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Based on a review of medical records, staff interviews, and review of facility policies, it was determined that the facility failed to ensure that one Patient (P) #1 of 20 sampled patients (P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13, P#14, P#15, P#16, P#17, P#18, P#19, and P#20) received a medical screening examination.

Specifically, P#1, a patient with dementia, was transported from a skilled nursing facility to the facility's emergency department (ED) on 12/16/22 for increased confusion. After an initial screening by the ED physician at 10:29 a.m., closer monitoring was requested. P#1 eloped from the ED without the staff's knowledge, time unknown. P#1 was returned to the ED, and the physician conducted a re-evaluation at 12:54 p.m.

Cross-refer A2406 as it relates to the facility's failure to ensure that an appropriate medical screening examination was completed.

Based on a review of medical records, Central Log review, facility policy review, and staff interviews, it was determined that the facility failed to ensure that an appropriate medical screening examination was within the capability of the hospital ' s emergency department (ED), to determine whether or not an emergency medical condition exists for one Patient (P) #1 of 20 sampled patients with altered mental status eloped from the emergency department
on his initial visit prior to receiving a complete medical screening examination.


Findings:

A review of the facility's Central Log revealed that P#1 presented to the ED via emergency medical services (EMS) from a skilled nursing facility and was registered as a patient on 12/16/22 at 10:20 a.m.

A review of the initial history and physical notes by physician (MD) AA on 12/16/22 at 10:29 a.m. revealed that P#1 had a reported history of dementia and was sent to the ED from a nursing facility due to P#1 acting more confused than typical. P#1 was on a stretcher in the hallway but was pacing around the hallway. MD AA requested that P#1 be placed in a room and monitored. A review of the physical assessment revealed that P#1 was oriented to self but not time or situation

A review of the Rapid Initial Assessment by Registered Nurse (RN) BB on 12/16/22 at 10:33 a.m. revealed that P#1 eloped from the examination room.

A review of Emergency Notes at 11:46 a.m. revealed that P#1 was placed at the charge desk for observation due to P#1's history of dementia and wandering. The physician requested that P#1 be placed in a room. P#1 eloped from the room. Bathrooms and ED rooms were checked. Security and law enforcement was notified.

A review of the Re-evaluation and MDM (medical decision making) Note revealed in part, "I ordered Labs (blood work), urine, x-ray, to look for source of infection of possible AMS. I also requested that he (patient #1) be monitored more closely as he was wondering around the hallway. As was my concern the pt.(patient) subsequently eloped from the ED. Security is looking for him here, and the police have been informed."


A review of a Re-Evaluation/Progress note # 1, documentation by MD AA at 12:54 p.m. revealed that P#1 had returned to the ED with no complaints and ambulating without difficulty. In addition, P#1 was cooperative with completing the work-up.

A review of the Elopement Policy, #13021611, revealed that Elopement was defined as an act by an at-risk patient who was aware that he was advised not to leave, but the patient left with intent. An at-risk patient was any patient determined to be a potential danger to themselves or others. The policy revealed that Altered Mental Status (AMS) was one factor that could have placed the patient at risk. The RN or designated staff member was responsible for the ongoing monitoring of each patient presenting with a behavioral health complaint.

A review of "EMTALA- Medical Screening Examination and Stabilization Policy," #952841, reviewed 3/21, revealed that the ED was required to provide an individual who came to the ED an appropriate Medical Screening Examination (MSE) within the capability of the ED to determine whether or not an Emergency Medical Condition (EMC) existed.

An interview took place with dayshift ED Nurse Manager (RN) DD on 1/24/23 at 3:53 p.m. in the Magnolia Room. RN DD stated P#1 came to the ED via EMS and was triaged quickly for increased AMS. P#1 was initially placed in an EMS bed right in front of the nurse's station and then transferred to an examination room close to the nurse's station. RN DD said the staff noticed that P#1 was missing, and security and the sheriff were called. RN DD said P#1 was only gone for 25 to 30 minutes. P#1's son found P#1 and brought him back to the facility. P#1 was treated and discharged shortly after returning to the ED. RN DD further said that nurses did not always stay at the nurse's station, and there were no sitters available in the ED.

An interview took place with security officer (SO) NN on 1/25/23 at 11:44 a.m. in the Magnolia Room. SO NN stated the day P#1 eloped from the ED, there had not been any calls to security for an elopement. Security kept a log of all activities, and there was nothing on the log about a patient elopement. Security would have broadcast the patient's information over the radio.

An interview took place with RN PP on 1/25/23 at 12:29 p.m. RN PP said she remembered P#1 in an examination room in front of the nurse's station. RN PP said the ED did not have technicians or sitters. RN PP said she had heard that P#1 had eloped, and everybody was looking for P#1. RN PP did not remember security being involved. RN PP further said that at the time of the incident, each nurse was responsible for four to five rooms and was doing a lot. The nurse could have been in a patient room when P#1 eloped.


The facility failed to provide ongoing monitoring of patient #1 on 12/16/2022, as evidenced failing to ensure that this high-risk patient identified with a diagnosis AMS, and not competent to make his own decisions was continuously monitored as requested by the physician. Patient #1 required a sitter for monitoring and safe observstion, as this resulted in the patient eloping from the facility, and not receiving an appropriate MSE on his initial visit to the ED.