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KINGS COUNTY HOSPITAL CENTER 451 CLARKSON AVENUE BROOKLYN, NY 11203 Jan. 24, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record review, document review, and interview, in eight (8) of 24 medical records reviewed, the facility failed to maintain a safe environment for patients. Specifically, the facility failed to:
(a) Ensure that all patients with high risk for elopement including mental impairment, were assessed to identify their risk for elopement.
(b) Implement monitoring every 15 minutes for patients on one to one observation as per facility's policy.
These findings were identified for Patient #s 1, 2, 3, 5, 6, 7, 8 and 9.

This failure placed patients at risk for harm.


Findings include:

Review of the medical records identified patients who were assessed in the Emergency Department (ED) with history of mental/cognitive impairment. The ED assessments did not include identifying the patients' risk for elopement. (Patient #s 1, 2, 3, 5, 6, 7, 8, and 9). Patient #s 1, 5, 7, and 9 eloped from the ED.


Upon admission to the Inpatient Units, patients who were identified by the psychiatrist to not have the capacity to refuse potentially life-saving procedures and needed to be on one to one observation were not assessed and identified to be an elopement risk and elopement precautions implemented. (Patient #s 2, 3, and 6)

Additionally, patients who were ordered/placed on one to one observation did not have documented evidence of monitoring for one to one observation every 15 minutes. The patients eloped from the facility. (Patient #s 2, 3, and 8)

See Tag A 144.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review, interview and in eight (8) of 24 medical records reviewed, the facility failed to:
(a) Follow their policy to ensure that all patients with high risk for elopement, including mental impairment, were assessed to identify their risk for elopement.
(b) Implement monitoring every 15 minutes for patients on one to one observation.
(c) Ensure that an immediate action plan for Building D elevators was implemented to ensure a safe environment.
These findings were identified for Patient #s 1, 2, 3, 5, 6, 7, 8, and 9.


Findings include:


Review of facility policy titled "Leaving Against Medical Advise, Elopement, Left Without Being Seen," last revised April 2017, states:

Policy Statement:
It is the policy of Kings County Hospital Center that all patients are provided with a safe environment and protected from injury harm. To this effect, all patients upon admission to the hospital will be screened for safety risk, including the risk of unadvised separation prior to the completion of treatment. Patients who are assessed to be at risk for escape from facility will be placed on Elopement Precaution.

Elopement is defined as departure from the treatment area undetected prior to scheduled discharge by a patient with or without cognitive or physical ability. A patient is considered to be at high risk for elopement if he/she has a history of mental impairment (temporary or permanent), and/or lacks capacity to sign out against medical advise...

Risk Assessment
1. In the Emergency Department (ED)
All patients assessed and identified by the nursing staff to be at elopement risk at triage will be treated as follows: (a) Application of a Green Identification Band (signifying high elopement risk), (b) Placement of hospital gown on patient, (c) Removal of patient's belongings including clothing and shoes, (d) Notification of the treatment team, including ED Hospital Police, and family members if present of the elopement risk, (e) Educating/reinforcing to patient on the need to stay in the treatment area, (f) Assigning staff to accompany patient whenever he/she leaves the unit.

2. Inpatient Unit
All patients will be re-assessed upon admission to the in-patient unit, and on as needed basis. Assessment of the patient deemed to be at risk for elopement will be documented in the patient's medical record...


Patient #1

Review of the facility's "Occurrence Reporting Form" dated 10/19/19 at 6:00 PM, documented: A [AGE] year old male who presented in the Emergency Department (ED) with Emergency Medical Service (EMS) on 10/19/19 at 12: 21 PM. The patient's chief complaint was Confusion/Altered Mental Status. The patient had medical history of mild dementia and asthma. At 6:00 PM, the patient was not found on stretcher. The staff was unable to locate patient in treatment area. The patient's wife was called and stated the "patient was not at home."


