HospitalInspections.org

Based on review of medical records, policies and other hospital documentation and staff interview, it was determined that the hospital failed to ensure the safety of 5 of 7 (71%) patients (Patient #'s 3, 4, 5, 6 and 7) in the sample and the remaining patient population. Findings include:


I. The hospital failed to identify how staffing and unit schedule of activities could lead to insufficient patient observation, leading to two patients (Patients #6 and #7) to be unsupervised, and creating an opportunity for alleged sexual activity between the two.

"Rockford Center, Adolescent Services, Parent Handbook" states, "...Rockford Center strives to provide a place of absolute safety and respect for the people we serve...Sexual acts or inappropriate physical contact between patients are not permitted..."

Hospital policy titled, "Reporting Suspected Victims of Abuse, Mistreatment, and Neglect" states, "...The hospital does not condone any action, which can be construed as abuse...Sexual abuse is the intentional mistreatment of a sexual nature of any individual that may cause physical or psychological injury which includes sexual harassment, sexual coercion, and sexual assault..."

Hospital policy titled, "Patient Observation Policy" states, "...At least one staff per unit would always remain in the hallways... While monitoring hallways and patient care areas ensure patients are not entering rooms not assigned to them..."

Review of facility document, "Adolescent Junior Unit Schedule" revealed, "...Monday through Friday...8pm... Wrap up/Meds/Snack..."


A. Review of Patient #6's medical record revealed:

- Patient #6 was voluntarily admitted to the facility on 4/9/2023 for increased aggression, depression with psychosis, anxiety, and PTSD (post-traumatic stress disorder).
- "Patient Observation Record" dated 4/10/2023 stated, "... Q (every) 15-minute checks...SV (sexual victimization) precautions..."
- "MHW (Mental Health Worker)/Nursing Progress Note" dated 4/12/2023 at 10:30 P.M. stated, "Pt (patient) with suspected sexual activity with peer. Pt stable, no s/s (signs and symptoms) distress...Bio (biological) father called and was notified of possible event that took place in peer's room. Consent to send to ED (Emergency Department) obtained from father..."

B. Review of Patient #7's medical record revealed:
- Patient #7 was voluntarily admitted to the facility on 4/6/2023 for bipolar disorder, current episode manic and disruptive mood dysregulation disorder.
- "Patient Observation Record" dated 4/12/2023 stated, "Q (every) 15-minute checks...lacks boundaries..."
- "Nursing Progress Note" dated, 4/12/2023 at 10:50 P.M. stated, "Pt (Patient) with suspected sexual activity with peer. Pt (Patient) currently stable; no distress observed or reported by pt (patient) ... Suspected event occurred at approximately 8-9 PM this evening...Bio (biological) mother contacted, mother aware of suspected activity and consent was obtained to send to ED (Emergency Department) for evaluation..."

C. Review of video surveillance provided by Employee #3 revealed:
- At time dated 22:30 on the video, Patient #7 entered his/her room.
- At 23:00, Patient #6 entered Patient #7's room.
- At 25:38, a peer ran down the hallway and notified Employee #8.
- At 26:32, staff entered the room and both Patient #6 and Patient #7 exited the room.
- Patient #6 and #7 were able to occupy the same room unsupervised for approximately 3 minutes and 32 seconds.

D. Review of Unit schedule for Wednesday, 4/12/23, revealed 8 PM time slot was for Wrap up group, medications, and snack.

E. Interview conducted with the Employee #3 on 5/1/2023 between 1:50 PM and 2:15 PM revealed:

The staff to patient ratio on that unit on the evening of the incident was 9 patients to 2 staff members. The patients were allowed to perform hygiene activities after going to the gym. The nurse was in the medication room at that time. Employee #8 was conducting a wrap-up group in the unit's dayroom at the time of this incident which allowed the opportunity for the female patient to enter the male patient's room. Employee #3 stated that both staff members, Employee #7 and Employee #8 were provided education on changing the scheduled programming if the nurse is in the medication room and not all the patients are in the dayroom for group therapy.

