Kings County Hospital Center

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48940 Based on medical record (MR) review, document review and interview, in two (2) of five (5) medical records reviewed, it was determined that the facility failed to assess, identify, and implement protective measures for patients who are at risk for elopement. (Patient #1, #2) Findings: The facility failed to assess, identify, and implement protective measures for patients at risk for elopement and implement the facility’s policy and procedure on “Elopement ...” that directs staff to assess all patients for elopement. See Tag A0144”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48940 Based on medical record (MR) review, document review and interview, in two (2) of five (5) medical records reviewed, it was determined that the facility failed to assess, identify, and implement protective measures for patients who are at risk for elopement. (Patient #1 & #2). Findings include: The facility’s policy and procedure titled, “Elopement, Leaving Against Medical Advice, Left Without Being Evaluated,” revised date of May 2023 states: II. POLICY STATEMENT: It is the policy of NYC Health + Hospitals/Kings County that all patients receive care and treatment in a safe environment and are protected from injury and harm. To this end, all patients upon triage in the Emergency Department, and/or upon admission to an inpatient unit, will be screened for elopement risk, as well as the risk for unauthorized departure. Patients who are assessed to be at risk for elopement from the facility will be placed on the appropriate level of elopement precautions. III. SCOPE: This policy applies to all patients receiving care at NYC Health + Hospitals/Kings County’s Emergency Department and Inpatient Units and to all staff providing care to patients identified to be at risk for elopement. IV. DEFINITIONS: B. Elopement: An elopement refers to an event in which a patient, who lacks decisional capacity or who is cognitively, physically, mentally, emotionally, or chemically impaired, leaves the facility unsupervised, unnoticed and prior to their scheduled discharge. C. Against Medical Advice (AMA): Against Medical Advice refers to the process by which an adult patient with decisional capacity refuses medical treatment or admission and insists upon leaving the facility despite provider recommendations. VI. PROCEDURE: A. Elopement Risk Assessment: All patients at triage, and/or upon admission to an inpatient unit, will be assessed for elopement risk. In assessing whether a patient is at risk for elopement, staff may consider the following: 1. Is the patient cognitively impaired? 2. Does the patient have a prior history of elopement from this or any other facility? 3. Is the patient threatening, verbally or otherwise, to leave the unit without permission? 4. Is the patient under a Court Order for Hospital stay and/or Legal Guardian? 5. Does the patient lack decisional capacity to make medical decisions? i. A patient is deemed at risk for elopement if any of the above criteria are met. Review of the MR of Patient #1 identified an 87-year-old patient who presented to the emergency department (ED) on 4/23/24 at 6:48 PM with symptoms of a urinary tract infection (UTI). On 4/23/24 at 6:56 PM, Patient #1 was triaged, and an elopement risk assessment was completed by the ED Staff RN (Staff M). The patient was identified to not be at risk for elopement. On 4/23/24 at 4:48 AM, patient was evaluated by the ED Resident (Staff D) who documented, the patient had a past medical history of prostate cancer and dementia, wife reported patient had dementia and was not a reliable historian. The ED Resident physical exam documented: neurological mental status was alert, and oriented to person, place, and time with some confusion at baseline. The patient was admitted to the hospital and remained in the ED waiting for an inpatient bed. On 4/24/24 at 2:53 PM, Medicine Resident PGY I (Staff C) completed patient’s History and Physical and documented the patient’s past medical history of prostate cancer, benign prostate hyperplasia (enlargement of the prostate), and dementia. Neurological mental status: patient was alert and oriented to person, place, and time. The resident also documented “Elopement risk: low.” On 4/25/24 at 3:30 AM, Medicine Resident PGY III (Staff E) documented in a Progress Note, patient wanted to leave against medical advice (AMA). The diagnosis and reasons why it was important for him to stay at the hospital and be treated with intravenous antibiotics was explained and the patient verbalized understanding and agreed with staying. On 4/25/24 at 6:05 AM, ED Staff RN (Staff H) documented “the patient left without signing AMA and that the physician spoke with the patient earlier and refused to stay.” There was no documented evidence in the medical record the patient was assessed for elopement risk when patient verbalized wanting to the leave the hospital. On 4/25/24 at 5:38 PM, the Vital Signs Flowsheet indicated the patient received vital signs upon his return to the hospital. On 4/25/24 at 6:43 PM, ED Attending Provider Notes (Staff N) stated that the patient had returned to the hospital after leaving AMA this morning and that he would be admitted to the floor as his inpatient bed was available. During interview conducted on 6/5/24 at 12:18 PM, Staff C (Medicine Resident PGY I) confirmed completing the History and Physical for Patient #1. Staff C stated that according to the assessment, the patient understood why they were in the hospital and verbalized understanding of the