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As result of the review of patient records and other documentation, interview with staff and observation of the physical plant, it was determined that the hospital failed to protect the patient from the potential of harm.

As noted in A 0144, patient #1 was a 47 year old male admitted to University Specialty Hospital on 12/1/09 from another rehabilitation hospital. The patient was struck by a motor vehicle while riding a bicycle on October 18. 2009 and had resultant diagnoses of Traumatic Brain Injury, Anoxic Brain Injury, fractures of the face, ribs and scapula. Additional diagnoses included dysphagia, left hemiparesis (weakness of one side of the body), bilateral pneumothoraces, gait dysfunction, and percutaneous endoscopic gastrostomy tube for feeding. The patient by history has been blind in the left eye since birth. The patient was admitted for physical and occupational therapy with gait training. He was to be evaluated and treated for cognitive and attention span deficits. In sum, patient #1 had significant physical and cognitive limitations that made it extremely unsafe for him to leave the locked unit without any supervision. The medical record revealed that patient #1 frequently wanders in and out of rooms and needs constant redirection away from the exit doors.

On 12/29/09 the record indicated that the sitter provided to supervise patient #1 was discontinued though the patient remained an elopement risk.

At 1500 on 12/31/09 the patient eloped from the unit to another unit. There was no documentation entered into the medical record regarding the 12/31 patient elopement from the unit. No changes were made in patient #1's plan of care and he was not placed on an increased level of observation despite his known risk as noted in the deficiency at A0396. No documented investigation on how the patient was able to leave the unit was found, nor was any hospital plan to prevent not only this patient but other patients from eloping from the unit.

On 01/02/2010, patient #1 eloped a second time from the locked Traumatic Brain Injury Unit. This time the patient was able to leave the hospital wearing pajama pants, a tee shirt and sneakers on bitterly cold day. Nursing staff did not notice that the patient was missing until 12:10 after he was noted off the unit on the hospital's security camera at 10:50 am . The code to initiate a search was not called until 12:41 pm and the police were not called until 1:27pm. The patient was located at another hospital's ED at 9:14 PM.

The hospital failed to protect the patient when (1) the patient was identified as an elopement risk but was not maintained on precautions; (2) the hospital failed to have any policies or procedures defining observation levels for patients at risk for elopement; (3) the hospital failed to change patient #1's treatment plan after his 12/31 elopement from the unit; (4) the hospital failed to address any environmental risks to identify how patient #1 was able to elope, following the 12/31 elopement; and (5) following patient #1's second elopement on 01/02, staff failed to recognize he was missing for more than an hour and failed to initiate a code to look for him for nearly two hours after he had left the building.

Based on staff and patient interviews, observations, review of policies, procedures, the medical record for patient #1, and other pertinent documentation, the hospital failed to provide care in a safe setting when a patient with a traumatic brain injury eloped from a locked unit two times in less than 48 hours. After the first elopement on 12/31/2009 the hospital failed to document the elopement anywhere in the record, failed to change the patient's plan of care and failed to initiate any actions to deter the patient from eloping again despite his successful elopement from the unit and his vulnerable cognitive state. Due to this failure to initiate any corrective measures to protect patient #1, he was able to again elope on 01/02/2010. At the time of the second elopement staff remained unaware he was missing for more than an hour and failed to initiate a code to look for him for nearly two hours.

Patient #1 was a 47 year old male admitted to University Specialty Hospital on 12/1/09 from Kernan Orthopedic & Rehabilitation Hospital. The patient was struck by a motor vehicle while riding a bicycle on October 18. 2009 and had resultant diagnoses of Traumatic Brain Injury, Anoxic Brain Injury, fractures of the face, ribs and scapula. Additional diagnoses included dysphagia, left hemiparesis (weakness of one side of the body), bilateral pneumothoraces, gait dysfunction, and percutaneous endoscopic gastrostomy tube for feeding. The patient by history has been blind in the left eye since birth. The patient was admitted to University Specialty Hospital for physical and occupational therapy with gait training. Additionally patient was to be evaluated and treated for cognitive and attention span deficits. In sum, patient #1 had significant physical and cognitive limitations that made it extremely unsafe for him to leave the locked unit without any supervision.

On admission, patient #1 was assessed to be at risk for falls, risk for injury related to the PEG tube, and risk for elopement. The patient was placed on 1:1 observation. The surveyor noted that although the patient was placed on 1:1 observation, the hospital has no policy or procedure for 1: 1 observation or any other observation levels including elopement. On 12/15/2009, the interdisciplinary treatment plan was updated and the 1:1 observation discontinued.

On 12/29/09 the record indicated that the sitter provided to supervise patient #1 was discontinued though the patient remained an elopement risk. The medical record revealed that patient #1 frequently wanders in and out of rooms and needs constant redirection away from the exit doors.

