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Based on interview, record review, and review of facility's policies and documents, it was determined the facility failed to provide care in a safe setting for one (1) patient, Patient #1, who eloped from the facility with subsequent harm to himself/herself with self-inflicted injury of multiple lacerations to the neck, bilateral wrists, and left thigh (see A0144). Patient #1 was admitted to the facility on 04/21/14 with diagnoses of Psychosis, Not Otherwise Specified; Suicidal Ideation (SI); and Homicidal Ideation (HI) with no history of psychological disorder. Patient #1 was admitted to a locked unit which included an outside patio with a twelve (12) foot wooden fence surrounding it and was ordered by the Physician to be on routine monitoring which was every fifteen (15) minute visualization by staff.

On 04/22/14 at approximately 8:00 PM, during visitation with family, Patient #1 expressed SI and that he/she was going to elope from the facility and kill self. Patient #1's family also reported he/she would not talk with staff about these feelings. Record review revealed this information was reported to nursing staff at the time of the visit. Also on 04/22/14 at 9:00 PM, Patient #1's cousin called nursing staff on the unit to report Patient #1 had called to say he/she was going to elope from the facility and kill self. Also, on 04/22/14, during visitation, Patient #1's family gave two (2) sheets of printed paper to the nursing staff that detailed his/her recent behavior, such as auditory hallucinations to hurt self and others and that he/she had developed plans to do so. Nursing staff decided to move Patient #1 to the "safe room" by the Nurses Station on the unit; however, when going to do this, Patient #1 was asleep, and it was decided to let him/her sleep until morning at which time the Physician would see the information passed along to nursing staff from the family. Patient #1 slept through the night, was in the Day Room at 8:00 AM and 8:15 AM per observations, and by 8:30 AM had eloped. There were no eyewitnesses to the elopement. On the wooden fence, surrounding the court yard, one (1) twelve (12) foot plank had been broken off to approximately four (4) feet, and there was a chair by the fence at this location. Per Nursing Discharge Note, on 04/23/14 at 9:00 AM, a Police report revealed Patient #1 was being transferred to another facility Emergency Department via ambulance. Medical records from the facility that Patient #1 transferred to revealed he/she had multiple, self-inflicted lacerations to neck, bilateral wrists, and left thigh which required surgery to repair. The failure of the facility to provide a safe environment and effective supervision placed Patient #1 at risk for serious injury, harm, impairment or death. The facility was notified on 05/08/14 that Immediate Jeopardy was determined to exist related to Patient Rights. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be abated on 05/09/14, prior to exit on that date. (Refer to A0144)

Based on interview, record review, and review of facility policies and documents, it was determined the facility failed to ensure patients were in a safe environment by inadequate supervision of one (1) of ten (10) sampled patients, Patient #1. The facility failed to ensure Patient #1 was prevented from eloping from the facility. Patient #1 had expressed to family and then family to staff, on 4/22/14 at 8:00 PM and 9:00 PM, the evening before his/her elopement, his/her intent to elope from the facility and kill self.

The findings include:

Review of facility policy, "Patient Rights and Responsibilities," number RI.046, revised date 04/11/13, revealed without limitation, patients would be entitled to care in a safe and sanitary setting.

Review of facility policy, "High Risk Behavior Precautions," number PC.001, revised date 02/2012, revealed all patients would be assessed for the following high risk behaviors which included suicide/self harm, homicide/assault/aggression, and elopement, and a Physician's order would be obtained for each high risk behavior precaution identified upon admission or for any change to the high risk precautions during the course of treatment. The policy also stated unit staff would notify Charge Nurse, Nurse Supervisor, and/or Physician of any patient behaviors indicating a change in the patient's status. Further review of the policy revealed there were two observation levels: 1) one (1) to one (1) where the patient should remain within arms length of the assigned staff even during toileting and showering and the patient was typically restricted to the unit and 2) every fifteen (15) minute checks. In addition, the policy also listed elopement precautions which included unit restriction, Nurse safety checks that would be performed each shift which ensured all doors that were supposed to be locked were locked, and staff being aware of and monitoring the patient during high risk times such as change of shift, visiting hours, or anytime there were people coming onto or leaving the unit.

