HospitalInspections.org

Based on review of facility policy, review of Quality Assessment and Performance Improvement (QAPI) Plan, medical record review, review of video surveillance footage, review of facility documentation, observation, and interviews the facility's Governing Body failed to provide oversight to ensure the Behavioral Health (BH) courtyard fence was maintained to prevent elopement (ran away), failed to ensure investigation of a patient elopement, and failed to ensure implementation of processes to prevent recurrence of elopement for 1 patient (Patient #9) who eloped of 2 behavioral health patients reviewed of 12 patients reviewed, which had the potential to affect all BH patients.

The findings include:

Review of the facility's policy titled, "Event Reporting Policy," last reviewed 1/5/2023 showed "...The purpose of this policy is to provide guidance for communicating, reporting, investigating and acting upon a patient safety event including near miss, precursor and serious safety events, sentinel events, serious reportable/never event and hospital acquired conditions...Required Action Steps (Supervisor/Department Manager)...Supervisor on duty to notify the Department Manager and/or Administrator On-Call (AOC) of an event that is potentially serious, sentinel, serious reportable/never event or hospital acquired condition...Review events reported and if the event appears to have resulted in moderate to severe harm or death, immediately notify next level leader, Risk and/or Quality...Conduct brief/limited investigation (apparent cause analysis) on events which are precursor [events where a deviation from generally accepted performance standards reaches the patient and results in minimal harm or no detectable harm] or near miss [close call] harm events...This information is critical for patient safety efforts and to prevent recurrence...Required Action Steps (Risk and/or Quality...Review Supervisor/Department Manager investigation and determine if additional investigation is needed...Apply the Safety Event Classification [an outcome based classification system involving 3 steps: determining if there were deviations from generally accepted performance standards (GAPS), establish if there is a direct cause-and-effect relationship between deviations and the outcome and classify the level of patient harm resulting from the event]...Serious Safety Events, Sentinel Events, Serious Reportable/Never Events and Hospital Acquired Conditions require a more thorough and credible Root Cause Analysis [RCA-a process to find out what happened, why it happened, and determine what changes need to be made] and will be facilitated by trained Risk and Quality professionals...Required Action Steps (Executive Team-CEO [Chief Executive Officer], CNO [Chief Nursing Officer], CQO [Chief Quality Officer])...If it is determined the event meets or potentially meets (pending investigation) the definition of a Serious Safety Event, Sentinel Event, Serious Reportable/Never Event, and/or Hospital Acquired Condition notify Market CEO/CMO [Chief Medical Officer] /CQO and Regional President...Patient safety event types in ERS [event reporting system] include Preventable Events, Sentinel Events, Never Events, Serious, and Near Misses and Hospital Acquired Conditions and are generally categorized as follows...Behavioral - Patient Protection Events, Elopement..."

Review of the facility's policy titled, "Quality Assessment and Performance Improvement Plan," dated 3/2/2023 showed "...The Board of Trustees (BOT), Medical Staff, and Administration have the overall responsibility and accountability for the quality of care and services provided...The Board of Trustees has ultimate authority and responsibility for the effective implementation of the Quality Assessment and Performance Improvement Plan and Program (QAPI), and authorized the Medical Staff and Administration to enact this plan...Administration has responsibility for the provision of patient care and services provided by the hospital..."

Medical record review showed Patient #9 was admitted to the facility's Behavioral Health Unit (West Campus) on 6/16/2023 with diagnoses of Psychosis. Other diagnoses included Behavioral Disturbance, Schizoaffective Disorder, Drug Induced Psychosis, Depression, Amphetamine and THC (marijuana) Abuse, and Hepatitis C. During a psychiatric evaluation on 6/17/2023, Patient #9 became belligerent and aggressive, yelling and demanding to leave at once. On 6/19/2023, Patient #9 asked when she would be able to leave the facility. On 6/20/2023, the patient requested to leave against medical advice (AMA). She began screaming that she would be "...leaving today..." when she was told a physician would have to evaluate her before she could leave AMA. The patient continued to make threatening comments and gestures toward staff on through 6/23/2023.

Medical record review of a Behavioral Health Nursing note dated 6/24/2023 showed "...At approximately 1400 [2:00 PM], pt [Patient #9] pushed her way through small opening in fenced area outside as the patient's were taken outside for nursing group therapy...Work order placed to fence repair..."

