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Based on observation, interview, and document review, the hospital failed to ensure 1 of 1 patients (P1) with known, obvious cognitive impairment was assessed for safety and/or supervision needs, and had appropriate interventions placed to ensure safety and prevent elopement from the hospital setting. As a result, the hospital was found out of compliance with the Condition of Participation - Patient Rights at 42 CFR 482.13.

A condition-level deficiency was issued.

Findings include:

See A-0144; Based on observation, interview, and document review, the hospital failed to ensure 1 of 1 patients (P1) with known, obvious cognitive impairment was assessed for safety and/or supervision needs, and had appropriate interventions placed to ensure safety and prevent elopement from the hospital setting. P1 subseqeuently eloped while waiting for care in the emergency department (ED) and was found several blocks away from the the medical-campus, several hours later and with early signs of hypothermia. These findings constituted an immediate jeopardy (IJ) situation.

Based on observation, interview, and document review, the hospital failed to ensure 1 of 1 patients (P1) with known, obvious cognitive impairment was assessed for safety and/or supervision needs, and had appropriate interventions placed to ensure safety and prevent elopement from the hospital setting. P1 subsequently eloped while waiting for care in the emergency department (ED) and was found several blocks away from the medical-campus, several hours later and with early signs of hypothermia. These findings constituted an immediate jeopardy (IJ) situation.

The IJ began on 4/20/23, when P1 presented unaccompanied to the emergency department (ED) via emergency medical services (EMS) and no assessment or adequate interventions were implemented to ensure appropriate supervision to help prevent elopement despite P1 having known, obvious cognitive impairment. P1 eloped from the medical-campus and, due to staff not reporting P1's condition and risks from shift-to-shift, was not identified as missing for several hours. P1 was subsequently located by a local police department several blocks away from the medical-campus, and had early signs of hypothermia (i.e., shivering, cool body temperature). On 5/9/23 at 8:48 a.m., the program manager for regulatory and accreditation (PMRA), the vice president of hospital operations (VPHO), and the nursing director for emergency services (NDES) were notified of the IJ. The IJ was removed on 5/10/23 at 10:15 a.m., when an acceptable removal plan was verified as being implemented; however, condition-level non-compliance remained.

Findings include:

A Vulnerable Adult Maltreatment Report, dated 4/24/23, was submitted by the hospital which outlined P1 presented to the East bank ED via EMS (Emergency Medical Services) on 4/20/23, for complaints of rectal bleeding. P1 was seen by the triage nurse and a physician, and had a diagnosis of dementia. While attempting to re-evaluate P1, it was discovered they were no longer in the ED. The patient was unable to be reached by telephone, was unable to be located upon search of the unit and waiting room, and security was notified who also notified the local police department. P1 was subsequently located on 4/21/23 at 1:05 a.m., and brought back to the ED before being discharged back to home.

On 5/8/23 at 9:47 a.m., the campus East bank ED was toured with registered nurse manager (RN)-A present. RN-A explained the ED consisted of 28 beds and handled approximately 70 to 80 cases per day, serving "primarily adult" populations. The main entrance to the ED was located off Harvard Street, and presented through a series of automatic, sliding glass doors which opened into the waiting room. On the opposite side of the waiting room, and opposite the registration desk and security station, were another set of double doors which were locked and only able to be opened with an employee badge. The waiting area was confirmed to have video monitoring present. RN-A explained patients brought in via EMS, at times, will be directed to the triage area and waiting room if the ED is at capacity and has no beds immediately available. When such happens, the EMS team will provide report and hand-off to the triage nurse where the patient, if stable, would fall into the triage process and be seen when able and in accordance with the rest of the ED population and their illness severity. RN-A verified these patients will, at times, also remain in the waiting room while waiting to be seen.

