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Based on record review, and interview, the hospital failed to meet the requirements of the Condition of Participation in Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by failure to ensure care in a safe setting. This deficient practice is evidenced by failure to ensure the emergency system used to call a code related to an elopement was available and functioning at all times potentially leading to injuries in Patient #4. This resulted in an Immediate Jeopardy Situation. S1CVP, S2SD, and S3RM were notified on 04/30/2025 at 2:05 PM.

The hospital provided the following plan of removal for the Immediate jeopardy situation on 05/01/2025:
"Date Notified of Immediate Jeopardy: 04/30/2025
Date Removal Plan Developed: 04/30/2025
Date Removal Plan Initiated: 04/30/2025
Date Removal Plan Fully Implemented or Planned to be Fully Implemented: All operators will be trained to answer the emergency call line (2-5000) immediately per Dr. Flight (Elopement) policy. Each person will be trained prior to their next shift and will not be allowed to work until trained.
The entity's removal plan must: Identify those who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Any PEC/CEC patient attempting to elope.
Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete or was taken.
Immediately a plan was developed by the Chief Operating Officer, the Senior Director of Facilities, Nursing Leadership, and Quality/Patient Safety Leadership on 4/30/2025 to retrain all Operators immediately, and prior to starting their next shift. The senior director of facilities, who oversees the Operators, provided the training as described in the University Medical Center policy Emergency Management 15004 Dr. Flight (Elopement). The Chief Operating Officer is ultimately responsible for the implementation of the training. The Senior Director of Facilities, or his leadership designee, will monitor the training daily.
1. All operators will be trained to answer the emergency call line (2-5000), immediately. Each person will be trained before their next shift and will not be allowed to work until trained.
2. The emergency communication system will be evaluated to ensure proper functionality immediately.
3. The emergency communication system will be reprogrammed so that the 2-5000 emergency line does not roll into a queue. It will ring until answered. This re-programming will be completed immediately.
Process/ System Involved: Maintain a safe environment by ensuring the safety of all patients who are PEC/CEC'd to prevent a potential delay in the communication of the emergency system for calling all codes and auditing compliance.
Factors Involved: Equipment and Human
Other: Individual error/potential delay in answering the 2-5000 line within the first two rings/calls. Potential emergency communications system programming error.
Action(s) Taken/ Planned to be Taken: See above action plan above. The operator on shift will have verbal coaching.
Date Action(s) Taken/ Planned to be Taken: 4/30/2025 at 5:30 pm
Staff Education Plan:
Who: Facilities Leadership When: IJ received at 2:00 PM; training started at 5:30 PM. What: In person- Red Huddle format to train on policy, procedure, and auditing of compliance with signatures of the staff who were educated.
Mode of Education: daily huddle ( X )
Monitoring of Implemented Action(s): Monitoring of answering 2-5000; monitoring to ensure 2-5000 is no longer rolling into the queue.
What will be monitored: Compliance of answering 2-5000; compliance of re-educating operators prior to the next shift.
How long will it be monitored? For three months at 100% compliance; then via the incident reporting process.
Who / What Committee will receive reports - Patient Safety & Quality Committee and the Quality sub committee of the hospital board, who will then report it to the full hospital board.
What is the plan if the action does not meet expectations? If noncompliance is found, the disciplinary policy Health Human Resources will be followed titled HR 404 Code of Conduct.
RCA: Yes."

On 05/01/2025 at 10:30 AM, the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiencies remain at Condition levels (See findings in A-0144).

