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Based on staff interviews, medical record review, and review of facility documents, it was determined the facility failed to ensure: 1) a process to screen patients for elopement risk is developed and implemented; 2) interventions to prevent future elopements are implemented, in accordance with facility policy; 3) a policy to address interventions and prevention measures for patients at high risk for elopements, is developed and implemented; 4) risk assessments are conducted after incidents of elopement or patient safety concerns; 5) the patient's representative is notified after incidents of elopement or patient safety concerns, in accordance with facility policy. (Cross refer to Tags A-131, A-144).

Based on review of three (3) of nine (9) medical records (#1, #6, #9), staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure patient representatives are notified about changes in the patient's health status.

Findings include:

Reference: Facility policy, "Code Gray (Elopement)" states, "... An elopement is when a patient (who is incapable of adequately protecting themselves) departs the hospital unsupervised and undetected. ... 8) The charge nurse should call the family of the patient, if a 'Release of Information' form has been signed and advise them of the situation. ... 13) The Charge Nurse must notify the Director of Nursing (who will in turn notify the Administrator) and the patient's family (if consent is indicated in the patient's chart) of the patient's return."

Review of medical record #1 on 2/8/22 revealed that the patient was involuntarily admitted to the facility on 1/27/22. An incident report dated 2/5/22 at 5:40 PM states, "Patient went outside for fresh air together with other patients and immediately scaled the back fence and ran into the woods. 911 called and the police located him fours [sic] later. Sent to the ER. ... Name of Family Notified (if required): N/A."

Treatment Team notes dated 1/31/22 at 3:15 PM state, "[Name of patient] presented with poor insight into his mental health diagnosis. He signed a ROI (Release of Information) for his mother and signed his treatment plan." Social Worker notes dated 1/31/22 at 6:10 PM identifies the patient's mother as his/her representative and lists the mother's phone number.

Nurse's notes dated 2/5/22 at 7:50 PM, entered after the patient's elopement, states, "... Staff on duty immediately search the nearby woods for the patient. The director of nursing was notified and all appropriate authorities. The patient has no emergency contact on file for the patient as patient is his own guarantor. ... ."

Upon interview on 2/8/22 at 10:00 AM, Staff #1 and Staff #2 confirmed Patient #1 eloped on 2/5/22 at approximately 5:30 PM. Staff #1 stated, "The police were finally able to find him around 9:30 PM. He was still in the woods. They brought him inside and he was medically assessed. He had lacerations to his arms, hands, and face, and he also had some bruises. We sent him to the ER at [name of hospital] and he returned back to the unit at approximately 2:30 AM." There was no evidence in the medical record that the patient's mother, who was identified as his/her next of kin, was notified about the patient's elopement and hospital visit. Staff #1 was asked if the patient's next of kin was notified about his/her elopement and subsequent hospital visit. He/she stated, "It doesn't look like it."

Review of Medical Record #6 on 2/9/22 revealed the patient was admitted to the facility on 4/26/21. An incident report dated 4/29/21 at 2:55 PM states, "pt (patient) stated she was lying in bed and turned to move her pillow and her finger got dislocated. ... Name of Family Notified: (left blank)."

Nurse's notes dated 4/29/21 at 3:17 PM state, "[Name of patient] came to the nursing station and reported her left ring finger is dislocated. Per [name of patient], she was fixing her bed and hit the wall with her left hand and her left ring finger got 'dislocated.' Fourth digit does appear dislocated, per MD transfer to ED. ... ." Nurse's notes indicate the patient arrived back to the unit from the hospital on 4/29/21 at 10:40 PM.

The patient's "Consent for Contact" form, signed and dated on 4/30/21, states, "I hereby authorize facility staff to contact [name and telephone number of patient's mother] for the purpose of inviting them to participate in my treatment program. (Including but not limited to... diagnosis & prognosis... and medical status). Staff may verbally disclose information pertinent to my treatment in order to obtain their understanding and support."

On 2/9/22, Staff #2 confirmed there was no evidence in the medical record that the patient's authorized representative was notified regarding the patient's dislocated finger and subsequent hospital visit.