Review of the medical record for Patient #1 identified: On 10/19/19 at 12:39 PM, the patient was triaged with chief complaint from wife, who stated her husband was more confused. The patient was assessed with altered mental status, with fall risk, and no suicidal risk. The patient had previous medical history of asthma and was on Albuterol (asthma medication) and Namenda (dementia medication). The ED Provider documentation 1:31 PM included a history of dementia.
At 2:00 PM, ED Nursing Progress Note indicated the patient was awake, and alert. As per report patient was confused.
At 6:00 PM, ED Nursing Progress Note revealed the patient was not in the treatment area. The wife's cell phone was called and wife stated the patient was not at home. The head nurse, supervisor and hospital police were notified...

There was no documented evidence that the patient was assessed and identified for high risk for elopement.

The facility's review of the case, undated and timed, attached to Occurrence Report, documented the patient returned to the ED on 10/20/19 at 2:59 PM. The wife reported the patient arrived home at about 12:00 PM.
There was no documentation in the medical record regarding this additional information.


Patient #2:

The facility's "Occurrence Reporting Form" dated 9/6/19 at 12:45 AM, documented the following: "The patient was on one to one observation. He was unable to sign himself out because he showed signs of forgetfulness. The patient walked out of his room and said he wanted to leave. A Code White (Hospital Police Emergency/Crisis Intervention) was called STAT (Immediately). The physician was unable to convince patient to stay. The patient walked to the elevators, to the MICU (Medical Intensive Care Unit) side, and ran off. The staff followed the patient up to the MICU side and lost him.


Review of the medical record for Patient #2 identified: On 9/1/19 at 8:14 AM, the patient arrived in the ED by EMS and was triaged for chief complaint of shortness of breathing. He was brought in on oxygen support. Triaged Emergency Severity Index=2 (Very ill and at High Risk). At 8:17 AM, the patient received emergent evaluation and assessment and was subsequently intubated (placement of artificial ventilation tube into the trachea) for control of agitation and respiratory management.

From 9/1/19 to 9/4/19, the patient received intensive management in the Intensive Care Unit.

On 9/4/19 at 1:20 AM, the patient self-extubated (removal of artificial ventilation tube). No reintubation was recommended by the respiratory therapist and the physician at that time.

On 9/5/19 at 11:06 AM, the patient was evaluated by a psychiatrist. Psychiatry Consult documented; " Impression: Delirium due to medical condition. It has affected his ability to appreciate and recall what he was told about his condition. He does not have the capacity to refuse potentially life-saving procedures. Plan: 1. Patient needs to be on one to one observation ...Call psychiatry PRN (as needed)."

On 9/6/19 1:22 AM, Physician's Progress Note revealed patient noted to be walking around the ICU unit in street clothes. Patient was very agitated stating he wanted to leave right away. Staff attempted to redirect patient but patient became more agitated. Code White was called. The patient walked off the unit through the stairs. Security, Nursing, and MICU (Medical Intensive Care Unit) resident followed the path down but were unable to find the patient. The staff notified the Hospital Police, NYPD, Mobile Crisis and Family but the patient was never located.

There was no documented reassessment of a patient who was non-adherent to recommended treatment, and with mental impairment, to identify his risk for elopement.

There was no documented evidence of monitoring every 15 minutes for one to one observation, as per facility's policy.


Per interview of Staff A, RN Assistant Director of Nursing Critical Care Unit, on 12/30/19 at 11:21 AM, Staff A acknowledged the findings. For high risk for elopement, she acknowledged that patient's clothing is to be secured. Staff also stated the Patient Care Associate (PCA) completes the one to one observation form, and the RN reviews and signs the form.

Review of the facility policy titled "One to One Observation and Close Observation," last revised May 2015 states:
"Staff assigned to observation documents on the "One-to-One Observation Record" regarding the patient's behavior/status, activity and location every 15 minutes, even when the patient leaves the clinical unit for any reason. The nurse will review and sign the observation sheet at the end of each shift."
The policy also states: "The provider may order One to One Observation in the following cases including: Elopement Risk for patient without decision making capacity and have demonstrated elopement attempt; Safety precaution for patient currently exhibiting combative and/or disruptive to therapy..."