Review of facility document, "Physician Please Be Advised," IHC Communication 001, undated, revealed for Patient #1 there were three (3) filled out. The first, dated 04/22/14 at 8:15 PM, was signed by the House Supervisor, and stated Patient #1 told family in visitation that he/she wanted to commit suicide, and he/she was planning to elope and do this. This document also stated Patient #1 told family he/she would not talk with staff and felt uncomfortable telling these things to the Psychiatrist. The second, dated 04/22/14 at 9:00 PM, signed by Charge Registered Nurse (RN), revealed Patient #1's cousin had telephoned the unit and stated he/she called and told the cousin that he/she planned to escape from the facility and commit suicide. The third, dated 04/22/14 at 9:36 PM, signed by RN #1, revealed it was requesting the Physician to schedule a meeting with Patient #1's mother. The last document, entitled with Patient #1's name and medical record number, was undated and unsigned, was printed and listed some behaviors seen in Patient #1, for example auditory hallucinations that directed Patient #1 to harm self and others, and there was a plan for him/her to do so.

Review of Patient #1's medical record revealed he/she was admitted on 04/21/14 with diagnoses including Psychosis, Not Otherwise Specified (NOS); Suicidal Ideation (SI); and Homicidal Ideation (HI). Further review revealed the Physician orders were for high-risk for SI and monitor every fifteen (15) minutes. The "Psychiatric Admission Assessment" revealed the Physician thought the risk of harm to self and others was low in the absence of ongoing ideation, intention, or plan. Further review revealed the immediate treatment plan was to place Patient #1 on Seroquel (an antipsychotic) 50 milligrams twice a day. However, an addendum stated Patient #1 wanted to talk with family prior to starting, and the medication administration record (MAR) and orders revealed it was not given. Review of "Patient Observation Rounds," from 04/22/14 and 04/23/14, revealed Patient #1 was monitored every fifteen (15) minutes and was under suicide/self harm precaution type, and on 04/22/14 from 9:30 PM until 6:00 AM on 04/23/14 was asleep in his/her room. Then, from 6:00 AM to 8:00 AM on 4/23/14, the rounds sheet showed he/she was awake in various rooms. Further review revealed at 8:15 PM, he/she was awake in the Day Room; then at 8:30 AM he/she could not be located and per Nurse Progress Record, a facility lock down, search, and police, family, and Physician notification occurred. Further review of the Nurse Progress Record from 04/23/14 revealed a peer informed staff that Patient #1 had pulled down a board to the twelve (12) foot wooden fence surrounding the patio and went over it, and the record further stated that all boards to the fence were intact during safety and security checks prior to the incident with Patient #1.

Interview with the Maintenance Technician, on 05/07/14 at 2:30 PM, revealed the wooden fence surrounding the patio on Unit 2 was currently sturdy and in good shape without any broken planks. He further revealed when Patient #1 eloped, a plank was broken four (4) feet from the ground which he replaced within the hour of discovery, and Unit 2 was secured until the fence was repaired.

Interview with Patient #7, on 05/07/14 at 2:40 PM, revealed Patient #1 told her/him while eating supper on 04/22/14, that he/she had a plan to leave, and Patient #1 stood by the fence staring at the boards, but Patient #1 did not tell Patient #7 a specific plan for elopement.

Interview with Family Member #1, on 05/06/14 at 2:05 PM, revealed she had visited Patient #1 the evening of 04/22/14 and he/she told her about hearing voices telling him/her to kill his/her family by going room to room and shooting them. Family Member #1 further revealed she wrote this down in a note and gave it to the House Supervisor who said Patient #1 would be placed in a safe room and the information passed along to the oncoming nursing staff. Family Member #1 stated Patient #1 was not placed in a safe room.

Interview with the House Supervisor, on 05/06/14 at 5:50 PM, revealed she supervised the visitation on Unit 2, the evening of 04/22/14. She revealed the family was not comfortable about information Patient #1 was sharing with the Physician and nursing staff. The House Supervisor further revealed Family Member #1 then gave her a note for the Physician which she copied, gave the original back to Family member #1, wrote out the "Physician Please Be Advised" form, and flagged the copy with this form in Patient #1's chart, under Physician Orders, so the Physician could see the morning of 04/23/14 when making rounds. The House Supervisor also reported she told the Charge RN to pass this information along in report for the next shift and RN #1 about the extent of family concern, to keep a close eye on Patient #1, even sitting outside his/her room. The House Supervisor also revealed she told Mental Health Technician (MHT) #1 to put the patient in the "safe room" (a room with minimal furniture which is located close to the Nurses Station); however, Patient #1 was asleep so she revealed she made the decision to leave Patient #1 in the same room but to pass on family's concern with close monitoring. She further revealed she did not pass this information along to the Night Supervisor, and she should have. The House Supervisor further revealed if she had passed the information along to the Night Supervisor, perhaps the Physician would have seen Patient #1 before he/she eloped.

