Date
of Last Review 4/8/11
SME: Chief Nurse Officer
Elopement is when a patient leaves the hospital grounds, without permission (unauthorized).
When any patient elopes or is believed to be missing, it is the policy of the hospital to act in accordance with the welfare of the patient and the public while respecting the patient's rights.
When it becomes reasonably certain that a patient is missing without authorization, the person making the observation must initiate action to locate the patient.
Step |
Action | ||||||||||
1 |
Staff immediately notifies operator to call Code Green (see Code Green P&P) | ||||||||||
2 |
The employee immediately contacts UT Police/Security, providing them with a patient description and other pertinent information. | ||||||||||
3 |
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4 |
If the patient is located in the building by Security, Security notifies operator. Operator notifies unit staff and clears Code Green. | ||||||||||
5 |
UT Police/Security is responsible for contacting the appropriate police agency as deemed necessary. | ||||||||||
6 |
The staff/designee notifies the Nurse Manager, Monday-Friday (8 am-5 pm), and at all other times, notifies the Nursing Supervisor. | ||||||||||
7 |
The Nurse Manager/Nursing Supervisor notifies the CNO/designee Monday-Friday (8 am-5 pm), and at all other times the Administrator on-call. | ||||||||||
8 |
The assigned nurse notifies the attending physician Monday-Friday (8 am-5 pm), and at all other times the House Officer. | ||||||||||
9 |
If the patient cannot be found and is deemed suicidal/homicidal at the time of elopement, contact UT Dispatch 713-792-2890 immediately. | ||||||||||
10 |
See additional procedures related to the following:
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Patients who are hospitalized by court order are classified as involuntary.
Examples of court orders: Order of Emergency Detention or Protective Custody, Court-Ordered Temporary and Extended Mental Health Services
If an involuntary patient elopes, staff follow these steps immediately:
Step |
Action | ||||||||||
1 |
Follow Elopement Process instructions. | ||||||||||
2 |
Initiate Certificate of Return process. | ||||||||||
3 |
As appropriate per patient consent, notify the emergency contact person as follows:
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4 |
Staff documents notification/attempted notification in the progress notes daily until the:
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Voluntary patients are those who have signed themselves into the hospital and upon elopement have no commitment papers or other documentation on file changing their status to involuntary.
Step |
Action | ||||||||
1 |
Follow Elopement Process instructions, except for Step 5. | ||||||||
2 |
As appropriate per patient consent, notify the emergency contact person as follows:
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3 |
Staff documents notification/attempted notification in the progress notes daily until the:
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4 |
It is the responsibility of the family to request police assistance in locating the patient. | ||||||||
5 |
The physician discharges the absent patient after 48 hours or sooner if deemed appropriate. | ||||||||
6 |
If a voluntary patient request to leave from an off-campus appointment, the escorting staff will contact the unit to inform the nurse of the patient's request. 6.1 The physician will be notified to obtain an order for Against Medical Advice (AMA) discharge. |
For Child and Adolescent services, additional procedures are needed as follows:
Child/Adolescent Services |
Action | ||||||||||||||||||||
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Child/ Adolescent voluntary |
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Involuntary |
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Related to regulatory standards
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