HospitalInspections.org

Based on record review, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation for Emergency Services due to the hospital's failure to follow their own policy and provide appropriate supervision for 1 of 1 patient being involuntarily detained under an emergency psychiatric certification, who was transferred to the Emergency Department (ED) and was at risk for elopement (Patient ID #1).

Findings are as follows:

The hospital failed to provide Patient ID #1, the appropriate supervision according to their policy. (A-1104)

Based on policy review, record review, and staff interview, it has been determined that the hospital failed to prevent an elopement due to failure to follow their own policy related to "patient sitters" after receiving a report from the transferring facility informing that the patient sent to the emergency department (ED) was being involuntarily detained by an emergency psychiatric certification, for 1 of 1 patient reviewed at risk for elopement, Patient ID #1.

Findings are as follows:

A facility reported incident was submitted to the Rhode Island Department of Health on 6/27/2025, identifying that on 6/25/2025 at 10:56 PM, a patient that was transferred to the hospitals ED while being involuntarily detained at a psychiatric hospital, and was not provided appropriate supervision and eloped from the ED without being treated.

Review of the hospital's policy titled, "Patient Sitter Role/Constant Observation" last revised May 2023, states in part,
..III. Policy:
...patient sitter will be utilized to ensure patient safety in selected circumstances including but not limited to:
Suicide precautions, Potential Elopements ...

A review of the patient's ED medical record revealed a transfer report was given to staff prior to the patient being transferred to the ED explaining that the patient was being sent to the hospital for an evaluation of a possible wound dehiscence (surgical complication in which a wound ruptures along a surgical incision) following a caesarian section on 6/17/2025. The transferring psychiatric facility identified that the patient was currently being involuntarily detained by a psychiatric emergency certification at their facility due to symptoms of postpartum psychosis.

Review of the ED documentation reveals the patient arrived by ambulance and was brought to the triage area on 6/25/2025, at approximately 10:29 PM.

A Nurse Progress note dated 6/25/2025, at 10:35 PM, indicated there was no bed available in the main ED area and the patient was placed in triage bay 3 to await an evaluation. At 10:38 PM, Staff B went to complete the triage assessment for this patient and noted the patient was missing. Security was notified of the elopement.

At 10:40 PM, the ED received call from Security who notified that the patient was observed off hospital grounds, Police were then notified.

During a surveyor interview with Employee A on 6/27/2025 at 2:00 PM, she stated that the hospital was informed by the transferring facility that the patient was being involuntarily detained by a psychiatric emergency certification. She acknowledged that both Staff B, and Staff C did not follow the hospital's policy for "Patient sitters and/or Constant Observation" by their failure to assign Patient ID #1 a constant observation while in the ED.