Interview with RN #1, on 05/06/14 at 6:35 PM, revealed she had given Patient #1 a Vistaril (medication used to treat anxiety) 50 milligram tablet at 6:00 PM on 04/22/14, he/she had been at visitation, and then he/she went to bed. RN #1 further revealed she gave report to the oncoming nurse, RN #2 and did not remember passing along any special information about Patient #1 concerning closer observation or family concerns. RN #1 further revealed she had received a telephone call from Patient #1's Family Member #2 wanting to schedule an appointment with the Physician. RN #1 stated she completed the "Physician Please Be Advised" form with the information about the mother's call in Patient #1's chart.

Interview with the Charge RN, on 05/06/14 at 4:00 PM, revealed she worked on Unit 2 for the 3:00 PM to 11:00 PM shift on 04/22/14. She further revealed she did not recall receiving any information about Patient #1's visitors or any information given by visitors for Patient #1 on 04/22/14. She did state she received a telephone call from an individual, Family Member #3 stating Patient #1 had called her and stated he/she was going to escape from the facility and kill self. Patient #1 was admitted with SI so that information was not new; the Charge RN stated she believed the newer knowledge would have been that he/she was going to escape from the facility. The Charge RN stated she believed Patient #1 was safe, being in a locked unit, and there was no way he/she could elope; she stated she completed a "Physician Please Be Advised" form with the information about the Family Member #3's telephone call and placed in Patient #1's chart. The Charge RN revealed, RN #1 gave RN #2 report at shift change, and she had made the House Supervisor aware of the content of the telephone call and placing the form about it in the chart for the Physician. The Charge RN also stated the House Supervisor told her she had done everything she could do for Patient #1, and he/she should be safe until morning; in addition, "we decided to move Patient #1 closer to the Nurses Station but since he/she was already asleep, we deferred doing so".

Interview with MHT #1, on 05/07/14 at 10:15 AM, revealed he worked on Unit 2 the evening of 04/22/14 and observed Patient #1's behavior as calm. He further revealed he had a conversation with the House Supervisor about moving Patient #1 to a "safe room" but he/she was already asleep, and he communicated this to the House Supervisor. He further revealed it was decided to let Patient #1 continue to sleep and then move him/her if awakened.

Interview with RN #2, on 05/07/14 at 8:10 AM, revealed he worked from 11:00 PM 04/22/14 to 7:30 AM 04/23/14 on Unit 2 and was told at shift change that a family member of Patient #1 had called with concerns, a note was made about it, and the House Supervisor had been contacted. The Charge RN stated he/she was asleep, and RN #2 stated Patient #1 slept all night, without being awake for a conversation. RN #2 further revealed he gave report for the next shift to RN #3 on 04/23/14 at 7:00 AM and the content was that Patient #1 had expressed wanting to leave the facility. He stated when he left, Patient #1 was in his/her room without any behavior problems.

Interview with RN #3, on 05/06/14 at 11:30 AM and 05/07/14 at 10:40 AM, revealed Patient #1 never expressed any SI or HI when she was his/her nurse on 04/22/14 and 04/23/14. She stated she saw Patient #1 during rounds the morning of 04/23/14 sitting in the Day Room watching television, and he/she expressed feeling good. RN #3 also revealed Patient #1's mother had called the Nurses Station the morning of 04/23/14 to see how Patient #1 had slept and did not express any concerns at that time. RN #3 further revealed she had received report and was counting medications when at 8:30 AM, Patient #1 could not be found on the unit. A Code Lock Down was called, the police, the family, and the Physician were notified. RN #3 further revealed when Patient #1 eloped, she had not seen the chart with the "Physician Please Be Advised" forms and the two (2) page family note; she stated she saw them after the elopement. RN #3 also stated she did not recall the verbal content of these forms being passed along in report, only that Patient #1 had slept. RN #3 further revealed she could say what she would have done had she seen the additional family information in the chart; however, she stated she had seen Patient #1 the morning of 04/23/14, and he/she was not expressing SI and was calm. She also stated if she believed Patient #1 had been in immediate danger, she would have notified the Physician.