Based on record review, and interview, the hospital failed to ensure care in a safe setting as evidenced by failure to ensure the emergency system used to call a code related to an elopement was available and functioning at all times potentially leading to traumatic injuries in Patient #4.
Findings:

Review of hospital policy titled "Emergency Management" last revised 09/2023, revealed in part: "Policy Statement: It is the policy of University Medical Center Management Corporation, doing business as University Medical Center New Orleans (UMCNO) to take all appropriate measures necessary to prevent patients committed via a Formal Voluntary Admission (FVA), Physician's Emergency Commitment (PEC), Coroner's Emergency Commitment (CEC) or Judicial Commitment (JC) from leaving the hospital without authorization and to ensure the safe and timely return of patients who leave without authorization. Procedure, in part: Elopement from Hospital: When a patient elopes or cannot be found from a unit/department, the originating unit/department shall initiate the following step and place the patient on an elopement status: i. The staff member with the patient shall call for immediate assistance of co-workers by pressing the "Staff Assist" button on the inpatient bed control panel or verbally alert all staff in the area that the patient has left the assigned area. The staff member shall not physically attempt to detain the patient from leaving but can attempt to verbally redirect the patient. The staff member shall call Communications via 2-5000 and state the following:
i. The unit the patient eloped from
ii. The description of the patient including:
iii. Race
iv. Features (age, sex, height, weight, color of hair)
V. Clothing
vi. Direction of flight
vii.Was the patient dangerous to himself/herself or others.
Elopement Status Notification: When a patient elopes, the following departments will be notified and shall follow the procedure described below:
i. Communications a. It is the responsibility of Communications to overhead page the following information: Calling Dr. Flight to (give originating location).
ii. Hospital Public Safety a. It is the responsibility of Hospital Public Safety (HPS) to: Notify all HPS officers via radio; Disperse to areas surrounding the originating location as well as exits and entrances throughout the facility; Conduct a full search of the hospital premises; Follow HPS policy regarding notification of local law enforcement, if unable to locate the patient.
All UMCNO Staff: a. It is the responsibility of all UMCNO staff to: Monitor all pathways and areas; Attempt to locate any patient that is outside of the patient care area and appears to be fleeing the building; If the patient is identified, call 2-5000 and provide the patient description and location; Do not attempt to engage unless you have completed the Crisis Prevention Intervention (CP|) training and can attempt to de-escalate or redirect patient verbally; and Do not attempt to physically restrain the patient."

Review of hospital document titled "Hospital / Licensed Provider Abuse/Neglect Initial Report" dated 4/15/2025 and documented "Final Report", revealed in part: "Patient #4 was admitted on 04/02/2025 diagnosed with suicide attempt-drug ingestion and eloped from the Cardiology Unit, room 'a', on 04/06/2025 at 12:34 PM. Patient was a 1:1 with an assigned sitter and was CEC'd."

Following was the description of the incident:
"Patient became verbally aggressive with S10PCT. Patient stated to the PCT that she could not keep him here. Sitter along with another PCT followed the patient encouraging him to return to his room. Charge nurse was notified. Staff members kept line of sight with the patient as he ran out of the Galvez Exit. Further review of the incident report revealed at 4:03 PM the patient presented to the ED via NOPD due to being found walking along the side of the road with facial bleeding. He was evaluated and treated for his injuries. The patient was PEC'd, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care. Injuries listed on report included open skull fracture, right pneumothorax, minimally displaced fracture of the right 1st, 2nd, 3rd , 5th, and 10th ribs, displaced fracture of the right mid clavicle, right scapular, fracture of the right transverse process of T6-T8, 2nd - 4th transverse process fractures of L2 - L4. Initial actions taken: Two staff members maintained a visual on the patient from his room to the Galvez exit. They were unable to return the patient to his room. NOPD and family were notified. Upon patient's return to UMC, the patient was PEC'd, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care. Additionally, a RCA was immediately triggered."

