The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on record review and interview, the facility failed to ensure the patient's right to receive care in a safe setting to prevent elopement of 1 (SP#1) out of 3 sampled patients (SP).

Findings include:

Review of SP#1 History and Physical, Date of Service: 12/17/2019 at 1:10 AM documented Past Medical History to include Alzheimer's disease. Physical Exam: Neurological: Mental Status: Patient is alert. Mental status is at baseline. Assessment: Patient will admit to observation for monitoring.

Review of SP#1 Nursing Admission Neurological assessment dated [DATE] at 8:00 AM documented Conscious Level: Alert. Orientation Level: Oriented to person. Disoriented to place. Disoriented to time. Disoriented to situation. Cognition: Poor judgement. Poor attention/concentration. Poor safety awareness. Short term memory loss. Impulsive. Neuro Symptoms: Forgetful.

Review of SP#1 Clinical Nursing Note, Date of Service: 12/17/2019 at 8:00 AM documented patient received in bed and in stable condition. Patient oriented X 1, very confused. Bed alarm in place. Redirection used several times. Encouraged to use the call light for assistance. Frequent rounds done due to patient being very confused.

Review of SP#1 Clinical Nursing Note, Date of Service: 12/17/2019 at 9:00 AM documented patient continues to be very confused. Getting out of bed frequently walking around the room. Wanting to go home to see family. Redirection used several times. Patient assisted to bed and bed alarm placed.

Review of SP#1 Clinical Nursing Note, Date of Service: 12/17/2019 at 10:00 AM documented patient eloped from unit. Removed intravenous (IV) and took personal belongings. Last seen by Nurse around 10 minutes ago 9:50AM, security called and made aware of elopement. They are looking for patient. Nursing Office Supervisor made aware and Charge Nurse. Social Worker tried to get in contact with wife, phone number disconnected.

Review of SP#1 video surveillance with Staff H- Security Manager on 12/26/2019 at 1:00 PM revealed that on 12/17/2019 at 9:59AM patient passed the nursing station, exited the unit, and entered the elevator on the 13th Floor. Patient seen wearing white cap, gray shirt and black pants. At 10:02 AM, patient exited the elevator on the ground floor. At 10:03AM, patient seen walking down the hallway toward the west lobby. At 10:05AM, patient exited the facility through the west lobby.

Police Report- reported at 12:21 PM on 12/17/2019: At approximately 1000 hours on today's date 12/17/2019 SP #1 left the hospital on foot. Myself and off duty unit then canvassed the area but were unable to locate SP#1. Patient's Sister In Law then responded to the hospital and advised unit that SP#1 is a threat to himself if not located because he will not be able to make it home.

Interview with Staff B- Risk Manager on 12/26/2019 at 9:44 AM revealed Date of incident: 12/17/2019 at 12:12 PM. Stated patient eloped from unit removed intravenous (IV) and took personal belongings. Stated patient was last seen by a nurse at 9:50 AM. Stated security was called and made aware of elopement. Stated they are looking for patient. Stated nursing office supervisor was made aware along with the charge nurse and social worker. Stated that the registered nurse tried to get in contact with patient's spouse, but phone number was disconnected. Stated police was called to assist and communicated with the family. Stated facility received verbal confirmation that the patient was found. Stated no other outside agency was notified.

Interview with Staff J- Nursing Supervisor n 12/26/2019 at 1:33 PM revealed security viewed cameras and identified the patient had left the building. Stated tried to contact the family several times but did not get a hold of anyone. Stated waited on call back after leaving several messages. Stated security contacted the police department and a campus search via car was conducted. Stated an alternative number was provided by the spouse to the emergency department on admission. Stated Staff K-Nursing Supervisor (B) left message on alternate number. Stated undetermined if family was coming to facility to visit SP#1 on 12/17/2019 or if the family arrived in response to a message left from Staff K. Stated police met with family on 12/17/2019, the day of the incident. Stated noted incident on supervisor report. Stated DCF (Florida Department of Children's and Families) was not contacted. Stated only contact DCF specifically for abuse and there was no abuse in this case.

Interview with Staff A -the Executive Director Risk Management on 12/26/2019 at 11:35 AM revealed that a "Be On The Lookout" (B.O.L.O.) was created and disseminated via postings. Stated there is no general elopement policy for the facility. Stated there is a behavioral health elopement policy specific to Baker Act patients. Stated no corrective action or action plan was completed. Stated investigation was closed when verbal communication was received that the patient was found. Stated unable to identify specific date and time patient was found.

Reviewed of PolicyStat ID: 29, Last approved/revised: 11/2017. "Patient Rights and Responsibilities", documented: Attachment A: As a patient, you have the right to receive care in a safe setting.