When interviewed on 5/8/23 at 10:02 a.m., RN-E explained they had worked in the ED for several years. RN-E verified EMS patients would, when the ED was busy or at capacity, be sent to the triage nurse and, at times, left to wait in the ED waiting room with walk-in patients. RN-E explained they worked in the triage position and if a patient has known or obvious cognitive impairment, those persons should be placed in a room "right away" so someone could help supervise them. RN-E stated it "is possible" though, at times and depending on ED capacity, when EMS would bring a patient into the waiting room without the triage nurse being able to "lay eyes on the patient" until they are called back for triage. RN-E expressed EMS typically just provides a verbal report to the nurses who then sign on an iPad they had received it. RN-E explained there was no formal process or protocol to assess patients, including those with severe cognitive impairment, for potential interventions which may be needed while in the pre-ED setting (i.e., waiting room) to ensure their safety. RN-E added, "We don't have a standard protocol for that." RN-E stated any interventions determined to be necessary or needed to promote safety would come "through conversation" between the physician and the nurses. RN-E stated they had, just that day (5/8/23), been told of an incident involving an elderly patient who was left in the lobby after being triaged, however, the next shift (starting at 7:00 p.m.) had not been told of their cognition or to watch the patient and, as result, the patient had "walked off" and was not found until hours later and was "hypothermic." Further, RN-E stated the nurse who was triaging patients was really the single person able to supervise the waiting room and "run the show" which "can be challenging" when the ED was busy.

During interview on 5/8/23 at 10:20 a.m., RN-C stated they worked in the ED as a triage nurse and verified, at times, EMS patients would be brought to the triage area and left to wait until roomed if the ED was busy or at capacity. The physician would still visit and see the patients, and then, if needed, the patient may go to the "vertical" area and start having lab work or IV(s) placed before being returned to the waiting room until a room was ready for them. RN-C explained the EMS crew will typically provide a verbal hand-off; however, the charge nurse was not always updated on the "whole picture" of the patient by them; usually just being told the patient is "green, yellow, or red" to signal their condition. RN-C stated patients with cognitive impairment who are alone (i.e., no family present) likely should not be left alone in the waiting room so they would "communicate with the doctor" and attempt to secure a room or hallway bed for the patient. However, RN-C stated they were unsure if there was a formal policy which directed that, however, continued and explained there was not an assessment process the nurses perform which would help determine what, if any, interventions to promote safety while the person was waiting to be roomed were needed. RN-C stated patients with dementia or cognitive impairment were "always hard and never easy" to figure out in regards with how to handle them until admitted or discharged and reiterated the interventions, if any, used to help keep them safe would likely result from the nurse working and their respective discretion and their "nursing judgment." Further, RN-C stated they were unaware of any recent incidents were unattended patients may have eloped or wandered away from the hospital; however, explained the hospital had recently started to reiterate the nurses could use a "health officer hold" to help keep patients onsite until evaluated by the physician. However, this likely would not prevent someone from eloping or wandering away if the person had cognitive impairment and was left unattended in the waiting room.

P1's medical record was reviewed with NDES. P1's EMS/Ambulance Record, dated 4/20/23, identified P1 was picked up from their home, and was an elderly male with a primary complaint listed as, "Possible GI bleed." A section of the record labeled, "Narrative," identified P1's wife reported to the EMS team P1 had "memory issues and isn't a good caretaker." The note concluded with, "EMS monitored [P1] during transport and handed [P1] off to staff, EMS let [hospital] staff know about memory issues and possible dementia." A subsequent section labeled, "Facility Signatures," included a signature from the hospital staff who took the report from EMS. The hospital staff signature was dated 4/20/23 at 4:16 p.m.

P1's ED notes, dated 4/20/23, identified P1's triage evaluation upon presenting to the ED with a complaint of blood in the stool for multiple days. P1 was recorded as denying abdominal pain, taking a daily aspirin, along with dictation reading, "Hx [history] dementia." The triage evaluation included a review labeled, "Cognitive/Neuro/Behavioral," which identified P1 as being within-defined-limits (WDL). This evaluation was signed by RN-D on 4/20/23 at 4:21 p.m.