Similar findings were identified of patients at risk for elopement, who were not assessed and identified for elopement and have elopement precautions implemented, including monitoring for one to one observation every 15 minutes as per policy. (Patient #s 3, 5, 6, 7, 8, 9)


Patient # 3:

Patient was admitted to the facility on [DATE] with a diagnosis of endometritis (inflammation to the inner lining of the uterus).
On 2/21/19 at 5:49 PM, Nursing documentation noted that the patient became restless and wanted to leave against medical advice (AMA).
On 2/22/19 at 10:49 PM, the patient was observed dressed in regular clothes and was adamant about signing out AMA and a Code White was called. (Code White is the code for Hospital Police Assistance).
On 2/22/19 at 2:51 PM, Psychiatrist documented: "Patient is unable to appreciate risks and benefits of her treatment and has no capacity to refuse emergency treatment and sign AMA. Risk moderate due to delirium. Patient is confused and disoriented, unable to maintain attention and remember what she has been told a few seconds ago." At 4:00 PM, the patient was still very belligerent was patient medicated.
On 2/23/19, RN documented that the patient ran out of the unit via stair case at approximately 4:00 AM. The patient was located on a public street near the facility, and was returned to the facility by the hospital police, on 2/23/19 at 4:20 AM.


Patient # 5:

Patient was brought to the Emergency Department on 3/23/19 at 11:47 AM by the Emergency Medical Service (EMS) and the New York Police Department, for agitation. RN triage note documented that the patient was identified as fall risk status and a yellow wrist band placed.
The patient was medicated at 1:00 PM and 1:1 supervision initiated for safety.
ED Attending Physician documentation indicated at 2:35 PM, one of patient's restraints was free, after the patient received sedation. The patient removed both restraints and ran out of ED. Hospital Police attempted unsuccessfully to stop the patient, who eloped onto the street.


Patient #6:

Patient arrived at the Emergency Department by Emergency Medical Service (EMS) on 4/28/2019 at 12:25 PM. Physical exam noted the patient was assessed with a laceration on her left wrist and underwent surgical repair. Patient was admitted to medical unit on 4/29/19 at 12:20 PM from the Recovery Room. Nursing Psychosocial assessment documented patient exhibiting signs of psychiatric issues. Social Worker Progress Note at 12:46 PM, noted patient was requesting to be discharged . At 2:35 PM, Psychiatric Consult noted, "Patient does not have capacity to leave AMA or make medical decisions.

An "Occurrence Reporting Form" dated 4/29/19 at 1:20 PM, documented patient left the unit and got on the hospital elevator. She was caught by nursing and a Code White was activated.
"Occurrence Reporting Form" dated 4/30/19, documented the same patient eloped from the unit at 7:40AM. Patient was caught, and Code White initiated.
The patient eloped twice from the unit with no elopement assessment or elopement precautions in place.
These elopements were not recorded in the medical record.


Patient #7:

Patient was brought to the Emergency Department by ambulance on 6/16/2019 at 6:00 PM. The chief complaint, "I am feeling sad, so I took a bunch of pills." Nursing Assessment noted patient is High Risk, no suicidal ideation and had feelings of hopelessness. On 6/16/2019 at 8:39 PM, ED Physician noted "went to go obtain EKG on patient but patient is not present in bed. Patient was in the room with psychiatrist minutes prior. Patient was on 1:1. Paged psych, called patient cell phone, reported incident to hospital police.
Documentation in the medical record, patient was found and brought back to the ED by NYPD on 6/17/19 at 2:06 AM.


Patient #8:

Review of the "Occurrence Reporting Form" dated 8/28/19 at 4:00 PM documented, the patient walked off the unit and was last seen at 3:30 PM. Risk Management, ED Attending, Assistant Director of Nursing, Hospital Police and Mobile Crisis were notified."

Review of the medical record identified patient was brought to the Emergency Department (ED) by EMS on 8/26/19 at 1:04 PM. The patient was assessed as High Risk, no suicidal ideation and with feelings of hopelessness.

The patient presented with chief complaints of multiple seizures and hearing voices. On 8/26/19 at ED Psychiatry Consult at 4:01 PM documented, "Impression: Delirium due to multiple causes, rule out post-ictal (post seizure) delirium, rule out Ativan induced delirium ...Recommendations: Continue one to one observation ...Please call for psychiatry reevaluation.

