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Based on observation, interview and record review, the hospital failed to provide sufficient interventions to assure each patient's rights were protected by maintaining care in a safe setting as evidence by the failure to recognize and implement interventions to reduce or eliminate the opportunity for potential harm associated with the physical environment in the Emergency Department. Findings include:

1. The hospital failed to identify the environmental safety risk when transporting psychiatric patients from the Emergency Department East wing through an exit door whose location is in close proximity to unsecured outside exit creating the potential opportunity for patient elopement. Per record review Patient #1 was brought to the hospital Emergency Department (ED) on 12/5/17 at 22:52 for a psychiatric evaluation after experiencing psychiatric symptoms. On 12/6/17 at 2:00 AM it was determined Patient #1 was at risk of harm and was to be involuntarily admitted to the PSIU (Psychiatric Services Inpatient Unit). While waiting for a bed to become available on PSIU, Patient #1 was assigned to the ED East wing, a locked unit often utilized for psychiatric patients awaiting bed placement or transfer to another facility.

Per ED Note: Nursing on 12/6/17 at 10:53 states "report given to PSIU ...". Per ED policy Security was notified to come to the East wing to assist the PSA in transporting Patient #1 to PSIU. Patient #1 was placed in a wheelchair and it was decided by Security Officer #1 to exit Patient #1 from the East wing through the South entrance door. Upon exiting through the South door the patient was wheeled into a small entryway which includes both the ambulance bay entrance and separate entrance to the ED. During the escort, Patient #1 jumped out of the wheelchair and proceeded towards the ambulance bay. The PSA attempted to prevent Patient #1 from exiting, but was knocked down by Patient #1 resulting in the PSA sustaining an injury when s/he fell onto an oxygen tank stand becoming disabled by the fall. Patient #1 eloped by running through the ambulance bay, exiting an unlocked door and proceeded to run rapidly across the hospital campus and eventually into a wooded area. The Security guard attempted to pursue Patient #1, however was directed by a staff member to stop the pursuit as the patient exited the campus. The Rutland police department was immediately contacted regarding the elopement of Patient #1.

On 12/18/17 at 11:20 AM accompanied by the ED Nurse Manager, the location where Patient #1 eloped was observed. Within the triangular shaped area glass sliding doors exit into the ED and a second set of sliding doors exit into a large enclosed ambulance bay, neither sliding doors were secured. Within the ambulance bay is an unsecured exit door which leads to the outside hospital campus. Also within this South exit area (also named the "breezeway" by staff) multiple oxygen canisters and a large linen cart were stored.

During a tour of the East wing a second exit was observed located on the opposite end of the South exit. The exit opens into a contained hallway in another location in the ED, was identified as the North exit and is also used to transport patients to and from the East wing. Per review of Environmental Safety Rounds conducted in the ED on 7/18/17 and 11/17/17 by a team of hospital staff representing various departments, there was a failure to identify the environmental risk associated with the transport of patients via the South exit. There was no evidence staff considered the possibility of a safety risk to include the close proximity of an exit and the opportunity for patient elopement. The unsafe pathway created an easy exit for Patient #1 to elope. Since the incident of 12/6/17, staff have been instructed to not use the South exit during patient transport in an effort to ensure care in a safe setting.

Based on staff interview and record review there was a failure of Quality Assurance/Performance Improvement (QA/PI) department to effectively evaluate, fully analyze and fully implement immediate actions when a significant adverse patient event occurred for 1 applicable patient. (Patient #1) Findings include:

