HospitalInspections.org

Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.55, Emergency Services.

Findings include:

1. The hospital failed to ensure that hospital policy was adhered by staff to prevent the patient from eloping from the ED (emergency department). A-1104 A.

2. The hospital failed to ensure that the hospital's elopement policy was adhered to, following a patient's (Pt.#1) elopement. A-1104 B.

3. The hospital failed to ensure that hospital policy was adhered to by staff to provide a triage assessment within a timely manner. A-1104 C.

A. Based on document review, video surveillance review and interview, it was determined that for 1 of 1 (Pt. #1) patient who presented to the hospital's emergency department (ED) from a psychiatric hospital for medical clearance, the hospital failed to ensure that hospital policy was adhered by staff to prevent the patient from eloping from the ED.

Findings include:

1. The hospital's policy titled, "Psychiatric Patient Evaluation Admission, and Transfer" (revised 04/2022) was reviewed and required, "Emergency Department personnel will deliver care to protect the patient, family, and/or others ... Only patients who are medically stable may be transferred to a psychiatric unit/facility."

2. The clinical record of Pt #1 was reviewed on 3/31/2025. Pt #1 presented to the ED on 8/14/2024 at 10:40 AM, as a transfer from an outside psychiatric hospital with an escort. Pt #1 eloped from the hospital's ED on 8/14/2024 at 1:45 PM.

Pt #1's clinical record included:

-Medical Transportation Report, dated 08/14/24 at 10:30 AM, "Medic dispatched to (name of outside psychiatric hospital) ... Nurse states (Pt.#1) is a voluntary admission and is alert, oriented, and ambulatory ... (outside psychiatric hospital) escort will be coming with (Pt.#1) to the hospital ... wants to smoke a cigarette and began unbuckling cot belt, (Pt.#1) is becoming restless and agitated. Crew advised (Pt.#1) smoking outside is not possible at this time. Crew advised staff to bring security. (Pt.#1) states believe vomiting is due to not being able to smoke ... (Pt.#1) then was advised to go to room #7 ... handoff report and paperwork given to nurse who signed off and care was transferred."

-Triage Assessment (E#1) note dated 08/14/24 at 10:45 AM, "Stated Complaint: Vomiting 3 days; Mode of Arrival: Ambulance ... Another Hospital ... vital signs: Temperature: 97 (reference range 97-100) Pulse: 86 (60-90) Blood Pressure 136/78 (90/60 - 140/90) ... Point of care testing results: Pregnancy - Negative ... (Pt.#1) brought to ER (emergency room) by ambulance ... from (name of outside psychiatric hospital) ... (Pt.#1) is reluctant to be treated and stating 'I can be discharged. I am not suicidal.' (Pt.#1) denies homicidal ideation ... (name of physician/MD#2) made aware ... Presents intentional harm to self? No; Presents intentional harm to others? No ... Have you had any thoughts of killing yourself? No; Have you been thinking about how to might do this ... acting on them? No ..."

-HPI (history of present illness) (entered by ED Physician/ MD#2), dated 08/14/24 at 10:49 AM, "(Pt.#1) with history of anxiety, schizophrenia presents for nausea and vomiting that think is related to psychiatric medication on an empty stomach ... denies belly pain, no SI (suicidal ideation) ... will give fluids ... check labs ... if feeling better (Pt.#1) to go back to psych facility after."

-ED Timeline:
-10:50 AM, "(MD#2) speaking with (Pt.#1)."
-11:30 AM, "(MD#2) spoke with (name of outside psychiatric hospital) and they are accepting (Pt.#1) back."
-11:58 AM, "(Pt.#1) very difficult IV (intravenous) access and blood draw. Blood drawn and sent to lab."
-12:54 PM, "(Pt.#1) tolerating po (by mouthl) water given."
-1:45 PM, "(Pt.#1) left ER without staff knowledge. Pulled IV out (themselves) (MD#2) aware. (Pt.#1) left ER with (outside hospital) escort."

Pt #1's clinical record lacked documentation that a hospital employee was assigned as a one-to-one for observation while in the ED.

