HospitalInspections.org

Based on interview, record and policy review the facility failed to:
-Provide care in a safe setting to ensure that one (#3) out of one current patient and two (#10 and #11) out of two discharged patient records reviewed for elopement did not successfully elope from facility property.
-Staff did not follow expected observation protocol/policy when they failed to transport one (#3) current patient back inside the building after being on the playground outside, which allowed him to climb over the fence and elope off facility property.
-To prevent one (#11) patient from climbing over the playground fence and elope off facility property.
-Include elopement prevention/interventions in the treatment plan for six patients (#3, #4, #5, #6, #7 and #8) out of six current patients reviewed for elopement risk and for two discharged patients (#10 and #11) of two discharged patients reviewed for elopement risk .
The facility census was 81. This had the potential to affect all patients seeking care at the facility.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13 Condition of Participation: Patient's Rights

Based on interview, record and policy review the facility failed to:
-Provide care in a safe setting to ensure that one (#3) out of one current patient and two (#10 and #11) out of two discharged patient records reviewed for elopement did not successfully elope from facility property.
-Staff did not follow expected observation protocol/policy when they failed to transport one (#3) current patient back inside the building after being on the playground outside, which allowed him to climb over the fence and elope off facility property.
-To prevent one (#11) discharged patient from climbing over the playground fence and elope off facility property.
-Include elopement prevention/interventions in the treatment plan for six (#3, #4, #5, #6, #7 and #8) out of six current patients reviewed for elopement risk and for two (#10 and #11) out of two discharged patients reviewed for elopement risk .
The facility census was 81. This had the potential to affect all patients seeking care at the facility.

Findings included:

1. Record review of the facility's policy titled, "Elopement or Unauthorized Leave of absence" revised 09/18/12, showed the facility defined elopement as an unassisted, unsupervised, and/or unscheduled departure from facility property (including transport vehicles) by a patient/resident. The policy showed the following direction:
-Clinical Staff to assess each patient/resident for elopement upon admission, at the time of Individualized Crisis Management Plan (ICMP)development and during treatment upon indication of elopement due to stressful situations.
-Indicators of potential elopement include, but are not limited to, the following examples:
-Cognitive status (thinking, reasoning, or remembering)
-Aggressiveness
-Agitation/restlessness
-Change in schedule or routine
-Medication regimen
-Stressful situations
-Prior history of elopement
-Wearing layered clothing
-Discussing with other patients or staff ways to run from the building
-Verbal threats to run from the building
-Successful elopement from the hospital campus
-Pulling fire alarm or testing doors with intent to exit the building.
-Update the Master Treatment Plan (MTP) and ICMP as necessary.
-Discuss patients/residents who have been assessed and found to be at-risk for elopement (i.e. those who are known to elope are beginning to exhibit signs of desire to elope, or are new to the facility).
-Make assignments to staff regarding constant, frequent, or periodic checks on these at-risk patients/residents.

Record review of the facility's undated document entitled "Elopement Program Assessment Tool" showed the following direction:
-Education/Staff Competency: Staff training related to exit-seeking behaviors and how to minimize this behavior before an elopement occurs has been conducted and is documented.
-Environmental Precautions: Interventions are documented for the facility's use to minimize the risk of elopement.
-Medical Record Review: Elopement risk assessment tool is completed within four hours of admission, and on chart.
-General Questions: For elopement or near miss elopements, the incidents are evaluated and measures have been put into place to reduce the same type of occurrence from happening again.

Record review of the facility policy titled, "Observation and Patient Monitoring" revised 04/03/12, showed the following direction:
-Facility staff should monitor patients visually and randomly within 15 minute intervals. The real time is to be documented and ensure there is a minimum of four observations in an hour. The intervals between patient observations should not be greater than 20 minutes apart.
-The purpose of the policy is to provide guidelines to clinical staff to ensure a safe and secure environment through assessment, intervention, and treatment for those patients who are high risk for harm to self, harm to others or elopement.
-A line of sight (LOS) patient is to remain in line of sight of staff at all times, including bathroom and shower times, but does not have to be within arm's length. These patients are assigned to rooms close to the nurses' station to ensure continuous monitoring and will be restricted to the unit.
-Assign staff to document a narrative note once a shift for patients on line of sight which address progress or lack of progress towards the Multidisciplinary Treatment Plan (MTP) goals.
-Assign staff to document a narrative note on day and evening shifts for patients on 15 minute checks which address progress or lack of progress towards the MTP goals. Night shift is to monitor for any sleep or safety concerns and document as needed.

