On the icy morning of December 3, 2008, the body of an 89-year-old woman was found on the roof of the University of Pittsburgh Medical Center (UPMC) Montefiore.
Rose Lee Diggs, who had a history of dementia, died after she allegedly wandered away from her hospital room and onto the facility’s roof.
Dressed in a hospital gown and slippers, Diggs left her 12th floor room and made her way to the roof through an unlocked door on a night with 20° temperatures. She was found shortly before 8 a.m., more than 13 hours after she was last seen one story below in her hospital room, according to a report in the Pittsburgh Post-Gazette.
Her death sparked a review by the state health department, as well as a lawsuit brought by her son, and prompted major changes in hospital procedures.
“We are applying the lessons learned in this incident to improve the safety of our most vulnerable patients,” Tami Merryman, chief quality officer at UPMC, said in a press release about the new safety procedures. The hospital did not respond to a request for an interview.
Those lessons may help other hospitals struggling to keep patients with Alzheimer’s disease and dementia, who sometimes have a habit of wandering, safe while in their facilities.
According to a 2007 report from the Alzheimer’s Association, about 25% of older adults who are hospitalized have some form of dementia. And hospitalization brings a change of environment that often leads to an increase in confusion, agitation, and behavioral problems in such persons.
Security and safety officials should work closely with clinical staff members to ensure the safety of this vulnerable population. Hospitals can take the following actions to help protect dementia patients:
1. Complete patient assessments. Be sure that clinical staff members complete patient assessments that will determine whether a patient is at risk for wandering. The state cited UPMC for failing to adequately assess Diggs’ history and complete an appropriate plan of care for her, even though a report from the skilled nursing facility in which she had been before her admission noted she had a habit of wandering. In response, UPMC will now have geriatric or psychiatric nurses thoroughly assess certain patients to identify those most at risk for wandering, according to the hospital. Following the assessment, staff members will develop individualized patient care plans and decide which specific interventions to use.
The assessment process is a responsibility of the nursing department rather than a security function, says Russell Colling, MS, CHPA, CPP, healthcare security consultant at Colling and Kramer in Salida, CO. Identifying patients at risk of wandering is key to preventing problems, Colling says.
Be sure that staff members report cases of wandering to supervisors and document instances in the patient’s medical record. In the health department report, seven staff members confirmed that Diggs frequently wandered and staff members had to take additional measures to ensure her safety. The lawsuit against UPMC alleges that no one created a plan to address safety concerns. If a patient is at risk for wandering, have a plan for monitoring the person, says Colling.
Keep in mind that a trip to the hospital can be a recipe for disaster for patients whose memory and judgment are compromised.
“A new environment is a key red flag,” says Gerald Flaherty, vice president of medical and scientific programs at the Alzheimer’s Association, Massachusetts/New Hampshire Chapter.
When admitted to a strange new setting, such patients may not recognize where they are and struggle to make sense of their new environment. They are also faced with unfamiliar caregivers and might undergo intrusive procedures. They may attempt to escape from the facility or go home and can get lost in or outside the hospital. Once lost, they are in danger of injury or death from falls, accidents, and exposure, Flaherty says.
Even if patients have not wandered from their home or in a nursing home or assisted living facility, they could be at risk for this behavior in the unfamiliar hospital.
Staff members may find that dementia symptoms were not recognized in older patients before their hospitalization.
Clinicial staff members should also be aware of the risk of delirium in Alzheimer’s patients, Flaherty says.
2. Provide appropriate supervision to patients at risk for wandering. Once a risk assessment is completed, make sure all employees interacting with a patient at risk for wandering—particularly nursing staff members—are aware of the situation, says Flaherty.
Staff members should conduct more frequent checks of such patients, says Colling. If possible, place the patient in a room that allows for maximum staff surveillance, such as one near the nurses’ station.
With the nursing staff stretched thin at many hospitals, some facilities hire sitters—employees who earn about $10 per hour to stay outside the rooms of wandering patients. In summer 2008, UPMC eliminated most of its sitters, according to the lawsuit filed in the case.
In an emergency, security staff members may be called to do a patient watch until a more permanent sitter is found, Colling says.
Staff members should also be aware that they must not leave patients at risk for wandering alone, such as while waiting for x-rays or other tests, says Flaherty.
Hospitals can reduce environmental triggers for wandering by placing at-risk patients in rooms that are away from areas of high traffic or noise. Although there may be many reasons for wandering (e.g., the patient is restless or looking for the bathroom, something to eat, or a loved one), the bottom line is supervision, Flaherty says.
3. Establish a search process for missing patients. Hospitals should have lost-person protocols, says Nina M. Silverstein, PhD, professor of gerontology at the University of Massachusetts in Boston and coauthor of two books on the issue, Improving Hospital Care for People with Dementia and Dementia and Wandering Behavior: Concern for the Lost Elder.
This was one of the most significant steps UPMC took in response to Diggs’ death. The hospital created a procedure to rapidly locate missing patients.
Modeled after other rapid response teams used in hospital emergencies, the Condition L safety procedure mobilizes hospital staff members from across the facility for a comprehensive, systematic search in the rare -cases when patients wander from their units, the hospital stated in a press release.
UPMC plans to eventually adopt the Condition L procedure at all its facilities.
