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Based on review of medical records, staff interviews, and facility policies and procedures, it was determined that the facility failed to ensure that patients are informed of their rights through consents when two (P#1 and P#3) of four (P#1, P#2, P#3, and P#4) medical records failed to include a signed consent to treatment.

Findings Included:

A review of P#1's medical record failed to reveal a consent for treatment.

A review of P#3's medical record failed to reveal a consent for treatment.

A review of the facility's policy titled, "Patient Rights and Responsibilities", last reviewed 04/2024, revealed that the purpose of the policy was to:
Continued review revealed, Procedure, A, Patient Rights, the facility recognizes that each patient has the right to:
2. Participate and make informed decisions about his or her care, treatment, or services.
3. Give or withhold informed consent.

During a telephone interview on 7/30/25 at 11:45 a.m., MD FF said that if a patient comes into the ED staff should make an attempt to obtain the patient's consent for treatment. MD FF said that if the situation is emergent, then the physician may bypass this due to the critical nature of the situation however, nursing staff or registration will obtain consent for treatment afterwards with the patient or family members as appropriate.

During a telephone interview on 7/30/25 at 10:02 a.m., Charge Nurse (CN) HH said that she has been a nurse for almost 16 years and worked as a CN for 6 years. CN HH said that registration and sometimes nursing staff will obtain consent for treatment with a patient. CN HH said that depending on the situation it may be difficult to, so staff are informed to contact family members if possible and appropriate. CN HH said that staff will not halt any lifesaving interventions to obtain consent, but rather they may obtain it afterwards.

Based on review of medical records, staff interviews, and review of facility policies and procedures, it was determined that the facility failed to provide care in a safe setting when one (P#1) of four (P#1, P#2, P#3, and P#4) sampled patients was being treated in the facility's emergency department (ED) for confusion and potential stroke and left the facility without the staff's knowledge. Specifically, P#1 was screened in the ED on 7/22/25, received a sedative and a computed tomography (CT). The treating provider in the ED had determined that P#1 required an inpatient admission. P#1 left the facility without staff's knowledge and was taken to another hospital's ED by law enforcement one day later.


Findings Included:

A review of Patient (P) #1's medical record revealed that P#1 presented to the facility's emergency department (ED) On 7/22/25 at 1:58 p.m. via emergency medical services (EMS) due to dysarthria (a motor speech disorder that makes it difficult to articulate words due to weakness or impaired control of the muscles used for speaking) and signs of a stroke (when blood flow to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen potentially causing disabilities or death).

A review of "ED Notes" dated 7/22/25 at 2:12 p.m. revealed that a stroke alert was activated.

A review of an "ED Provider Notes" dated 7/22/25 at 2:24 p.m. by MD FF revealed that P#1 was stable, had a stroke scale score of five (zero to four indicates a minor stroke, five to 15 indicated a moderate stroke, 16 to 20 indicates a moderately severe stroke, and 21-42 indicates a severe stroke), and would require additional work up and inpatient admission to expand for stroke work up.
Continued review revealed that P#1 required 2.5 milligrams (mg) of Versed, medication used for a sedative effect or anxiolytics, prior to the computed tomography (CT) (medical imaging technique that uses x-rays to create detailed cross-sectional images of the body).

Continued review revealed P#1 had a disposition of eloped.

A review of an "Emory Neurology Stork Consult", dated 7/22/25 at 3:29 p.m. by MD LL revealed that upon examination, P#1 had expressive aphasia, delay in following commands, and decreased right upper extremity sided sensory deficits. Continued review revealed that MD LL recommended further workup for toxic, metabolic, or infectious contributing etiology (the cause or reason for something).

A review of an "ED Note", dated 7/22/25 at 4:57 p.m., by RN AA revealed that RN AA was unable to located P#1 at that time and looked throughout the ED unit. RN AA notified MD FF.

A review of an "ED Note", dated 7/22/25 at 5:27 p.m., by RN AA revealed that RN AA was still unable to locate P#1 at the time. RN AA notified security to activate a Code Green. (facility's internal code for missing patient).

A review of an "ED Note" dated 7/22/25 at 6:20 p.m., by RN AA revealed that RN AA was still unable to locate P#1, a brief description of P#1 was given to security and per security contact will be made to the Atlanta Police Department (APD). RN AA notified Charge Nurse (CN) HH.

A review of the facility's policy titled, "Patient Rights and Responsibilities", last reviewed 04/2024, revealed Procedure, A, Patient Rights, the facility recognizes that each patient has the right to:
3. Receive care in a safe environment free of neglect, exploitation, verbal, mental, physical, or sexual abuse.

A review of the facility's policy titled, "Assessment / Reassessment in the Emergency Department", last reviewed 3/10/25, revealed that the purpose of the policy was to establish guidelines, timelines, and expectations for the assessment and reassessment of patients in the emergency department (ED).

A. Reassessment
1. All ED patients must be reassessed regularly based on their acuity level.
2. Reassessment is a focused review of systems pertinent to the patient's presenting complaints and condition.

Continued review revealed, IV, Definitions, Reassessment, a focused evaluation performed after the initial assessment to monitor changes in a patient's condition, response to treatment, and to ensure continued appropriate care.

During a telephone interview on 7/30/25 at 9:29 a.m., Registered Nurse (RN) BB recalled that P#1 came to the ED via ambulance. RN BB recalled that a stroke alert was eventually activated for P#1 however P#1 was uncooperative and refusing care.
RN BB recalled that the Medical Doctor (MD) LL was present at the bedside performing a stroke assessment and MD FF was redirecting P#1 and providing education on the reason why P#1 should agree with treatment. RN BB recalled that P#1 eventually agreed. RN BB recalled that P#1 was agitated and anxious prior to getting a computed tomography (CT) scan and required a small dosage of Versed (a medication used for its anxiolytic and sedative effects).

