Thomas Jefferson University Hospital cited after elderly patient goes missing

A disoriented nursing home resident in need of urgent medical care walked out of Thomas Jefferson University Hospital’s emergency department without anyone noticing for hours, because staff failed to routinely check on him.

The January incident drew one of the state’s most serious warnings for Jefferson Health’s flagship Center City hospital, after inspectors concluded that the hospital failed to provide a safe environment in its emergency room, according to an inspection report released earlier this month.

Hospital staff determined the 71-year-old man needed to be seen urgently because he was disoriented and increasingly agitated, but then failed to document routine checks on him during the 13 hours he sat in a waiting room. Staff reported him missing almost three hours after he walked out of the emergency department.

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

State inspectors levied an immediate jeopardy warning, a sign of potentially life-threatening safety problems, during an investigation on Jan. 26. Sanctions were lifted hours later, after Jefferson administrators provided a plan to address urgent safety concerns, including adding another nurse to the emergency department to help triage patients.

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.

“Thomas Jefferson University Hospital (TJUH) is committed to providing the highest standard of care to our community,” she said.

The 71-year-old man arrived at Jefferson’s emergency department by ambulance shortly before 11 a.m. on Jan. 23. His medical issues included an “altered mental status,” urinary tract infection, and aggressive behavior.

He was triaged as a Level 3, meaning his condition was urgent and could progress to a serious problem requiring emergency action. Level 3 patients must be reassessed at least every two hours, according to the hospital’s policies.

Nursing notes show his blood sugar was tested at 12:05 p.m., after he complained he was hungry.

Inspectors found that staff didn’t document any checks on the man or make any any updates to his patient record after the blood sugar test.

The man walked out of the hospital 12 hours later, shortly after midnight on Jan. 24, security footage shows.

Staff didn’t file an internal missing person report until almost 3 a.m. They told health department inspectors they were “not aware” when the patient had left or where he went.

The hospital reported him missing to police around 9:30 p.m. that night, according to police reports. Police say the man was found the next day, when he returned to the hospital.

In response to the state’s citation, Jefferson determined that any patients arriving by ambulance with an altered mental state should be taken to an internal waiting room, where they could be watched more closely and couldn’t walk out unnoticed.

Staff were trained on how to evaluate patients to determine if they should be taken to the primary waiting room or an internal waiting room.

Staff were also retrained on how often they should reassess patients, based on their emergency severity level, and how to document all patient checks.

The hospital also added an extra full-time nurse to the emergency department to help triage patients.

Administrators agreed to audit patient charts to ensure patients are being triaged appropriately.