Interview with the Program Supervisor for Unit 2, on 05/06/14 at 1:40 PM, revealed he saw Patient #1 the morning of 04/23/14 sitting on the patio smoking a cigarette. He further revealed at 8:15 AM he asked Patient #1 if he/she wanted to go with him and a group of peers to breakfast, but he/she declined the offer and appeared calm with decreased anxiety. The Program Supervisor also stated in hindsight it appeared Patient #1 had a plan to elope during this encounter. He further revealed he would not have anticipated anyone being able to go over the twelve (12) foot wooden fence.

Interview with the Physician, on 05/08/14 at 10:45 AM, revealed his interview/assessment of Patient #1 on 04/22/14 at 12:50 PM showed nothing that would have indicated Patient #1 should have been on one (1) to one (1) supervision instead of the routine every fifteen minutes monitoring which is appropriate of most of the patients admitted to the facility, even those with SI. The Physician also stated the one to one observation was for patients that had acting out behavior, posing a threat of harm to self and others; those with credible threats; and those that were medically compromised. He further revealed there was nothing in conversation or behavior from Patient #1 that would have led him to believe he/she had a credible threat of elopement or suicidal behavior. The Physician also revealed he was unaware of any of the information given in the evening of 04/22/14 to the nursing staff about Patient #1's thoughts of SI/HI and his/her intention of escaping the facility; it was new information, and it was "scary sounding". He also stated he trusted the nurses' judgment, but if he had been called about putting the patient on one (1) to one (1) observation or placing Patient #1 on elopement precautions, he would have supported the decision. The Physician also revealed the "Physician Please Be Advised" forms were used to communicate many things to the Physician, but for an urgent matter, a telephone call would typically be used as the form of communication to the Physician.

Interview with the Chief Nursing Officer, on 05/09/14 at 6:25 PM, revealed the evening of 04/22/14 was a busy evening on Unit 2, and she believed communication could have been better concerning the information given to the nursing staff about Patient #1. She further revealed the nurses actions were done using their professional judgment, and at the time there was no policy violation.

Interview with the Chief Executive Officer (CEO), on 05/09/14 at 6:30 PM, revealed she believed the nursing staff thought they were performing correctly concerning their actions for Patient #1. However, she stated the facility's processes have been improved with the changes that have been made and the education done on these changes. The CEO further revealed the changes made would improve patient safety which was a continual improvement process.

Interview with the Risk Manager and Chief Operating Officer (COO), on 05/07/14 at 2:00 PM, revealed the facility had taken actions since the elopement of Patient #1 on 04/23/14. These actions included:

1) Patios were open for adult psychiatric and adult chemical dependent patients at designated times only with staff assigned to patient observation responsible for unlocking and relocking doors, and when patients were on the patio, there must be direct observation of them at all times;

2) All patients would receive a lime green wrist bracelet at admission which identifies them as a new patient meaning they would be unit restricted typically for twenty-four (24) hours until a History and Physical and Psychiatric Admission Assessment were done. When released from unit restriction, the green bracelet would be replaced by a clear one. At any point, if the Nurse assessed the patient to be at increased risk, he/she could place the patient on unit restriction and replace the clear wrist bracelet with the lime green wrist bracelet. If this occurred, the Nurse must call the Physician; and

3) Senior leaders would monitor for locked doors/patio doors/direct supervision of patio during Administrative Rounds each weekend.

The facility failed to ensure patients at high risk for self harm were adequately supervised which also violated their right to receive care in a safe setting. This failure placed patients at risk for injury, harm, impairment, or death. On 05/08/14, Immediate Jeopardy was determined to exist because the facility had not instructed nurses on what a change in condition for Physician notification specifically entailed. The facility initiated the following corrective actions:

1) All nurses were required to receive additional instruction before being allowed to work that nurses were responsible for calling the Physician anytime a patient had a change in condition from their baseline that increased the patient's risk, to include the parameters of information from family or others about self harm; harm to others reported to nursing regarding the patient; increased agitation; increased hallucinations, psychosis, or odd behavior; and expressing thoughts of self harm, SI/HI, with or without a plan. This was entitled, "Patient Safety Processes: Clarification for Nurses" (Form 2); and

2) All employees were required to receive instruction on "Patient Safety Processes; Staff Observation of Patients on Patios; Unit Restriction/Elopement Precautions/72 Hour Hold; Patient ID Band Change" (Form 1) before being allowed to work.

These actions started shortly after Immediate Jeopardy was determined to exist on 05/08/14, and by 4:30 PM on 05/09/14, according to the COO, sixty-three (63) of seventy-one (71) nurses, (approximately eighty-nine (89) percent) had received instruction on Form 2 . The completion of instruction on Form 1, revealed by the COO, was two hundred seventeen (217) of two hundred thirty-eight (238) employees, or ninety-one (91) percent. The COO also stated there was a plan to instruct on these forms before the remaining employees would be allowed to work, and new employees would be instructed on these forms at orientation.

