HospitalInspections.org

Based on record review and interview, the hospital failed to ensure care in a safe setting. The deficient practice is evidenced by the elopement of a patient admitted with a Corner's Emergency Certificate to prevent self-harm..
Findings:

Review of the medical record for Patient #3 revealed he was admitted on 07/18/2024 with a diagnosis of drug overdose/suicide attempt. The patient was placed under a Corner's Emergency Certificate and one to one sitter was assigned to the patient. Further review of the medical record revealed the patient eloped on 07/20/2024.

Review of the initial report sent to the licensing authority documented a review of the video surveillance was performed by the hospital and revealed the patient left the room in a purple hospital gown at 4:49 p.m. and the sitter followed him out the room 21 seconds later. The patient was seen on video exiting the floor via the "back stairwell," and the sitter was seen entering the lobby elevator.

In interview on 07/23/2024 at 10:56 a.m., S6RN verified that the investigation into the elopement was not complete. S6RN verified she had collected the statement of the sitter, but the sitter had not been interviewed yet. In her statement, the sitter indicated that Patient #3 had forced his way passed her. S6RN verified that the sitter was taken off the schedule until the investigation could be completed.

In interview on 07/23/2024 at 12:20 p.m., S5DS verified he had not completed his investigation and had not interviewed the security officer. S5DS verified security officers were assigned to perform real-time video surveillance of the exits that did not have a security officer physically present and one of the security officers should have seen Patient #3 as he left the building. S5DS verified that when a Dr. Flight is called, the officers typically try to secure the doors that are likely sites of egress based on the last known position of the patient. S5DS verified either the security officer was not watching the monitor and missed seeing the patient leave through the physician's office building door, or when the Dr. Flight was called, the security officer missed seeing Patient #3 exit the door because he was in route to help secure the door. S5DS verified there was a security lapse when Patient #3 eloped from the facility.

In interview on 07/23/2024 at 12:37 p.m., S1CNO verified that the operator recieved the call for the Dr. Fight at 4:52 p.m.

In interview on 07/23/2024 at 1:10 p.m., S1CNO verified the review of the video surveillance of the doors revealed the patient exited the building at 4:52 p.m. through an egress door in the physician's office building adjacent to the hospital. S1CNO verified security missed seeing Patient #3 leave the facility in real-time and, if they had seen him exit the building they might have caught him before he left hospital property.

Based on record review and interview the director of nursing failed to ensure all nursing staff adhered to the policies and procedures of the hospital. The deficient practice is evidenced by failure of the nursing staff to verify a means of transportation prior to release from the emergency department for 2 (#1, #2) of 2 reviewed records of discharged patients.
Findings:

Review of the hospital policy "Discharge from the Emergency Department," last reviewed 01/18/24, revealed in part, "8. Proper means of transportation is verified prior to the patient's discharge." -

Review of the medical record for Patient #1 revealed the patient arrived via police. Review of the record for the departure mode for Patient #1 revealed in part, "Departure Mode: By Self." '

Review of the medical record for Patient #2 revealed the patient arrived via police. Review of the record for the departure mode for Patient #2 revealed in part, "Departure Mode: By Self."

In interview on 07/22/2024 at 1:34 p.m., S3RN verified that the documented departure mode was how they left the department by self or with assistance.

In interview on 07/22/2024 at 1:35 p.m., S4SRN verified that the emergency department record did not contain documentation that the staff verified Patient #1 and Patient #2 had a proper means of transportation to take them home after discharge.