Review of Medical Record #9 on 2/9/22 revealed the patient was admitted to the facility on 7/2/21. An incident report dated 7/11/21 at 1:30 PM states, "Patient was at the hallway, loud, talking, refusing to go back to her room. Another patient [name of patient] thought she was talking about her and punched her in the face. ... Name of Family Notified: (left blank)."

Nurse's notes dated 7/11/21 at 4:30 PM state, "Patient was in the hallway, loud, talking, RN tried to redirect patient back to her room, but she refused redirection. Another patient [name of patient] thought she was talking about her and punched her in the face. Patient complained of pain, rated 10, and also complained of seeing stars. MD was made aware... and the doctor ordered for her to be sent out to the hospital for evaluation." Nurse's notes indicate the patient returned to the unit from the hospital on 7/11/21 at 8:45 PM.

The patient's "Consent for Contact" form, signed and dated 7/6/21, states, "I hereby authorize facility staff to contact [name of patient's spouse and Dad] for the purpose of inviting them to participate in my treatment program. (Including but not limited to... diagnosis & prognosis... and medical status). Staff may verbally disclose information pertinent to my treatment in order to obtain their understanding and support."

On 2/9/22, Staff #2 confirmed there was no evidence in the medical record that neither of the patient's authorized representatives were notified regarding the patient's assault and subsequent hospital visit.

A request was made to Staff #1 on 2/8/22 and 2/9/22 for the facility's policy on notifying the patient's representative or next of kin. No policy was provided. Staff #1 stated the facility did not have a policy on notification of the patient's representative or next of kin.

Based on staff interviews, review of nine (9) of nine (9) medical records (#'s 1-9), and review of facility documents, it was determined the facility failed to ensure: 1) a process to screen patients for elopement risk is developed and implemented; 2) interventions to prevent future elopements are implemented, in accordance with facility policy; 3) a policy to address interventions and prevention measures for patients at high risk for elopements, is developed and implemented; 4) risk assessments are conducted after incidents of elopement or patient safety concerns; 5) the patient's representative is notified after incidents of elopement or patient safety concerns, in accordance with facility policy.

On 2/10/22, Staff #1 and Staff #2 were notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility on 2/10/22 at 11:55 AM. An acceptable IJ removal plan was received from the facility on 2/10/22 and on-site verification of the implementation of the IJ removal plan was conducted on 2/11/22, the last day of the survey. The IJ was abated on 2/11/22.

Findings include:

1) Upon interview on 2/8/22 at 9:59 AM, Staff #2 stated that on 2/5/22 at approximately 5:30 PM, Patient #1 eloped from the facility by scaling a chain-link fence that enclosed a courtyard used by patients during "fresh air time." Staff #2 stated that the patient was found by police in the woods approximately four (4) hours after he/she eloped, and was brought back to the facility.

Upon interview on 2/8/22 at 12:35 PM, Staff #2 was asked if patients admitted to the facility are screened for elopement risk. He/she stated, "If the patient was an elopement risk, the transferring facility would give us that information and we would document it." Staff #2 was asked if the facility screens patients for elopement, independent of the information received from the sending facility. He/she stated, "There are no elopement screening tools in the EMR (electronic medical record). There is no automatic assessment for elopement. The transferring facility would give us that information."

Review of Patient #1's medical record revealed the patient was involuntarily admitted to the facility on 1/27/22. There was no evidence in the medical record that the patient was screened or assessed for elopement risk, upon admission to the facility.

Nurse's notes dated 1/29/22 at 11:59 AM state, "... when visible on the unit he has episodes of bizairre [sic] pacing in the hallway checking doors... ." Nurse's notes dated 2/1/22 at 1:17 PM state, "... [Name of patient] had a moment of difficulty where he was witnessed kicking at back door stating 'They kidnapped me, I have to get out.' [Name of patient] was able to be verbally redirected. At that time [Name of patient] reported he spent a few months in prison and being locked in here triggered the same anxieties. [Name of patient] stated being able to go outside at that moment helped him to be able to calm down and not feel so trapped. ... ." There was no evidence in the medical record that the patient was assessed for elopement risk after being observed checking doors on 1/29/22, and verbalizing to staff that he/she needed to "get out" on 2/1/22. The patient successfully eloped on 2/5/22.