2. Record review of Patient #3's medical record showed he was admitted to the facility on 04/01/13 with complaints of Bipolar Disorder (a person goes between very good moods to irritable to very depressed)

3. Record review of Patient #3's Psychiatric Initial Evaluation Note dated 04/02/13 at 12:00 PM showed the following information:
-Chief complaint: The patient stated, "My brother says I hit him."
-History of Present Illness: This patient is progressively and increasingly assaultive to his brother. The patient had hidden knives, broken windows, and destroyed property. He smears feces of his and the dog's on himself and puts fireworks in the microwave. He has run away recently.

4. Record review of Patient #3's Admission Orders dated 04/01/13 showed the physician ordered under Risk Categories: Suicide risk, assault risk, and elopement risk.

5. Record review of Patient #3's MTP showed staff did not address or include specific interventions, goals, or timetables related to the physician ordered suicide risk, assault risk, or elopement risk in the patient's treatment plan.

6. Record review of the facility document titled, "15 Minute Precaution Check & Point Sheet," dated 04/07/13 for Patient #3 showed he was off the unit from 5:15 PM until 6:15 PM. Review showed in the section titled, "Comments," staff had documented the word eloped. One line was marked through the 5:00 PM to 6:00 PM times with the word, "error."

7. During an interview on 04/09/13 at 12:40 PM, Staff C, Chief Clinical Officer (CCO) and Staff D, Director of Nursing (DON), stated that on Sunday evening 04/07/13 a patient was left on the playground. They stated that no immediate changes in processes, staff education, or new quality monitoring were completed at this time to ensure patient safety.

8. Record review of the facility's document titled, "Incident Report Form," dated 04/07/13 at 6:20 PM showed Patient #3 was left outside on the south playground when the rest of the patients from 2-Central Unit went inside the building on 04/07/13 during the 3:00 PM to 11:00 PM shift.

9. During an interview on 04/10/13 at 9:10 AM Staff R, Registered Nurse (RN), stated that on the evening of 04/07/13 the patients from 2-Central and staff were playing in the south playground. She stated that when the patients lined up to go inside she assisted a patient to remove sand from her shoes. She stated that she did not count the patients before going inside the building at approximately 5:45 PM.

10. During an interview on 04/10/13 at 9:40 AM, Staff I, Behavioral Health Tech (BHT), stated that on the evening of 04/07/13 the patients from 2-Central and staff were playing in the south playground. He stated that the patients lined up and he moved to the end of the line. Staff I stated that Staff T, BHT, counted 18 patients which was the correct number. He stated that the line of patients and staff walked into the building. Staff I stated that staff failed to re-count patients after entering the building.

11. During an interview on 04/10/13 at 10:00 AM, Staff T, BHT, stated that on the evening of 04/07/13 the patients from 2-Central and staff were playing in the south playground. She stated that the patients lined up at approximately 5:35 PM and then the patients removed the sand from their shoes. Staff T, stated that she saw Patient #3 in line and the patient count was 18, which was correct. Staff T stated that the patients and staff entered the building. and she did not see Patient #3 leave the line. Staff T stated that staff failed to re-count patients after entering the building.

12. During an interview on 04/10/13 at 10:25 AM, Staff L, RN, stated that she went back to the unit due to an injured patient while the unit staff and patients were on the south playground on the evening of 04/07/13. She stated that she became aware of the incident when she came to the cafeteria. Staff L stated that staff are to re-count patients when staff come into the building. She stated that Patient #3 told her that he had thrown his shoes over the fence so he climbed over the fence to get his shoes. She stated that Patient #3 then climbed back over the fence into the playground and knocked on the gym door. Staff L stated that Patient #3 stated that he was playing hide and seek and gave her the impression he was not ever in line. Staff L stated that she heard there was a witness that saw the patient outside of the fence.