risk and benefits of the treatment. The patient was alert and oriented to person, place, time, and situation. When speaking with the patient, they did not seem like a patient who had dementia, and according to the assessment, the patient had the capacity to make the decision to leave AMA. Staff C also stated, their assessment of the patient’s elopement risk was low based on the patient’s understanding of the treatment plan. Based on their assessment, Staff C did not feel that the patient was at risk for elopement. During interview conducted on 6/5/24 at 1:10 PM, Staff D (ED Resident) stated they evaluated the patient and according to their assessment, the patient was alert and oriented to person, place, and time and had capacity to make medical decisions. The patient was able to verbalize understanding for the plan of care and Staff D had no concerns regarding patient’s capacity. Staff D stated that they documented patient’s history of dementia because the wife mentioned the medical history and described that her husband has difficulty describing his symptoms at times. Staff D stated they did not believe the patient met criteria to be an elopement risk. Staff D acknowledged the history of dementia and stated that it would be something to consider when making a determination for being an elopement risk, but it is not a determinant. During interview conducted on 6/5/24 at 1:27 PM, Staff E (Medicine Resident PGY III) stated they were called by the nurse because the patient wanted to leave against medical advice, and so they went to assess the patient face-to-face in the ED. At this time, the patient was alert and oriented to person, place, time, and situation. The patient was able to verbalize the reason he was in the hospital and had full capacity to make a medical decision for himself. At the end of this conversation, the patient agreed to stay. When asked by the surveyor if the patient should have been an elopement risk at that time, Staff E stated that the patient did not meet criteria to be an elopement risk due to the patient having capacity to make the decision. Staff E stated they then received a call to inform that the patient had left the ED. Staff E recalled that he did not receive notification prior to the patient departing and stated, they were not able to evaluate the patient for capacity at the time of the patient’s departure. Staff E stated that capacity for patients with dementia is fluid, so they would have liked to have been notified prior to the patient’s departure so that he could properly assess the patient. The triage RN and primary RN were not available for interview. Similar finding of ED elopement was identified for Patient #2: On 1/30/2024, at 1335 (1:35 PM), the patient was brought to the ED by Emergency Medical Service (EMS) for chief complaint of shortness of breathing. As per EMS and mother, the patient had history of asthma and autism. On 1/30/2024, at 1348 (1:48 PM), ED Medicine Resident’s (Staff O) History and Physical noted patient with history of Autism, Learning disability, and Obesity. There was no documented evidence in the medical record the patient was assessed for elopement risk. The patient was admitted to medicine service due to asthma exacerbation worsened by Influenza A, location still in ED. On 2/3/2024 at 1303 (1:03 PM), ED Medicine Resident (Staff P) Progress Note addendum stated, that 45 minutes after the medical team evaluated the patient, medical team received information from covering nurse that the patient had left his bed. Medical team responded to the ED immediately. Hospital police and charge nurse were notified. Family’s home was called several times. Final attempt was made, and the patient was home. The provider spoke with the patient’s mother who stated the patient was independent. The provider explained to the mother that the patient needed further in-hospital care and to bring patient back to the ER. On 2/3/2024 at 1409 (2:09 PM), RN documented, the patient eloped, and IV (intravenous) catheter was found at bedside. The physician reported patient elopement to the charge nurse and head nurse. At 1431 (2:31 PM), the ED Medicine Resident, noted, hospital police was notified at this time as patient was autistic and provider believed the patient not completely understood his medical condition. At 2:45 PM, the ED Resident noted the patient’s mother called and stated the patient walked home. The patient’s mother stated that she would bring patient back to the hospital for treatment. At 1619 (4:19 PM), RN notes documented the patient returned to the ED accompanied by brother and father. ED attending requested to place 1:1 order for patient secondary to elopement. During interview on 6/5/2024 at 12:00 PM, Staff I (ED Staff RN) involved in the patient’s care, stated doing a lunch coverage. The patient was handed off not on elopement risk and wearing a regular gown. The patient was alert and oriented, calm, and sitting up on bed when received. Staff I stated, patient had autistic spectrum with no indication to put patient on elopement. The patient had no behavioral issue. Staff I stated that when a follow-up check on patient was done, bed was found empty. Staff I stated head nurse was notified. During interview with Staff K (Hospitalist) on 6/5/2024 at 1:45 PM, Staff K confirmed these findings. An Immediate Jeopardy situation was identified on 6/7/24 at 12:30 PM due to the facility’s failure to assess, identify, and implement protective measures for patients at risk for elopement. The facility policy and procedure on “Elopement ...” that directs staff to assess all patients for