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Based on record review and interview, the hospital failed to protect and promote each patient's rights when they failed to ensure a safe environment for 1of 10 patients (patient #1) who had decreased cognition and poor safety judgement, and was at risk for wandering and elopement. Patient #1 eloped from the hospital (left the facility unsupervised) on 5/21/2010. The hospital was unaware of the patient's location until they received a phone call from Patient #1's husband. This failure places the Condition of Participation for Patient Rights out of compliance. See documentation at A 144.

Based on interviews and documentation review, the hospital failed to provide a safe environment for 1 of 10 patients (Patient #1) who was assessed to have decreased cognition and poor safety judgement and was at a risk for wandering and elopement.

Findings include:

Patient #1's medical record revealed that Patient #1 had diagnoses including traumatic brain injury and behavioral dyscontrol. An Integrated Admission Assessment form dated 4/26/2010 documented that patient #1 was oriented to person only, had no limitations with mobility, and had the following behaviors on admission: risk to elope, wandering, restlessness, confusion/disoriented, decreased cognition and unawareness of deficit. Patient #1 resided on unit Four South which is an unlocked unit.

Although her cognition was discussed at the Interdiciplinary Team meeting on 5/19/2010, no communication with staff, or any additional safeguards were implemented to address her safety risks prior to her elopement.

Patient #1 eloped from the facility on 5/21/2010 while awaiting transfer from the therapy department to the nursing unit where patient #1 resided. At the time of elopement, patient #1 had a care plan in place for wandering behavior that included interventions to prevent a patient from leaving an assigned area. These interventions instructed staff to "monitor patient for safety", "intervene when patient begins to leave assigned area", "redirect patient when leaving assigned areas" and "wander guard on patient (unlocked unit)". Patient #1 resided on unit Four South which is an unlocked unit. She also had an elopement care plan that was discontinued on 5/19/2010 by the interdiciplinary care team. There is no documentation in patient #1's chart as to why the care plan was discontinued.

A Focused Review Meeting (no date noted) following the elopement incident, documents that patient #1 walked off of the Physical Medicine floor, and was not utilizing the wanderguard system. It documents that patient #1 had been discussed in weekly rounds, and it was felt the wanderguard was not needed.

Employee (O) stated that staff met for medical and behavioral rounds (two days prior to patient #1's elopement incident (5/19/2010)) and discussed patient #1 's confusion and the need for a wanderguard. She stated that they discussed the use of a wanderguard as a "back up" plan, since Patient #1 was confused, though they determined her to be a minimal risk of elopement.

A review of Patient #1's records for the wanderguard use titled Admitted Person History and Alert Summary indicated that patient #1 had a wanderguard from 5/21/2010 at 4:11 p.m. to her discharge on 5/24/2010 at 2:30 p.m.

The facility has a policy titled Interdisciplinary Care Plan for Brain Injury Services (effective 5/1994 and revised 3/2008) which documents that "the patient's interdiciplinary care plan will be utilized by all personnel involved in the care of that patient." and "all diciplines are responsible to implement the plan developed by the team." The facility did not have a specific policy for the wanderguard system.

Several staff were interviewed during the course of the investigation and inconsistencies were noted in the interviews as to whether patient #1 had a wanderguard in place before the elopement incident.

Employee (D)/Physical Therapy Manager was interviewed on 9/22/2010 at 12:00 p.m., and indicated that she was not aware of patient #1's behavioral plan for the targeted behavior of wandering. She stated patient #1 waited in the "return/transport area of physical medicine" (an unlocked unit) immediately prior to the elopement incident. Employee (D) reported there were no "special processes" in place for monitoring or the transporting of patient #1 while residing in the return/transport area. Employee (D) stated that patient #1 independently walked out of the physical medicine area at 2:04 p.m. At 2:10 p.m. Employee (L)/physical therapist noted that patient #1 was missing. Employee (L) verified that the therapy transport staff did not take her up to her unit, and called the nursing unit and was informed patient #1 was not on the unit. At 2:11 p.m. the facility staff initiated the facility protocol for resident elopement.

Employee (L)/Physical Therapist was interviewed on 10/6/2010 at 11:00 a.m. and stated that she was not aware if patient #1 had a wanderguard in place prior to her elopement on 5/21/2010. She stated that patient #1 was waiting in the waiting area to go up to her unit following therapy, and she was not aware if she was an elopement risk.

Employee (O)/neuropsychologist was interviewed on 10/27/2010 at 3:36 p.m. and stated that the interdisciplinary team meets weekly, for each patient, to review all 20 targeted behaviors. Employee (O) stated that staff met for medical and behavioral rounds (two days prior to patient #1's elopement incident (5/19/2010)) and discussed patient #1 's confusion and the need for a wanderguard. She stated that they discussed the use of a wanderguard as a "back up" plan, since Patient #1 was confused, though they determined her to be a minimal risk of elopement. Employee (O) wrote the order for the wanderguard on 5/21/2010 after noticing the order was not in patient #1's record (this occurred prior to the elopement incident).

A review of the Interdependent Team Signature Form dated 5/19/2010 documented that representatives from nursing, psychology, physical, occupational, and speech therapies, therapeutic recreation, and spiritual care were present at this meeting.

Employee (G)/LPN was interviewed on 9/22/2010 at 2:40 p.m. and stated that patient #1 had a wanderguard on at the time of the elopement incident. On 10/26/2010 at approximately 10:25 a.m., she was reinterviewed and stated that she was unsure if patient #1 had a wanderguard in place at the time of the elopemnt. She stated that on 5/21/2010, patient #1 was waiting in the therapy department to be brought back to the unit, and "got tired of waiting." Patient #1 left the hospital from the therapy department.

Employee (F)/psychology associate was interviewed on 9/22/2010 at 3:00 p.m. and reported patient #1 was " incredibly confused " and had a wanderguard on prior to the elopement incident.

Employee (A)/RN was interviewed on 10/6/2010 at 10:05 a.m. and stated that patient #1 had a wanderguard on prior to the elopement incident. She stated that the wanderguard order was written when patient #1 was in therapy, and she was unsure if the therapy department received communication regarding this order.

Individual (P)/St Paul Police Officer was interviewed on 10/4/2010 at 2:30 p.m. and stated that the St Paul Police Department did not respond to this report of elopement, and did not pick up or transfer Patient #1 back to the facility. The investigator also contacted capitol police and the metro transit police department who also verifed no knowledge of this incident. Patient #1's medical record did not include any documentation regarding this elopement incident.

Individual (J)/family member was interviewed on 9/27/2010 at 3:20 p.m. and reported that patient #1 "wanted out of there (the hospital) pretty badly". On 5/21/2010, Individual (J) left the facility(unsure of time) and he later received a phone message from the hospital "hoping I knew where she (patient #1) was." Individual (J) then received a cell phone call from patient #1. She stated that she was on Rice Street, at the House of Representatives, at the capitol building. (The capitol building is two blocks south of the hospital, and across University Avenue, which is a busy four lane street.) Individual (J) reported patient #1 ' s whereabouts to the facility. Individual (J) verified that patient #1 did not have a wanderguard in place until after this incident. He stated that she "just wanted to get out of there."

Patient #1 was interviewed on 9/27/2010 at 3:20 p.m. (with her husband present) and stated that she "doesn't remember a thing" about her stay at Bethesda, or the day she left the facility. She stated that she is still having difficulty remembering things.