13. During an interview on 04/15/13 at 2:36 PM Staff JJ, House Supervisor, stated that he was working the evening of 04/07/13 when he was notified by the operator that a staff from 4 South had notified her that there was a child on the playground. Staff JJ stated that he was headed to the playground (a person would go through the gym to get to the door that leads to the playground) and when he got to the gym he heard someone knocking on the door. He stated it was Patient #3 who stated that he had not been outside the fence and his unit was upstairs. Staff JJ stated that he took the patient to the cafeteria where the patients from 2-Central were eating.

14. During an interview on 04/15/13 at 4:36 PM Staff KK, BHT, stated that she witnessed the boy outside the playground and he was trying to get in by pulling on the gate. Staff KK stated that she went to her unit and called the operator to report the situation.

15. During an interview on 04/15/13 at 4:41 PM Staff LL, BHT, stated that the 4-South patients and staff were going up the stairs to their unit. She stated that they looked outside a window in the stairwell between third and fourth floors. Staff LL stated that they noticed a young boy outside of the playground fence, on the sidewalk, and he grabbed the wood gate trying to open it. Staff LL stated she stayed and observed the boy while Staff KK went to the unit to notify someone just in case it was a patient. She stated that another staff came down the hall and stated that they would go outside and check the boy to see if it was a patient. Staff LL stated that the boy continued to walk back and forth on the side walk. Staff LL stated that a little while later she was in the cafeteria and saw Staff JJ, House Supervisor, with the boy she had seen outside. She stated that Staff JJ asked if he was a patient of 2-Central. She stated that the 2-Central staff said he was their patient and seemed surprised. Staff LL stated that she felt the staff did not act as if they knew he was gone.

16. During an interview on 04/16/13 at 1:15 PM Staff NN, Certified Recreational Therapist, stated that she had seen the boy outside through the window in the stairwell and went outside to check on him. She stated that when she arrived outside the boy was gone. Staff NN stated that the facility has not given any formal education that she was involved in since 04/07/13 regarding this elopement or the escorting of patients off the unit.

17. Record review of the facility investigation and education document provided on 04/16/13 at 4:51 PM showed no plan for Quality Assessment Performance Improvement (QAPI) to ensure the education given to staff and changes made in procedures were maintained to ensure patient safety. It was noted that the patients lined up at 5:35 PM and were at the cafeteria at 5:45 PM. At 5:45 PM the Precaution Check was completed when the patient was not there and the staff was unable to visualize the patient. The patient was by himself outside for approximately 20 minutes.

18. Record review of Patient #10's medical chart showed he was admitted to the facility on 02/27/13 with complaints of major depressive disorder (a mental disorder characterized by episodes of all-encompassing low mood accompanied by low self-esteem and loss of interest or pleasure in normally enjoyable activities).

19. Record review of the patient's Admission Orders dated 02/27/13 showed the physician ordered 15 minute checks and line of sight (LOS) and suicide risk, assault risk and elopement risk.

20. Record review of Patient #10's Physician's Order Sheet dated 02/28/13 showed the physician discontinued LOS due to no suicidal or homicidal ideation.

The physician did not discontinue the patient's assault risk or elopement risk.

21. Record review of Patient #10's Psychological Evaluation dated 03/10/13 showed the patient reported being in the hospital "for suicidal and homicidal thoughts because of too much pressure everywhere." He reported feeling helpless, hopeless and worthless. His insight and judgment were poor considering patient's past behavior and recent conflicts. He reported having a "low" energy level.

22. Record review of the patient's MTP dated 02/28/13 showed staff did not address or include specific interventions, goals or timetables related to the physician ordered LOS monitoring, assault risk or elopement risk in the patient's treatment plan.

23. Record review of Patient #10's Clinical Formulation Update-Acute showed on 03/04/12, 03/11/13 and 03/18/13 staff only addressed Problem Number 1: MDD (major depressive disorder) but did not include in the patient's treatment plan the physician ordered assault risk or elopement risk.

