD resident noted he spoke with the patient's husband who said he last saw the patient in their yard an hour ago and stated that the patient must have wandered off. The MD resident noted that the patient has had multiple ED visits for being found wandering on the street. The patient was undergoing assessment when at 5:00 pm, a nurse documented the patient had eloped. The facility informed 911, the 49 precinct Police Department and patient's husband of the patient elopement. The status of the patient was not documented in the medical record.

There was no documented evidence the patient was assessed and identified as a risk for elopement and prevention measures implemented.

Patient #5: 39-year-old patient arrived in the ED by ambulance on 9/5/21 at 2:37 am with aggressive behavior. Emergency Medical Services ' prehospital report noted the patient was found by the New York Police Department drinking and may have used chemical substances. Triage assessment at approximately 2:40 am noted the patient was not suicidal or homicidal and was not at risk for elopement.
The physician noted at 2:53 am that patient was uncooperative, acutely agitated, yelling, and making threatening gestures to staff. Code for de-escalation assistance was activated. Between 2:49 am and 2:53 am, patient received Haldol 5 mg IM, Versed 2 mg IV Push and Ativan 2 mg IV Push for agitation. The patient was put in a two-point restraint and a vest restraint for violent behavior to prevent self-harm. The nurse documented that patient had eloped at approximately 5:00 am. The ED physician noted at 6:58 am that patient removed his restraints and eloped from the ED. The patient was contacted after his elopement, and he stated that he left because his care took too long.

The elopement risk assessment did not identify this patient who presented with severe agitation and altered mental status as a high risk for elopement.

Review of policy titled "Patient Elopement" dated September 2018 did not define elopement and did not include cognitive impairment in the list of criteria used to identify patients at risk for elopement. The 2021 Quality Assessment document states, "elopement is the same as left during evaluation, except there is a concern about capacity/decision making on the part of the patient. Example, Intoxication, Dementia, Leaves with IV in place."

However, the ED elopement screening tool did not include cognitive impairment in the ten criteria the tool uses to identify patients at risk for elopement.

On 6/06/22, at 10:44 am, Staff F (ED MD) was interviewed, and he stated that the risk of elopement is not solely based on medical history but more on the patient's presentation at the time of evaluation. During a concurrent interview with Staff G (MD, Chairman), he stated, "If a patient is not suicidal or homicidal, we do not place the patient on 1:1 observation, - we do not have the resources."

Interviews with Triage and ED nurses during a tour of the ED on 6/06/22 at approximately 11:00 am, Staff D (Walk in Triage RN) reported that a patient is screened for elopement based on the ED elopement tool and the nurse's perception of the patient's risk for elopement.

On 06/14/2022 at 03:58 pm, an Immediate Jeopardy (IJ) situation was announced due to the facility's failure to identify and protect patients at risk for elopement.

The facility provided an IJ removal plan to survey staff on 06/14/2022 at 10 pm.
The plan included:
(a) A revised policy (effective 06/2022) titled, "Prevention Strategies For High-Risk Patients With A Potential For Elopement." All patients would be assessed for risk of elopement and particular attention would be paid to patient's cognitive status as well as patients from nursing homes and group homes. (b) modification to elopement screening tool that includes cognitively impaired patients as being at risk for elopement, (c) Education of all ED staff to the revised elopement policy and the elopement screening tool. Staff who has not completed the training would not be placed on duty.

On 6/15/2022 at 1:41 PM, IJ was removed based on (a) verification of staff training to the new elopement policy, (b) observation of the implementation of the revised elopement screening tool in the ED that identifies cognitively impaired patients at risk for elopement, (c) the monitoring of patients identified at risk for elopement.

Based on medical record review, document review and interview, in one (1) of fourteen medical records of patient in restraints, the facility failed to ensure that a patient in restraints had a physician order and was monitored (Patient #5).

This failure could result in harm to patients.

Findings include:

Review of the medical record for Patient #5 revealed the patient, 39-years-old presented to the Emergency Department (ED) with New York Police Department personnel on 09/05/21 at 02:37 am for evaluation of aggressive behavior. The physician noted at 2:53 am that patient was uncooperative, acutely agitated, yelling, and making threatening gesture to staff. Code for de-escalation assistance was activated. Between 2:49 am and 2:53 am, patient received Haldol 5 mg IM, Versed 2 mg IV Push and Ativan 2 mg IV Push for agitation. The patient was put in a two-point restraint and a vest restraint for violent behavior to prevent self-harm. The nurse documented that patient had eloped at approximately 5:00 am. The ED physician noted at 6:58 am that patient removed his restraints and eloped from the ED.

Review of "Restraints/seclusion" policy (Revised 03/2022) noted the following for restraints used for violent behavior: "In emergency situations of immediate danger to self or others, restraints may be applied by a registered nurse.
1. The RN must document the circumstances requiring use of restraint and must notify the prescriber immediately.
2. The patient must be constantly supervised and assessed at least every 15 minutes until the prescriber arrives.
3. The prescriber must: a. Conduct a face-to-face assessment documented in the medical record within 30 minutes of the
emergency application of restraint; (b) Complete an electronic or paper order. Notify the attending physician.
4. The nurse is responsible for ensuring a written order within 30 minutes of restraint application and is expected to escalate communication if needed.
5. To the extent possible, the rationale for the use of restraint is explained to the patient and family.
B. Ordering Requirements:
...The physician order must include reason for restraint; type of restraint used, and time limitations..."