Review of Patient #2's medical record revealed the patient was admitted to the facility on 12/29/20. On 1/1/21 at 6:27 PM, the patient exited his/her room with "a piece of wood with nails," assaulted staff, destroyed property at the nurse's station, broke through a window in the breakroom to exit the unit, and exited the facility by prying open sliding doors in the lobby. The patient was able to cross a field outside the facility and was met by police. He/She was taken to the hospital for cuts to his/her legs and did not return to the facility. There was no evidence that Patient #2 was screened or assessed for elopement risk, upon admission to the facility.

Review of Patient #3's medical record revealed that the patient was admitted to the facility on on 3/28/21. On 3/31/21 at 12:51 PM, the patient was observed climbing the outside fence in an attempt to elope, and was stopped by staff. There was no evidence that Patient #3 was screened or assessed for elopement risk, upon admission to the facility.

Review of the facility's policy and procedure on elopement lacked evidence of a process to screen patients for elopement risk, upon admission to the facility.

2) Reference: Facility policy, "Code Gray (Elopement)" states, "... 9) Upon immediate return of the patient to the unit, he/she is to be placed in a hospital gown and shoes removed, to deter the patient from further elopement attempts. ... ."

Review of Patient #1's medical record revealed that on 2/5/22 at approximately 5:30 PM, Patient #1 eloped from the facility by scaling a chain-link fence that enclosed a courtyard used by patients during "fresh air time." Staff #2 stated that the patient was found by police in the woods approximately four (4) hours after he/she eloped, and was brought back to the facility by police at approximately 9:30 PM. The patient was transferred to the hospital for evaluation at 10:50 PM, and returned to the unit at 2:30 AM. There was no evidence in the medical record that the patient was placed in a hospital gown and his/her shoes removed to deter him/her from further elopement attempts, as indicated in facility policy. Upon interview on 2/8/22 at 12:25 PM, Staff #6 stated, "I was here when the patient eloped, but I didn't witness it. I came in the next day at 7:00 AM. I didn't talk to the patient, but I saw him at breakfast. He was wearing his regular clothing."

During a tour of the inpatient unit on 2/8/22 at 10:35 AM, Patient #1 was observed in his/her assigned room (Room #17-2), wearing his/her personal clothing and sneakers. Room #17-2 is immediately adjacent to the exit doors leading to the outside courtyard. Upon interview on 2/8/22 at 12:25 PM, Staff #6 stated that patients line up at the exit doors after an announcement is made for "fresh air time," prior to staff opening the doors to allow patients to exit into the courtyard. Staff #6 confirmed that "fresh air time" is scheduled four (4) times per day. Upon interview on 2/8/22 at 12:30 PM, Staff #1 and Staff #2 were asked why Patient #1 was kept in a room immediately next to the same exit doors from which he/she was able to successfully elope. Staff #2 stated, "We had a conversation that it was not necessary to move his room. The psychiatrist also didn't think it was necessary." There was no evidence in the medical record that facility staff and/or the psychiatrist assessed the patient's risk of further elopement attempts and determined moving his/her room away from the exit doors was unnecessary.

3) Reference: Facility policy, "Code Gray (Elopement)" states, "... 11) The RN must communicate assessment results to the Medical Director as soon as possible, as well as determining if the patient should be placed on an increased observation level (i.e., 15-minute close observation, 1:1 observation, or elopement precautions)... ."

Review of Patient #1's medical record revealed physician progress notes dated 2/6/22 that state, "... Patient is reported to have jumped the courtyard fence and eloped yesterday. He was brought back to the facility by the [name of township] police department after 4 hrs (hours). ... Patient reports that 'I just want to leave and go back to [name of city].' ... He is discharged focused, 'I shouldn't be here at all.' ... Medication Plan... Elopement precautions."

A request was made to Staff #1 and Staff #2 for the facility's policy and procedure on elopement precautions. No policy and procedure was provided. Staff #1 and Staff #2 were asked what interventions and prevention measures are initiated for patients at high risk for elopement. Staff #1 stated, "They sign a denial of rights to go outside." Staff #1 and Staff #2 were unable to identify additional interventions and prevention measures initiated for patients at high risk for elopement. Staff #1 and Staff #2 confirmed the facility does not have a policy addressing prevention measures for patients at high risk for elopement.

