Observations:
Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined that the hospital failed to implement measures to keep an incapacitated patient safe from eloping from the facility for one of ten medical records reviewed (MR1).
Findings include:
Review on February 7, 2024, of the facility policy "Patient Rights and Responsibilities" with an effective date of 11/30/2020, revealed "... II. PATIENT RIGHTS AND RESPONSIBILITIES ... Your Rights as a patient, you or your legally responsible party, have the right to care without discrimination due to age, AIDS or HIV status, ancestry, color, culture, disability, education, gender identity, income, language, marital status, national origin, race religious creed, sex, sexual orientation, union membership, or who will pay your bill. As our patient, you have the right to safe, respectful, and dignified care at all times. You will receive services and care that are medically suggested and within the hospital's services, its stated mission, and required law and regulation ... Visitation: You have the right to: 1. Decide if you want visitors or not while you are here. The hospital may need to limit visitors to better care for you or other patients. 2. Designate those persons who can visit you during your stay. These individuals do not need to be legally related to you. 3. Designate a support person who may determine who can visit you if you become incapacitated ... Care Delivery You have the right to: ... 8. Receive efficient and quality care with high professional standards that are continually maintained and reviewed ..."
Review of the facilities security report of incidents revealed on January 19, 2024, at approximately 4:00 PM, "I observed a disturbance in the lobby. Upon further investigation I determined that patient [name redacted] ... who is under guardianship was in the lobby attempting to push through the hospital staff and make ... way to a white male .... The male was later identified as [name redacted], son .... After [name redacted] was allowed to visit with son for a few minutes [name redacted] wad [sic] escorted to room."
Further review of the facilities security report of incidents revealed on January 31, 2024, at approximately 3:35 PM, "I was informed that [name redacted] ... was not in room and could not be located. The decision was made to contact the [name redacted] Police Department because [name redacted] is currently under guardianship ... A search of the building and a review of the camera system were conducted with negative results. ..."
Review of MR1 revealed that the patient was admitted to the rehabilitation unit from an outside facility on August 14, 2023. On September 26, 2023, document "COURT OF COMMON PLEAS OF DELAWARE COUNTY PENNSYLVANIA ORPHAN'S COURT DIVISION EXPERT REPORT" revealed, "... PART II: ALLEGED INCAPACITATED PERSON (AIP) 13. ... In your expert opinion, within a reasonable degree of professional certainty and based on your knowledge, skills, experience, and education, is the ATP incapacitated? Yes, totally impaired. ..."
Further review of MR1 revealed the patient had been admitted in August 2023, to the rehabilitation unit. On September 12, 2023, patient was transferred to the second-floor medical surg unit for a change in condition. The patient resided on the second-floor unit until January 31, 2024, date of the elopement incident. Patient was ambulatory on the unit and was awaiting guardianship for placement. Nursing progress note on September 21, 2023, revealed a staff member found the patient in the lobby area, and the staff were made aware that the patient was a flight risk.
The nursing note on January 31, 2024, stated "nurse was alerted by the MD (Medical Doctor) that the pt (patient) was not in room around 1400 when he went in to complete his assessment. Nurse immediately went to the pts room where she checked to see if the pt was in the restroom and the pt was not in the room. Nurse alerted the other nursing staff and they all checked the unit as the pt is known to wander to talk to other staff. When the pt was not found on the unit the nurse immediately notified the nursing director. The nursing director and other staff checked other parts of the hospital and outside surrounding areas. Security was notified by the nurse. Police were notified and the nurse gave a statement. Pt appears to have left behind all belongings except ... cell phone. Pt also appears to have changed ... clothes and left without her shoes."
Interview with EMP1 on February 6, 2024, at approximately 11:00 AM revealed that the police had located the patient six days after eloping from the hospital, in a hotel room in another state. EMP1 stated the police then took the patient to a nearby hospital emergency room for evaluation in that state.
Interview with EMP7 on February 7, 2024, at approximately 11:30 AM revealed the patient did leave the unit one time before and made it to the lobby. EMP7 was in the lobby talking with the son who refused to leave, and EMP7 intercepted the patient from going into the lobby. The patient was aware that son was in lobby as had talked to the son on the patient's cell phone. The son had previously been restricted from visiting. EMP7 confirmed there was not any interventions in place at that time and stated security would have stopped patient. Patient was then moved closer to the nurse's desk and staff confiscated the patient's phone. EMP7 stated that the patient was not understanding, would become agitated, and was not always easily redirected. EMP7 confirmed the patients care plan did not address elopement risks.
Interview with EMP6 on February 7, 2024, confirmed that there were no interventions put in place for the patient when was found in the lobby on January 19, 2024, other than moving closer to the nurse's station.
| | Plan of Correction - To be completed: 05/03/2024
An elopement log was developed to ensure risks for elopement are appropriately identified and managed. If any patient is identified to lack capacity for decision making and or verbalizes desire to elope or attempts to elope, the nursing supervisor will be notified immediately, security will be notified, and the patient will be evaluated by the nursing supervisor to determine next steps. This information will be captured on the elopement log in all inpatient units. Patient assessments will be completed upon admission and every 12 hour shift. If there are any changes to capacity or desire to leave, those at risk will be placed on the log and the nursing supervisor will determine next steps.
The Chief Nursing Office or a designee will ensure a read & sign is completed by all nursing staff regarding this process by 5/3/2024.
The Chief Nursing Officer or designee will complete 5 random audits per week to ensure the elopement logs are being completed appropriately. Audits will be completed until 100% compliance has been achieved for three consecutive months. Any instance of noncompliance identified will be immediately addressed with the staff identified and reported to the Chief Nursing Officer. Audit results will also be reported to the Quality of Care Committee monthly.
The Chief Nursing Officer is ultimately responsible for this plan of correction.
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