Employee #3 provided surveyors with the following document titled, "Employee Corrective Action Report" which stated, "...Corrective Action, education on Program change with staffing restriction...Recent incident...On April 12, 2023, at 8:25 PM, staff went and found female patient dressed hiding in the shower in male's room in the bathroom. Staff went to check because another peer came running to the dayroom telling staff both patients were in the male's room... Ensure that all patients are constantly being observed in hallway. Adjust schedule to ensure patient observation..."

The failure of the staff to adjust the programming schedule and provide a staff member to remain in the hallway allowed the female patient to enter the male patient's room. The programming schedule for Wrap up/Meds/Snack at 8pm leaves open the future possibility for similar incidents to occur because of the three activities taking place simultaneously. While the facility did provide re-education to Employee #7 and #8, they did not educate other staff members that routinely work on that unit at 8 PM, nor did they address the 8 PM scheduling of three different activities.


II. The hospital failed to address the ability of patients (Patient #s 3, 4, and 5) to overpower the locking mechanisms of unit doors, allowing for elopement.
Hospital policy "Elopements: Prevention and Response Guidelines" stated, "...All patients should be evaluated for elopement risk...Risk factors or warning behaviors...can include...lack of understanding or insight; poor impulse control...Restrictions include...staff should maintain visual and verbal contact sufficient to the patient's condition...The patient should be housed on a secure, locked unit..."

A. Review of Patient #3's medical record revealed:

- Patient #3 was admitted on 2/17/23 with a diagnosis of Major depressive disorder, single. Patient #3 was discharged on 3/11/23.
- Standardized Intake Assessment from 2/17/23 listed "running away from home" as a risk factor for elopement.
- Nursing Progress Note dated 3/9/23 at 12:41 PM stated, "...Patient presented with defiant behaviors throughout the evening threatening to elope the unit banging doors and actually eloping..."
- Nursing Progress Note from 3/10/23 noted that it was a late entry from 3/9/23 at 7:30 PM. Progress Note stated, "...Pt [patient] had eloped the unit...This writer walked out to redirect patient, patient was at this time running down the halls banging doors and threatening to elope again...Patient received PO [by mouth] meds but continued running around banging doors. On-call provider notified...more re-direction given and patient went to bed..."
- Patient Observation Nursing Progress Note dated 3/10/23 (untimed) stated, "...Still very uncompliant (sic). Pt [patient] seems to influence the other pts [patients] very easily..."
- Interdisciplinary Master Treatment Plan included an addition of "elopement" to the Psychiatric Problems, on 3/10/23. The specific Intervention Focus stated, "...will wear hospital scrubs and socks and restricted to the unit..."
- Patient Observation Record on 3/10/23 listed "Elopement" as a precaution. From 6:45 PM to 7:45 PM, patients behavior is listed as "combative", and location is "off-site"
- Nursing Progress Note from 3/10/23 at 11:30 AM stated, "After pt [patient] was told...was RTU [Restricted to Unit]...went into the dayroom and began throwing water around. Attempted to redirect...then began throwing chairs..."
- Nursing Progress Note from 3/10/23 a 8:50 PM stated, "...This pt [patient] along with 2 others were running up and down the halls kicking the exit door, punching holes in the wall and eventually eloping off the unit leaving out the door by the docks. Several staff members followed the pts [patients]...The police were on the premises attending another crisis...The police returned the pt [patient] to the facility as the pts [patients] ran around the front of the building. On-call [doctor] notified..."
- Discharge Summary from 3/11/23 stated, "...The patient...has been getting frustrated...does not want to stay in the Inpatient Unit...wants to stay at home...showing a lot of defiant behaviors, instigating other peers with negative actions and then actually stole someone's key and eloped outside the hospital, ran around the building and walked in within a minute..."