On 8/27/19 at 4:58 AM, Nursing Admission Assessment indicated was admitted to the medical unit. Follow-up Psychiatry Inpatient Consult at 3:03 PM, indicated ..." Patient remains depressed and hallucinating." Recommendations included start of medications, for transfer to psychiatry, and continue one to one observation.

On 8/28/19 at "At approximately 3:30 PM, the patient was noted in his room with his mother. At 4:45 PM, the patient was not in his room. The patient was unable to be located. Risk Management, Mobile Crisis, Hospital Police, and patient's mother were called and notified."


Patient #9:

On 10/24/19 at 11:36 PM, patient was brought by EMS to ED for altered mental status, unresponsive and with history of excessive drinking. The patient was triaged with intoxication. He was assessed with fall risk, and no risk for suicide. In the ED, the patient was managed for intoxication.
On 10/25/19 at 5:26 PM, the patient's ethyl alcohol level resulted 428.9 (Reference: greater than 100 mg/dl, depression of Central Nervous System).
On 10/25/19 at 8:20 AM, the patient left ED.


During survey tour on 12/3/19 at approximately 11:00 AM, two (2) of the 4 Visitors' Elevators were labelled, "Temporarily Out of Service."

Review of the facility's "D Building Out of Service Plan," dated 12/6/19, documented that on August 12, 2019, a fire in the mechanical room located in the 8th Floor Penthouse of the D Building, permanently damaged/disabled two (2) of the D Building Visitors' Elevators. The fire was caused by an elevator motor malfunction.
The Plan indicated D Building has eight (8) elevators: 4 Visitors' Elevators (with 2 out of service), 2 Elevators for Patient transport and 2 for Service. The D Building "Out of Service Plan" indicated that a full assessment of the D Building Visitors' Elevators were done.

There was no documented evidence in the facility's "D Building Action Plan" that a risk assessment of all the other elevators of the D Building was conducted for the likelihood of elevator motor malfunction, immediately after the fire.


During interview with Staff F, Associate Executive Director Support Services, on 12/3/19 at 3:00 PM, staff stated that a full assessment of the D Building Visitors' Elevators was done. Staff was unable to provide assessment of the other six elevators in the D Building after the fire event, to ensure safety.
VIOLATION: QAPI Tag No: A0263
Based on document review and interview, the facility failed to utilize its Quality Assurance and Performance Improvement (QAPI) program to analyze data collected on patient elopements in the facility, and develop and implement action plan to ensure patients' safety.

This failure placed patients at risk for harm.

Findings include:

Review of the facility's Hospital-Wide Quality Assurance/Patient Safety Minutes for 2019, identified the documentation of elopement data for the First, Second and Third Quarters of 2019.

There was no documented evidence in the Hospital-Wide Quality Assurance/Safety Minutes, that elopements were analyzed, trended and corrective action plan developed and implemented.

These findings were reviewed with Staff D, Risk Manager on 1/22/2020 at 10:00 AM. Staff D acknowledged the findings.

See Tag A 273.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and staff interview, it was determined that elopements were not investigated, reviewed and addressed in the facility's Quality Assurance/Performance Improvement Program.


Findings include:

Review of the facility's Hospital-Wide Quality Assurance/Patient Safety Minutes for 2019, identified documentation of data as follows:

First Quarter ( January, February and March 2019) - 22 elopements.

Second Quarter (April, May, June) - 24 elopements.

Third Quarter (July, August, and September 2019) - 23 elopements.

There was no documented evidence in the Hospital-Wide Quality Assurance/Safety Minutes, that the elopement data collected, was analyzed and trended to identify areas for improvement of care and patient safety.

During interview with Staff D, Risk Manager, on 1/22/2020 at 10:00 AM, staff stated there were no quality assurance reviews for elopements, including root cause analyses, because the incidents were not reportable to New York Patient Occurrence Reporting Tracking System (NYPORTS) or to the Justice Center. Staff indicated NYPORTS reportability is when there is death or serious injury.

Per interview with Staff E, Chief Quality Officer on 1/22/20 at 10:45 AM, staff acknowledged the findings.