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Based on interview and record review the facility failed to prevent 1 of 1 patients (Patient #1) identified as high risk for elopement from eloping in a total universe of 10 medical records reviewed.

Findings:

Facility staff failed to prevent a patient identified as high risk from eloping while hospitalized. see TAG-A-0144

Based on interview and record review the facility failed to ensure a safe and secure environment for 1 of 1 patients (Patient #1) identifed as high risk for elopement in a total universe of 10 medical records reviewed.

Findings Include:

Patient (Pt.) #1 was a 63 year old admitted to the facility with a traumatic brain injury (TBI) as a result of a cardiac (heart) arrest (stop) and required multiple resuscitation attempts. Pt. #1 was admitted to the facility on 12/19/2024 for intensive rehabilitation therapy and was discharged on 01/17/2025 with home health services. Pt. #1 had a temporary guardian and an activated POA (Power of Attorney) for health care. Pt. #1 had a history of alcohol substance abuse, anxiety, depression, hypertension (high blood pressure), hyperlipidemia (high cholesterol). While hospitalized for rehabilitation, Pt. #1 was also being managed medically for follow up to a cardiac arrest, respiratory failure and acute (sudden) metabolic encephalopathy (decrease in blood flow to the brain), and chronic (long term) alcoholism. Pt. #1 had a court ordered temporary guardianship in place.

Review of facility policy titled, "Patient Rights and Responsibilities [Facility]," last revised 06/21/2024 revealed, "Receive....care consistent with sound medical and nursing practice....in a....safe and secure environment."

Review of facility policy titled, "Hospital Based Assessment & Documentation Policy [Facility]," last revised 02/02/2025 revealed, "...As patient care needs are identified, it is the responsibility of the healthcare team to prioritize the care and service delivered to assure that the patient's needs are met.....The plan of care should be developed.... A care plan has individualized patient priorities.... and appropriate interventions. When the plan of care has been developed, the healthcare team implements it....Members of the healthcare team collaborate....to ensure that implementation of the plan of care is coordinated, timely, and effective."

Review of Patient #1's Medical record revealed Pt. #1 was hospitalized from 12/19/2024-01/17/2025 for extensive rehabilitation therapy following a brain injury due to lack of oxygen to the brain following a cardiac arrest (heart attack). Pt. #1 was assessed every day for safety and had a nursing care plan initiated that addressed the concerns for elopement risk. Interventions for Pt. #1 during their hospitalization included a wanderguard (bracelet that alarms when close to an exit), bed alarm, Visual Monitoring system (VSM) (remote video monitoring), medications for agitation, 1:1 sitter, placement closer to the nurses station and psychiatric consults for medication changes/adjustments. Ongoing review of Pt. #1's medical record revealed Pt. #1 left the unit twice, once getting into another hospital unit and once getting into the stairwell, and eloped from the facility twice, once in the parking lot with staff and once without staff where he was found by police 2.5 miles away.

Review of Security Report completed on 12/22/2024 at 2:44 PM revealed Pt. #1 had eloped from the unit and was in the parking lot surrounded by facility staff and was able to be redirected back to their room. Interventions in place at the time of Pt. #1's elopement included a wanderguard (bracelet that alarms when close to an exit) and VSM (virtual safety monitoring) (remote video monitoring). Upon Pt. #1 returning to the unit, medication was given and a 1:1 sitter was implemented. A psychiatric evaluation was ordered for 12/23/2024.