There was no documented evidence in the patient's record of a restraint order, the time restraints were applied, and monitoring of the patient while in restraints.

On 06/14/2022, at approximately 12 pm, during an interview with Staff A (Chief Nursing Officer) she acknowledged findings and stated that the patient was never placed on 1:1 observation, and there was no physician's order for the restraints. She said, "the assumption is that the staff released the restraints shortly after the patient was medicated."

Based on document review, and interviews, it was determined the facility failed to develop an effective Quality Assurance Improvement Program (QAPI) that incorporated data on the safety and quality of the care provided in the Emergency Department (ED).

This failure prevents identification and resolution of problems that could result in potential harm to patients.

Findings include:

A review of the Incidence/Occurrence Reports from 6/1/2021 to 6/6/2022 and the QAPI meeting minutes from 5/24/21 to 5/23/22, showed no documented evidence that patient incidence and adverse events that occurred in the ED were addressed or incorporated in the Quality Assurance Improvement Program.

See findings 0273 and 0283.

Based on document review and interviews, the facility failed to ensure that (a) incidents of patient elopement were documented, investigated, and analyzed, and (b) corrective actions developed and implemented to maintain patient safety and prevent future elopements.

Findings include:

Review of the Quality Assessment and Performance Improvement (QAPI) minutes for 5/24/21 to 5/23/22 revealed that incidents in the ED were not tracked and analyzed. Additionally, the elopement incident for Patient #1 was not included in the Emergency Department Occurrence Reports from 6/01/21 to 6/6/22.


On 2/2/22, Patient #1, was sent to the emergency room from a group home for a medical condition. This patient has a history of traumatic brain injury, intellectual disability, anxiety, conduct/intermittent explosive disorder, and schizoaffective disorder. He was also known to be a danger to himself and others. The patient eloped from the ED after he was discharged and was awaiting transportation to the group home. The patient was found several hours later in the street and was returned to an affiliate facility several miles away.

The elopement was not documented in the facility incidence reporting system known as VOICE (Voicing our issues concerns and experiences).
There was no evidence that the facility analyzed the occurrence to identify opportunities for improvement to ensure the safety of other patients.

During an interview on 6/9/22 at 10:35 AM, Staff P, Vice Chair of the Emergency Department acknowledged the findings and stated that they only have one hour each month to conduct the QAPI meeting. We can only "hyper focus on the issues, so we don't do incidents and occurrences."

During interview on 6/14/22 at 10:20 AM Staff M, Chief Quality Officer acknowledged the findings and stated that the issues were discussed but not documented in the minutes, stating, "It has been a work in progress."

The "2022 Quality Assurance Performance Improvement Plan and Evaluation of the 2021 Plan" reviewed on 3/8/22 states, each department is responsible for developing Performance Improvement Initiatives, monitoring the activities within their areas and to initiate projects based on issues identified throughout the process.
The QAPI Plan defines Eloped as: "Same as left during evaluation, except there is a concern about capacity/decision making on the part of the patient (e.g. intoxication, dementia, leaves with IV in place)... Every eloped patient needs an incidence report (use the VOICE System)"

Review of the VOICE Emergency Occurrence Reports and the Emergency Department QAPI minutes from 5/2021 to 5/2022, showed no evidence that Patient #1 elopement was documented, reviewed, and analyzed.

Based on document review and interview, it was determined that the facility failed to utilize its Quality Assurance Improvement Program (QAPI) to track and analyze incidents in the Emergency Department and implement corrective actions to ensure patients safety.

Findings include:

Review of the Emergency Department QAPI minutes from 5/24/21 to 5/23/22 showed no documented evidence that incidents that occurred in the department were reviewed and corrective actions implemented. The documents showed collection of data on patient elopements from the emergency department, left without been seen and left during evaluation. The data showed that from February to March 2022, the number of patient elopements went from 94 to 169. It dropped to 126 in April then went up to 159 in May 2022. Patients who 'Left without been seen' went from 2.6% in the first quarter of 2021 to 3% in the fourth quarter of 2021. The minutes does not reflect any data on left without been seen for 2022. The facility's goal for left without been seen is less than 1%. The QAPI minutes showed no evidence that the facility met their stated goal. There was no documented evidence of any review, discussion, or analysis to determine causation of patients leaving without being seen and there was no plan in place to reduce the numbers.

During an interview on 6/9/2022 at 10:35 AM, Staff P, Vice Chair of the Emergency Department acknowledged these findings and stated that they only have one hour each month to conduct the QAPI meeting. We can only "hyper focus" on the issues, so we do not track incidents and occurrences."

The Hospital's QAPI Plan for 2021-2022, last reviewed 3/8/22, does not include Incidence/Occurrence and Adverse Events as one of the indicators to be reviewed or included in the program.

During interview on 6/14/22 at 12:05 PM, Staff A, Chief Nursing Officer acknowledged the findings and stated, "That is something we have to work on."