HospitalInspections.org

Based on policy reviews, medical record review, incident report reviews, staff meeting review, facility meeting, and staff interviews, the facility failed to investigate a patient's repeated elopement attempts for 1 of 1 behavioral health patients with attempted elopements (Patient #1).

The findings include:

Review of hospital policy "Elopement - PC 210.106," effective 06/2022, revealed, "Definitions: A. Elopement - Occurs when a patient departs from a care area without the knowledge/permission of the patient care team. A fully cognizant and competent patient may elope, or elopement may be related to a patient's underlying medical or behavioral health condition, e.g. dementia, delirium, psychosis, etc. ... "

Review of hospital policy "Plan for Quality and Patient Safety," effective 10/2021, revealed, " ... Meaningful performance improvement activities and action plans are dependent on the collection, analysis, and reporting of clinical quality and patient safety indicators... There is a need to proactively address potential quality and patient safety risks in addition to reacting to quality and patient safety events in a retrospective manner... "

Closed medical record review on 10/16/2024 revealed a 22 year old patient (Patient #1) presented to the ED (Emergency Department) on 08/15/2024 at 2120 for worsening psychosis and had been off medications for approximately 19 months. The patient was roomed in the locked behavioral health (BH) area of the ED at 2151. MD#11 initiated IVC (involuntary commitment) paperwork at 2200, as the patient experienced delusional and psychotic behaviors, had illogical thought, and could not contract for safety; the patient was deemed to be a threat/danger to self. A security alert was called at 2354 to the BH area of the ED as the patient was throwing chairs and trying to get out of the locked unit. BH Consult was conducted on 08/16/2024 at 0006, which recommended inpatient psychiatric care. Psychiatric Consult was conducted on 08/16/2024 at 0903 and revealed, IVC status was maintained with concerns for acute psychosis and differential diagnosis of schizophrenia. The patient was accepted to Campus B and was transferred at 1530. Behavioral Response Significant Event Note revealed, at 1643, the patient was standing at the doorway trying to open the door. RN #4 approached the patient to redirect the patient away from the door when the patient lunged at RN #4, grabbed and pulled RN#4's hair, then tried to put RN#4 in a chokehold. RN#4 blocked the patient when Patient #8 jumped on Patient #1 and punched Patient #1 in the head multiple times. Security alert was called, staff separated the patients, and Patient #1 received IM (Intramuscular) medications for agitation and aggression. A CT scan (computed tomography scan, specialized x-ray to produce cross-sectional images) of the patient's head was performed at 1955, which was negative. On 08/17/2024 at approximately 2350, the patient was checking the doors to elope and climbed the door on the female side of the unit. The patient had to be redirected several times and was given oral medications for agitation. SW (Social Worker) Note on 08/18/2024 at 1604 revealed, the SW was bringing patients back from the group session, and Patient #1 came from the dayroom towards the unit door. The patient grabbed the door and wrapped their fingers around it to keep it from closing. The SW redirected the patient to let go of the door and return to the dayroom. On 08/20/2024 at 1615, the patient followed a staff member off the unit without the staff member noticing. Staff and security immediately went after the patient, who was stopped by the West unit door; the patient was escorted back to the East unit. At 1655, the patient was moved to the West unit. SW Note on 08/21/2024 at 1613 revealed, SW met the patient at the entrance to the West unit and made repeated requests for the patient to move back from the door. SW then demanded in a forceful tone for the patient to move away from the door, and the patient retreated to the unit. The patient was observed at the end of the hall at the exit door. Nurse's Note at 1727 revealed, the patient was agitated, restless, and paced around the door. The patient climbed through the door to the unit that was closed off. Security was called, and the patient came back to the unit without assistance. Nurse's Note on 08/24/2024 at 0449 revealed, the patient was seen pacing at the beginning of the night shift, stood at the unit doors, and required much redirection from the staff. Patient #1 was discharged home on 08/28/2024. Record review revealed the patient did not have an order for elopement precautions and level of observation was maintained at Q15 (every 15) minute checks throughout the patient's hospitalization.

Incident Report review on 10/17/2024 revealed on 08/15/2024 at 2354, (named security officers) responded to a security alert in the ED locked BH area regarding Patient #1, who had thrown chairs, thrown water on the floor, and locked themselves in the restroom. Upon security's arrival, the clinical staff had redirected the patient back to the assigned room without further incident.