Based on interview, record review, and review of facility's policies and documents, it was determined the facility failed to ensure nursing supervision in order to provide care in a safe setting for one (1) patient, Patient #1, who eloped from the facility with subsequent harm to himself/herself with self-inflicted injury of multiple lacerations to the neck, bilateral wrists, and left thigh (see A0395). Patient #1 was admitted to the facility on 04/21/14 with diagnoses which included Psychosis, Not Otherwise Specified; Suicidal Ideation (SI); and Homicidal Ideation (HI) with no history of psychological disorder. Patient #1 was admitted to a locked unit which included an outside patio with a twelve (12) foot wooden fence surrounding it and was ordered by the Physician to be on routine monitoring which was every fifteen (15) minute visualization by staff.

On 04/22/14 at approximately 8:00 PM, during visitation with family, Patient #1 expressed SI and stated he/she was going to elope from the facility and kill self. Patient #1's family also reported this information to the nursing staff as well as he/she would not talk with staff about these feelings. Also on 04/22/14 at 9:00 PM, Patient #1's family called nursing staff on the unit to report Patient #1 had called to say he/she was going to elope from the facility and kill self. Also, on 04/22/14, during visitation, Patient #1's family gave two (2) sheets of printed paper to the nursing staff that detailed his/her recent behavior of auditory hallucinations to hurt self and others and that he/she had developed plans to do so. Nursing staff decided to move Patient #1 to the "safe room" by the Nurses Station on the unit; however, nursing staff did not move the patient because he/she was sleeping at the time. Patient #1 slept through the night, was in the Day Room at 8:00 AM and 8:15 AM per observations, and by 8:30 AM had eloped. There were no eyewitnesses to the elopement. On the wooden fence around the patio, there was one (1) twelve (12) foot plank that had been broken off approximately four (4) feet, and there was a chair by the fence at this location. Per the Nursing Discharge Note, on 04/23/14 at 9:00 AM, the Police reported Patient #1 was being transferred to another facility Emergency Department via ambulance. Medical records from that facility revealed Patient #1 had multiple, self-inflicted lacerations to neck, bilateral wrists, and left thigh which required surgery to repair. The failure of the facility to provide nursing supervision in order to provide a safe environment and effective supervision placed Patient #1 at risk for serious injury, harm, impairment or death. The facility was notified on 05/08/14 that Immediate Jeopardy was determined to exist related to Nursing Services. The facility initiated corrective actions, and the Immediate Jeopardy was determined to be abated on 05/09/14, prior to exit on that date. (Refer to A0395)

Based on interview, record review, and review of facility policies and documents, it was determined the facility failed to ensure patients were in a safe environment by inadequate supervision of one (1) of ten (10) sampled patients, Patient #1. The facility failed to ensure Patient #1 was prevented from eloping from the facility. Patient #1 had expressed to family and then family to staff, on 4/22/14 at 8:00 PM and 9:00 PM, the evening before his/her elopement, his/her intent to elope from the facility and kill self.

The findings include:

Review of facility policy, "Patient Rights and Responsibilities," number RI.046, revised date 04/11/13, revealed without limitation, patients would be entitled to care in a safe and sanitary setting.

Review of facility policy, "High Risk Behavior Precautions," number PC.001, revised date 02/2012, revealed all patients would be assessed for the following high risk behaviors which included suicide/self harm, homicide/assault/aggression, and elopement, and a Physician's order would be obtained for each high risk behavior precaution identified upon admission or for any change to the high risk precautions during the course of treatment. The policy also stated unit staff would notify Charge Nurse, Nurse Supervisor, and/or Physician of any patient behaviors indicating a change in the patient's status. Further review of the policy revealed there were two observation levels: 1) one (1) to one (1) where the patient should remain within arms length of the assigned staff even during toileting and showering and the patient was typically restricted to the unit and 2) every fifteen (15) minutes. In addition, the policy also listed elopement precautions which included unit restriction, Nurse safety checks that would be performed each shift which ensured all doors that were supposed to be locked were locked, and staff being aware of and monitoring the patient during high risk times such as change of shift, visiting hours, or anytime there were people coming onto or leaving the unit.