Following was video observation:
"Video revealed at 12:33 PM Patient #4 exited the room with the PCT and walked down the hallway. He attempted to open a door and was unsuccessful. He began to walk down the hallway. An additional PCT and a nurse presented and appeared to de-escalate but were unsuccessful. Patient #4 continued to walk down the hallway with the two PCTs following closely behind him. He exited the unit and attempted to open double doors leading to Tower 'T' but was unsuccessful. He turned around and took the elevator. The two PCTs remained with him. At 12:35 PM, he exited the elevator on the first floor. Patient #4 walked down the hallway and turned right toward street 'G'. The patient began to run down the hallway toward street 'G' with the PCTs following him. He exited the street 'G' entrance. Patient #4 then ran out the door toward street 'C'. Two PCTs and an Allied Officer exit and stop at the entrance, maintaining visual contact. Notifications: Police agency 'N' notified at 12:45 PM. Mother notified at 1:00 PM and physician notified at 1:06 PM. Further notifications in part: On 4/6/25 at 12:34 PM S12CN; 12:36 PM S13HS; and 1:09 PM S15ND. Comments: On 4/2/2025, patient presented to the ED via EMS with a potential intentional overdose. The patient was intubated and sedated. He was transferred to MICU. He had a history of Bipolar Disorder, anxiety, and panic disorder. On 4/4/2025 he was extubated and placed on a PEC at 11:09 AM.
On 4/4/2025 Psychiatry completed their consult and noted once patient is medically cleared he would need psychiatric admission for suicide attempt. On 4/5/2025 psychiatry noted that patient understands he may need inpatient admission after he is medically stable. The patient denied suicide ideation. On 4/6/2025 patient was placed on a lower aquity level of care and assigned a sitter for 1:1 observation. On 4/6/2025 at 9:50 AM, S12CN noted that the patient stated, "he doesn't want to go to jail because he has done horrible things." S12CN was able to de-escalate and reassure the patient that they are here to help him. He appeared to be reassured. On 4/6/2025 at 10:40 AM, per physician order, patient was given Vistaril. On 4/6/2025 at 11:40 AM, psychiatry was at the bedside and noted the patient stated he has trouble focusing and concentrating. On 4/6/2025 at approximately 12:35 PM, as stated previously, he eloped.
On 4/6/2025 at 4:02 PM patient presented to UMC via EMS. Agency "N" found the patient walking along the side the road with facial bleeding. He was evaluated and treated for his injuries. The patient was PEC'd, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care."

The report documented that upon investigation, it was determined that "staff reacted appropriately by maintaining a visual and following the patient closely. Once the patient exited the elevator, he began running toward the street 'G' entrance. Hospital Police Security (HPS) and the House Supervisor were notified. HPS notified agency 'N'. The Quality Department will continue to investigate this matter in order to identify whether there are opportunities for improvement."

Investigation Results concluded: "We do not substantiate the allegation. We consider this our final report."

Review of S12CN's Nursing Note Addendum for Patient #4, dated 4/6/2025 at 12:33 PM, revealed the following:
"Patient #4 expressed to the sitter at the doorway if he could leave. She explained that he couldn't and he pushed past her and went down the hall to the right looking for the elevator. S12CN attempted to call a doctor flight (Elopement) using the emergency number 2-5000. There was no answer after 2 calls. On the 3rd call the phone rolled over to the operator, S14OP, and he called a doctor flight (Elopement). The patient then circled back and went past his room and kept going with the sitter and PCT following him. As stated by the sitter, the patient got on the elevator to the first floor, he headed to the street 'G' entrance and took off running. S12CN met hospital police and the house supervisor at the entrance to the unit and told them that the sitter had informed that the patient was headed to the street 'G' entrance. Both left the unit to assess situation.
12:45 PM-Attempted to contact primary team. No answer.
12:55 PM-Attempted to contact primary team. No answer.
1:06 PM-Notified S16MD via secure chat that patient had eloped.
1:06 PM- S16MD responded via secure chat, 'Wow, thanks for letting me know'."

Review of Patient #4's trauma note dated 4/6/2025 at 4:02 PM (the elopement occured on 04/06/2025 at approximately 12:35 PM) revealed: "Patient #4 presented to emergency room found by agency 'N' walking along the side of the road with facial bleeding. Per report, Patient escaped from UMC behavioral health earlier today and was trying to jump in front of cars. Patient arrived with dried blood around avulsion to right forehead. Found to have right clavicle fracture, possible bowel contusion, right 2nd through 4th transverse process fractures. Right hemopneumothorax, pulmonary contusions, fracture of the right scapular, fractures of the right 2nd, 3rd, and left ribs and displaced fractures of right 5th through 10th ribs and right transverse processes of T6-T8. Right anterior frontal/temporal bone fracture extending into the skull base. Comminuted right lateral orbital wall fracture with proptosis. Right anterior frontal/temporal bone fracture extending the skull base with hemorrhage. Found to have skull fracture and intracranial findings."