3. On 03/31/25 at approximately 1:45 PM, video surveillance of 08/14/24 from 13:43 (1:43 PM) to 13:50 (1:50 PM) was reviewed along with the Chief Nursing Officer (CNO/E#4). The video showed the following:

-At 1:43:40 PM, (Pt.#1) is observed walking out of room #7, followed by escort (outside hospital) to the front ED doors. At the same time a Physician (MD#2) is observed walking rapidly behind (Pt.#1) and gets in front of (Pt.#1). (Pt.#1) is observed going around (MD#2). MD#2 is then observed going through a door leading to ED waiting room and returns with a Public Safety Officer (E#3) and a Psychiatric Liaison (E#5). All staff are seen going outside the ED and out of cameral view.
-At 1:45 PM, MD#2, E#3, and E#5 return inside ED without (Pt.#1).

4. An interview was conducted with an ED Registered Nurse (E#1) on 03/31/24 at 12:45 PM. E#1 stated that (Pt.#1) came to ED by ambulance from outside psychiatric hospital and had an escort with them. E#1 stated that E#1 does not recall (Pt.#1) requiring a sitter, (Pt.#1) did not show behaviors for eloping or at risk for harm to self or others. E#1 stated that E#1 did not see when (Pt.#1) eloped. E#1 stated that is very rare to get patients with escorts, but if they do, a hospital staff needs to be assigned to monitor. E#1 has not had any other incidents of patients eloping.

5. An interview was conducted with the Chief Nursing Officer (E#4) on 04/01/25 at 9:15 AM. E#4 stated that if patients in the ED come with an outside escort, the ED staff are required to obtain a hospital staff for one-to-one observation.

6. An interview was conducted with the Psychiatric Liaison (E#5) on 04/01/25 at 12:30 PM. E#5 stated that E#5 remembers (Pt.#1) because they had an escort, and this is very rare. The patient (Pt.#1) was here for medical clearance, there was no petition or certification, (Pt.#1) was calm, not showing high risk behaviors. E#5 heard the doctor (MD#1) ask for help getting a patient back inside. E#5 went outside and spoke with (Pt.#1) to ask them to return and wait for transportation, but they both just kept walking away, the escort was not trying to get (Pt.#1) to come back.


B. Based on document review and interview, it was determined that for 1 of 1 (Pt #1), clinical records reviewed for elopement, the hospital failed to ensure that the hospital's elopement policy was adhered to, following a patient's (Pt.#1) elopement.

Findings include:

1. The hospital's policy titled, "Patients Leaving the Hospital Against Medical Advice and Elopement" (revised 04/2022) was reviewed and required, "B. In all instances where a patient leaves the hospital against medical advice, the nurse manager/nurse supervisor, physicians, risk manager must be notified ... Elopement: A. When a patient is missing, staff must immediately notify Public Safety Officers ... then inform Nursing Supervisor and immediately start a search for the patient. B. If the staff is unable to locate a patient promptly, the Nursing Supervisor or designee shall immediately notify the patient's physician and report to Chicago Police Department ..."

2. The clinical record of Pt #1 was reviewed on 3/31/2025. Pt #1 presented to the ED (emergency department) on 8/14/2024 at 10:40 AM, as a transfer from an outside psychiatric hospital with an escort. Pt #1 eloped from the hospital's ED on 8/14/2024 at 1:45 PM.

Pt #1's clinical record included:

-Medical Transportation Report, dated 08/14/24 at 10:30 AM, "Medic dispatched to (name of outside hospital) ... Nurse states (Pt.#1) is a voluntary admission and is alert, oriented, and ambulatory ... (outside psychiatric hospital) escort will be coming with (Pt.#1) to the hospital ... wants to smoke a cigarette and began unbuckling cot belt, (Pt.#1) is becoming restless and agitated. Crew advised (Pt.#1) smoking outside is not possible at this time. Crew advised staff to bring security. (Pt.#1) states believe vomiting is due to not being able to smoke ... (Pt.#1) then was advised to go to room 7 ... handoff report and paperwork given to nurse who signed off and care was transferred."

-Triage Assessment (E#1) note dated 08/14/24 at 10:45 AM, "Stated Complaint: Vomiting 3 days; Mode of Arrival: Ambulance ... Another Hospital ... (Pt.#1) brought to ER by ambulance ... from (name of outside psychiatric hospital) ... (Pt.#1) is reluctant to be treated and stating 'I can be discharged. I am not suicidal.' (Pt.#1) denies homicidal ideation ... (name of physician/MD#2) made aware ... Presents intentional harm to self? No; Presents intentional harm to others? No ... Have you had any thoughts of killing yourself? No; Have you been thinking about how to might do this ... acting on them? No ..."

