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Based on interview, record review, policy review and video review, the hospital failed to provide care in a safe setting when they failed to follow their internal policy for patients requesting to leave Against Medical Advice (AMA), when one patient (#7) was allowed to sign out AMA without physician notification, crawled out into highway traffic and died. (A-0144)

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation (CoP): Patient's Rights.

Based on interview, record review, policy review and video review, the hospital failed to provide care in a safe setting when they failed to follow their internal policy for patients requesting to leave Against Medical Advice (AMA), when one patient (#7) was allowed to sign out AMA without physician notification, crawled out into highway traffic and died.
Findings Include:
Review of Patient #7's medical record showed:
- She was a 62-year-old female admitted on 07/12/25 for altered mental status (AMS, mental functioning ranging from slight confusion to coma).
- At the time of her admission she was alert and oriented (A&O) to only her person and the time. She could not recall what led up to her hospitalization.
- She was determined to be an elopement risk and was placed with a one-to-one (1:1, continuous visual contact with close physical proximity) sitter.
- On 07/12/25, a Neurology (a branch of medicine concerned with the study and treatment of disorders of the nervous system) Consult Note showed the patient's electroencephalography (EEG, a recording of brain activity, often used to evaluate presence of seizure activity), Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) and computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) testing, resulted in no acute findings. The neurologist documented it was possible this was the patient's baseline cognitive level, and that the patient's confusion was "likely due to multiple medical/metabolic derangements and medication effects."
- On 07/13/25, a Psychiatry (branch of medicine concerned with the study of mental health disorders) Consult showed that she scored an eight out of 30 on the Saint Louis University Mental Status (SLUMS, an assessment tool for mild cognitive impairment and dementia. Score of 27-30 is normal, 21-26 suggests mild neurocognitive disorder, and 20 or below indicates dementia) assessment tool. The primary concern was neurocognitive, and she did not meet criteria for inpatient psychiatric care. She did not have capacity for medical decision making. The psychiatrist documented that the "patient would benefit from appointing a surrogate medical decision maker, a medical durable power of attorney for health care (DPOA, a legal document that lets a person name someone else to make decisions about their health care in case they were not able to make those decisions themselves)" as the patient was refusing medications to help with agitation and AMS.
- On 07/13/25 at 5:25 PM, a Nursing Progress Note showed the patient's 1:1 sitter reported that the patient was pacing, looking for her keys and getting ready to leave. The nurse documented, "the patient is A&O to name and time and is unable to safely leave and make decisions for herself." Shortly after 6:00 PM the patient left her room and attempted to elope. The sitter walked along with her so she would remain safe and attempted to re-direct her, which did not work and made the patient more upset. The patient insisted she needed to pick up her grandkids. The patient spoke with her daughter on the phone and when her daughter said she wasn't coming, the patient stated she would take the bus instead. Security was notified, and after redirection and medication the patient was calmer.
- On 07/14/25, a Physician Progress note showed the patient still had some confusion, but was medically stable, and needed long-term facility placement.
- On 07/14/25, a Neurology Progress note showed the patient's AMS was likely "toxic metabolic encephalopathy (a disease in which the functioning of the brain is affected by an illness or organs that are not working as well as they should, such as with a viral infection or toxins in the blood) secondary to a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) which had resolved."
- On 07/14/25, a Social Services Consult Note showed the patient needed nursing home placement. The Social Worker (SW) sent out seven referrals for placement.
- On 07/15/25 at 11:22 AM, a Social Service Resource Note showed the SW spoke with the patient's daughter who expressed that the family was unsure if they would like to proceed with nursing home placement or if they wanted the patient return home. "SW made her aware the patient is stable for discharge, and requested she have further discussion with family today, and have a final answer regarding possible home discharge."
- On 07/15/25 at 3:13 PM, a Care Coordination Progress Note showed the patient's son stated that the family was wanting to take the patient home, and they were working on arrangements. Her expected discharge date was 07/16/25.
- On 07/15/25 at 7:35 PM, a Nursing Progress Note showed the "patient comes down to desk, followed by sitter and states she is leaving AMA. Patient is A&O times four, able to state name, birthdate, location, situation and time. Papers signed by patient, and she ambulated out of the hospital."
- On 07/15/25 at 7:37 PM, an internal electronic health record (EHR) chat conversation showed Staff N, Charge Nurse, sent the night shift Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients) a message that stated that the patient "signed AMA papers, was assessed and she is A&O x four. Aware of situation, time and location. Insisted on leaving. FYI." The hospitalist responded, "ok."
- On 07/16/25, 10:19 AM, a Discharge Summary documented by the patient's primary physician showed, "patient was allowed to leave AMA by charge nurse despite sitter being at patient's bedside and the fact that patient is not able to make her own decisions, per psych. I was not notified either."

Review of the hospital's policy titled, "Patient Leaving Against Medical Advice, Leaving Before Being Evaluated or Discharged, Patient Elopement and Abduction," dated 10/03/23, showed:
- Patients identified as an elopement risk would not be permitted to leave the
unit without a staff member.
- If a patient expressed a desire to leave, the nurse was to contact the provider caring for the patient immediately and encourage the patient to stay until they speak to, or were evaluated by, the provider.
- The provider, or staff, should attempt to inform the patient of the risks associated with refusing examination or treatment or leaving the healthcare facility AMA.
- Patients had the right to leave the healthcare facility at their discretion unless the patient had a cognitive impairment that resulted in the patient's inability to care for their basic physical needs.