Review of video surveillance footage of the Behavioral Health Unit courtyard for 6/24/2023 from 1:30 PM-2:20 PM showed a group of patients and 2 staff members identified as Registered Nurses (RNs) entered the courtyard at 1:31 PM. The RNs sat down in the picnic area and did not have all patients in their line of sight. Patient #9 (identified by facility staff) entered the courtyard at 1:38 PM and 52 seconds and began walking around the picnic area. At 1:40 PM, Patient #9 walked toward the back of the courtyard, toward the fence, and out of camera view. The RNs remained in the picnic table area. The patients and 2 RNs returned to the building at 2:12 PM. Patient #9 was not seen on video surveillance footage after 1:40 PM. The patients route of elopement could not be visualized.

Review of an event report showed an elopement from the Behavioral Health Unit occurred on 6/24/2023 at 2:00 PM. "...RN x2 assisted pt's outside for group therapy. As RN #1 was escorting another patient back inside to use the bathroom, the patient [Patient #9] (who eloped) pushed her way through an opening in the fenced area outside and eloped from facility...A work order has been placed to have the fence repaired..."

Review of a purchase order dated 8/8/2023 (45 days after elopement) showed pricing for renovations of the Behavioral Health Unit (West Campus), including replacement of the courtyard fence. The delivery date listed on the purchase order was 10/20/2023.

Review of a letter from the general contractor to the Facilities Director showed "...Fencing for the behavioral health unit has been ordered (10/25/2023) [4 months after elopement] and we intend to install as soon as material arrives. Materials is scheduled to be delivered the 2nd week of November and we will begin asap [as soon as possible]..."

During an interview on 11/1/2023 at 9:17 AM, in the conference room, the Risk Manager confirmed she was not involved in a Root Cause Analysis with Behavioral Health management or staff regarding Patient #9's elopement.

Observation of the Behavioral Health Unit (West Campus) on 11/1/2023 at 10:15 AM showed the facility had 2 courtyards. Each courtyard had a 6-foot wooden fence around the perimeter of the courtyard. The fence in the courtyard where Patient #9 eloped had 2 new boards (not worn/weathered). There was what appeared to be a new corner board in the corner where it was thought Patient #9 eloped. New screws (not rusted) were observed in the boards on each side of the corner.

During an interview on 11/1/2023 at 10:40 AM, in the BH conference room, the BH Nurse Manager confirmed an RCA had not been conducted and new processes had not been implemented following Patient #9's elopement from the courtyard. In a second interview on 11/2/2023 at 11:03 AM, the BH Nurse Manager confirmed the patients present in the courtyard when Patient #9 eloped were not interviewed to determine if anyone witnessed the patient's elopement. The BH Nurse Manager confirmed the courtyard had video surveillance cameras, confirmed the video surveillance footage for 6/24/2023 had not been reviewed, and confirmed the BH facility did not have a specific process to monitor patients during outdoor activities.

During an interview on 11/1/2023 at 1:20 PM, in the conference room, the Facilities Director stated a broken section of the courtyard fence was repaired, a broken corner piece was replaced, and the area where it was thought the patient eloped through was secured with metal straps on 6/25/2023. In a second interview on 11/2/2023 at 10:49 AM, the Facilities Director stated the facility received an estimate for planned renovations of the Behavioral Health Unit, including supplies and labor for a new courtyard fence on 8/8/2023. The Facilities Director stated the fencing for the courtyard was not ordered until 10/25/2023 (4 months after the elopement). When asked why ordering was delayed, the Facilities Director stated instead of having 2 separate capital equipment requests for the fence and renovations, the facility wanted to do 1 capital equipment request to include the fence replacement and other renovations at the facility.

Based on facility policy review, medical record review, review of video surveillance footage, review of facility documentation, observation, and interviews the facility failed to protect patient rights to receive care in a safe environment for 1 Behavioral Health (BH) patient (Patient #9) of 2 BH patients reviewed of 12 patients reviewed, which had potential to affect all BH patients.