24. During an interview on 04/09/13 at 11:00 AM, Staff EE, Recreational Therapist (RT), stated the following information.
-That patients were lined up to go to the gym for recreational therapy;
-There were three staff to transport approximately 16 patients from the unit to the gym.
-He ensured one staff was at the front of the patient line, one in the middle and one at the back.
-When the patients got to the landing of the stairwell, Patient #10 and another patient broke line and ran down the last set of stairs into the main lobby area.
-The one patient tried to get out the main door but could not exit.
-Patient #10 pulled the fire alarm and ran to the door at the end of the hall of the main lobby and exited through the door.
-Staff EE informed the receptionist to call a code to alert other staff of the elopement.
-The staff to patient ratio or the process to transport patients off the unit has not changed since the elopement and patient ratio is one staff to six patients.
-For transporting 12 or fewer patients two staff are used during transport with one staff at the front of the line and one at the back of the line.
-To his knowledge there had not been any policy change related to transporting patients off the unit since the elopement incident and the facility had not done any in-service or education for staff since the elopement.
-He learned about patient precautions by looking at the RN's "brain" (nursing report sheet) and talking to BHTs.
-The other patient who attempted to elope was allowed to go off the unit for breakfast and recreational therapy the next day.
-Staff EE stated that he treats all patients as elopement risk.

25. Record review of the patient's Progress Care Record-Acute showed the following information:
-On 03/20/13 at 9:27 AM, staff documented patient had a blunted affect (a significantly reduced intensity in emotional expression). Patient was cued (a sensory signal used to identify experiences and to facilitate memory) on talking out and wandering. Patient did go off the unit for breakfast. Patient stated "I'm supposed to go back to the residential home soon." Patient did need staff redirection. Patient left school and went to his room.
-On 03/20/13 at 2:07 PM, staff documented patient pulled fire alarm, ran out north door and eloped.
-On 03/20/13 at 11:59 PM, staff documented patient had not been returned to facility or found by authorities and was discharged at that time.

Staff did not address the patient's increased risk for elopement when he required cuing from staff for wandering and left school to go to his room.

26. Record review of the patient's Incident Report Form dated 03/20/13 showed that staff documented the patient removed a maroon sweater and was wearing a striped black and cream shirt and khaki pants.

Staff did not address the patient's layering of clothing to indicate increased behaviors of elopement risk.

27. During an interview on 04/08/13 at 3:00 PM, Staff E, RN, stated that there was no nursing assessment for patient elopement risk documentation.

28. During an interview on 04/09/13 at 9:30 AM, Patient #10 stated that a peer on the unit approached him and suggested that they leave the facility. He stated that the peer told him a friend would be waiting at the entrance of the building with a car to take them to a friend's house and have some fun. He stated that you know how something sounds good at the time but later you find it wasn't such a good idea, well that was what happened with this idea to leave the facility. He stated that he knew if he pulled the fire alarm it would release the locks on the doors and he could run out. He denied having issues with how staff treated him. He stated that he just thought it sounded like a good idea at the time to run away from the facility. He stated that he was not stressed about being discharged back to the residential home.

29. During an interview on 04/09/13 at 10:00 AM, Staff Y, RN Day Charge Nurse, stated that assessments for patients' precautions are taken from review of the intake information and interviewing the patient. Staff Y stated that after behaviors have been identified she asked patients about triggers and coping skills they have. Staff Y stated that the precautions are included in the patients' treatment plan. Staff Y stated that she has not had any in-service or training from administration since the patient eloped on 03/20/13. Staff Y stated that to her knowledge there has not been any policy or procedure change related with transporting patients off the unit. Staff Y stated that the nursing manager talked to staff but the process to transport patients off the unit has not changed since the elopement occurred on 03/20/13.

30. During an interview on 04/09/13 at 10:15 AM, Staff Z, RN, stated that the facility has not done any in-service or education and that she has not seen a change in policy since the elopement incident that happened on 03/20/13.

31. During an interview on 04/10/13 at 10:25 AM, Staff GG, RN, stated that she finds out if a patient is at risk for elopement from the intake assessment and if the patient is admitted for running away. Staff GG stated that precautions are listed on the "brain" and is communicated. Staff GG stated in reality elopement should be included in the patient's treatment plan and it was a good idea to include it. Staff GG stated that it should be expected to be included in the treatment plan if a patient is at risk for elopement.

32. During an interview on 04/09/13 at 10:25 PM, Staff M, RN, stated that there were not any changes in processes on the 2-South Unit since the elopement on 03/20/13. There was not any nursing assessment for patient elopement risk documentation.

33. During an interview on 04/09/13 at 10:30 AM, Staff AA, Behavioral Health Technician (BHT), stated that to his knowledge the facility has not done any in-service or education or changed the process to transport patients off the unit since the elopement incident. Staff AA stated that no policy change has occurred to his knowledge. Staff AA stated that he received information about patients' precaution levels from shift report and the worksheet "brain".