-HPI (MD#2), dated 08/14/24 at 10:49 AM, "(Pt.#1) with history of anxiety, schizophrenia presents for nausea and vomiting that think is related to psychiatric medication on an empty stomach ... denies belly pain, no SI (suicidal ideation) ... will give fluids ... check labs ... if feeling better (Pt.#1) to go back to psych facility after."

-ED Timeline:
-10:50 AM, "(MD#2) speaking with (Pt.#1)."
-11:30 AM, "(MD#2) spoke with (name of outside psychiatric hospital) and they are accepting (Pt.#1) back."
-11:58 AM, "(Pt.#1) very difficult IV (intravenous) access and blood draw. Blood drawn and sent to lab."
-12:54 PM, "(Pt.#1) tolerating po water given."
-1:45 PM, "(Pt.#1) left ER without staff knowledge. Pulled IV out (themselves) (MD#2) aware. (Pt.#1) left ER with (outside hospital) escort."

The clinical record lacked follow-up documentation about reporting Pt.#1's elopement and contacting Chicago Police Department as required per policy.

3. The Incident logs dated 08/2024 and 01/01/25 to 03/30/25, were reviewed, there were no incidents related to Elopement.

4. An interview was conducted with an ED RN (E#1) on 03/31/24 at 12:45 PM. E#1 stated that for patients that elope, staff are required to notify the nurse supervisor, call 911, and file an incident report. E#1 stated that E#1 could not recall if this was done for (Pt.#1). E#1 stated that is very rare to get patients with escorts, E#1 has not had any other incidents of patients eloping.

5. An interview was conducted with the Chief Nursing Officer (E#4) on 04/01/25 at 9:15 AM. E#4 stated that for (Pt.#1) there is no incident report for the elopement on 08/14/24, staff did not follow the protocol to report to a supervisor or contact 911 to report a patient elopement. E#4 stated that staff are required to file an incident report for elopements and call Chicago Police Department if the patient is not prevented from leaving.


C. Based on document review and interview, it was determined that for 2 of 3 (Pt.#8 and Pt.#11) patients who presented to the hospital's emergency department (ED) for chest pain, the hospital failed to ensure that hospital policy was adhered by staff to provide a triage assessment within a timely manner.

Findings include:

1. The hospital's policy titled, "Triage Procedure" (revised 04/2022) was reviewed and required, "1. All patients presenting to the ED, will be seen by a registered nurse for initial assessment to determine the priority of care and the appropriate area for further evaluation and treatment."

2. The hospital's policy titled, "Chest Pain" (revised 07/2023) was reviewed and required, "All patients ...who present to the Emergency Department with complaints of chest pain ... will be assessed by the RN (registered nurse) in the Medical Screening Area for cardiac causes for the pain... a. RN will do an EKG (electrocardiogram-used to monitor heart activity) as soon as possible and notify the ED MD. b. Patient will be placed in a room with a cardiac monitor..."

3. The clinical record of Pt.#8 was reviewed on 04/01/2025. Pt.#8 presented to the ED on 03/30/25 at 7:35 PM, as a walk-in with a chief complaint of chest pain. The ED Census dated 03/30/25 indicated that Pt.#8 left without being seen at 8:32 PM (57 minutes later). There was no documentation that a triage assessment was done.

4. The clinical record of Pt. #11 was reviewed on 04/02/2025. Pt. #11 presented to the ED on 03/24/2025 at 1:24 AM with complaints of chest wall pain. The ED timeline included that Pt. #11 was triaged at 5:15 AM (3 hours and 51 minutes later).

5. An interview was conducted with an ED Physician (MD#2) on 04/02/25 at 9:15 AM. MD#2 stated that for patients presenting to the ED with a chief complaint of chest pain should be seen immediately, and on the top of the list. The nurse will start an EKG and start labs.

6. An interview was conducted with the Chief Nursing Officer (E#4) on 04/02/25 at 11:30 AM. E#4 stated that all patients presenting to the ED are required to be triaged by the nurse to determine their level of acuity for further evaluation and treatment. E#4 agreed that for Pt.#8 and Pt.#11 the nurse should have been notified for a timely assessment.