The findings include:

Patient #9 was admitted to the Behavioral Health Unit (West Campus) on 6/16/2023 with diagnoses of Psychosis. Other diagnoses included Behavioral Disturbance, Schizoaffective Disorder, Drug Induced Psychosis, Depression, Amphetamine and THC (marijuana) Abuse, and Hepatitis C. Patient #9 asked when she would be able to leave the facility on 6/19/2023. She requested to leave against medical advice (AMA) on 6/20/2023 and began screaming that she would be "...leaving today..." when she was told a physician would have to evaluate her before she could leave AMA. On 6/24/2023 at approximately 2:00 PM, Patient #9 eloped, undetected, from the courtyard through an opening in the fence during outdoor activities. Review of video surveillance footage showed the 2 RNs supervising the patients did not have all patients in their line of sight. Patient #9 left view of the camera at 1:40 PM and did not return into view. Surveillance video footage showed the patients and 2 RNs returned to the building at 2:12 PM (32 minutes after Patient #9 left view of the camera). Interviews with the 2 RNs present in the courtyard revealed the group of patients were taken inside when they realized Patient #9 was missing. Patient #9 returned to the facility on 6/24/2023 at 7:02 PM. The elopement event was entered in the event reporting system on 6/24/2023 and had been reviewed by the Risk Manager and the Interim Behavioral Health Director. A Root Cause Analysis (RCA-a process to find out what happened, why it happened, and determine what changes need to be made) had not been conducted by the facility. The facility's failure to conduct a thorough investigation, failure to implement processes to prevent further patient elopements, and failure to ensure patient rights to receive care in a safe setting placed all BH patients at risk.

Refer to A-0144.

Based on facility policy review, review of Quality Assessment and Performance Improvement Plan (QAPI)medical record review, review of video surveillance footage, review of facility documentation, observation, and interviews the facility failed to provide care in a safe setting during outdoor activities resulting in elopement (ran away) for 1 Behavioral Health (BH) patient (Patient #9) of 2 BH patients reviewed of 12 patients reviewed which had potential to affect all BH patients.

The findings include:

Review of the facility's policy titled, "Elopement Prevention/Response Plan," last reviewed 4/12/2023 showed once an elopement occurs "...Available staff will immediately search for patient on unit and any suspected location of exit...The Security Staff and Administrative House Supervisor will monitor the video footage for location of patient...Following an actual event, appropriate investigation will be conducted to assess for additional actions that may lead to improvements in patient safety related to elopement..."

Review of the facility's policy titled, "Event Reporting Policy," last reviewed 1/5/2023 showed "...The purpose of this policy is to provide guidance for communicating, reporting, investigating and acting upon a patient safety event including near miss, precursor and serious safety events, sentinel events, serious reportable/never event and hospital acquired conditions...Required Action Steps (Supervisor/Department Manager)...Supervisor on duty to notify the Department Manager and/or Administrator On-Call (AOC) of an event that is potentially serious, sentinel, serious reportable/never event or hospital acquired condition...Review events reported and if the event appears to have resulted in moderate to severe harm or death, immediately notify next level leader, Risk and/or Quality...Conduct brief/limited investigation (apparent cause analysis) on events which are precursor [events where a deviation from generally accepted performance standards reaches the patient and results in minimal harm or no detectable harm] or near miss [close call] harm events...This information is critical for patient safety efforts and to prevent recurrence...Required Action Steps (Risk and/or Quality...Review Supervisor/Department Manager investigation and determine if additional investigation is needed...Apply the Safety Event Classification [an outcome based classification system involving 3 steps: determining if there were deviations from generally accepted performance standards (GAPS), establish if there is a direct cause-and-effect relationship between deviations and the outcome and classify the level of patient harm resulting from the event]...Serious Safety Events, Sentinel Events, Serious Reportable/Never Events and Hospital Acquired Conditions require a more thorough and credible Root Cause Analysis [RCA-a process to find out what happened, why it happened, and determine what changes need to be made] and will be facilitated by trained Risk and Quality professionals...Required Action Steps (Executive Team-CEO [Chief Executive Officer], CNO [Chief Nursing Officer], CQO [Chief Quality Officer])...If it is determined the event meets or potentially meets (pending investigation) the definition of a Serious Safety Event, Sentinel Event, Serious Reportable/Never Event, and/or Hospital Acquired Condition notify Market CEO/CMO [Chief Medical Officer] /CQO and Regional President...Patient safety event types in ERS [event reporting system] include Preventable Events, Sentinel Events, Never Events, Serious, and Near Misses and Hospital Acquired Conditions and are generally categorized as follows...Behavioral - Patient Protection Events, Elopement..."

Review of the facility's policy titled, "Quality Assessment and Performance Improvement Plan," dated 3/2/2023 showed "...The committees, departments and improvement teams are responsible for the delivery and evaluation of care and service they provide on an on-going basis...Priorities for safety and quality improvement are identified based upon improvement opportunities identified from...analysis of safety events, and root cause analysis investigations. The QIC [Quality Improvement Committee], MEC [Medical Executive Committee], BOT [Board of Trustees] and Hospital Executive Leadership will collaborate to establish hospital-level quality and patient safety strategic imperatives. Prioritization is performed annually, when improvement opportunities arise, or when changes occur in the internal or external environment..."