Review of facility document, "Physician Please Be Advised," IHC Communication 001, undated, revealed for Patient #1 there were three (3) filled out. The first, dated 04/22/14 at 8:15 PM, was signed by the House Supervisor, and stated Patient #1 told family in visitation that he/she wanted to commit suicide, and he/she was planning to elope and do this. This document also stated Patient #1 told family he/she would not talk with staff and felt uncomfortable telling these things to the Psychiatrist. The second, dated 04/22/14 at 9:00 PM, signed by Charge Registered Nurse (RN), revealed Patient #1's cousin had telephoned the unit and stated he/she called and told the cousin that he/she planned to escape from the facility and commit suicide. The third, dated 04/22/14 at 9:36 PM, signed by RN #1, revealed it was requesting the Physician to schedule a meeting with Patient #1's mother. The last document, entitled with Patient #1's name and medical record number, was undated and unsigned, was printed and listed some behaviors seen in Patient #1, for example auditory hallucinations that directed Patient #1 to harm self and others, and there was a plan for him/her to do so.

Review of Patient #1's medical record revealed he/she was admitted on 04/21/14 to the facility with diagnses which included Psychosis, Not Otherwise Specified (NOS); Suicidal Ideation (SI); and Homicidal Ideation (HI). Further review revealed the Physician orders were for high-risk for SI and monitor every fifteen (15) minutes. The "Psychiatric Admission Assessment" revealed the Physician thought the risk of harm to self and others was low in the absence of ongoing ideation, intention, or plan. Further review revealed the immediate treatment plan was to place Patient #1 on Seroquel (an antipsychotic) 50 milligrams twice a day. However, an addendum stated Patient #1 wanted to talk with family prior to starting the medication, and the medication administration record (MAR) and orders revealed it was not given. Review of "Patient Observation Rounds," from 04/22/14 and 04/23/14, revealed Patient #1 was monitored every fifteen (15) minutes and was under suicide/self harm precaution type, and on 04/22/14 from 9:30 PM until 6:00 AM on 04/23/14 was asleep in his/her room. Then, from 6:00 AM to 8:00 AM on 4/23/14, the rounds sheet showed he/she was awake in various rooms. Further review revealed at 8:15 PM, he/she was awake in the Day Room; then at 8:30 AM he/she could not be located and per Nurse Progress Record, a facility lock down, search, and police, family, and Physician notification occurred. Further review of the Nurse Progress Record from 04/23/14 revealed a peer informed staff that Patient #1 had pulled down a board to the twelve (12) foot wooden fence surrounding the patio and went over it, and the record further stated that all boards to the fence were intact during safety and security checks prior to the incident with Patient #1.

Interview with Patient #7, on 05/07/14 at 2:40 PM, revealed Patient #1 told her/him while eating supper on 04/22/14 that he/she had a plan to leave, and Patient #1 stood by the fence staring at the boards, but Patient #1 did not tell Patient #7 a specific plan for elopement.

Interview with Family Member #1, on 05/06/14 at 2:05 PM, revealed she had visited Patient #1 the evening of 04/22/14 and Patient #1 told her about hearing voices telling him/her to kill his/her family by going room to room and shooting them. Family Member #1 further revealed she wrote this down in a note and gave it to the House Supervisor who said Patient #1 would be placed in a safe room and the information passed along to the oncoming nursing staff. The Family Member #1 stated nursing staff assured her patient #1 would be kept safe; however, Patient #1 was not placed in a safe room.

Interview with the House Supervisor, on 05/06/14 at 5:50 PM, revealed she supervised the visitation on Unit 2, the evening of 04/22/14. She revealed the family was not comfortable about information Patient #1 was sharing with the Physician and nursing staff. The House Supervisor further revealed Family Member #1 then gave her a note for the Physician which she copied, gave the original back to the Family Member #1, wrote out the "Physician Please Be Advised" form, and flagged the copy with this form in Patient #1's chart, under Physician Orders, so the Physician could see the morning of 04/23/14 when making rounds. The House Supervisor also reported she told the Charge RN to pass this information along in report for the next shift and informed RN #1 about the extent of family concern and to keep a close eye on Patient #1, even sitting outside his/her room. The House Supervisor also revealed she told Mental Health Technician (MHT) #1 to put the patient in the "safe room" (a room with minimal furniture which is located close to the Nurses Station); however, Patient #1 was asleep so she revealed she made the decision to leave Patient #1 in the same room but to pass on family's concern with close monitoring. She further revealed she did not pass this information along to the Night Supervisor, and she should have. The House Supervisor further revealed if she had passed the information along to the Night Supervisor, perhaps the Physician would have seen Patient #1 before he/she eloped.