Review of Pt. #1's Nursing Note on 1/13/2025 at 6:57 PM completed by RN H, revealed, "[Pt. #1] had team conference this afternoon at 1:30 PM and was informed...will need to go to another facility.....for more therapy. After team conference he became upset with wife, so she left. He became more agitated and kept trying to leave the unit. Did make it to stairway but was able to redirect back to unit around [2:30 PM]...Did give PRN (as needed) lorazepam (medication for anxiety) around [2:34 PM] with little to no relief. Noted no wanderguard on patient when back in room and applied a new one....Had scheduled Zyprexa (medication for anxiety/agitation) at [4:12PM], with little to no relief....continued to come to nurses station....was able to redirect back to room...VSM (Virtual Safety Monitor) was discontinued this morning and was able to redirect throughout the day, frequent checks completed in between patient rooms. Ate dinner around 5 PM. Checked on him prior to giving meds (medication) at [5:02 PM] and when came out of patient room at 5:05 PM patient was not in room. All staff checked unit and building and unable to locate patient, called security and was checking areas....Wander guard system did not go off. Has removed wander guard in the past. Unable to locate patient, so police were called....Received a call around 6:30 PM that patient was located a couple of blocks away on a porch and would call an ambulance to bring back." Further review of the medical record revealed Pt. #1 was wearing a wanderguard bracelet when they eloped.

Review of Security Report completed on 01/13/2025 at 5:05 PM by Security Staff M revealed, "[Facility Patient #1]....eloped from hospital. He traveled approximately 2.5 miles southeast before being found on a porch of someone's residence." Ongoing review of this report revealed security checked parking lots, vending area, cafeteria and was unable to locate Pt. #1. Officer N told Officer M the last time anyone had seen Pt. #1 was approximately at 5:00 PM. Officer N called the police to assist. Police interviewed RN H who said, '[Pt. #1] was wearing a tan shirt, gray sweat pants, and a red and black fleece.'...Security was unable to log into the camera system to see if they could determine which exit Pt. #1 used...At approximately [5:50 PM] a description of the patient was given to the hospital safety officer and an overhead announcement was made that everyone look for someone matching Pt. #1's description.....Police officers present indicated they hadn't received any calls of anybody matching Pt. #1's description walking along the road. 'Due to the extreme cold, we believed that that (sic) passing motorists would call law enforcement if he was seen walking down a busy street.' " Security and police began checking all facility stairwells and rooms in the facility. Ongoing review of this report revealed, "At approximately [6:30 PM]...Security Officer N was contacted by [Police Officer] who informed him...[Pt. #1] had been found sitting on the porch of a residence...approximately 2.5 miles southeast of the [facility].....the patient was being transported to the hospital by an [ambulance]... 2 EMS (Emergency Medical Services) personnel...with [Pt. #1] at [6:55 PM]...[Pt.#1] was admitted to ...the ED to be medically cleared before going back to [facility]....I was approached by [Administrator I]...She stated that she would contact [Pt. #1's] wife to update her...She wondered out loud how [Pt. #1] made it off the unit without staff being alerted. She informed me that [facility] utilizes a program called Wanderguard. Wanderguard is a program where a patient wears a bracelet with a....chip on it, and if they get close to an exit, an alarm will sound. She was under the impression that [Pt. #1] was wearing one...indicated she would look into it....at around [8:30 PM] I passed [Administrator I] in the hallway. She informed me that the Wanderguard program was currently down, and that she put in a work ticket for our IT department to restore it to working ....At approximately [9:30 AM], I met with ER RN....informed me that [Pt.#1] had been medically screened, and had no injuries or health concerns....and had been readmitted to the [facility]."

Further review of the medical record revealed when Pt. #1 was returned to the unit, VSM was reinstated and a 1:1 sitter was implemented.

In an interview with Security officer G on 02/26/2025 at 1:16 PM, Officer G confirmed Pt. #1 had eloped from the facility twice, once into the parking lot and once when found by police.

In an interview on 02/26/2025 at 2:30 PM RN H stated, "[Pt. #1] had previously gotten into the stairwell and either didn't have a wanderguard or it didn't go off. He could take the wanderguard off and I tested another one and applied it." When asked how did Pt. #1 elope if they had a wanderguard on, RN I stated, "We determined it was a gap in our system that it didn't alarm."

In an interview with Administrator I on 02/26/2025 at 4:30 PM, I stated, "The VSM didn't sound an alarm. We found the wanderguard system failed. There was a 2 hour window that the battery had died." Administrator I continued that there hadn't been an elopement or wanderguard policy in place and this is being developed and in draft format and further education with the new policy would happen once the policy was approved.