Medical record review showed Patient #9 was admitted to the facility's Behavioral Health Unit (West Campus) on 6/16/2023 with diagnoses of Psychosis. Other diagnoses included Behavioral Disturbance, Schizoaffective Disorder, Drug Induced Psychosis, Depression, Amphetamine and THC (marijuana) Abuse, and Hepatitis C. During a psychiatric evaluation on 6/17/2023, Patient #9 became belligerent and aggressive, yelling and demanding to leave at once. On 6/19/2023, Patient #9 asked when she would be able to leave the facility. On 6/20/2023, the patient requested to leave against medical advice (AMA). She began screaming that she would be "...leaving today..." when she was told a physician would have to evaluate her before she could leave AMA. The patient continued to make threatening comments and gestures toward staff on through 6/23/2023.

Medical record review of a Psychiatry Progress note dated 6/24/2023 at 4:30 PM showed "...Pt eloped from the unit prior to seeing the pt...'

Medical record review of a Behavioral Health Nursing note dated 6/24/2023 showed "...At approximately 1400 [2:00 PM], pt [Patient #9] pushed her way through small opening in fenced area outside as the patient's were taken outside for nursing group therapy...At approximately 1600 [4:00 PM], the patient's mother notified this facility...that pt had arrived at her house [approximately 13 miles from the facility]...Work order placed to fence repair..."

Review of video surveillance footage of the Behavioral Health Unit courtyard for 6/24/2023 from 1:30 PM-2:20 PM showed a group of patients and 2 staff members identified as Registered Nurses (RNs) entered the courtyard at 1:31 PM. The RNs sat down in the picnic area and did not have all patients in their line of sight. Patient #9 (identified by facility staff) entered the courtyard at 1:38 PM and 52 seconds and began walking around the picnic area. At 1:40 PM, Patient #9 walked toward the back of the courtyard, toward the fence, and out of camera view. The RNs remained in the picnic table area. The patients and 2 RNs returned to the building at 2:12 PM. Patient #9 was not seen on video surveillance footage after 1:40 PM. The patients route of elopement could not be visualized.

Review of an event report showed an elopement from the Behavioral Health Unit occurred on 6/24/2023 at 2:00 PM. "...RN x2 assisted pt's outside for group therapy. As RN #1 was escorting another patient back inside to use the bathroom, the patient [Patient #9] (who eloped) pushed her way through an opening in the fenced area outside and eloped from facility...A work order has been placed to have the fence repaired..."

Review of a purchase order dated 8/8/2023 showed pricing for renovations of the Behavioral Health Unit (West Campus), including replacement of the courtyard fence. The anticipated delivery date listed on the purchase order was 10/20/2023.

Review of a letter from the general contractor to the Facilities Director showed "...Fencing for the behavioral health unit has been ordered (10/25/2023) and we intend to install as soon as material arrives. Materials is scheduled to be delivered the 2nd week of November and we will begin asap [as soon as possible]..."

Observation of the Behavioral Health Unit (West Campus) on 11/1/2023 at 10:15 AM showed the facility had 2 courtyards. Each courtyard had a 6-foot wooden fence around the perimeter of the courtyard. The fence in the courtyard where Patient #9 eloped had 2 new boards (not worn/weathered). There was what appeared to be a new corner board in the corner where it was thought Patient #9 eloped. New screws (not rusted) were observed in the boards on each side of the corner.

During an interview on 11/1/2023 at 10:40 AM, in the BH conference room, the BH Nurse Manager confirmed an RCA had not been conducted and new processes had not been implemented following Patient #9's elopement from the courtyard. In a second interview on 11/2/2023 at 11:03 AM, the BH Nurse Manager confirmed the patients present in the courtyard when Patient #9 eloped were not interviewed to determine if anyone witnessed the patient's elopement. The BH Nurse Manager confirmed the courtyard had video surveillance cameras, confirmed the video surveillance footage for 6/24/2023 had not been reviewed, and confirmed the BH facility did not have a specific process to monitor patients during outdoor activities.

