HospitalInspections.org

Based on observation, interview and document review, it was determined after implementing a "bedroom window integrity safety log"aimed at performance improvement, hospital staff failed to measure and track the success of the activity.

The findings are:

On 12/9/19 at 7:30 PM it was discovered three (3) individuals had eloped. The individuals removed a metal bracket (used to secure the bed to the wall) and used the bracket to pry open a locked window. A search for the missing individuals ensued and the individuals were returned to the hospital by 9:00 on 12/10/19.
A root cause analysis was conducted on the event and interventions were put into place to prevent recurrence. It was determined the metal brace used to secure the bed to the wall had been broken by kicking down on the bracket and/or consistently manipulating the bed. The brace was then used to pry open the window. Until new beds can be procured it was determined the existing bracket was best suited to secure the furniture. Environmental services staff were trained to alert unit staff members of any abnormal findings during routine cleaning. The existing locking mechanism on the windows is being replaced with a barrel bolt placed through the sashes of the window. Priority was given to windows facing an open campus however all windows appear to have been completed.

Until beds can be replaced hospital staff have implemented a "bedroom window integrity safety log" to be completed on day shift. This was communicated to staff via email by SM # 17 to begin on January 8th, 2020. The log records safety checks in bedrooms with windows that open to an unsecured outside area. A checkmark indicates window locks and beds are assessed to ensure integrity of bolts or other metal parts. Surveyor review of logs for units A & B found the log was completed 4 of 24 days in January 2020 and 6 of 11 days in February 2020. Surveyor review of logs for units C & D found logs completed 5 of 24 days in January 2020 and 4 of 11 in February. Units E, F, H and I window check logs were complete. The elopement occurred on unit B. Staff Member #7 (a registered nurse) was questioned as to his/her knowledge of the logs. SM #7 was unaware of the existence of the logs. SM #4 stated the expectation would be for staff to check their email at least once daily and that it was apparent that more education/training was needed for staff.

On 2/11/20 at approximately 12:30 PM, the surveyor informed SM #4 the failure of hospital staff to ensure the implementation of the safety checks and to monitor staff adherence in completing the log daily would be a deficient practice in the area of quality. The above findings were shared with the management team prior to exit on 2/12/20. No further information was presented to the surveyor.