P1's ED Provider Note, dated 4/20/23, identified P1 arrived at the ED on the same date at 4:13 p.m. with a chief complaint of rectal bleeding. P1 was recorded as an 80 year old male with dictation listed, "History at this time is significantly limited as the patient came by ambulance without his caregiver, and has significant dementia to the point of being unsure of why he is here ... denies any rectal bleeding that he is aware of." As a result, P1's family member was contacted who provided history on the situation via telephone. The note listed a section labeled, "Assessment & Plan," which outlined P1's medical history, including dementia, and a plan of obtaining lab work to determine if more was needed.

However, the note then included, " ... around [5:30 p.m.], his labs were drawn, and they resulted by around 7 PM. While attempting to reevaluate him, he was found to not be in the emergency department waiting room where he had been ... attempted to call him multiple times, and this provider went out to the emergency department waiting room to attempt to locate him ... he was unable to be located, we contacted security who contacted police ... family was updated that we did not know where he was." The note continued, "1:05 AM [4/21/23] Pt [patient] was found by security and returned to the ER ... body temperature 95 F (degrees). Will warm with blankets and Bair hugger [a temperature management system used to maintain a patient's core body temperature] ... plan for DC [discharge] back to his [family member]."

NDES verified P1 admitted to the ED on 4/20/23 at 4:13 p.m., and acknowledged the medical record had identified P1 as having dementia and cognitive impairment when they arrived to the ED. NDES explained there was no formal evaluation or assessment process to determine what, if any, interventions were needed for cognitively impaired patients to ensure their safety while in the ED setting (including waiting room); however, if a nurse identified a risk, they could respond and place interventions. At this time, the patient care supervisor (PCS)-A for the ED was present and verified interventions for safety while in the ED, aside from someone reporting a suicidal ideation, were "up to the nurse." PCS-A stated P1 was an individual which would likely be "disguisable" with their dementia and have periods of lucidity which could 'mask' the severity of the cognitive impairment. Regardless, the nurses and physician did have a "hand off" between each other and if there was an unsafe situation for the patient, PCS-A felt it would be addressed accordingly adding, "We take it very serious." However, PCS-A verified there was no documented evaluation or assessment process in the medical record to demonstrate such decision making had occurred.

The medical record lacked evidence P1 had been assessed or evaluated upon arrival to the ED for what, if any, safety interventions were needed to ensure P1 remained safe while waiting to be roomed within the ED, despite P1 having severe cognitive impairment which was identified on the EMS Ambulance Record, the initial triage of P1, and the physician' provider note. There was no evidence the hospital implemented any increased monitoring or what, if any, attempts were made to secure an immediate room or 'hallway bed' for P1 despite the cognitive impairment.

On 5/8/23 at 12:20 p.m., a telephone call was placed to RN-D. A return call was provided on 5/8/23 at 12:47 p.m., and RN-D was interviewed, and verified they were the triage nurse working until 7:00 p.m. on 4/20/23 when P1 presented to the ED via ambulance. RN-D verified P1 presented to the ED on their shift, and they explained the triage process included evaluating a patient and assigning them a number from one (1) to five (5) to demonstrate "how immediate" they needed to be roomed and attended to for their respective medical concern. RN-D verified the EMS crew had verbalized to them P1 "was confused," to which RN-D responded by asking the EMS crew if P1 was able to remain in the waiting room until seen. RN-D indicated the EMS crew expressed no objection to such placement. The physician then saw P1 for their examination and discussed the need for a room with RN-D as a rectal examination would need to be done. RN-D did not recall the physician ever mentioning concerns or a potential plan to address P1's cognitive impairment while in the ED. P1 was then returned to the waiting room after their physician evaluation as no rooms or beds were available at the time. RN-D stated their shift then ended; however, at some point between the physician evaluation and the shift ending, P1 had "got up and walked out" of the waiting room. RN-D returned to work the following day, on 4/21/23, and then heard about the incident which they expressed made them feel "really bad." RN-D stated, in hindsight, P1 likely should have been immediately roomed or supervised closer given the severe cognitive impairment. RN-D explained there was no formal evaluation process or assessment the triage nurse completed to determine what, if any, interventions were needed when someone presented with severe cognitive impairment to ensure their safety while in the hospital campus unless the person was intoxicated or suicidal. RN-D reiterated P1 likely should have had someone watching or supervising them closer while in the waiting room but added, "I don't know who the person is [would be]." RN-D again expressed remorse for the incident and added, "[P1] got overlooked." RN-D stated they were unable to recall what, if any, information on P1 (including their cognitive impairment) had been discussed with the oncoming triage or charge nurse(s) who took over on 4/20/23 (7:00 p.m.) but added such information would have been "an important thing to tell [them]." Further, RN-D expressed since the incident happened the nurse managers had discussed the situation with them in a "what could have been done differently" manner, however, there had been no formal re-education or new processes implemented to their knowledge.