Review of ED Trauma Activation Note dated 4/6/2025 at 4:29 PM (the elopement occured on 04/06/2025 at approximately 12:35 PM) revealed: "Patient #4 presented to the emergency department via EMS after being found on the streets with concerns for blunt trauma. EMS reports that patient was found near the hospital with obvious wound to his head, was confused and there was concern for blunt trauma. Presented with obvious head trauma and decreased mental status. Patient was found wandering around by police and noted to have obvious laceration to forehead, was brought to ED as trauma activation. Large right-sided scalp laceration with exposed skull. Patient agitated and requiring both chemical and physical restraints in order to facility necessary care and prevent self-harm and harm to others."

Review of Patient #4's Neurosurgery consult note dated 4/6/2025 at 6:13 PM (the elopement occured on 04/06/2025 at approximately 12:35 PM) revealed: "Patient #4 presented to emergency department after jumping in front of a car. He escaped from UMC's behavioral health unit earlier today."

Review of Psychiatry Consult for Patient #4 dated 04/06/2025 at 7:20 PM (the elopement occured on 04/06/2025 at approximately 12:35 PM) revealed: "adult with past psychiatric history of anxiety and bipolar disorder who presents after jumping in front of car. Patient most recently eloped from UMC while on a PEC. Per S12CN at 12:33 PM on 4/6/2025 she attempted to call a doctor flight (Elopement) using the emergency number 2-5000. There was no answer after 2 calls. On the 3rd call, the phone rolled over to the operator who called a doctor flight (Elopement)."

During an interview on 04/30/2025 at 8:53 AM, S12CN stated she was Patient #4's nurse on 04/06/2025 starting at 7:00 AM. He had come to unit 'A' sometime between 12:00 AM and 6:00 AM, probably around 2:00 AM. He was sent to unit 'A' because there was an open bed, not because he was a cardiology patient. S12CN reported Patient #4 would not speak at first then he started talking. He had locked himself in bathroom on the morning of the 6th and was asking to see psychiatry. He was CEC'd around 11:33 AM. He did not come out of his room until 12:33 PM. Patient #4 asked the sitter if he tried to leave would she stop him. The sitter told him he could not leave. S12CN then tried to call the emergency line and no one answered until the 3rd time when the call rolled over to the operator. By the time of the third call, he was already on the elevator.

During an interview on 04/30/2025 at 10:31 AM, S2SD reported the staff should call dispatch and not the emergency number but the process was not yet implemented.

During an interview on 05/01/2025 between 9:52 AM-10:02 AM, S17SG with agency 'S' stated the doctor flight (Elopement) call was late and she saw the patient in purple scrubs running towards the street 'G' entrance before the call came through. She could hear staff running behind the patient trying to stop him and knew it was an elopement. She reported she then got up from her chair near the door but he was already going out the door. She stated her walkie-talkie was not working that day and she had to use the phone to call it in to headquarters. She said as she was on the phone with them she could hear a lady in the background trying to get the doctor flight (Elopement) called. She said she had to decide if she was going to follow him or call it in but they had been trained not to chase the eloping patients because they could run out into traffic and get hit so she went to the house phone to call it in.

In interview on 04/30/2025 at 11:45 AM, S3RM verified that the facility had just finished its root cause analysis and had not implimented any changes as a result of the investigation into the event. S3RM also verified their investigation revealed only one call was made to the operator.

In interview on 04/30/2025 at 2:00 PM, S1CVP stated that there was no delay in the hospital's response to the elopment.