During an interview on 11/1/2023 at 1:20 PM, in the conference room, the Facilities Director stated a broken section of the courtyard fence was repaired, a broken corner piece was replaced, and the area where it was thought the patient eloped through was secured with metal straps on 6/25/2023. In a second interview on 11/2/2023 at 10:49 AM, the Facilities Director stated the facility received an estimate for planned renovations of the Behavioral Health Unit, including supplies and labor for a new courtyard fence on 8/8/2023. The Facilities Director stated the fencing for the courtyard was not ordered until 10/25/2023 (4 months after the elopement). When asked why ordering was delayed, the Facilities Director stated instead of having 2 separate capital equipment requests for the fence and renovations, the facility wanted to do 1 capital equipment request to include the fence replacement and other renovations at the facility.

Based on review of facility policy, review of Quality Assessment and Performance Improvement Plan (QAPI), medical record review, review of video surveillance footage, review of facility documentation, observation, and interviews the facility's QAPI failed to ensure an ongoing, quality assessment and performance improvement program related to the Behavioral Health (BH) facility and monitoring of BH patients for 1 BH patient of 2 BH patients reviewed of 12 patients reviewed which had potential to place all BH patients at risk.

The findings include:

Patient #9 was admitted to the Behavioral Health Unit (West Campus) on 6/16/2023 with diagnoses of Psychosis. Other diagnoses included Behavioral Disturbance, Schizoaffective Disorder, Drug Induced Psychosis, Depression, Amphetamine and THC (marijuana) Abuse, and Hepatitis C. Patient #9 asked when she would be able to leave the facility on 6/19/2023. She requested to leave against medical advice (AMA) on 6/20/2023 and began screaming that she would be "...leaving today..." when she was told a physician would have to evaluate her before she could leave AMA. On 6/24/2023 at approximately 2:00 PM, Patient #9 eloped, undetected, from the courtyard through an opening in the fence during outdoor activities. Review of video surveillance footage showed the 2 RNs supervising the patients did not have all patients in their line of sight. Patient #9 left view of the camera at 1:40 PM and did not return into view. Surveillance video footage showed the patients and 2 RNs returned to the building at 2:12 PM (32 minutes after Patient #9 left view of the camera). Interviews with the 2 RNs present in the courtyard revealed the group of patients were taken inside when they realized Patient #9 was missing. Patient #9 returned to the facility on 6/24/2023 at 7:02 PM. The elopement event was entered in the event reporting system on 6/24/2023 and had been reviewed by the Risk Manager and the Interim Behavioral Health Director. A Root Cause Analysis had not been conducted by the facility. The Chief Quality Officer was not aware of the elopement until 10/30/2023. The facility's failure to conduct a thorough investigation and failure to implement processes to prevent further patient elopements placed all behavioral patients at risk.

Refer to A-0286.

Based on review of facility policy, review of Quality Assessment and Performance Improvement Plan (QAPI), medical record review, review of video surveillance footage, review of facility documentation, observation, and interviews the facility failed to identify an adverse event (event in which care resulted in an undesirable clinical outcome) as a serious safety event, failed to conduct a root cause analysis (RCA-a process to find out what happened, why it happened, and determine what changes need to be made), failed to implement preventative actions and mechanisms and systematically monitor processes to ensure no future patient events occurred after 1 BH patient (Patient #9) eloped during outdoor activities of 2 BH patients reviewed of 12 patients reviewed. The facility's failure had potential to affect all BH patients.

The findings include:

Review of the facility's policy titled, "Elopement Prevention/Response Plan," last reviewed 4/12/2023 showed once a patient's unauthorized absence was discovered "...Available staff will immediately search for patient on unit and any suspected location of exit...The Security Staff and Administrative House Supervisor will monitor the video footage for location of patient...Following an actual event, appropriate investigation will be conducted to assess for additional actions that may lead to improvements in patient safety related to elopement..."