Review of the hospital's policy titled, "Continuous Observation for Patient Safety: Use of Patient Safety Assistant or Tele Sitter," dated 04/10/25, showed:
- The primary staff nurse was expected to provide a report to the Patient Safety Assistants (PSA).
- The PSA was expected to verbally redirect patients, as warranted, and utilize appropriate redirection/de-escalation techniques, relevant to the patient specific situations. They would receive a hand-off from the off-going PSA at the start of a shift, and from the nurse/charge nurse every shift. They would notify the bedside team of any abnormal findings, observations and/or safety concerns.
- The nurse would assess for the following risk factors for discontinuation; patient was able/willing to follow safety instructions, patient no longer had a medical or behavioral need for continuous observation and patient was no longer a wandering or elopement risk.

During an interview on 07/23/25, at 11:20 AM, Staff J, Registered Nurse (RN) Case Manager, stated that she spoke with the patient's daughter, whom the patient lived with, as well as the patient's son, to determine what the patient's baseline cognition was. They reported that she had been confused for more than a year but at the time of admission her confusion was worse than it had ever been. On 07/14/25, after speaking with the daughter during the initial assessment, she agreed to nursing home placement, but later during an interdisciplinary team meeting, she learned that the son wanted to take the patient home. During that meeting, they also heard from the psychiatrist, who felt the patient would benefit from having a DPOA. She did not speak to the patient's family again but, "that was to be discussed with the patient's daughter or son on the 15th, however, no one was able to reach them."

During an interview on 07/23/25, at 10:50 AM, Staff I, Master of Social Work (MSW), stated that on 07/15/25, she spoke with the patient's daughter, who stated the family was still unsure about taking the patient home, or proceeding with nursing home placement. Staff I explained that the patient was medically stable, and that the family needed to decide about discharge. She had called the patient's son "a couple of times, with no answer, and no option to leave a voicemail."

During a telephone interview on 07/23/25 at 10:10 AM, Staff H, Clinical Partner (CP), stated that he was Patient #7's sitter during day shift on 07/15/25. He had been assigned to her previously and was familiar with her. He stated that the first day he was her sitter, on 07/12/25, she was confused, would repeatedly ask the same questions and was always saying she needed to get home to her grandchildren. During the day on 07/15/25, the patient's cousin came to visit and brought the patient flowers. She was slightly confused, and slept on and off, but became more confused as the afternoon when on. In the early afternoon hours, she put on her shoes, then looked in her purse and pulled out a spoon. She attempted to leave the room and said that she needed to get to the kitchen to clean the dishes. He was able to redirect her. He stated he reported that incident to the day shift nurse. At the end of his shift Staff F, Patient Care Technician (PCT), was taking his place. During report he told her that the patient was pleasant but was possibly becoming more confused and explained "the spoon incident" to her.

During a telephone interview on 07/23/25, at 9:45 AM, Staff F, PCT, stated that she was Patient #7's sitter during evening shift on 07/15/25. It was the first time she had been the sitter for this patient. She received report from Staff H, CP, and was told the patient had a sitter for safety. Staff H did not elaborate any further. When she walked into Patient #7's room she was packing her bags. The patient stated, "she had to get home because she had a granddaughter with a disability." She had on a blue paper scrub shirt, with a cardigan sweater over top, and pants on. The patient left her room and walked to the nurse's station. At the nurse's station she told Staff N, Charge RN, that the patient was wanting to leave. Staff N grabbed an AMA form and "told me she had the patient. She said she would call and let me know where I was floating to next."

During the hospital's telephone interview on 07/17/25, at 11:22 AM, Staff N, Charge RN, stated that at 7:30 PM the sitter was behind the patient, who expressed intent to leave AMA. She assessed the patient's orientation, and her responses were appropriate. The patient claimed a car was waiting for her. She proceeded with the AMA as she felt she was unable to stop the patient. No bus pass was provided to the patient, as the unit did not stock them. The patient was given, and signed, the AMA form after reading it. She contacted the hospitalist, via secure chat, after the patient left and received an "ok" response. She attempted to contact both the patient's son and daughter but there was no answer. She informed the House Supervisor of the patient's discharge. She did not review the note from 07/13/25 indicating the patient's incompetence. She was unaware of any notes that the patient was incompetent. She stated there was no mention of that during the handoff report she received from the off-going shift nurse. She reported having difficulty reviewing charts, due to her workload, and typically didn't have time to access patient charts until midnight.

Review of the hospital's video footage, dated 07/15/25, showed:
- At 7:30:50 PM, Patient #7 walked toward and entered the sixth-floor elevator. She proceeded to the main lobby and exited out the main lobby entrance at 7:32:41 PM.
- From 7:32:46 PM through 7:37:02 PM, she walked toward the main road, onto the sidewalk and proceeded past parking lots four and five.
- At 7:38:00 PM, she walked back across the main road, into parking lot six, and continued through parking lot six, toward parking lot seven.
- From 7:41:01 PM through 7:41:45 PM, she was speaking to someone in their car, in parking lot seven. She then proceeded north toward parking lot eight. (Staff M, Regulatory Specialist, stated the hospital conducted an interview with the person in the car, who was a hospital employee, and Patient #7 had asked them how to get to the bus stop).
- From 7:41:46 PM through 7:46:23 PM, she continued to walk north on the sidewalk along the main road, past parking lots eight, nine and 10.
- At 7:48:12 PM, she exited the sidewalk, walked through a non-hospital parking lot, and onto a sidewalk heading north, until she was out of camera view at 7:52:06 PM.