B. Review of Patient #5's medical record revealed:

- Patient #5 was admitted on 3/3/23 with a diagnosis of disruptive mood dysregulation disorder. Discharged on 3/17/23.
- Admission order from 3/3/23 listed precautions for "Assault/Homicidal Precautions", "Self Harm Risk", and "Suicidal Precautions".
- Interdisciplinary Master Treatment Plan listed "Elopement" as added on 3/11/23.
- Discharge Summary from 3/17/23 stated, "... [Patient #5] reportedly gets very easily agitated, irritability, lacks coping skills...The patient did have some behavioral issues...Reportedly eloped from the facility with two other peers. The patient went from the unit to the front of the hospital. The patient was restricted to the unit for a few days. Did have some remorse, and bothers that family was notified...no major behavioral issues other than that..."

C. Review of Patient #4's medical record revealed:

- Patient #4 was admitted on 2/22/23 with a diagnosis of major depressive disorder, single episode, and remains an active patient.
- Psychiatric Evaluation from 2/22/23 stated, "...Insight...Impaired...The patient has been eloping from placement and not engaged in school or treatment..."
- Patient Observation Record from 3/9/23 included "Elopement" precaution.
- Patient Observation Record Nursing Progress Note on 3/9/23 at 7:00 PM stated, "...Patient kicked open the door leading off the unit...then refused to move from the doorway when told...could not go to the gym..."
- Nursing Progress Note from 3/10/23 stated late entry for 3/9/23 at 7:10 PM. The noted stated, "...Pt [patient] had busted through the doors to elope the unit. Pt [patient] behavior escalated because she had been informed that she won't be able to go to the gym due to...extreme behaviors...patient needed constant redirection to move away from the door...On-call provider was notified..."
- Patient Observation Record from 3/10/23 listed patient's behavior as "combative" and location as "off-site" from 6:45 PM to 8:00 PM.
- Nursing Progress Note from 3/10/23 at 8:54 PM stated, "...This pt [patient] along with 2 other peers running down the hw [hallway] kicking the exit doors and eventually eloped off the unit, leaving by the kitchen dock doors along with two other peers. Several staff members attempted to return pt [patient] to the unit. Pts [patients] continued to run...Dr [doctor] was called...client currently 1:1 [one to one observation] ...grandmother made aware."
- Interdisciplinary Master Treatment Plan with "Elopement" added 3/10/23.
- Nursing Progress Note from 3/11/23 stated, "...Pt [patient] on 1:1 [one-to-one observation] and separated from the milieu per doctor..."

D. Review of hospital's Incident Reports revealed Patient #3 and #4 both had incidents on 3/9/23, the day prior to the elopement - Patient #3 was "found in unauthorized area" and Patient #4 for "physical confrontation with other patients". No other elopements were attempted after 3/10/23.

Review of video surveillance showed Patient #s 3, 4, and 5 in the hallway at 7:07 PM, and in the parking lot at 7:18 PM. It is unknown what the patients were doing in the time elapsed between both videos. It is also unknown the accuracy of the timestamps of the videos, as they were from two separate cameras.

In an interview on 5/1/23 at 2:05 PM, Employee #3 stated that the patients were able to elope by breaking through the adult program door to the loading dock door. They damaged the loading dock door and kicked it open. The hospital had recognized an ongoing problem of adolescents breaking through locked doors, and plan on replacing doors to increase the strength of the magnets that cause the doors to be locked. Employee #3 identified three additional doors to the exterior hospital parking lot. One had recently been replaced and fortified after a previous elopement. One is located at the front entrance and is heavily manned by staff. The third is through the Partial Hospital Program wing and would require patients to break through three additional doors before attempting to breach the exterior door.

Employee#1 provided documents including estimates and fiscal approval for replacing and reinforcing all doors within the facility. Construction has yet to start.

The hospital identified that doors between units could be breached with physical strength by adolescent patients, but have yet to fortify the doors, leading to an increased risk for elopement and inability to keep patients safe.