4) During a tour of the inpatient unit on 2/8/22 at 10:50 AM, an interview with Staff #4 was conducted. Staff #4 was asked if he/she was aware of any patient elopements. Staff #4 stated, "Well I heard about the elopement this weekend. We had an issue with an elopement one time a long time ago. He tried to climb the fence but we were able to grab him." At 12:25 PM, an interview was conducted with Staff #6. Staff #6 was asked if he/she was aware of any patient elopements. Staff #6 indicated that he/she was aware of Patient #1's recent elopement. Staff #6 was asked if he/she was aware of any other patient elopements. Staff #6 stated, "There was an incident of a patient trying to hop the fence, but we got to him. The last time was in April of '21. There was a similar circumstance where a young woman jumped on top of the bus stop (enclosed structure located in the courtyard) trying to get over the fence. But we were able to get to her and get her down."

Review of the facility's Environmental Risk Assessment for 2021 and 2022 lacked evidence of a risk assessment for the outside courtyard. Upon interview on 2/8/22 at 12:35 PM, Staff #1 stated, "The Environmental Risk Assessment does not include the outside because the tool that we use doesn't require it. The tool doesn't include the outside. We at least identify that the area is fenced."

On 2/8/22 at 10:06 AM, Staff #1 and Staff #2 were asked if the facility conducted, or planned to conduct, a root cause analysis (RCA) regarding Patient #1's elopement. Staff #1 stated, "We are not doing an RCA. This event does not require an RCA since we did not have to report it under the Patient Safety Act. We are not required to do one."

Review of Patient #2's medical record revealed that on 1/1/21 at 6:27 PM, the patient exited his/her room with "a piece of wood with nails," assaulted staff, destroyed property at the nurse's station, broke through a window in the breakroom to exit the unit, and exited the facility by prying open sliding doors in the lobby.

Upon interview on 2/28/22 at 1:15 PM, Staff #2 was asked how Patient #2 was able to retrieve "a piece of wood with nails." Staff #2 stated that the patient was able to remove a piece of wood from the cubby area in his/her room. Staff #2 was asked if a risk assessment was performed on all the cubbies in the unit, to determine if they were a safety risk. Staff #2 stated, "We called maintenance and they evaluated the cubby and fixed it. There were no other concerns. All of the other rooms were evaluated."

A request was made to Staff #2 for the facility's risk assessment performed for the cubbies on the unit. A copy of a handwritten page from a notebook was provided. An entry on the page states, "1/3/2021... Replaced top trim @ cubbie Rm. 6 BBHH... All safe!"

Upon interview on 2/9/22 at 11:20 AM, Staff #1 stated, "There was nothing else that we have from maintenance to show that the cubbies were assessed after the incident." A risk assessment of the cubbies was conducted by the facility on 2/10/22. Review of the risk assessment indicated that of the eighteen (18) rooms on the unit, cubbies in sixteen (16) of the rooms required repair "to secure and reinforce molding above the cubbies."

Upon interview on 2/9/22 at 9:50 AM, Staff #1 and Staff #2 were asked if an RCA was conducted on Patient #2's elopement. Staff #1 stated, "An RCA was not done. We don't consider her leaving an elopement. She left the unit, but we don't consider that to be an elopement. The police were in the lobby and witnessed her leaving the hospital, so we don't consider it an elopement. We consider what happened to her to be an accidental injury."

5) Reference: Facility policy, "Code Gray (Elopement) states, "... An elopement is when a patient (who is incapable of adequately protecting themselves) departs the hospital unsupervised and undetected. ... 8) The charge nurse should call the family of the patient, if a 'Release of Information' form has been signed and advise them of the situation. ... 13) The Charge Nurse must notify the Director of Nursing (who will in turn notify the Administrator) and the patient's family (if consent is indicated in the patient's chart) of the patient's return."

Review of medical record #1 on 2/8/22 revealed that the patient was involuntarily admitted to the facility on 1/27/22. An incident report dated 2/5/22 at 5:40 PM states, "Patient went outside for fresh air together with other patients and immediately scaled the back fence and ran into the woods. 911 called and the police located him fours [sic] later. Sent to the ER. ... Name of Family Notified (if required): N/A."