34. During an interview on 04/10/13 at 10:35 AM, Staff HH, RN stated that she finds out if a patient is on elopement precautions from the intake assessment, recent behaviors, if the patient has eloped prior to admission, and from the staff "brain" and the information is passed on in report. Staff HH stated that elopement risk is expected to be included in the Master Treatment Plan and Individualized Crisis Management Plan. Staff HH stated that she felt like elopement risk does not need to be included in the patient's MTP because of the "brain" and communication between staff including the BHTs.

35. During an interview on 04/09/13 at 10:40 AM, Staff BB, BHT, stated that no specific change in process has happened to transport patients off the unit. Staff BB stated that staff to patient ratio to transport patients off the unit has not changed since the elopement on 03/20/13. Staff BB stated that there has not been any in-service or education related to the elopement incident.

36. During an interview on 04/09/13 at 10:45 AM, Staff CC, BHT, stated that there has not been any process change with transporting patients off the unit since the elopement on 03/20/13. Staff CC stated that the facility has not provided any in-service or education since the elopement incident occurred. Staff CC stated that nothing regarding the elopement incident has come from administrative staff. Staff CC stated that information about patients' precautions is given during the change of shift report.

37. During an interview on 04/09/13 at 12:00 PM, Staff D, RN, Director of Nursing (DON), stated that she had not done any in-service or education with staff related to the elopement or transporting patients off the unit since the incident on 03/20/13.

During an interview on 04/10/13 at 8:30 AM, Staff D, DON, stated that there is no further assessment documented of the patient's elopement risk after admission. She stated that the staff observed for signs that a patient was an elopement risk, but failed to document those observations.

During an interview on 04/10/13 at 2:55 PM, Staff D, DON, stated that if a patient continued to be an elopement risk after the assessment is completed then she would expect staff to include elopement in the patient's treatment plan.

38. During an interview on 04/09/13 at 12:40 PM, Staff C, Chief Operating Officer (COO) and Staff D, DON, stated that after the March elopement there was no analysis completed, no policy changes, and no education of staff completed. The staff followed the elopement policy so the facility felt the policy was okay. Administration did talk with staff regarding the incident, but did not document the discussion.

39. During an interview on 04/09/13 at 3:15 PM, Staff C, COO stated that all patients were considered elopement risks on admission and the patients could go anywhere in the building and to the south playground (escorted by staff). He stated that the south playground was considered a locked parameter.

40. During an interview on 04/09/13 at 1:40 PM, Staff A, Chief Executive Officer (CEO), stated that the elopement committee failed to meet after the March elopement incident. He stated that he felt the elopement committee should have met after the incident. He stated that the managers discussed the incident and reviewed the policy, but there were no minutes documented of the meeting. He also stated that the facility failed to complete an in depth investigation.

41. During an interview on 04/09/13 at 1:55 PM, Staff G, Director of Maintenance, stated that he did not have any quality data collected on the maintenance of the boxes that covered the fire alarm pulls to ensure they were well secured to the wall and staff would be able to lock and unlock the boxes as needed.

42. During an interview on 04/09/13 at 2:15 PM, Staff DD, BHT, stated that he was in the middle of the line during transporting patients off the unit on 03/20/13. Staff DD stated that there were three staff transporting approximately 18 patients to recreational therapy. Staff DD stated that since he was in the middle of the line he did not see Patient #10 brake line and run. Staff DD stated that when Patient #10 broke line and ran he was instructed by the Recreational Therapist to return the patients back to the unit. Staff DD stated that he received training about transporting patients off the unit in orientation and felt like staff did what they were trained to do. Staff DD stated that maybe more staff was needed when transporting patients off the unit. Staff DD stated that the facility had not changed the process of transporting patients or done any in-service or education related to transporting patients off the unit since the elopement. Staff DD stated that patient precautions are shared during report and are documented in the medical record.

43. During an interview on 04/09/13 at 3:00 PM, Staff FF, BHT, stated that he was at the back of the line when Patient #10 broke line and he did not see anything. Staff FF stated the only thing that changed after Patient #10 eloped from the facility was that a red metal box was put over the fire alarms. Staff FF stated that there had not been any change in policy or procedure since the elopement and the facility has not provided any in-service or education. Staff FF stated that he felt patients on precautions, for example, suicide, homicide and elopement, should stay on the unit until the physician has cleared them to go off unit. Staff FF stated after the elopement he was not asked to sit in on the elopement committee or take part in an analysis of the elopement.