On 5/8/23 at 12:36 p.m., RN-B was interviewed. RN-B recalled the incident involving P1 on 4/20/23, and verified they were the charge nurse in the ED who started at 7:00 p.m. on 4/20/23. RN-B explained P1 had been triaged and evaluated by the physician and was in the waiting room, to their knowledge, until approximately "around 9:00 p.m.," when the physician attempted to locate P1 to re-evaluate them. The physician was unable to locate P1 and notified RN-B they were absent from the waiting room. RN-B stated they felt P1 had potentially left without being seen; however, the physician then responded P1 had severe cognitive impairment and dementia. RN-B expressed the physician voicing such right then was the first time anyone on the 7:00 p.m. shift, including triage and charge nurse, had been told P1 had cognitive impairment and should not have been allowed to leave the waiting room. RN-B stated, "[We] weren't made aware of it." RN-B stated they immediately then enacted protocols for "an eloped patient" and contacted security. RN-B stated if they had been told of P1's cognitive impairment, they would have moved patients or done what was possible to secure a 'hallway bed' back in the ED for them to allow better supervision. RN-B explained there was a shift-to-shift verbal report process which happened from the departing to oncoming nurses; however, reiterated the information on P1 and their cognition did not get communicated. RN-B stated P1 was eventually returned to the ED and was not physically injured adding, "Thank goodness he was fine." Further, RN-B stated they were unaware what, if any, actions or education had been implemented or completed since the incident to help prevent a similar situation.

A provided Case Report, dated 4/21/23, identified the hospital' security report and details surrounding the incident with P1 on 4/20/23. The report identified security was notified at approximately 10:10 p.m., of a "BOLO [be on lookout]" for a missing person from the ED who had been missing for 30-60 minutes already. The report named P1, and identified they suffered from dementia. A search was completed around the ED and P1 was unable to be located. The local police department was contacted, and a floor-by-floor search for P1 was completed at the hospital grounds. A timeline of events was then listed, which identified the police squad arrived onsite at 10:09 p.m., and a foot search of the grounds and exterior was completed. At 1:00 a.m. (on 4/21/23), the police had found the missing person at "11th and University [Ave]" and were bringing them back to the ED.

On 5/8/23 at 1:25 p.m., Hennepin County social worker (SW)-A was interviewed via telephone. SW-A explained they had reviewed the police department's report of the incident on 4/20/23, involving P1 and their elopement from the hospital. The police were notified of a "missing person" on 4/20/23 at 9:56 p.m., and officers were dispatched. P1's family member was contacted who described P1 as wearing a black jacket with black sweat pants when sent to the hospital. The officers completed a search for P1 and, several hours later, did locate P1 on the "1100 block of University Avenue Southeast [SE]" which was nearly one mile away from the medical campus. SW-A explained P1 was recorded in the report as "shaking," and "disorganized," and being unable to speak coherently when found. P1 was returned to the ED where it was identified his temperature was 95 F and blankets and a Bair Hugger were used to warm him up prior to being discharged home from the ED a few hours later.

A National Weather Service (NWS) Preliminary Local Climatological Data report dated 5/5/23, identified the Minneapolis/St. Paul area weather readings for the month of April 2023. This report identified on 4/20/23 (the day P1 eloped from the hospital), a high temperature of 43 degrees (F) and a low temperature of 37 (F) was recorded along with 0.51 inches of precipitation falling.