Treatment Team notes dated 1/31/22 at 3:15 PM state, "[Name of patient] presented with poor insight into his mental health diagnosis. He signed a ROI (Release of Information) for his mother and signed his treatment plan." Social Worker notes dated 1/31/22 at 6:10 PM identifies the patient's mother as his/her representative and lists the mother's phone number.

Nurse's notes dated 2/5/22 at 7:50 PM, entered after the patient's elopement, states, "... Staff on duty immediately search the nearby woods for the patient. The director of nursing was notified and all appropriate authorities. The patient has no emergency contact on file for the patient as patient is his own guarantor. ... ."

Upon interview on 2/8/22 at 10:00 AM, Staff #1 and Staff #2 confirmed that Patient #1 eloped on 2/5/22 at approximately 5:30 PM. Staff #1 stated, "The police were finally able to find him around 9:30 PM. He was still in the woods. They brought him inside and he was medically assessed. He had lacerations to his arms, hands, and face, and he also had some bruises. We sent him to the ER at [name of hospital] and he returned back to the unit at approximately 2:30 AM." There was no evidence in the medical record that the patient's mother, identified as the patient's next of kin, was notified of the patient's elopement and hospital visit. Staff #1 was asked if the patient's next of kin was notified about his/her elopement and subsequent hospital visit. He/she stated, "It doesn't look like it."

Review of Medical Record #6 on 2/9/22 revealed the patient was admitted to the facility on 4/26/21. An incident report dated 4/29/21 at 2:55 PM states, "pt (patient) stated she was lying in bed and turned to move her pillow and her finger got dislocated. ... Name of Family Notified: (left blank)."

Nurse's notes dated 4/29/21 at 3:17 PM state, "[Name of patient] came to the nursing station and reported her left ring finger is dislocated. Per [name of patient], she was fixing her bed and hit the wall with her left hand and her left ring finger got 'dislocated.' Fourth digit does appear dislocated, per MD transfer to ED. ... ." Nurse's notes indicate the patient arrived back to the unit from the hospital on 4/29/21 at 10:40 PM.

The patient's "Consent for Contact" form, signed and dated on 4/30/21, states, "I hereby authorize facility staff to contact [name and telephone number of patient's mother] for the purpose of inviting them to participate in my treatment program. (Including but not limited to... diagnosis & prognosis... and medical status). Staff may verbally disclose information pertinent to my treatment in order to obtain their understanding and support."

On 2/9/22, Staff #2 confirmed there was no evidence in the medical record that the patient's authorized representative was notified regarding the patient's dislocated finger and subsequent hospital visit.

Review of Medical Record #9 on 2/9/22 revealed the patient was admitted to the facility on 7/2/21. An incident report dated 7/11/21 at 1:30 PM states, "Patient was at the hallway, loud, talking, refusing to go back to her room. Another patient [name of patient] thought she was talking about her and punched her in the face. ... Name of Family Notified: (left blank)."

Nurse's notes dated 7/11/21 at 4:30 PM state, "Patient was on the hallway, loud, talking, RN tried to redirect patient back to her room, but she refused redirection. Another patient [name of patient] thought she was talking about her and punched her in the face. Patient complained of pain, rated 10, and also complained of seeing stars. MD was made aware... and the doctor ordered for her to be sent out to the hospital for evaluation." Nurse's notes indicate the patient returned to the unit from the hospital on 7/11/21 at 8:45 PM.

The patient's "Consent for Contact" form, signed and dated on 7/6/21, states, "I hereby authorize facility staff to contact [name of patient's spouse and Dad] for the purpose of inviting them to participate in my treatment program. (Including but not limited to... diagnosis & prognosis... and medical status). Staff may verbally disclose information pertinent to my treatment in order to obtain their understanding and support."

On 2/9/22, Staff #2 confirmed there was no evidence in the medical record that the patient's authorized representative was notified regarding the patient's assault and subsequent hospital visit.

A request was made to Staff #1 on 2/8/22 and 2/9/22 for the facility's policy on notifying the patient's representative or next of kin. No policy was provided. Staff #1 stated the facility did not have a policy on notification of the patient's representative or next of kin.

Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure the quality assessment performance improvement program (QAPI) analyzes and tracks patient elopements, and develops activities for improvement. (Cross refer to Tag A-268).

Based on review of three (3) of nine (9) medical records (#1, #2, #3), staff interviews, and review of facility documents, it was determined the facility failed to ensure the quality assessment performance improvement (QAPI) program analyzes and tracks patient elopements, and develops activities for improvement.

Findings include:

During a tour of the inpatient unit on 2/8/22 at 10:50 AM, an interview with Staff #4 was conducted. Staff #4 was asked if he/she was aware of any patient elopements. Staff #4 stated, "Well I heard about the elopement this weekend. We had an issue with an elopement one time a long time ago. He tried to climb the fence but we were able to grab him." At 12:25 PM, an interview was conducted with Staff #6. Staff #6 was asked if he/she was aware of any patient elopements. Staff #6 indicated that he/she was aware of Patient #1's recent elopement. Staff #6 was asked if he/she was aware of any other elopements. Staff #6 stated, "There was an incident of a patient trying to hop the fence, but we got to him. The last time was in April of '21. There was a similar circumstance where a young woman jumped on top of the bus stop (enclosed structure located in the courtyard) trying to get over the fence. But we were able to get to her and get her down."

Review of Patient #1's medical record revealed the patient was involuntarily admitted to the facility on 1/27/22. On 2/5/22 at approximately 5:30 PM, Patient #1 eloped from the facility by scaling a chain-link fence that enclosed a courtyard used by patients during "fresh air time." The patient was found by police in the woods approximately four (4) hours after he/she eloped, and was brought back to the facility.

On 2/8/22 at 10:06 AM, Staff #1 and Staff #2 were asked if the facility conducted, or planned to conduct, a root cause analysis (RCA) regarding Patient #1's elopement. Staff #1 stated, "We are not doing an RCA. This event does not require an RCA since we did not have to report it under the Patient Safety Act. We are not required to do one."

Review of Patient #2's medical record revealed that on 1/1/21 at 6:27 PM, the patient exited his/her room with "a piece of wood with nails," assaulted staff, destroyed property at the nurse's station, broke through a window in the breakroom to exit the unit, and exited the facility by prying open sliding doors in the lobby.

Upon interview on 2/9/22 at 9:50 AM, Staff #1 and Staff #2 were asked if an RCA was conducted on Patient #2's elopement. Staff #1 stated, "An RCA was not done. We don't consider her leaving an elopement. She left the unit, but we don't consider that to be an elopement. The police were in the lobby and witnessed her leaving the hospital, so we don't consider it an elopement. We consider what happened to her to be an accidental injury."

Review of Patient #3's medical record revealed that on 3/3/21 at 12:51 PM, the patient was observed climbing the outside fence in an attempt to elope, and was stopped by staff.

Upon interview on 2/8/22 at 1:40 PM, Staff #1 stated, "Incident reports are reviewed at the Patient Safety Committee meetings. The committee meets quarterly. Safety issues like elopements would be discussed at the Patient Safety Committee meeting."

Review of the Patient Safety Committee meeting minutes dated 1/21/21 lacked evidence that Patient #2's elopement, occurring on 1/1/21, was presented to or discussed at the Patient Safety Committee meeting. Upon interview on 2/9/22 at 9:50 AM, Staff #1 stated, "It would not be in the meeting minutes because we don't consider it an elopement."

Review of the Patient Safety Committee meeting minutes dated 4/15/21 lacked evidence that Patient #3's attempted elopement, occurring on 3/3/21, was presented to or discussed at the Patient Safety Committee meeting. Upon interview on 2/9/22 at 9:45 AM, Staff #1 stated, "The patient did not attempt to elope. The patient had elopement ideology, but he did not attempt to elope."

There was no evidence of data tracking or analyzing elopements identified in the Patient Safety Committee meeting minutes dated 1/21/21, 4/15/21, 7/15/21, and 10/21/21.

Upon interview on 2/9/22 at 9:45 AM, Staff #2 stated, "We discussed these incidents, but it may not be in writing."