elopement were not implemented. The facility provided an IJ Removal Plan to survey staff on 6/7/24 at 8:42 PM which included the following: -Modifications to the policy and procedure titled “Elopement, Leaving Against Medical Advice, Left Without Being Evaluated,” and are as follows: “VI. PROCEDURE A. Elopement Risk Assessment: All patients at first point of contact (triage or admission) will be assessed for elopement risk. In the event a patient is unstable upon presentation, this assessment will be performed when medical stability is achieved. The Epic elopement risk assessment tool will be used by nurses in the ED in assessing whether a patient is at risk for elopement. The criteria in this tool are as follows: 1.Patient cognitively impaired 2.Prior history of elopement 3.Patient has prior history of eloping from other facilities 4.Patient is making attempts to escape from the unit. 5.Patient is verbally threatening to leave the unit without permission 6.Patient is checking doors and windows 7.Patient is fearful and demonstrating paranoia related to the hospital environment 8.Patient constantly requested personal belongings 9.Patient has current substance withdrawal and expressing a strong urge to use. 10.Special observation by psychiatry 11.Court order for hospital stay/legal guardian 12.Is the patient a risk for elopement? A patient is deemed at risk for elopement if any of the above criteria are met. -This plan will be immediately implemented. All registered nurses In the Emergency Department (ED) will receive training on the revised policy, all staff will be trained prior to the start of their shift. No employee will provide patient care until training and education have been completed. The IJ was removed on 6/10/24 at 5:23 PM after an onsite verification of the changed policy and procedure, interviews, and verification of staff education.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 48940 Based on medical record (MR) review, document review and interview, in two (2) of five (5) Medical Records reviewed, it was determined that the facility failed to investigate and perform an assessment or analysis of elopements from the emergency department (ED) to identify potential issues and implement corrective actions to prevent future occurrences. (Patient #1, #2) Findings include: The facility’s policy and procedure titled “Occurrence Reporting/Adverse Events Reporting Program,” revised date 06/2023 documented: I. PURPOSE: A. To identify and evaluate adverse events, under the New York State Patient Occurrence Reporting and Tracking System (NYPORTS), and to track and trend other patient, staff and visitor related safety events that have the potential to cause harm. V. RESPONSIBILITY: C. Risk Management Department: Tracks and trends occurrences, investigates events, schedules RCA meetings, determines reportability of events, facilitates identification, and follow-up of risk reduction strategies. VI. PROCEDURE: A. HOW and WHEN TO REPORT: b. Within 24 hours, but as soon as practical, the staff member should enter the report electronically in VOICE. B. WHAT TO REPORT: a. Reportable adverse events which require notification within 24 hours but as soon as practical include, but are not limited to: >Elopement and unauthorized departure of a patient from a staffed around the clock care setting (including ED) ... Review of the facility’s VOICE Report documented Patient #1 an elopement event dated 4/25/2024 at 6:05 AM. -Brief Factual Description: Patient verbalized to team and primary nurse that he wanted to leave, team spoke with him. Writer was approached by patient’s wife around 12:00 PM that he did not reach home after leaving the hospital. Hospital Police notified, 911 called and information provided to operator #1391. -Assessment: Patient verbalizes to nurse about him leaving the hospital. MD notified. Patient left AMA. -Recommendations: none noted on the report. -Resolutions and Outcomes of Event: “No Harm Reached Patient No Monitoring Required.” The facility’s VOICE Report for Patient #2 documented an elopement event dated 2/3/2024 at 1350 (1:30 PM). Description: -The patient eloped from assigned area. The (IV) intravenous catheter was left on the floor and the wrist band was on bed. Patient belonging bags were found empty on his assigned bed. -Contributing factors: Cognitive Impairment, Mental Status/Capacity, Patient -Lack of Understanding. -Resolutions and Outcomes of Event: “No Harm Reached Patient No Monitoring Required.” Resolution/Outcome Notes included on 2/3/2024, patient left the hospital without any notification and was brought back to the hospital by his family for further treatment. No harm or injury indicated upon examination. Patient was placed on 1:1 observation for safety. No further investigation required. During interview on 6/3/2024 at 2:18 PM, Staff A (Director of Risk Management (RM)) confirmed that for Patient #2 VOICE Report, per RM review, the Resolutions and Outcomes of the Event was, “No Harm Reached Patient No Monitoring Required.” During a second interview on 6/4/2024 at 10:26 AM, Staff A stated that the VOICE Report for Patient #1 was reopened on 6/3/24 at 3:02 PM, because the report was not completed in its entirety by Staff F (ED Director of Nursing). During an interview on 6/6/2024 at 11:19 AM, Staff F (ED Director of Nursing) stated that she reviewed the VOICE Report for Patient #1. Staff F recalled counseling the staff regarding calling the patient’s family members. Staff F also acknowledged that there were no recommendations or actions taken on the VOICE Report regarding this incident.”