Jefferson hospital hit with warning after patient disappeared from ED

Philadelphia-based Thomas Jefferson University Hospital received an immediate jeopardy warning — and resolved it in a few hours — after a disoriented nursing home resident walked out of the emergency department unnoticed, The Philadelphia Inquirer reported April 9.

Shortly before 11 a.m. Jan. 23, a 71-year-old man was brought to the emergency department by ambulance with an "altered mental status," a urinary tract infection and aggressive behavior. He was triaged as level 3 and, per the hospital's policies, should have been reassessed at least every two hours. The man sat in the waiting room for about 12 hours before walking out of the ED unnoticed. Three hours passed before the staff reported him missing internally, and nearly 10 hours passed before the police were notified, the report said.

The patient was found the next day when he returned to the hospital, according to police reports. 

The hospital reported the incident to the state and did a "comprehensive review of our emergency department operations, policies and procedures to identify any opportunities for improvement," Jefferson spokesperson Deana Gamble said in a statement to the Inquirer.

State inspectors issued an immediate jeopardy warning to the hospital during a Jan. 26 investigation. Sanctions were lifted hours later after Jefferson administrators provided a plan of corrections. Corrections include taking patients with an altered mental state to an internal waiting room where they can be better watched, training staff to evaluate patients to determine which waiting room they should go to, retraining staff on how often to reassess patients and how to document patient checks, and adding an extra full-time nurse to the emergency department to help triage patients.

"Thomas Jefferson University Hospital is committed to providing the highest standard of care to our community," Ms. Gamble said.

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