44. During an interview on 04/10/13 at 9:10 AM, Staff R, RN, stated that she was unaware she could open the box covering the fire alarm pull with the keys she had. She stated that the staff received no education after the elopement event on 03/20/13.

45. During an interview on 04/10/13 at 12:00 PM, Staff Q, Educational Consultant, stated that staff received the following education about elopement:
-Purpose
-What an elopement is
-How to call a code
-Information to give the operator
-Monitoring patients when going out (signs of elopement)
-Report elopement to supervisor
Staff Q stated that she has not reviewed elopement risk nor done any additional education for staff related to elopement after Patient #10 eloped.

46. Record review of Patient #11's medical chart showed she was admitted to the facility on 09/11/12 with complaints of Bipolar Disorder.

47. Record review of Patient #11's Psychiatric Evaluation showed
Chief Complaint was the patient harmed herself. The patient displayed self-harm. She had scratches on her chest and she evidently took a steak knife and was cutting herself. This patient was defiant and aggressive with suicidal and self-harming behaviors. She had made threats to jump out of a moving vehicle when she was in the police car the time.

48. Record review of Patient #11's Admission Orders dated 09/11/12 showed the physician ordered suicide risk, assault risk, and elopement risk.

49. Record review of Patient #11's MTP showed staff did not address or include specific interventions, goals, or timetables related to the physician ordered suicide risk, assault risk, or elopement risk in the patient's treatment plan.

50. Record review of Patient #11's Patient Care Record-Acute showed on 09/22/12 at 5:15 PM Patient #11 was in the south playground and jumped over the fence. The patient was found approximately 30 minutes later and was happy and excited about the elopement. During the time staff chased Patient #11, she would show herself and then walk/run off so she would not be caught. The patient was on elopement risk until discharged on 10/10/12.

51. Record review of the facility document, "Incident Report Form," dated 09/22/12 showed Patient #11 went outside in the south playground with other patients and staff from the unit. She bolted to the fence and was over the fence before staff could stop her. Patient #11 was apprehended by staff and came back to the facility without a struggle. The patient arrived back to the facility in less than 30 minutes. The patient complained mainly of pain in her heels and up into her ankles. The pain increased with walking (the patient landed on her feet when she jumped the fence). The investigation consisted of four statements from staff involved.

52. Record review of the documentation presented by the facility on 04/15/13 at 5:10 PM showed:
-On 09/27/12 (five days after Patient #11 eloped) at 2:30 PM a staff meeting was held on 2-South by Staff MM, RN. Staff MM stated that the staff needed to be aware of people security while outside on the playground as the fence can be easily jumped over.

The facility provided no documentation of any facility wide education, no documentation of policy review or changes and provided no documentation of any Quality Assessment Performance Improvement (QAPI) processes put in place to ensure future patient safety.

53. Observation on 04/10/13 at approximately 2:00 PM of the south playground showed a fence that was approximately five and one half to six feet tall. It was made of boards that were vertically butted up next to each other (not allowing for space between the boards). On the inside of the fence (side facing the playground) there were two boards running horizontally across the vertical boards for support. The horizontal boards were continuous across the entire fence area. One board was placed in the middle of the top half of the fence and the other horizontal board was placed across the middle of the bottom half. The horizontal boards were approximately two inches wide and had a depth (from the fence outward) of approximately one inch. This increased the potential for a patient to be able to put feet on these support boards and go over the fence to the outside.

54. Record review of Patient #4's medical record showed she was admitted to the facility on 04/09/13 with complaints of major depressive disorder.

55. Record review of the patient's Psychiatric Evaluation dated 04/10/13 showed that the patient was overwhelmed and stressed at being in the facility and wanted to go home. She hears her aunt's voice, and she is asking whether she can go home tonight. She stated that she was missing her family. She states, "I wanted to go out, but they would not let me, so I will not sleep or eat while I'm here." She asked permission to just stay up on the corridor, and was told that she had to be in bed.

56. Record review of the patient's Admission Orders dated 04/09/13 showed the physician ordered suicide risk, assault risk and elopement risk.

