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Based on medical record review, document review and interview, the facility failed to protect a patient at risk for elopement. Specifically, the facility failed to conduct a patient assessment for risk of elopement, identify a patient at risk for elopement, and implement preventive measures to prevent elopement. This finding was identified in one (1) of eight (8) medical records reviewed. (Patient #1).

This failure may result in serious adverse outcome to patients at risk for elopement.


Findings include:

Review of the medical record for Patient #1 identified: a 62-year-old male who was brought to the Emergency Department (ED) by FDNY Emergency Medical Service (EMS) on 6/6/2022 at 9:27 AM. At 9:31 AM, the patient was triaged, and the nurse documented the patient had history of psychiatric disorder and dementia. The patient's current medications included Seroquel (Antipsychotic) and Trazodone (Antidepressant). Suicide Risk Screen - patient was not positive for suicide risk.

There was no documented evidence the patient was assessed for the risk for elopement.

At 10:09 AM, 38 minutes after triage, the nurse documented that the patient left without physician evaluation and eloped.

See Tag A 0144

Based on medical record review, document review, and interview, the facility failed to protect patients at risk for elopement. Specifically, the facility failed to evaluate patients for risk of elopement, identify patients at risk for elopement, and implement appropriate preventive measures. This finding was identified in one (1) of eight (8) medical records reviewed. (Patient #1).

This failure resulted in a patient elopement from the facility.


Findings include:

Review of the facility's policy and procedure on "Elopement," last reviewed on 2/28/2022, revealed procedures/guidelines are as follows:

"A. Elopement Assessment.
- All patients will be assessed for the risk for elopement at the following times: During Emergency Department (ED) evaluation, at time of triage.

- Assessment for elopement includes, but not limited to, evaluation of history of elopement, physical or mental impairments that increase their risk for harm to self or others, and cognitive abilities for the patient to understand the reason to remain in treatment for the duration of time needed.

C. In the event of patient elopement:
1. Nursing
a. Assigned unit staff will immediately conduct a thorough search of the entire unit including but not limited to patient rooms, bathrooms, clean and soiled utility rooms...The above information will be communicated to security and documented as part of the incident report if patient is not found on the unit.

b. When the patient is determined missing: Staff will Activate Code E immediately by calling *22 and reporting the location. The following notification and action steps will be followed:
-Notify Security...
-Notify the Nursing Leader.
-Notify the Physician.
-The Nursing Supervisor will ensure that the elopement is communicated to the patient's attending physician.
-The nurse leader or designee will notify Risk Management Dept.
-The Nurse Supervisor and Security Personnel will collaborate to determine whether New York Police Department (NYPD) needs to be notified. However, if it is determined that the patient has left the facility the NYPD will be notified immediately.

2. Attending Physician
Once the patient is confirmed missing, the attending physician or designee must advise the patient's next of kin or emergency contact as soon as possible that the patient is missing. If the patient should return home, the next of kin or anyone with presumed knowledge of the patient's location after elopement will be advised to call the hospital for assistance with returning the patient. If the patient is a resident of a skilled nursing facility or Adult Home, the facility must be notified of the patient's missing status. Contact information must be left in the event the patient arrives.

7. Documentation Requirements:
a. The nurse must complete an occurrence report and inputs Elopement. The occurrence report should include the date, and time patient last seen, time Code E was activated, notification of supervisor. The patient record should include condition of patient when last seen, contact of patient family, and (include name and relationship). If patient is a resident of a facility, document the name and title of person notified of elopement, provide contact information in case the patient arrives at the facility.
b. The identification information (badge #, precinct information, and name of NYPD officer) should be recorded if contacted."


Review of the medical record for Patient #1 identified: a 62-year-old male was brought to the ED by NYPD Emergency Medical Services (EMS) on 6/6/2022 at 9:27 AM. The patient was brought to the ED from a nursing home facility.
At 9:31 AM, the patient was triaged, and the nurse documented, chief complaints were agitation and behavioral issues, for psych evaluation. Patient had history of psychiatric disorder and dementia. The patient's medication included Seroquel and Trazodone. Suicide Risk Screen - patient was not positive for suicide risk.
At 10:09 AM, thirty-eight (38) minutes after triage, the nurse documented that the patient left without physician evaluation and eloped.