Similar to existing emergency codes used at the hospital, a nurse on the unit will initiate the Condition L procedure, and the hospital operator will announce the code on an overhead system throughout the hospital complex and give a description of the patient. The hospital will immediately notify local police.
“Condition L summons and utilizes every available staff member, including security, nursing, maintenance, and housekeeping, to assist in a coordinated search of the hospital complex,” according to the UPMC press release. “Our goal is the safe and quick return of the patient to the unit,” said Holly Lorenz, chief nursing officer and vice president of patient care services at UPMC Presbyterian Shadyside. The hospital is also evaluating the use of trained search dogs to assist in the search, if necessary.
Cases of missing patients in a hospital are not uncommon, says Colling. Fortunately, most instances have a successful outcome in which the missing patient is found without a problem.
Staff members should notify security if a lost patient is not found within a certain time frame, and security should have a process to notify police, says Colling. The hospital should also designate someone to notify family members.
Train security staff members about wandering behavior and search-and-rescue procedures for lost patients. Hospitals may also want to encourage families to register their relatives with dementia in the Alzheimer’s Association’s nationwide Safe Return alert program.
4. Take advantage of technology. Some hospitals have adopted electronic monitoring systems for dementia patients. Hospitals can combat wandering by placing an electronic bracelet on the wrists of dementia patients, similar to systems designed to prevent infant abductions.
Patients wear a tag that contains a radio frequency circuit. The circuit communicates with a detection sensor usually installed at an exit door or elevator.
With other systems, a radio receiver is installed at a central location. The distance beween the tag and monitor is constantly measured with an alarm, which sounds when a predetermined distance is exceeded.
Another option is to consider pressure pad alarm sensors on beds and chairs that alert staff members when a patient gets out of bed or a chair, says Flaherty.
But don’t let technology substitute for appropriate supervision. “My feeling is that technology does not replace human interaction/supervision,” says Silverstein.
5. Be wary of restraint use. Hospitals must follow Joint Commission (formerly JCAHO) standards and Centers for Medicare & Medicaid Services regulations for restraint use.
Clinical staff members should avoid use of physical restraints on dementia patients because they can increase agitation and trigger more problems, says Flaherty.
Patients in restraints can also be injured trying to get out of them.
6. Be prepared to identify at-risk patients. How can staff members identify at-risk patients? Consider providing a different color or patterned hospital gown for patients at risk for wandering. At UPMC, at-risk patients now wear distinctively colored hospital gowns to make them easier to identify if they leave their hospital unit.
Be ready to provide a description of missing patients. UPMC plans to take photos of at-risk patients upon admission to the facility, if the patient or family permits it. In the event of a Condition L activation, the hospital will distribute the patient’s photo and description by e-mail to staff members throughout the complex.
7. Pay attention to facility maintenance and safety. At UPMC, lack of maintenance appears to have played a role in Diggs’ death. The door near her room, which was supposed to remain locked at all times, had a broken lock and was unsecured.
The state health department cited the facility for failure to maintain the hospital environment in a manner that ensured the safety and well-being of its patients.
Signs are now posted on all mechanical room doors indicating they must remain locked. Security and maintenance personnel collaborate to inspect door locks leading to mechanical areas and roofs on a daily basis. The hospital has set up an enhanced maintenance program for mechanical door testing.
Hospitals must secure their facility so patients cannot wander into areas in which they could be injured. One such area is the roof, Colling says, adding that two recent litigation cases he investigated involved patient deaths after they got onto rooftops.
8. Address problems as they arise. Don’t wait for a tragedy to happen before your hospital takes action. The lawsuit brought against UPMC claims there were at least 20–30 similar patient elopement cases during the past two years, reported the Post-Gazette. In one incident, an elderly man who wandered from a UPMC facility in summer 2008 was found 14 hours later by state police on the eastbound lanes of a Pittsburgh parkway, “cut, bruised, and dehydrated.” The lawsuit detailed other cases.
Silverstein says hospitals should practice their missing person protocols much the same way they practice fire drills.
But having more drills may not be practical, Colling says. “You practice every time you have an incident,” he says, adding that you should critique what went right and wrong when a patient goes missing.
Make sure your hospital’s emergency plans and procedures for handling missing patients are up to date. The lawsuit against UPMC claims that its disaster plan was created in the 1980s, and as of 2008, it featured an emergency contact number that connected to a Pizza Hut restaurant, according to the Post-Gazette.
The lawsuit also alleges there have been numerous incidents that demonstrate the need for better security at UPMC hospitals, including an assault on a nurse in a facility elevator and thefts of two laptop computers and a television.
The thefts prompted the security team to survey all doors and locks at Montefiore, which revealed problems with many doors and locks at the facility, the newspaper reported.
But at the time of Diggs’ death, no repairs had been made. One of the faulty locks was on the door to the 13th floor boiler room where Diggs gained access to the roof.
Your procedure for missing patients
All healthcare organizations should have a policy and procedure to follow if a patient is found missing, says Russell Colling, MS, CHPA, CPP, healthcare security consultant at Colling and Kramer in Salida, CO. This will dictate staff actions when a patient cannot be readily located.
Colling says the missing patient procedure should include:
- Who to notify
- Who will search
- Which areas will be searched and their priority
- Who will notify authorities, if necessary
- Who will notify family members
- Who will coordinate the search efforts