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Based on observation, interview, and record review, the facility failed to ensure that patients were protected in a safe environment as evidenced by the elopement of 3 of 3 adolescent patients (Patient #1, #2, and Patient #3) from the hospital.

Findings included:

Record review of the medical record for Patient #1 revealed:
· Preadmission Exam & Certification by MD #57 dated 10/08/2016 at 1225 revealed Patient #1 was a 17-year-old female admitted involuntary on an emergency detention warrant.

· Assessment Tool by Personnel #59 dated10/08/2016 at 1115 revealed Patient #1 had a history of runaway behavior and poor impulse control, and was a danger to herself and others.

· High Risk Notification Alert by Personnel #59 dated 10/08/2016 [no time] and cosigned by RN #60 on 10/08/2016 at 1400 revealed Patient #1 had " current " risk factors of self-injury and elopement.

· Physician Orders by MD #58 dated 10/08/2016 at 1421 revealed Patient #1 was on the following precautions: suicide, elopement, self-harm, medical alert, and assaultive, as well as every 15-minute checks were ordered. Unit restrictions were not ordered.

· Nursing Progress Note by RN #61 dated 10/09/2016 at 1040 revealed Patient #1had " Mood swings present - angry ... Easily agitates and refused morning medications. "

· Group Progress Note by Personnel #78 dated 10/09/2016 at 1145 revealed Patient #1 was agitated, hyperactive, and angry about being in the hospital.

In an interview with MD #58 on 10/13/2016 at 1455, she stated she saw Patient #1 briefly in the admissions department on 10/08/2016, the day of admission. MD #58 was shown RN #61 ' s documentation on Patient #1 dated 10/09/2016 at 1145, just minutes before Patient #1 eloped from the cafeteria [ " Mood swings present - angry ... Easily agitates and refused morning medications " ]. MD #58 stated, " Why did they let her [Patient #1] go to the cafeteria? "

In an interview with Personnel #51 on 10/14/2016 at 1415, he stated:
· At one time most patients were placed on unit restrictions at the time of admission;
· Blanket unit restrictions for all patients can be a patient rights issue;
· Perhaps they had swung too far in the other direction by not putting patients with a high elopement risk on unit restrictions;
· Patient #1 should have been on unit restriction; and
· He will recommend unit restriction be ordered for high elopement risk or suicide risk.


Record review of the medical record for Patient #2 revealed:
· Preadmission Exam & Certification by MD #62 dated 09/23/2016 at 1953 revealed Patient #2 was a 15-year-old female admitted with suicidal ideation " always " and a plan to walk into traffic. There had been five previous suicide attempts.

· Assessment Tool by Personnel #63 dated 09/23/2016 at 1900 revealed Patient #2 had self-mutilating behaviors (cutting both arms and legs), frequent runaway behavior, theft of motor vehicle, criminal mischief, and impaired judgment and insight.

· Restraint/Seclusion/Emergency Medication Order/Record by RN #65 dated 10/07/2016 at 1830 revealed Patient #2 was fighting and scratching self. She was restrained, medicated and secluded.

· Observation Rounds/Precautions dated 10/09/2016 revealed Patient #2 was on the following precautions at the time of elopement: suicide, assault/aggression and elopement. She was not on unit restrictions.


Record review of the medical record for Patient #3 revealed:
· Preadmission Exam & Certification by MD #57 dated 10/03/2016 at 1740 revealed Patient #3 was a 16-year-old female who ran away from a facility. She broke a lamp and used the bulb to make multiple cuts on her arms. She was restrained at the facility because of her aggression.

· Nursing Progress Notes by RN #61 dated 10/09/2016 at 1000 revealed Patient #3 " Easily agitates and is disruptive and loud. Can become aggressive. "

· Observation Rounds/Precautions dated 10/09/2016 revealed the Patient #3 was on the following precautions at the time of elopement: suicide, assault/aggression, and elopement. She was not on unit restrictions.


Record review of the video surveillance for 10/09/2016 at 1215, revealed:
· Patient #1, Patient #2 and Patient #3 ran from the cafeteria through the double doors leading into the lobby and then out the glass doors between the lobby and the outside.
· Staff had not position themselves between the patients and the double doors leading to the lobby as the patients exited the cafeteria.

In an interview with Personnel #69 (Safety Officer/Director of Plant Operations) on 10/13/2016 at 1415, he stated the glass door was not locked on 10/09/2016 at the time of the elopement.

In an interview with the Risk Manager (ID# 55) on 10/13/2016 at 1355, he stated:
· He was unsure about the policy on locking the glass doors between the lobby and the outside;
· " They would like for it to be locked " ; and
· The glass door was to be kept locked " except during visitation. "

In an interview with Personnel #51 (CEO) on 10/14/2016 at 1415, he stated the glass doors should have been locked.

In an interview with Receptionist (ID# 56) on 10/13/2016 at 1405, she stated both sets of doors (the double doors between the lobby and the main hallway and the glass doors between the lobby and the outside) were to remain locked at all times.

Observation of the cafeteria on 10/13/2016 at 1110 revealed 14 adolescent boys and 19 children and five staff in the cafeteria. Staff did not position themselves between the patients and the double doors leading to the lobby as the patients exited the cafeteria.

Observation of the cafeteria on 10/13/2016 at 1140 revealed 20 patients and three staff. Staff did not position themselves between the patients and the double doors leading to the lobby as the patients exited the cafeteria.


Record review of Policy # PC 190, Precautions, revised 03/2016 revealed: " Patients exhibiting an imminent risk of harm to self or others will be placed on precautions to ensure their safety and/or the safety of others ...