In interview on 05/01/2025 at 9:42 AM, S1CVP verified the facility did not have a record of calls missed by operator, and it was not possible to know how many calls were made if the nurse hung up after 2 rings because she did not want the call to go to the bottom of the operator call que.

In interview on 04/30/2025 at 10:35 AM, S3RM verified that she had spoken to the security supervisor and he indicated that the walkie talkie was working properly, but that S17SG need to be educated on areas of the hospital where the walkie talkies do not work.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to accurately document, fully investigate and identify safety issues related to the emergency call system following the elopement of suicidal Patient #4 that potentially led to traumatic injuries.
Findings:

Review of hospital document titled "Hospital / Licensed Provider Abuse/Neglect Initial Report" dated 4/15/2025 and documented "Final Report", revealed in part: "Patient #4 was admitted on 04/02/2025 diagnosed with suicide attempt-drug ingestion and eloped from unit 'A', room 'a' on 04/06/2025 at 12:34 PM. Patient was a 1:1 with an assigned sitter and was CEC'd."

Following was the description of the incident: "Patient became verbally aggressive with S10PCT. Patient stated to the PCT that she could not keep him here. Sitter along with another PCT followed the patient encouraging him to return to his room. Charge nurse was notified. Staff members kept line of sight with the patient as he ran out of the Galvez Exit. On 04/06/2025 at 4:03 PM, the patient presented to the ED via NOPD due to being found walking along the side of the road with facial bleeding. He was evaluated and treated for his injuries. The patient was PEC'd, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care."

Injuries listed on report: "Open skull fracture, right pneumothorax, minimally displaced fracture of the right 1st, 2nd, 3rd , 5th, and 10th ribs, displaced fracture of the right mid clavicle, right scapular, fracture of the right transverse process of T6-T8, 2nd - 4th transverse process fractures of L2 - L4."

Following were the initial actions taken: "Two staff members maintained a visual on the patient from his room to the Galvez exit. They were unable to return the patient to his room. NOPD and family were notified. Upon patient's return to UMC, the patient was PEC'd, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care. Additionally, a RCA was immediately triggered."

Following was video observation: "Video revealed at 12:33 PM the patient exited the room with the PCT and walked down the hallway. He attempted to open a door and was unsuccessful. He began to walk down the hallway. An additional PCT and a nurse presented and appeared to de-escalate but were unsuccessful. The patient continued to walk down the hallway with the two PCTs following closely behind him. He exited the unit and attempted to open double doors leading to Tower 'T' but was unsuccessful. He turned around and took the elevator. The two PCTs remained with him. At 12:35 PM, he exited the elevator on the first floor. He walked down the hallway and turned right toward street 'G'. The patient began to run down the hallway toward street 'G' with the PCTs following him. He exited the street 'G' entrance. He then ran out the door toward street 'C'. Two PCTs and an Allied Officer exit and stop at the entrance, maintaining visual contact."

Notifications: "Police agency 'N' notified at 12:45 PM. Mother notified at 1:00 PM and physician notified at 1:06 PM. Further notifications in part: On 4/6/25 at 12:34 PM S12CN; 12:36 PM S13HS; and 1:09 PM S15ND."

Comments: "On 4/2/2025, patient presented to the ED via EMS with a potential intentional overdose. The patient was intubated and sedated. He was transferred to MICU. He had a history of Bipolar Disorder, anxiety, and panic disorder.
On 4/4/2025 he was extubated and placed on a PEC at 11:09 AM.
On 4/4/2025 Psychiatry completed their consult and noted once patient is medically cleared he would need psychiatric admission for suicide attempt.
On 4/5/2025 psychiatry noted that patient understands he may need inpatient admission after he is medically stable. The patient denied suicide ideation.
On 4/6/2025 patient was stepped down and assigned a sitter for 1:1 observation.
On 4/6/2025 at 9:50 AM, S12CN noted that the patient stated, "he doesn't want to go to jail because he has done horrible things." S12CN was able to de-escalate and reassure the patient that they are here to help him. He appeared to be reassured.
On 4/6/2025 at 10:40 AM, per physician order, patient was given Vistaril.
On 4/6/2025 at 11:40 AM, psychiatry was at the bedside and noted the patient stated he has trouble focusing and concentrating.
On 4/6/2025 at approximately 12:35 PM, as stated previously, he eloped.
On 4/6/2025 at 4:02 PM patient presented to UMC via EMS. Agency "N" found the patient walking along the side the road with facial bleeding. He was evaluated and treated for his injuries. The patient was PEC'd, assigned a sitter for 1:1 observation, and admitted to TICU for further evaluation and care."