RN BB recalled that P#1 got the CT scan done and then when returning to the ED, Charge Nurse (CN) HH told RN BB to place P#1 in a hallway bed. RN BB gave a handoff to RN AA. RN BB recalled that P#1 was still in bed while the handoff occurred.
RN BB recalled that after she spent an hour or so in the CPR bay with the new patient, she later returned to the nurses' station where she learned that staff reported P#1 as missing. RN BB said that no physician mentioned that P#1 should be an elopement risk.

During a telephone interview on 7/30/25 at 10:02 a.m., Charge Nurse (CN) HH recalled P#1 in that he presented as a stroke callback. CN HH recalled that after P#1 received his computed tomography (CT) scans, he was placed in a hallway bed because a more critical patient was coming into the ED.

CN HH recalled that Registered Nurse (RN) AA received handoff from RN BB, but RN AA was also very busy with another intensive care unit (ICU) patient who required going to CT twice. CN HH said that it was never reported that P#1 was a high-risk patient or requiring a safety sitter. CN HH recalled that she later came back to the nurses' station and saw Security Officer (SO) GG filing out a report that P#1 was missing. CN HH recalled that she looked in P#1 chart and never saw any orders that P#1 was a high-risk or had diminished capacity which would have alerted nursing staff to implement other protocols for P#1.

During an interview on 7/30/25 at 10:22 a.m. in the conference room, Security Officer (SO) GG said that he has been employed with the facility for almost eight years in public safety. SO GG recalled 7/22/25 he received a called about a missing patient, P#1, in zone three of the emergency department (ED). SO GG recalled speaking with Registered Nurse (RN) AA who provided a description of P#1 and the last known whereabouts. SO GG recalled paging out a be on the lookout (BOLO) over facility radio for other SO to scan their areas of the hospital. SO GG recalled going to check the surrounding ED vicinity, both inside and outside. SO GG recalled contacting the Atlanta Police Department (APD). SO GG recalled that APD arrived around 8:00 p.m. and they spoke with P#1's family member. SO GG recalled that his supervisor did review camera footage, and they were able to trace where P#1 left out of the facility too but were still unable to locate him.

During a telephone interview on 7/30/25 at 11:05 a.m., Registered Nurse (RN) AA said that he was been an RN for five years and employed at the facility in the emergency department (ED) for four years.

RN AA recalled that on 7/22/25 he came back from the computed tomography (CT) room with an intensive care unit (ICU) patient he was caring for. RN AA recalled that RN BB gave him a handoff on P#1 and they both visualized P#1 in the hallway bed resting. RN AA recalled that after he provided care for another patient, he later saw P#1 speaking with two providers in the hallway but then his ICU patient required more attention. RN AA recalled that he then had to take his ICU patient back to CT and when he later got back, he noticed that P#1 was not in the hallway bed. RN AA said that he originally thought that maybe the patient went to the restroom. RN AA recalled that Medical Doctor (MD) FF later came up to RN AA and asked if RN AA knew about the location of P#1. RN AA recalled that MD FF told RN AA to call in a Code Green to security. RN AA recalled that there were never any orders in P#1's chart that suggested P#1 was an elopement risk or a high-risk patient that required closer monitoring. RN AA recalled that Security Officer (SO) GG interviewed RN AA and MD FF later spoke with P#1's family members.

During a telephone interview on 7/30/25 at 11:17 a.m., Doctor of Osteopathy (DO) EE said that she has been an attending physician in the emergency department (ED) since 2014 and employed at the facility since 2017.

DO EE recalled P#1 and that a stroke alert was called in. DO EE recalled that a physician assistant in triage initiated the stroke alert and reported that P#1 was alert, had some slight altered mental status changes per family, and a history of a stroke. DO EE recalled that P#1 was given some medication to assist with agitation and anxiety prior to the CT scan.

DO EE said that to place a patient on a high-risk or elopement precaution would be determined by factors of if a patient represented a danger to themselves or others or were unable to be verbally redirected. DO EE recalled that P#1 never displayed any signs of attempting to leave, danger, and he was redirectable. DO EE said that many patients come into the ED with altered mental status, but they do not all require to be placed on elopement precautions because every patient is different, and staff are trained to go by their assessments of the patient.

During a telephone interview on 7/30/25 at 11:45 a.m., Medical Doctor (MD) FF recalled P#1 and said that P#1 presented to the facility's emergency department (ED) via emergency medical services (EMS) due to a possible stroke which was activated by the triage team as a Code Stroke. MD FF recalled that P#1 initially refused care but was redirectable. MD FF recalled that P#1 did require medication, Versed, for the imaging because P#1 was agitated and anxious. MD FF recalled that after P#1 received the imaging P#1 went back to the ED while MD FF assisted with another emergency. MD FF recalled that when he went to reassess P#1, P#1 was nowhere to be found in the hallway bed. MD FF alerted nursing staff and instructed them to initiate a Code Green which prompted security to get involved and later Atlanta Police Department (APD). MD FF said that he never saw P#1 again after imaging.

During a telephone interview on 7/30/25 at 1:44 p.m., Medical Doctor (MD) LL said that she is a neurologist resident during the time that P#1 presented to the facility's emergency department (ED).

MD LL recalled performing a stroke assessment on P#1 and that he had some aphasia and that he could not get his age or the month right. MD LL recalled that P#1 made sentences that did not fully make sense but were in the right context.
MD LL recalled going downstairs to see P#1 in the ED with another provider and saw P#1 in the hallway bed. MD LL recalled explaining to P#1 that they wanted to admit P#1 for further workup and that they would tell the ED team. MD LL recalled that some time afterwards she saw a note by the ED team that P#1 walked out of the ED.