Review of the Nursing Home Transfer Record dated 6/6/2022, documented the patient had risk alerts as, high risk for elopement/wandering and wander guard (highlighted with asterisk. A wander guard is a monitoring alarm device attach to a patient identified with elopement risk. The device triggers the alarms and locks monitored doors when a patient approaches a monitored door thereby alerts staff and prevent wander-prone residents from elopement.) The patient had previous medical history of psychiatric disorder and dementia, of which patient was on medications.

As per review of the Pre-Hospital Care Report Summary by FDNY EMS, dated 6/6/2022, report documented patient information including patient from a facility, and with previous medical history of substance abuse, psychiatric problems, and hypertension. The patient was on current medications of Lisinopril (treats hypertension), Trazodone (antidepressant), Seroquel (antipsychotic), and Metformin (antidiabetic). Narrative Summary revealed patient was found on scene ambulatory. Staff reported the patient was acting verbally aggressive and staff wanted patient to be evaluated for psych.

There was no documented evidence in the medical record the patient was assessed for risk for elopement, identified at risk for elopement, and preventive measures implemented to prevent the elopement.

When the nurse documented on 6/6/2002, at 10:09 AM, thirty-eight (38) minutes after triage, that the patient left without physician evaluation and eloped, staff did not immediately conduct a search as per facility's policy.

Elopement Code E was not activated when the patient was determined missing/eloped.
Elopement event was not reported and escalated as per policy.
The nursing home next of kin was not notified of the patient's elopement.

The hospital staff realized the patient eloped, after a nursing home staff called the facility's ED on 6/7/2022 for an update of their resident.

Video Surveillance review on 8/1/2022 at 10:19 AM, confirmed Patient #1 was observed leaving the facility's ambulance entrance doors to the street on 6/6/2022 at 9:56 AM.


During interview with Staff C, ED Triage Nurse on 7/29/2022 at 11:59 AM, Staff C stated no recollection of Patient #1. Staff C was asked when is the elopement process initiated? Staff C stated elopement assessment is done during the secondary triage when the patient is in the Main ED, and not during primary triage in the Triage Room.

During interview with Staff D, ED Nurse Manager on 7/29/2022 at 12:34 PM, Staff D validated findings for Patient #1: there was no documented evidence of elopement risk assessment, patient not identified at risk for elopement, and preventive measures to prevent elopement were not implemented. Elopement code was not activated when the patient eloped, and elopement event was not reported and escalated in accordance with the facility's policy on elopement.

Staff D stated the facility had no knowledge of the patient's whereabouts.

During interview with Staff E, ED Director of Nursing on 7/29/2022 at 12:34 PM, Staff E stated after the nursing home called, day after the patient eloped on 6/7/2022, did not provide the time, they reviewed the medical record with not much written, watched the video surveillance, and saw Patient #1 left the facility. Staff E stated she notified Risk Management and spoke with the Director of Nursing in the nursing home who was upset. Staff E informed the Director of Nursing the Police was notified and had not updated the facility of the patient's status.

As of the date of survey, the facility staff was unable to provide information on the patient's status and whereabouts.

A root cause analysis (RCA) was not done, and preventative measures were not implemented to prevent this from happening again.

These concerns were acknowledged by Staff M, Director of Quality and Staff N, Manager, Quality Management on 8/1/2022 at 11:30 AM.



On 8/3/2022 at 2:05 PM, an Immediate Jeopardy (IJ) situation was announced due to the facility's failure to identify and protect patients at risk for elopement.

The facility provided an IJ Removal Plan to survey staff on 8/3/2022 at 7:50 PM.

The plan included:
-The Elopement Risk Assessment was placed in the primary triage assessment in Meditech (Electronic Medical Record system) and the Elopement Policy (Effective 8/3/2022) was updated to reflect this change. Based on this change, patients entering the ED will be triaged, assessed, and identified for risk for elopement at primary triage assessment.

-Education of all ED staff on this change in process, will be on-going until all identified staff are educated. Staff will not be allowed to work until education has been completed.

-In the event a patient elopes, the procedures outlined in the Elopement Policy go into effect immediately, including proper notification, escalation, and documentation. Re-education of the Elopement Policy began on July 29, 2022 and will be ongoing. This will include Patient Care Services (Nursing), Physicians, Registration, Security, and other departments providing services within the ED. Staff will not be allowed to work until education has been completed.


On 8/4/2022 at 3:47 PM, the IJ was removed as confirmed by an onsite verification by survey staff.