57. Record review of Patient #4's MTP dated 04/09/13 showed staff did not address or include specific interventions, goals or timetables related to the physician ordered assault risk or elopement risk.

58. Record review of Patient #5's medical chart showed she was admitted to the facility on 04/02/13 for complaints of major depressive disorder.

59. Record review of the patient's Psychiatric Evaluation dated 04/03/13 showed that the patient's mother thought she had run away and involved the police. The patient made statements that she was going to kill herself and was going to run away and leave the state.

60. Record review of Patient #5's Admission Orders dated 04/02/13 showed the physician ordered suicide risk, assault risk and elopement risk.

61. Record review of the patient's Individual Crisis Management Plan-Acute dated 04/02/13 showed staff assessed the patient as an elopement risk.

62. Record review of the patient's MTP dated 04/02/13 showed staff did not address or include specific interventions, goals or timetables related to the physician ordered assault risk or elopement risk.

63. Record review of Patient #6's medical record showed she was admitted to the facility on 04/01/13 for complaints of mood disorder (a persistent emotional state that affects how one sees the world).

64. Record review of the patient's Psychiatric Evaluation dated 04/02/13 showed the patient stated "I got in an argument with my parents and I ran away." The patient's mother requested inpatient acute care as she looked at the patient as a runaway and was missing. The patient denied having any trouble with the law except for her running away.

65. Record review of Patient #6's Admission Orders dated 04/01/13 showed the physician ordered suicide risk, assault risk and elopement risk.

66. Record review of the patient's MTP dated 04/01/13 showed staff did not address or include specific interventions, goals or timetables related to the physician ordered suicide risk, assault risk or elopement risk.

67. Record review of Patient #7's medical record showed she was admitted to the facility on 04/02/13 with comp

Based on interview, record and policy review the facility failed to:
-Provide care in a safe setting to ensure that one (#3) out of one current patient and two (#10 and #11) out of two discharged patient records reviewed for elopement did not successfully elope from facility property.
-Staff did not follow expected observation protocol/policy when they failed to transport one (#3) current patient back inside the building after being on the playground outside, which allowed him to climb over the fence and elope off facility property.
-To prevent one (#11) discharged patient from climbing over the playground fence and elope off facility property.
-Include elopement prevention/interventions in the treatment plan for six (#3, #4, #5, #6, #7 and #8) out of six current patients reviewed for elopement risk and for two (#10 and #11) out of two discharged patients reviewed for elopement risk .
The facility census was 81. This had the potential to affect all patients seeking care at the facility.

Findings included:

1. Record review of the facility's policy titled, "Elopement or Unauthorized Leave of absence" revised 09/18/12, showed the facility defined elopement as an unassisted, unsupervised, and/or unscheduled departure from facility property (including transport vehicles) by a patient/resident. The policy showed the following direction:
-Clinical Staff to assess each patient/resident for elopement upon admission, at the time of Individualized Crisis Management Plan (ICMP)development and during treatment upon indication of elopement due to stressful situations.
-Indicators of potential elopement include, but are not limited to, the following examples:
-Cognitive status (thinking, reasoning, or remembering)
-Aggressiveness
-Agitation/restlessness
-Change in schedule or routine
-Medication regimen
-Stressful situations
-Prior history of elopement
-Wearing layered clothing
-Discussing with other patients or staff ways to run from the building
-Verbal threats to run from the building
-Successful elopement from the hospital campus
-Pulling fire alarm or testing doors with intent to exit the building.
-Update the Master Treatment Plan (MTP) and ICMP as necessary.
-Discuss patients/residents who have been assessed and found to be at-risk for elopement (i.e. those who are known to elope are beginning to exhibit signs of desire to elope, or are new to the facility).
-Make assignments to staff regarding constant, frequent, or periodic checks on these at-risk patients/residents.

Record review of the facility's undated document entitled "Elopement Program Assessment Tool" showed the following direction:
-Education/Staff Competency: Staff training related to exit-seeking behaviors and how to minimize this behavior before an elopement occurs has been conducted and is documented.
-Environmental Precautions: Interventions are documented for the facility's use to minimize the risk of elopement.
-Medical Record Review: Elopement risk assessment tool is completed within four hours of admission, and on chart.
-General Questions: For elopement or near miss elopements, the incidents are evaluated and measures have been put into place to reduce the same type of occurrence from happening again.