Review of the facility's policy titled, "Event Reporting Policy," last reviewed 1/5/2023 showed "...The purpose of this policy is to provide guidance for communicating, reporting, investigating and acting upon a patient safety event including near miss, precursor and serious safety events, sentinel events, serious reportable/never event and hospital acquired conditions...Required Action Steps (Supervisor/Department Manager)...Supervisor on duty to notify the Department Manager and/or Administrator On-Call (AOC) of an event that is potentially serious, sentinel, serious reportable/never event or hospital acquired condition...Review events reported and if the event appears to have resulted in moderate to severe harm or death, immediately notify next level leader, Risk and/or Quality...Conduct brief/limited investigation (apparent cause analysis) on events which are precursor [events where a deviation from generally accepted performance standards reaches the patient and results in minimal harm or no detectable harm] or near miss [close call] harm events...This information is critical for patient safety efforts and to prevent recurrence...Required Action Steps (Risk and/or Quality...Review Supervisor/Department Manager investigation and determine if additional investigation is needed...Apply the Safety Event Classification [an outcome based classification system involving 3 steps: determining if there were deviations from generally accepted performance standards (GAPS), establish if there is a direct cause-and-effect relationship between deviations and the outcome and classify the level of patient harm resulting from the event]...Serious Safety Events, Sentinel Events, Serious Reportable/Never Events and Hospital Acquired Conditions require a more thorough and credible Root Cause Analysis and will be facilitated by trained Risk and Quality professionals...Required Action Steps (Executive Team-CEO [Chief Executive Officer], CNO [Chief Nursing Officer], CQO [Chief Quality Officer])...If it is determined the event meets or potentially meets (pending investigation) the definition of a Serious Safety Event, Sentinel Event, Serious Reportable/Never Event, and/or Hospital Acquired Condition notify Market CEO/CMO [Chief Medical Officer] /CQO and Regional President...Patient safety event types in ERS [event reporting system] include Preventable Events, Sentinel Events, Never Events, Serious, and Near Misses and Hospital Acquired Conditions and are generally categorized as follows...Behavioral - Patient Protection Events, Elopement..."

Review of the facility's policy titled, "Quality Assessment and Performance Improvement Plan," dated 3/2/2023 showed "...Administration has responsibility for the provision of patient care and services provided by the hospital. The committees, departments and improvement teams are responsible for the delivery and evaluation of care and service they provide on an on-going basis. Administration will provide the resources and education to empower the culture of continuous performance improvement...Priorities for safety and quality improvement are identified based upon improvement opportunities identified from Clinical Scorecard analysis, comparisons to external benchmarks, strategic objectives, analysis of safety events, and root cause analysis investigations. The QIC [Quality Improvement Committee], MEC [Medical Executive Committee], BOT [Board of Trustees] and Hospital Executive Leadership will collaborate to establish hospital-level quality and patient safety strategic imperatives. Prioritization is performed annually, when improvement opportunities arise, or when changes occur in the internal or external environment..."

Medical record review showed Patient #9 was admitted to the facility's Behavioral Health Unit (West Campus) on 6/16/2023 with diagnoses of Psychosis. Other diagnoses included Behavioral Disturbance, Schizoaffective Disorder, Drug Induced Psychosis, Depression, Amphetamine and THC (marijuana) Abuse, and Hepatitis C. During a psychiatric evaluation on 6/17/2023, Patient #9 became belligerent and aggressive, yelling and demanding to leave at once. On 6/19/2023, Patient #9 asked when she would be able to leave the facility. On 6/20/2023, the patient requested to leave against medical advice (AMA). She began screaming that she would be "...leaving today..." when she was told a physician would have to evaluate her before she could leave AMA. The patient continued to make threatening comments and gestures toward staff on through 6/23/2023. The patient eloped from the facility prior to being seen by the physician on 6/24/2023.

Medical record review of a Behavioral Health Nursing note dated 6/24/2023 showed "...At approximately 1400 [2:00 PM], pt [Patient #9] pushed her way through small opening in fenced area outside as the patient's were taken outside for nursing group therapy. At approximately 1600 [4:00 PM], the patient's mother notified this facility that pt had arrived at her house [approximately 13 miles from the facility]...Work order placed to fence repair..."

Review of video surveillance footage of the Behavioral Health Unit courtyard for 6/24/2023 from 1:30 PM-2:20 PM showed a group of patients and 2 staff members identified as Registered Nurses (RNs) entered the courtyard at 1:31 PM. The RNs sat down in the picnic area and did not have all patients in their line of sight. Patient #9 (identified by facility staff) entered the courtyard at 1:38 PM and 52 seconds and began walking around the picnic area. At 1:40 PM, Patient #9 walked toward the back of the courtyard, toward the fence, and out of camera view. The RNs remained in the picnic table area. The patients and 2 RNs returned to the building at 2:12 PM. Patient #9 was not seen on video surveillance footage after 1:40 PM. The patients route of elopement could not be visualized.

Review of an event report showed an elopement from the Behavioral Health Unit occurred on 6/24/2023 at 2:00 PM. "...RN x2 assisted pt's outside for group therapy. As RN #1 was escorting another patient back inside to use the bathroom, the patient [Patient #9] (who eloped) pushed her way through an opening in the fenced area outside and eloped from facility...A work order has been placed to have the fence repaired..."