Incident Reports review on 10/17/2024 revealed on 08/16/24 at 1642, RN #4 approached the patient who was trying to get out of the door when the patient lunged at RN #4, grabbed and pulled RN #4's hair, and attempted a chokehold. Another patient (Patient #8) jumped on Patient #1, repeatedly punched Patient #1 in the head. Security alert was called, staff intervened to separate and de-escalate the situation, and Patient #1 was medicated. Three incident reports were created for this event - one event type was listed as a disorderly person (patient) event; one was listed as a workplace violence event as a patient to staff physical assault; and the third was listed as a disruptive/intimidating behavior event (patient to patient).

Incident Reports review on 10/17/2024 revealed on 08/20/2024 at 1615, the patient followed a staff member off the unit without the staff member noticing. Staff and security immediately went after the patient, and a code elopement was called. The patient was stopped in the hall by the west unit door and was escorted back to the east unit with security and staff. Additional information in the second incident report created by security revealed, the patient pushed past the staff member, who was escorting a Provider off the unit, and attempted to open all the doors while running. The patient made it to the west unit, but the attempt to run was ended as the patient could not enter the unit. Security and another staff member escorted the patient back to the east unit. All doors in the hallway were secured and checked. Both incident reports were classified as an elopement event type.

Review on 10/18/2024 of Campus B Staff Meeting PowerPoint on 08/29/2024 revealed departmental updates related to staff safety, such as security notification and use of staff duress badges. Review revealed no documentation on departmental updates related to elopement.

Review on 10/18/2024 of additional information related to Campus B Staff Meeting revealed Dir #2 scheduled the staff meeting in response to workplace violent events and attempted elopement events. The meeting emphasized employee safety, interventions in place for safety such as duress badges and situational awareness, which included monitoring doors and their surroundings. Fifty-five of sixty-seven employees attended the staff meeting sessions (82% compliance rate). Compliance rate was expected to be 100% by November 1, 2024.

Review on 10/18/2024 of an education attestation created by ANM#1 revealed an education discussion between Secretary #12 and ANM#1 had occurred on 08/21/2024 regarding the importance of monitoring doors upon entrance to a unit and ensuring doors were closed when entering/exiting a unit. Situational awareness and utilizing clinical staff instead of entering a unit when patients were identified as a risk of elopement was also discussed.

Interview on 10/17/2024 at 1350 with ANM#1 and Dir#2 revealed no incident reports were created when the patient climbed on the door on 08/17/2024 and when the patient went through the door to the closed off part of the unit on 08/21/2024. ANM#1 and Dir#2 would not expect to see incident reports for these as there were no injuries and were psychosis-related behaviors; the nurse's notes would be sufficient.

Telephone Interview on 10/18/2024 at 1011 with NP#10 revealed the patient's level of observation was not changed as there was concern over aggression towards the staff if the patient was on a 1:1 observation and concern that the patient would feel like they were being followed if the observation was changed to line of sight. NP#10 revealed for elopement precautions, the staff would monitor the doors, ensure the doors closed behind the staff, with a heightened situational awareness among the staff. NP#10 emphasized communication between the staff and Providers when patients were a high risk for elopement.

Interview on 10/18/2024 at 1045 with ANM#1 revealed for Patient #1, there was not an order for Elopement Precautions/Risk.

Meeting with Dir#2 and RN#9 related to Patient #1's attempted elopements and the facility's response was held on 10/18/2024 at 1330. BH staff meeting was held on 08/29/2024, which was focused on staff safety, with additional verbal information related to elopement. There was not a separate/specific discussion related to elopement. Elopement precaution signs were updated in red and were always in place on the unit doors. Elopement Precautions would not change a lot with the patient's care unless the Provider changed the level of observation to 1:1. Patient #1 was moved to a smaller unit to keep a closer eye on the patient, and they did not think the patient needed 1:1 observation as there was concern of further agitation to the patient and safety risk to the staff. They could not recall if the patient's aggression in the ED was specifically mentioned prior to transfer to Campus B, but the ED RN did give report. Overall, the patient's elopement attempts were not reviewed or escalated for Quality as there was no patient or staff injury, and when the patient left the unit, it was not considered a true elopement as the patient did not leave care or leave the building itself.


NC00220961