Interview with RN #1, on 05/06/14 at 6:35 PM, revealed she had given Patient #1 a Vistaril (medication used to treat anxiety) 50 milligram tablet at 6:00 PM on 04/22/14, he/she had been at visitation, and then Patient #1 went to bed. RN #1 further revealed she gave report to the oncoming nurse, RN #2 and did not remember passing along any special information about Patient #1 concerning closer observation or family concerns. RN #1 further revealed she had received a telephone call from Patient #1's mother, Family Member #2 wanting to schedule an appointment with the Physician. RN #1 stated she completed the "Physician Please Be Advised" form with the information about the mother's call in Patient #1's chart.

Interview with the Charge RN, on 05/06/14 at 4:00 PM, revealed she worked on Unit 2 for the 3:00 PM to 11:00 PM shift on 04/22/14. She further revealed she did not recall receiving any information about Patient #1's visitors or any information given by visitors for Patient #1 on 04/22/14. She did state she received a telephone call from Family member #3 stating Patient #1 had called her and stated he/she was going to escape from the facility and kill self. Patient #1 was admitted with SI so that information was not new, but she believed the newer knowledge would have been the he/she was going to escape from the facility. The Charge RN stated she believed Patient #1 was safe, being in a locked unit, and there was no way he/she could elope; she stated she completed a "Physician Please Be Advised" form with the information about the cousin's telephone call and placed in Patient #1's chart. The Charge RN revealed, RN #1 gave RN #2 report at shift change, and she had made the House Supervisor aware of the content of the telephone call and placing the form about it in the chart for the Physician. The Charge RN also stated the House Supervisor told her she had done everything she could do for Patient #1, and he/she should be safe until morning; "in addition, we decided to move Patient #1 closer to the Nurses Station but since he/she was already asleep, we deferred doing so."

Interview with MHT #1, on 05/07/14 at 10:15 AM, revealed he worked on Unit 2 the evening of 04/22/14 and observed Patient #1's behavior as calm. He further revealed he had a conversation with the House Supervisor about moving Patient #1 to a "safe room" but he/she was already asleep, and he communicated this to the House Supervisor. He further revealed it was decided to let Patient #1 continue to sleep and then move him/her if awakened.

Interview with RN #2, on 05/07/14 at 8:10 AM, revealed he worked from 11:00 PM 04/22/14 to 7:30 AM 04/23/14 on Unit 2 and was told at shift change that a family member of Patient #1 had called with concerns, a note was made about it, and the House Supervisor had been contacted. The Charge RN stated Patient #1 was asleep, and RN #2 stated Patient #1 slept all night. RN #2 further revealed he gave report for the next shift to RN #3 on 04/23/14 at 7:00 AM and the content was that Patient #1 had expressed wanting to leave the facility, and when he left, Patient #1 was in his/her room without any behavior problems.

Interview with RN #3, on 05/06/14 at 11:30 AM and 05/07/14 at 10:40 AM, revealed Patient #1 never expressed any SI or HI when she was his/her nurse on 04/22/14 and 04/23/14. She stated she saw Patient #1 during rounds the morning of 04/23/14 sitting in the Day Room watching television, and he/she expressed feeling good. RN #3 further revealed she had received report and was counting medications when at 8:30 AM, Patient #1 could not be found on the unit. A Code Lock Down was called, the police, the family, and the Physician were notified. RN #3 further revealed when Patient #1 eloped, she had not seen the chart with the "Physician Please Be Advised" forms and the two (2) page family note; she stated she saw them after the elopement. RN #3 also stated she did not recall the verbal content of these forms being passed along in report, only that Patient #1 had slept. RN #3 further revealed she could not say what she would have done had she seen the additional family information in the chart; however, she stated she had seen Patient #1 the morning of 04/23/14, and he/she was not expressing SI and was calm. She also stated if she believed Patient #1 had been in immediate danger, she would have notified the Physician.

Interview with the Program Supervisor for Unit 2, on 05/06/14 at 1:40 PM, revealed he saw Patient #1 the morning of 04/23/14 sitting on the patio smoking a cigarette. He further revealed at 8:15 AM he asked Patient #1 if he/she wanted to go with him and a group of peers to breakfast, but he/she declined the offer and appeared calm with decreased anxiety. The Program Supervisor also stated in hindsight it appeared Patient #1 had a plan to elope during this encounter. He further revealed he would not have anticipated anyone being able to go over the twelve (12) foot wooden fence.