" Patients will be assessed and reassessed for behaviors that may require the use of precautions at the time of admission, as well as throughout treatment. The Registered Nurse will initiate respective precautions when indication of risk is present. Utilization of precautions and their applicability may be based upon past history, as well as current presentation of symptoms, behaviors, risk factors, and other variables ...

" Suicide Precautions ... Staff will request that the patient make them aware of their whereabouts if they are not in common areas of the milieu. Although patient observation rounds are documented at least every 15 minutes, staff will be cognizant of the whereabouts of the patients at all times ...

" Unit Restriction ... This is an added measure that can be in addition to other precautions, and is utilized if safety concern or risk is present, as well as uncertainty for the patient to leave the immediate locked unit area until seen face to face by a physician. This is utilized when the treatment team feels that the patient ' s behavior is unpredictable, potentially unsafe, or risk exists that precipitates the need for further evaluation or monitoring prior to allowing the patient off of the secured unit ...

" Assault/Aggression Precautions ... A patient on assaultive precautions may receive meals in the cafeteria when escorted and observed by staff ...

" Elopement Precautions ... A patient may be placed on elopement precautions if it is determined that the patient is likely to attempt to leave the treatment unit or the hospital without authorization and if it is determined that such action would pose a risk of harm to the patient or other persons. This determination shall be based on the patient ' s behavior while in the hospital, the patient ' s recent history or the patient ' s verbalization of intent to elope from the hospital. Depending on severity of elopement risk, i.e. previous attempt to elope from facility; patient may be placed on unit restriction (UR) ... Documentation by nursing staff shall include each day an assessment as to whether the patient continues to require elopement precautions ...
" Self-Harm (Self-Injury) ... Staff will closely observe ... the patient ... Staff assigned to observe patients on self-harm precautions shall be vigilant for ... significant signs of concern ... "

Based on observation, interview, and record review, the facility failed to ensure that mechanisms were in place to ensure patients were free from all forms of neglect as evidenced by:
(1) The elopement of 3 of 3 adolescent patients (Patient #1, #2, and Patient #3) from the hospital; and
(2) The CNO being unaware of 2 of 2 variances between the number of staff members specified in the staffing plan and the actual number of staff members on duty on unit 200 (the children ' s unit).

Findings included:

In an interview with Personnel #53 (Nursing Services) on 10/13/2016 at 1315, she stated:
· Patient #1, #2 and Patient #3 eloped from the facility ' s cafeteria on Sunday, October 9, 2016 around 1215;
· Patient #3 was apprehended on the hospital grounds and returned to the unit;
· Patient #1 and Patient #2 were not apprehended; and
· She had not reported the elopement to the Department of State Health Services.

Record review of the video surveillance for 10/09/2016 at 1215, revealed Patient #1 and Patient #2 eloped from the hospital through the double doors leading into the lobby and then out the glass doors between the lobby and the outside.

Record review of the Staffing Assignment Sheets on 10/14/2016 at 1100 revealed the following:
· On Saturday, 09/10/2016, unit 200 had 15 patient with three scheduled discharges. The unit had three staff members. John Essien Personnel #77 stated the unit should have had four staff members.
· On Sunday, 10/09/2016, unit 200 had 23 patients. The unit had four staff members. Personnel #77 stated the unit should have had six staff members.

In an interview with Personnel #53 on 10/14/2016 at 1030, she stated there were no staffing shortages, adding that staff are not to complain to her of staffing shortages " when you are the one on your cell phone at work. " [The two variances between planned and actual numbers of staff members (09/10/2016 and 10/09/2016) were shared with her.]

Record review of the Nurse Staff Advisory Committee quarterly minutes for September 2016 revealed an agenda. There was no documented discussion of variances between planned and actual numbers of staff members.

Based on interview and record review, the facility failed to ensure that Nursing Services had adequate numbers of staff to provide nursing care to patients as evidenced by:
(1) The children ' s unit did not have the minimum number of staff on 2 of 2 shifts and
(2) 6 of 6 staff (Personnel # 60, #72. #73, #74, #76 and #77) stated there were staffing problems on weekends.

Findings included:

In an interview with Personnel #60 (Nursing Services) on 10/13/2016 at 0930, she stated there are a lot of staff that call in sick on weekends, especially on payday weekends, which can result in the unit being understaffed.

In an interview with Personnel #72 (Nursing Services) on 10/13/2016 at 1000, he stated there was " no contingency plan when numerous staff call in [sick]. "

In an interview with Personnel #73 (Nursing Services) on 10/13/2016 at 1015, he stated he has seen " staffing uncomfortably low on an average of one weekend per month. "

In an interview with Personnel #74 (Nursing Services) on 10/13/2016 at 1030, she stated that staffing was sometimes a problem, adding, " Sometimes staffing has been dangerously low. "

In an interview with Personnel #76 (Nursing Services) on 10/13/2016 at 1300, she stated there were problems with staffing, especially on weekends.

Record review of the Staffing Assignment Sheets on 10/14/2016 at 1100 revealed the following:
· On Saturday, 09/10/2016, unit 200 had 15 patient with three scheduled discharges. The unit had three staff members. John Essien Personnel #77 stated the unit should have had four staff members.
· On Sunday, 10/09/2016, unit 200 had 23 patients. The unit had four staff members. Personnel #77 stated the unit should have had six staff members.

In an interview with Personnel #77 on 10/14/2016 at 1100, he stated there are staffing shortages sometimes. Record of the Staffing Assignment Sheets revealed the following:
· On Saturday, 09/10/2016, unit 200 had 15 patient with three scheduled discharges. The unit had three staff. John Essien He stated the unit should have had four staff.
· On Sunday, 10/09/2016, unit 200 had 23 patients. The unit had four staff. He stated the unit should have had six staff.
He also stated that he didn ' t know any details about the Nurse Staffing Advisory Committee and had not been asked to join the committee.