Record review of the facility policy titled, "Observation and Patient Monitoring" revised 04/03/12, showed the following direction:
-Facility staff should monitor patients visually and randomly within 15 minute intervals. The real time is to be documented and ensure there is a minimum of four observations in an hour. The intervals between patient observations should not be greater than 20 minutes apart.
-The purpose of the policy is to provide guidelines to clinical staff to ensure a safe and secure environment through assessment, intervention, and treatment for those patients who are high risk for harm to self, harm to others or elopement.
-A line of sight (LOS) patient is to remain in line of sight of staff at all times, including bathroom and shower times, but does not have to be within arm's length. These patients are assigned to rooms close to the nurses' station to ensure continuous monitoring and will be restricted to the unit.
-Assign staff to document a narrative note once a shift for patients on line of sight which address progress or lack of progress towards the Multidisciplinary Treatment Plan (MTP) goals.
-Assign staff to document a narrative note on day and evening shifts for patients on 15 minute checks which address progress or lack of progress towards the MTP goals. Night shift is to monitor for any sleep or safety concerns and document as needed.

2. Record review of Patient #3's medical record showed he was admitted to the facility on 04/01/13 with complaints of Bipolar Disorder (a person goes between very good moods to irritable to very depressed)

3. Record review of Patient #3's Psychiatric Initial Evaluation Note dated 04/02/13 at 12:00 PM showed the following information:
-Chief complaint: The patient stated, "My brother says I hit him."
-History of Present Illness: This patient is progressively and increasingly assaultive to his brother. The patient had hidden knives, broken windows, and destroyed property. He smears feces of his and the dog's on himself and puts fireworks in the microwave. He has run away recently.

4. Record review of Patient #3's Admission Orders dated 04/01/13 showed the physician ordered under Risk Categories: Suicide risk, assault risk, and elopement risk.

5. Record review of Patient #3's MTP showed staff did not address or include specific interventions, goals, or timetables related to the physician ordered suicide risk, assault risk, or elopement risk in the patient's treatment plan.

6. Record review of the facility document titled, "15 Minute Precaution Check & Point Sheet," dated 04/07/13 for Patient #3 showed he was off the unit from 5:15 PM until 6:15 PM. Review showed in the section titled, "Comments," staff had documented the word eloped. One line was marked through the 5:00 PM to 6:00 PM times with the word, "error."

7. During an interview on 04/09/13 at 12:40 PM, Staff C, Chief Clinical Officer (CCO) and Staff D, Director of Nursing (DON), stated that on Sunday evening 04/07/13 a patient was left on the playground. They stated that no immediate changes in processes, staff education, or new quality monitoring were completed at this time to ensure patient safety.

8. Record review of the facility's document titled, "Incident Report Form," dated 04/07/13 at 6:20 PM showed Patient #3 was left outside on the south playground when the rest of the patients from 2-Central Unit went inside the building on 04/07/13 during the 3:00 PM to 11:00 PM shift.

9. During an interview on 04/10/13 at 9:10 AM Staff R, Registered Nurse (RN), stated that on the evening of 04/07/13 the patients from 2-Central and staff were playing in the south playground. She stated that when the patients lined up to go inside she assisted a patient to remove sand from her shoes. She stated that she did not count the patients before going inside the building at approximately 5:45 PM.

10. During an interview on 04/10/13 at 9:40 AM, Staff I, Behavioral Health Tech (BHT), stated that on the evening of 04/07/13 the patients from 2-Central and staff were playing in the south playground. He stated that the patients lined up and he moved to the end of the line. Staff I stated that Staff T, BHT, counted 18 patients which was the correct number. He stated that the line of patients and staff walked into the building. Staff I stated that staff failed to re-count patients after entering the building.

11. During an interview on 04/10/13 at 10:00 AM, Staff T, BHT, stated that on the evening of 04/07/13 the patients from 2-Central and staff were playing in the south playground. She stated that the patients lined up at approximately 5:35 PM and then the patients removed the sand from their shoes. Staff T, stated that she saw Patient #3 in line and the patient count was 18, which was correct. Staff T stated that the patients and staff entered the building. and she did not see Patient #3 leave the line. Staff T stated that staff failed to re-coun