During the entrance conference on 10/30/2023 at 12:30 PM, in the conference room, the Chief Quality Officer (CQO) was asked if any elopements from the Behavioral Health Unit had occurred since 1/2023. The CQO stated she was not aware of any elopements from the Behavioral Health Unit.

During an interview on 11/1/2023 at 9:17 AM, in the conference room, the Risk Manager confirmed she was not involved in a RCA with Behavioral Health management or staff related to Patient #9's elopement.

During an interview on 11/1/2023 at 10:40 AM, in the BH conference room, the BH Nurse Manager confirmed an RCA had not been conducted and new processes had not been implemented following Patient #9's elopement from the courtyard. In a second interview on 11/2/2023 at 11:03 AM, the BH Nurse Manager confirmed the patients present in the courtyard when Patient #9 eloped were not interviewed to determine if anyone witnessed the patient's elopement. The BH Nurse Manager confirmed the courtyard had video surveillance cameras, confirmed the video surveillance footage for 6/24/2023 had not been reviewed, and confirmed the BH facility did not have a specific process to monitor patients during outdoor activities.

Based on medical record review, review of video surveillance footage, review of facility documentation, and interview the facility failed to ensure a Registered Nurse (RN) supervised Behavioral Health patients during outdoor activities for 1 BH patient (Patient #9) of 2 BH patients reviewed of 12 patients reviewed which had potential to affect all BH patients.

The findings include:

Patient #9 was admitted to the Behavioral Health Unit (West Campus) on 6/16/2023 with diagnoses of Psychosis. Other diagnoses included Behavioral Disturbance, Schizoaffective Disorder, Drug Induced Psychosis, Depression, Amphetamine and THC (marijuana) Abuse, and Hepatitis C. Patient #9 asked when she would be able to leave the facility on 6/19/2023. She requested to leave against medical advice (AMA) on 6/20/2023 and began screaming that she would be "...leaving today..." when she was told a physician would have to evaluate her before she could leave AMA. On 6/24/2023 at approximately 2:00 PM, Patient #9 eloped, undetected, from the courtyard through an opening in the fence during outdoor activities. Review of video surveillance footage showed the 2 RNs supervising the patients did not have all patients in their line of sight. Patient #9 left view of the camera at 1:40 PM and did not return into view. Surveillance video footage showed the patients and 2 RNs returned to the building at 2:12 PM (32 minutes after Patient #9 left view of the camera). Interviews with the 2 RNs present in the courtyard revealed the group of patients were taken inside when they realized Patient #9 was missing. The RN's failure to continually monitor Behavioral Health patients during outdoor activities placed all Behavioral Health patients at risk.

Refer to A-0395.

Based on medical record review, review of video surveillance footage, review of facility documentation, and interview the nursing staff failed to ensure all patients were monitored and accounted for during outdoor activities for 1 Behavioral Health (BH) patient (Patient #9) of 2 (BH) patients reviewed of 12 patients reviewed which had potential to affect all BH patients.

The findings include:

Medical record review of a Psychiatric Evaluation Report dated 6/17/2023 at 11:04 AM showed Patient #9 was admitted to the Behavioral Health Unit on 6/16/2023 at 4:08 PM. Patient #9's past medical history and active problems included Anxiety, Chronic Bipolar Disease, Drug use affecting pregnancy, Hepatitis C, and Pregnancy. The patient reported she was there "...because Jesus put her here. She denies AVH [audiovisual hallucinations], but did admit that she 'hears spirits'..." Patient denied suicidal and homicidal thoughts. She reported methamphetamine and marijuana use. "...Pt [patient] initially refused to come speak with Dr. [doctor]. Pt then came in and immediately became belligerent and aggressive, yelling and demanding to leave at once..." Medical and Mental health conditions were documented as Schizophrenia and Meth Use Disorder. The psychiatric evaluation recommended admission to inpatient psychiatric unit.

Medical record review of a Psychiatric history and physical dated 6/17/2023 at 1:37 PM showed Patient #9's diagnoses included Behavioral Disturbance, Schizoaffective Disorder, Drug Induced Psychosis, Depression, Amphetamine and THC abuse, and Hepatitis C. The treatment plan included continued rehabilitation and counseling.