At 1500 on 12/31/09 the patient eloped from the unit. The patient was found wandering on the third floor by another staff and was brought back to the locked unit. The physician assistant was made aware but no new orders were given. Although this was substantiated during the survey, no documentation was entered into the medical record regarding the 12/31 patient elopement from the unit. Even after this successful elopement, no changes were made in patient #1's plan of care and he was not placed on an increased level of observation despite his known risk. No documented investigation on how the patient was able to leave the unit was found, nor was any hospital plan to prevent not only this patient but other patients from eloping from the unit.

On 01/02/2010, patient #1 eloped a second time from the locked Traumatic Brain Injury Unit. The timeline of events on 01/02 are as follows:

At 9:00 am the patient was assessed by the nurse.
At 10:00 am per the nursing noted the patient received his medications without adverse reaction.
At 10:50 am per the hospital surveillance camera, the patient was seen in the executive hallway.
At 10:52 am per the surveillance camera, the patient went up in the elevator.
At 10:55 am per the surveillance camera, the patient was seen for the last time in the executive hallway.
At 12:10 pm per the nursing note the "writer noted the patient was not in the dining room, search unit, notified the charge nurse, searched the unit again, supervisor and security called and notified. 911 called, family notified." However, the security log showed that a code gray (Code to indicate a missing person) was not called unit 1241, nearly 2 hours after security cameras show patient #1 had left the unit; and the same log showed that the police were not contacted until 1327.
At 12:41 the security log showed that a code gray was called by the nurse coordinator.
At 1:27 pm per the security log the Baltimore City Police were called.
At 5:00 pm per the security log Baltimore City Police dispatched again.
At 9:14 pm per the security log the patient was located at Mercy Hospital Emergency Room.
At 9:41 pm per the security log the patient was returned to the hospital by family.

The hospital failed to maintain a safe environment of care when (1) the patient was identified as an elopement risk but was not maintained on precautions; (2) the hospital failed to have any policies or procedures defining observation levels for patients at risk for elopement; (3) the hospital failed to change patient #1's treatment plan after his 12/31 elopement from the unit; (4) the hospital failed to address any environmental risks to identify how patient #1 was able to elope, following the 12/31 elopement; and (5) following patient #1's second elopement on 01/02, staff failed to recognize he was missing for more than an hour and failed to initiate a code to look for him for nearly two hours.

A vulnerable patient #1 eloped from the hospital on 01/02/2010 wearing pajama pants, a tee shirt and sneakers. The National Weather Service reported that it was windy with a high temperature in Baltimore that day of only 29 degrees. The failure to maintain a safe environment of care could have led to serious harm and possible death.

Based on review of the medical record, policies and procedures, patient and staff interviews, observations and other pertinent documentation, the hospital failed to ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient.

Patient #1 whose diagnosed with traumatic brain injury eloped from a locked unit two times within 48 hours. After the first elopement on 12/31/09 from a locked unit to another floor as noted in A0144, the hospital failed to document the elopement anywhere in the medical record, failed to initiate any actions to deter the patient from eloping again and failed to change the patient's care plan. Due to this failure to initiate care plan changes and corrective measures to protect patient #1, he was able to again elope on 01/02/10 and was located in another hospital's ED more than nine hours later.

Patient #1 is a 47 year old male admitted to University Specialty Hospital on 12/1/09 from Kernan Orthopaedic & Rehabilitation Hospital. The patient was struck by a motor vehicle while riding a bicycle on October 18. 2009 and was has diagnosed with Traumatic Brain Injury, Anoxic Brain Injury, fractures of the face, ribs and scapula. The patient's other diagnoses included dysphagia, left hemiparesis, bilateral pneumothoraces, gait dysfunction and PEG tube. The patient by history has been blind in the left eye since birth. The patient was admitted to University Specialty Hospital for physical and occupational therapy with gait training. Additionally patient was to be evaluated and treated for cognitive and attention span deficits. There is documentation in the medical record that the patient frequently wanders in and out of rooms and needs constant redirection away from the exit doors. Patient # 1 had significant physical and cognitive limitations that made it extremely unsafe for him to leave the locked unit without supervision.

At 1500 on 12/31/09 the patient eloped from the unit. The patient was found wandering on the third floor by another staff and was brought back to the locked unit. The physician assistant was made aware but no new orders were given. Although this was substantiated during the survey, no documentation was entered into the medical record regarding the 12/31 patient elopement from the unit. Even after this successful elopement from the unit, no changes were made in patient #1's plan of care and he was not placed on an increased level of observation despite his known risk. No documented investigation on how the patient was able to leave the unit was found, nor was any hospital plan to prevent not only this patient but other patients from eloping from the unit.

Due to the failure to update the patient's care plan or to initiate corrective measures, patient #1 was able to again elope on 01/02/10. The patient #1 eloped from the hospital on 01/02/2009 wearing pajama pants, a tee shirt, and sneakers. The National Weather Service reported that it was windy with a high temperature in Baltimore that day of only 29 degrees. The patient was found in another hospital's ED unharmed nine hours later.