Further review of the report revealed upon investigation, it was determined that "staff reacted appropriately by maintaining a visual and following the patient closely. Once the patient exited the elevator, he began running toward the street 'G' entrance. Hospital Police Security (HPS) and the House Supervisor were notified. HPS notified agency 'N'. The Quality Department will continue to investigate this matter in order to identify whether there are opportunities for improvement."

Investigation Results revealed the following: "We do not substantiate the allegation. We consider this our final report."

Review of S12CN's Nursing Note Addendum for Patient #4 , dated 4/6/2025 at 12:33 PM, revealed the following in part: "Patient #4 expressed to the sitter at the doorway if he could leave. She explained that he couldn't and he pushed past her and went down the hall to the right looking for the elevator.
S12CN attempted to call a doctor flight using the emergency number 2-5000.
There was no answer after 2 calls. On the 3rd call the phone rolled over to the operator, S14OP, and he called a doctor flight. 12:45 PM-Attempted to contact primary team. No answer. 12:55 PM-Attempted to contact primary team. No answer."

During an interview on 04/30/2025 at 8:53 AM, S12CN stated in part: Patient #4 asked the sitter if he tried to leave would she stop him. The sitter told him he could not leave. S12CN then tried to call the emergency line and no one answered until the 3rd time when the call rolled over to the operator. By the time of the third call, he was already on the elevator.

During an interview on 05/01/2025 between 9:52 AM-10:02 AM, S17SG with agency 'S' stated the doctor flight call was late and that she saw the patient in purple scrubs running towards the street 'G' entrance before the call came through. She could hear staff running behind the patient trying to stop him and knew it was an elopement. She reported she then got up from her chair near the door but he was already going out the door. She stated her walkie-talkie was not working that day and she had to use the phone to call it in to headquarters. She said as she was on the phone with them, she could hear a lady in the background trying to get the doctor flight called. She indicated she had to decide if she was going to follow him or call it in but they had been trained not to chase the eloping patients because they could run out into traffic and get hit so she went to the house phone to call it in.

After review of the medical record, interviewing S12CN and S17SG, and review of "Hospital / Licensed Provider Abuse/Neglect Initial Report" dated 4/15/2025 and documented "Final Report", it was determined that the report failed to reveal the nurse had documented in the medical record she had difficulty contacting comunications or the primary team. The report failed to reveal the security officer had a malfunctioning walkie-talkie system. The report failed to reveal the hospital investigated and identified safety issues related to the emergency call system following the elopement of suicidal Patient #4 that potentially led to his traumatic injuries.

In interview on 04/30/2025 at 11:45 AM, S3RM verified that the facility had just finished its root cause analysis and had not implimented any changes as a result of the investigation into the event. S3RM also verified their investigation revealed only one call was made to the operator.

In interview on 04/30/2025 at 2:00 PM, S1CVP stated that there was no delay in the hospital's response to the elopment.

In interview on 05/01/2025 at 9:42 AM, S1CVP verified the facility did not have a record of calls missed by operator, and it was not possible to know how many calls were made if the nurse hung up after 2 rings because she did not want the call to go to the bottom of the operator call que.

In interview on 04/30/2025 at 10:35 AM, S3RM verified that she had spoken to the security supervisor and he indicated that the walkie talkie was working properly , but that S17SG need to be educated on areas of the hospital where the walkie talkies do not work.