Medical record review of Psychiatry Progress Notes showed Patient #9 was calm but was asking when she would be allowed to leave on 6/19/2023. On 6/20/2023, the patient was initially calm and asking to leave against medical advice (AMA). "...Discussed with patient that she will be evaluated by the MD [medical doctor] to determine if she is safe to be discharged AMA. Patient immediately became agitated and following provider down the hallway. Patient making threatening statements and gestures towards staff stating that she will be leaving today. Began yelling and cussing at staff..." On 6/21/2023, the patient continued to be intermittently irritable. "...Making threatening and aggressive comments and gestures towards certain staff members. Unable to properly evaluate patient on a daily basis secondary to patient becoming irritated and aggressive..." She was compliant with medications. There were no changes in Patient #9's behavior on 6/22/0223. Patient #9 threw a cup of water on the physician on 6/23/2023.

Medical record review of a Psychiatry Progress note dated 6/24/2023 at 4:30 PM showed "...Pt eloped from the unit prior to seeing the pt. Informed that the pt went to her mother's home and that she is now in route back to the hospital..."

Medical record review of a Behavioral Health Nursing note dated 6/24/2023 showed "...At approximately 1400 [2:00 PM], pt [Patient #9] pushed her way through small opening in fenced area outside as the patient's were taken outside for nursing group therapy...At approximately 1600 [4:00 PM], the patient's mother notified this facility...pt had arrived at her house [approximately 13 miles from the facility]..."

Review of video surveillance footage of the Behavioral Health Unit courtyard for 6/24/2023 from 1:30 PM-2:20 PM showed:
1:31 PM and16 seconds: Patients enter courtyard (9 patients)
1:31 PM and 51 seconds: Female Registered Nurse (RN) entered courtyard and sat
down with her back facing the back of the courtyard.
1:33 PM and 53 seconds: Male RN entered the courtyard.
1:34 PM and 42 seconds: Male RN sat down at the picnic table.
1:38 PM and 52 seconds: Patient #9 entered courtyard and walked to picnic table
area.
1:40 PM and 38 seconds: Patient #9 talked to another patient behind the picnic
tables (side toward back of courtyard).
1:40 PM and 51 seconds: Patient #9 walked toward back of courtyard toward
fence and out of camera view.
1:41 PM and 25 seconds: Both RNs remain in picnic table area.
1:57 PM and 44 seconds: Female RN and female patient walked toward building.
1:58 PM and 10 seconds: Female RN Reentered courtyard and sat on left side of
the picnic table.
2:00 PM and 01 second: Female patient returned to the courtyard.
2:11 PM and 46 seconds: Patients and RNs stood up. Patients start gathering
activity items and start walking toward building.
2:12 PM and 32 seconds: Patients and RNs out of view.
2:13 PM and 35 seconds: Male RN in view; briefly looks around and goes back
toward building.
2:15 PM and 33 seconds: Female staff member in view; briefly looks around and
goes back toward building.
Patient #9 was not seen on video surveillance footage after 1:40 PM. The patients route of elopement could not be visualized.

Review of an event report showed an elopement from the Behavioral Health Unit occurred on 6/24/2023 at 2:00 PM. "...RN x2 assisted pt's outside for group therapy. As RN #1 was escorting another patient back inside to use the bathroom, the patient [Patient #9] (who eloped) pushed her way through an opening in the fenced area outside and eloped from facility..."

During a telephone interview on 11/1/2023 at 8:45 AM, RN #1 stated sometime midday, he and another nurse took some patients outside for some fresh air. He stated they went back inside, did a head count, and discovered "...we had a patient missing..." When asked if Patient #9 eloped through the fence RN #1 replied "...I think we made the general assumption that was how she left..." RN #1 stated he did not see the patient go through the fence. RN #1 could not recall how many patients were in the courtyard when Patient #9 eloped.

During a telephone interview on 11/1/2023 at 9:03 AM, RN #2 stated "...We had gone outside for a group. I looked up and noticed I didn't see her [Patient #9]. We had been out there [courtyard] about 10 minutes. RN #2 stated she and the other RN took everyone back in and did a head count. RN #2 stated she immediately knew which patient was missing. "...She was very, very thin...I believe she got out through a loose board or opening. It's not a tall fence either..." When asked how many patients were in the courtyard, RN #2 stated "...I don't know...it was probably...maybe a dozen..."

During an interview on 11/2/2023 at 11:03 AM, in the BH conference room, the BH Nurse Manager confirmed the BH facility did not have a specific process to monitor patients during outdoor activities.