On 5/8/23 at 1:36 p.m., an interview was completed with the hospital administration team including NDES, VPHO, PMRA, and the chief nursing officer (CNO). NDES explained the incident with P1 on 4/20/23, and verified P1 had been located several blocks away from the medical campus after leaving the ED waiting room. NDES stated in the "current state" the interventions used for someone with cognitive impairment were at the nurses' discretion as there was no formal assessment or evaluation process they had to help determine what, if any, interventions were available or needed. However, the "practice and education" team was working on developing such tool, but it was not operational yet and there was no date of completion available. As a result of the incident on 4/20/23, NDES explained they did follow-up with the nurses involved who recognized P1 likely should have not been left in the waiting room unattended, and reviewed, in general, patients "who are vulnerable" and options to address them. These topics were being discussed in the shift-to-shift huddles and feedback from the staff was being taken. However, there was no education or discussions being had with staff on how to appropriately assess persons with severe cognitive impairment, nor the shift-to-shift communication process to ensure high-risk patients are discussed and the oncoming shift is aware of their needs. NDES stated there was "still opportunity with that," and reiterated the ED, in general, was "really stretched" when the incident happened and "close to capacity" which can contribute to events. In addition, the VPHO expressed they would immediately begin to develop a shift-to-shift communication tool and would likely be able to roll it out to staff within 24 hours.

A subsequent interview was held with NDES and PMRA on 5/8/23 at 3:36 p.m., to clarify events surrounding P1's elopement from the waiting room. PMRA explained the medical record was "pretty accurate" with it's timeline of events, and the security footage showed P1 brought back to the waiting room by a hospital employee at 5:50 p.m. where he remained until 6:07 p.m., when he left the waiting room. PMRA provided a camera still of the ED waiting room, dated 4/20/23 at 6:07 p.m., which showed P1 standing next to the locked (via badge access) double doors opposite the main entrance in the ED waiting room, and two non-hospital employees passing through the doors in the opposite direction. P1 then left through the opened door which had likely been opened from the other side to let the visitors through. NDES and PMRA both expressed P1 likely waited by the door until they opened and used the opportunity to leave when they did. PMRA stated security was still using the footage to track P1's movements after they left the waiting room, and they were unsure if P1 exited the campus on Harvard Street or remained in the hospital for a period after leaving the ED waiting room. NDES verified the medical record lacked evidence of any interventions being used or placed to supervise P1 while in the waiting room, and they explained P1 had been given an emergency severity index (ESI) score of "3" which, per ESI protocol, called for a re-evaluation every four hours. As a result, P1 was not checked on or assessed until close to 9:00 p.m., when he was then identified as missing and eloped patient protocols were implemented. NDES verified they had previously been unaware the shift-to-shift communication process had not addressed P1's cognition and subsequent risk to wander, and they again acknowledged the situation and expressed, "We missed it."

A provided Triage in the Emergency Department, Adult and Pediatric policy, dated 1/17/23, identified a purpose to help outline the process involved in performing an initial nursing evaluation. Patients presenting to the ED will have an initial assessment completed and a corresponding acuity assigned and, when rooms are not immediately available, would be triaged and roomed accordingly. The policy outlined several items were reviewing in the triage process including vital signs, pain assessments, communicable disease screening, and their risk of violent behavior. However, the process lacked evidence how to address a patient with severe cognitive impairment and subsequently ensure their safety within the ED setting. A policy on assessing and responding to patients with cognitive impairment in the ED was requested, however, none was received.

The IJ which began on 4/20/23, was removed on 5/10/23, when an acceptable removal plan was verified as being implemented. The plan included mandatory electronic learning on a "Safe Patient Environment in the Emergency Department," which included review of high-risk patients (including cognitively impaired persons) and appropriate interventions to ensure their safety; and development and implementation of a written communication tool to be used shift-to-shift to ensure high risk or needs patients were discussed and reviewed. This education was to be completed prior to the hospital employees' next shift and started on 5/9/23. These actions were reviewed and verified as being completed on 5/10/23, through employee interviews and corresponding documentation review.