Interview with the Physician, on 05/08/14 at 10:45 AM, revealed his interview/assessment of Patient #1 on 04/22/14 at 12:50 PM showed nothing that would have indicated Patient #1 should have been on one (1) to one (1) supervision instead of the routine every fifteen minutes monitoring which was appropriate of most of the patients admitted to the facility, even those with SI. The Physician also stated the one to one observation was for patients that had acting out behavior, posing a threat of harm to self and others; those with credible threats; and those that were medically compromised. He further revealed there was nothing in conversation or behavior from Patient #1 that would have led him to believe he/she had a credible threat of elopement or suicidal behavior; however, the Physician also revealed he was unaware of any of the information given in the evening of 04/22/14 to the nursing staff about Patient #1's thoughts of SI/HI and his/her intention of escaping the facility; it was new information, and it was "scary sounding". He also stated he trusted the nurses' judgment, but if he had been called about putting the patient on one (1) to one (1) observation or placing Patient #1 on elopement precautions, he would have supported the decision. The Physician also revealed the "Physician Please Be Advised" forms were used to communicate many things to the Physician, but for an urgent matter, a telephone call would typically be used as the form of communication to the Physician.

Interview with the Chief Nursing Officer, on 05/09/14 at 6:25 PM, revealed the evening of 04/22/14 was a busy evening on Unit 2, and she believed communication could have been better concerning the information given to the nursing staff about Patient #1. She further revealed the nurses actions were done using their professional judgment, and at the time there was no policy violation.

Interview with the Chief Executive Officer (CEO), on 05/09/14 at 6:30 PM, revealed she believed the nursing staff thought they were performing correctly concerning their actions for Patient #1. However, she stated the facility's processes have been improved with the changes that have been made and the education done on these changes. The CEO further revealed the changes made would improve patient safety which was a continual improvement process.

Interview with the Risk Manager and Chief Operating Officer (COO), on 05/07/14 at 2:00 PM, revealed the facility had taken actions since the elopement of Patient #1 on 04/23/14. These actions included:

1) Patios were open for adult psychiatric and adult chemical dependent patients at designated times only with staff assigned to patient observation responsible for unlocking and relocking doors, and when patients were on the patio, there must be direct observation of them at all times;

2) All patients would receive a lime green wrist bracelet at admission which identifies them as a new patient meaning they would be unit restricted typically for twenty-four (24) hours until a History and Physical and Psychiatric Admission Assessment were done. When released from unit restriction, the green bracelet would be replaced by a clear one. At any point, if the Nurse assessed the patient to be at increased risk, he/she could place the patient on unit restriction and replace the clear wrist bracelet with the lime green wrist bracelet. If this occurred, the Nurse must call the Physician; and

3) Senior leaders would monitor for locked doors/patio doors/direct supervision of patio during Administrative Rounds each weekend.

The facility failed to ensure patients at high risk for self harm were adequately supervised which also violated their right to receive care in a safe setting. This failure placed patients at risk for injury, harm, impairment, or death. On 05/08/14, Immediate Jeopardy was determined to exist because the facility had not instructed nurses on what a change in condition for Physician notification specifically entailed. The facility initiated the following corrective actions:

1) All nurses were required to receive additional instruction before being allowed to work that nurses were responsible for calling the Physician anytime a patient had a change in condition from their baseline that increased the patient's risk, to include the parameters of information from family or others about self harm; harm to others reported to nursing regarding the patient; increased agitation; increased hallucinations, psychosis, or odd behavior; and expressing thoughts of self harm, SI/HI, with or without a plan. This was entitled, "Patient Safety Processes: Clarification for Nurses" (Form 2); and

2) All employees were required to receive instruction on "Patient Safety Processes; Staff Observation of Patients on Patios; Unit Restriction/ElopementPrecautions/72 Hour Hold; Patient ID Band Change" (Form 1) before being allowed to work.

These actions started shortly after Immediate Jeopardy was determined to exist on 05/08/14, and by 4:30 PM on 05/09/14, according to the COO, sixty-three (63) of seventy-one (71) nurses, (approximately eighty-nine (89) percent) had received instruction on Form 2 . The completion of instruction on Form 1, revealed by the COO, was two hundred seventeen (217) of two hundred thirty-eight (238) employees, or ninety-one (91) percent. The COO also stated there was a plan to instruct on these forms before the remaining employees would be allowed to work, and new employees would be instructed on these forms at orientation.