Although the QA/PI department conducted a Root Cause Analysis (RCA) within 24 hours of a patient adverse event which occurred on 12/6/17 there was a failure by staff to fully analyze all the potential causes in an effort to identify opportunities for improvement and implement preventive actions in a timely manner. Per ED policy, Security was notified to come to the East wing to assist the PSA in transporting Patient #1 to PSIU when a bed became available. Patient #1 was placed in a wheelchair and it was decided by Security Officer #1 to exit Patient #1 from the East wing through the South entrance door. Upon exiting through the South door the patient was wheeled into a small entryway which includes both the ambulance bay entrance and separate entrance to the main section of the ED. During the escort, Patient #1 jumped out of the wheelchair and proceeded towards the ambulance bay. PSA #1 attempted to prevent Patient #1 from exiting, but was knocked down by Patient #1 resulting in the PSA sustaining an injury when s/he fell onto an oxygen tank stand and was disabled by the fall. Patient #1 eloped by running through the ambulance bay, exiting an unlocked door and proceeded to run rapidly across the hospital campus and eventually into a wooded area. The Security guard attempted to pursue Patient #1, however was directed by a staff member to stop the pursuit as the patient exited the campus. The Rutland police department was immediately contacted regarding the elopement of Patient #1.

On 12/6/17 an immediate initial response via email, verbal contact and ED staff meetings was conducted to assure ED staff no longer utilize the South exit when transporting patients from the Emergency Department East wing. On 12/7/17 a RCA was performed which included ED and PSIU management; VP of Community and Behavioral Health Services; Director of Performance Improvement; and QA/PI Manager; Risk Management Specialist; Chief Nursing Officer; Security Department management and staff involved in the adverse event. As a result a new ED Psychiatric Patient Transport Policy was developed made effective 12/8/17 which would now required 3 staff to accompany each patient during transport of psychiatric patient to diagnostics imaging and inpatient units within the hospital.

Per review of "Patient Safety Observations Documentation Worksheet" for 12/5/17-12/6/17 identifies Patient #1's "Level of Care" as "1:1 continuous monitoring" and a "flight risk". At approximately 10:55 on 12/6/17 Patient #1 was placed in a wheelchair and accompanied by Security Officer #1 and PSA #1 was wheeled through the South exit, proceeded to quickly stand up, assaults PSA #1 who attempted to prevent the patient from eloping. Security Guard #1 ran after Patient #1 who fled the hospital campus and was observed heading into a wooded area across the street from the hospital.

Because the Security Department provides the oversight and training for all the PSAs, the "green sheets" are not included in the patient's medical record. However, information specific to Patient #1's behavior during the morning of 12/6/17 was not included when the RCA was conducted. In addition, a risk assessment of Patient #1's behavior and safety factors were not conducted by the nurse assigned to the East wing prior to assigning Security Guard #1 and PSA #1 to transfer the patient for admission to PSIU. As a result, although the new ED Psychiatric Patient Transport
policy adds an additional staff member during transport, there is a failure to incorporate an assessment of risk for each patient prior to transport to assure protection of the patient, staff and others.

In addition, since this event, the hospital failed to develop an elopement policy which would specifically direct staff regarding their responsibilities when a patient elopes from the hospital, and more specifically psychiatric patients who are determined to require involuntary admission to PSIU. Per interview on 12/18/17 at 2:00 PM and 12/19/17 at 9:30 AM, Security Guard #1 confirmed s/he made the decision to transport Patient #1 out of the East wing via the South exit. When the elopement occurred, Security Guard #1 responded by following Patient #1 as s/he was leaving the hospital grounds. Security Guard #1 only stopped the pursuit when directed by an ED staff member who directed the guard by stating via radio contact to "..don't run off the property". It was further confirmed by the Director of Performance Improvement on 12/19/17 at 3:15 PM, an elopement policy has not be developed to assist staff when confronted with elopement situations, being aware of boundaries and safety for both the staff and the patient. Beside Security Guard #1 in pursuit, a second staff member from security did travel across the street from the hospital to the professional offices campus. During this response, and confirmed per interview on 12/19/17 at 1:50 PM this individual informed staff at one of the medical offices a patient had eloped however, the patient did not pose a risk to staff. This assumption could not be substantiated given the fact it was previously determined Patient #1 posed a risk to self or others requiring involuntary hospitalization.

Refer to Tag A-144