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|CARNEY HOSPITAL||2100 DORCHESTER AVENUE BOSTON, MA 02124||Jan. 19, 2011|
|VIOLATION: EMERGENCY SERVICES POLICIES||Tag No: A1104|
|Based on record review, physician and staff interview one of one applicable Patient #1's eloped from the Emergency Department (ED)after an appropriate medical screening in December 2010. The ED staff failed to implement a Code Amber for the Patient's elopement as per Hospital Policy.
The findings are as follow:
Patient #1 had eloped from a long-term care facility earlier the same day on 12/31/10.
Review of the Emergency Medical Service (EMS) Trip Report dated 12/31/10 indicated Patient #1 walked into a police station and requested an ambulance. Patient #1 reported having abdominal pain for a year with nausea and vomiting. The EMS Report indicated Patient #1 had been evaluated in the ED on 12/30/10. Patient #1 returned to the long-term care facility following the evaluation on 12/30/10. On 12/31/10, the EMS Report indicated Patient #1's abdomen was soft and non-tender. Patient #1 reported being a diabetic on insulin and having hypertension. Patien #1t's vital signs were recorded as a blood pressure of 182/50, heart rate of 88 beats per minute and respirations 16 breaths per minute. Patient #1 arrived to the ED on 12/31/10 without incident.
Continued review of the ED Record indicated Patient #1 had a legal guardian.
Review of Patient #1's ED Nursing Triage Record dated 12/31/10 at 11:30 AM indicated Patient #1 had eloped from a nursing home and was seen in the ED 12/30/10. The ED Triage Record indicated Patient #1 complained of having a hernia and a growth in the belly. Patient #1 reported having a mild pain level rated a 4 out of 10. The ED Triage Record indicated Patient #1 was alert and uncooperative. The ED Triage Record indicated Patient #1's abdomen was tender with flank pain. Patient #1 denied abuse or any incidents of physical assault. The ED Registered Nurse #1 indicated Patient #1 was placed on close observation in the corridor.Patient #1was later moved to a back corridor.
Review of the Hospital's Code Amber Policy dated November 2010 indicated the purpose of the policy was to provide guidelines to staff to ensure an appropriate response to an elopement event when the eloped patient is a safety risk to him/herself or others. The policy indicated all staff were to participate in the Code Amber to report possible sightings. The policy indicated the local police, Hospital's Risk Manager and the Administrator-On-Call were to be notified.
Registered Nurse #1 was interviewed in person on 01/19/11. RN #1 said Patient #1 complained of pain in the lower abdomen and that something was growing. RN #1 said Patient #1 was placed on a stretcher in front of the nursing station. RN #1 said Patient #1 was placed on close observation. RN #1 said Patient #1 was oriented, cooperative, normal looking, well dressed and well groomed. RN #1 said Patient #1 was evaluated by ED Attending Physician #1 on 12/31/10 at 1:30 PM. RN #1 was aware Patient #1 had been evaluated in the ED the night before and that Patient #1 resided in a nursing home. RN #1 said the nursing home was not called until Patient #1 was discharged and arrangements were made to send Patient #1 by ambulance. RN #1 said at 3:45 PM, the EMTs arrived and spoke to Patient #1. Patient #1 did not want to return to the nursing home but was not questioned as to why. RN #1 said Patient #1 requested to go to the bathroom which was located in the center of the ED and in front of the nursing station. RN #1 said there were three security officers located within the area just outside of the bathroom. RN #1 denied alerting security of any concerns with Patient #1. RN #1 said Patient #1 was missing within minutes. RN #1 said the security officers approached Patient #1 at the bus stop but they had no reason to stop Patient #1 from boarding the bus. It was not clear how the security officers were alerted to Patient#1's exit from the ED.
The Hospital's Risk Manager and Director of Quality and Patient Safety were interviewed on the day of survey. The Hospital's Risk Manager was unaware of Patient #1's elopement incident dated 12/31/10. The Hospital's Risk Manager said an incident report should have been filed by both RN #1 and security. The Hospital Risk Manager was unable to identify the security officers who approached Patient #1 at the bus stop located near the entrance to the Hospital. The Hospital Risk Manager said there were no specific policies for an episode of elopement; so a policy had been developed and implemented on 12/06/10. The Hospital Risk Manager said staff training was primarily offered on the inpatient units in September of 2010.
RN #1, RN #2, RN #3 and a security officer interviewed in the ED on 01/19/11 at 12 PM were unfamiliar with the alert name for a patient elopement. RN #2 needed to refer to a poster in the ED for the Code to call. The Security Officer interviewed said it was called Code Pink which was used for a child abduction.
The Chief of the ED was interviewed in person on 01/19/11 at 10:45 AM. The Chief of the ED said many patients elope from the ED. The Chief of the ED said the distinction was whether or not the patient was safe. The Chief of the ED said it would have been appropriate to detain the Patient and complete a Section 12 for a psychiatric evaluation or possibly case management consultation. The Chief of the ED said the ED Attending Physician should have been informed of Patient #1's elopement.
ED Attending Physician #2 was interviewed in person on 01/19/11 at 4 PM. ED Attending Physician #2 said report was given by the ED Attending Physician #1 who evaluated and discharged Patient #1 at approximately 4 PM. ED Attending Physician #2 said Patient#1 was to return to a long-term care facility. ED Attending Physician #2 denied being informed Patient #1eloped from the ED.
The Interim ED Nurse Manager was interviewed on 01/19/11 at 12:40 PM. The Interim ED Nurse Manager was unaware of Patient #1's elopement incident.The ED Interim Nurse Manager said there had been discussions regarding the new Code Amber over two to three months. The ED Interim Nurse Manager said there had not been a Code Amber since the policy had been implemented on 12/06/10.