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Based on record review and interview the facility failed to protect the rights to receive care in a safe setting for 10 of 10 (Patients #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11)) patients.

1. On 03/05/24 Patient #8 busted through the glass of 3 sets of doors and was able to elope the facility with Patient #7, Patient #9, Patient #10 and Patient #11. The facility was located approximately 200 yards from State Highway 287 a 3-lane highway with a speed limit of 65mph and an average annual daily traffic of 4,799 cars (Traffic Count Database System (TCDS) (ms2soft.com). All patients were returned to the facility on 03/05/24 about 1 hour and 20 minutes after they eloped.

2. On 03/09/24 Patient #2 jumped over the nurse's station and pulled the fire alarm which released all the magnetic locks on the facility's doors. Patient #2, Patient #3, and Patient #6 were able to elope from the facility via a courtyard gate. The patients returned to the facility on their own approximate 30 minutes after they eloped. A day later, on 03/10/24, Patient #2 again jumped over the nurse's station and pulled the fire alarm eloping the facility with Patient #3, Patient #4 and Patient #5. The patients were returned to the facility by the police approximately 1 hour and 30 minutes after they eloped. The facility's plan of correction was to place an employee in front of the fire alarm pull until the locked fire alarm covers could be installed. No employee was observed in front of the fire alarm pull during a tour of the facility on 03/13/24 at 12:35 PM and the fire alarm remained accessible to Patient #4 and Patient #5 who were still admitted to the facility.
In addition, the fire alarm code had been changed by the previous environment of care director and the staff were unable to turn the fire alarm off leaving the magnetic locks released until the alarm could be turned off on 03/09/24.


Cross Refer Tag A0144

Based on record review and interview the facility failed to protect the rights to receive care in a safe setting for 10 of 10 (Patients #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11)) patients.

1. On 03/05/24 Patient #8, an adolescent boy busted out the glass of 3 sets of doors and was able to elope the facility with Patient #7, Patient #9, Patient #10, and Patient #11.

2. On 03/09/24 Patient #2 jumped over the nurse's station and pulled the fire alarm. This released all the magnetic locks on the facility's doors. Patient #2, Patient #3, and Patient #6 were able to elope from the facility via a courtyard gate. On 03/10/24 Patient #2 again jumped over the nurse's station and pulled the fire alarm eloping from the facility with Patient #3, Patient #4 and Patient #5.


Findings included:
1. Patient #7, a 17-year-old male, was admitted to the facility on 02/29/24 for homicidal ideation, suicidal ideation with a plan, and running away from home. Patient #7 was initially placed on elopement precautions and unit restrictions. The Physician's orders for 03/01/24 through 03/05/24 did not evidence an order to continue or discontinue the unit restricts.
Patient #8, a 17-year-old male, was admitted to the facility on 03/04/24 from a juvenile detention center due to aggression/violence via punching and kicking things. The Physician's Orders did not evidence an order for unit restrictions or elopement precautions.
Patient #9, a 16-year-old male, was admitted to the facility on 02/28/24 for eloping from school daily, drug, and tobacco use. Patient #9 was initially placed on elopement precautions and unit restriction. The Physician's Orders reflected on 03/01/24 and 03/02/24 the order for elopement precautions was renewed. The Physician's Orders on 03/03/04 through 03/05/24 did not evidence an order to continue or discontinue the elopement precautions.
Patient # 10, a 15-year-old-male, was admitted to the facility on 02/20/24 from a juvenile detention center due to suspected psychosis. Patient # 10 was initially placed on elopement precautions and unit restrictions. The Physician's Orders for 03/02/24 and 03/03/24 evidenced an order for elopement precaution. The Physician's Orders for 03/04/24 and 03/05/24 did not evidence an order to continue or discontinue any type of precautions.
Patient # 11, a 13-year-old male. Was admitted to the facility on 03/03/24 via a detention warrant for suicidal ideation. Patient # 11 was not initially placed on elopement precautions or unit restrictions. The Physician's Orders for 03/04/24 did not evidence an order to continue or discontinue any type of precautions. The Physician's Orders for 03/05/24 did not evidence an order for elopement precautions or unit restrictions until after the patient eloped from the facility.
The camera reviewed reflected on 03/05/24 Patient #7, Patient #8, Patient #9, Patient # 10, and Patient # 11 were taken to the cafeteria to eat at around 06:17 PM. At 06:23 PM Patient # 8 flips over a table in the cafeteria, that is open to the hallway without doors, then walks into the hallway and flips over another table. At 06:24 PM Patient #8 breaks through a glass door and proceeds across a courtyard to another set of glass doors. Patient #8 breaks through that door and calls for other patients to follow him. At 06:26 Patient #8 breaks the glass in a third door that leads outside the hospital and Patient #7, Patient #9, Patient #10, and Patient #11 follow Patient #8 out of the facility. All 5 male patients were returned to the facility by police on 03/05/24 about 1 hour and 20 minutes after they eloped.
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During an interview on 03/13/24 at 12:35 PM Personnel #1 stated that if a patient is on elopement precautions the policy states, they should also be on unit restrictions. Personnel #1 stated the patient's level of precautions should be either reordered or discontinued every day.
The policy titled Precaution Interventions, revised on 02/12/24 reflected ...Procedure ...All precautions must be renewed every 24 hours ...Elopement ...Must be on Unit Restrictions ..."
2. Patient #2, a 17-year-old female, was admitted to the facility on 03/03/24 for suicidal ideation and eloping from a residential treatment center. Patient #2 was not initially placed on elopement precautions or unit restrictions. The Physician's orders for 03/09/24 evidenced the patient was placed on elopement precautions after they eloped from the facility that day. The Physician's orders on 03/10/24 evidenced the elopement precautions had been continued.
Patient #3, a 14-year-old female, was admitted to the facility on 03/08/24. The patient had been admitted to another facility 5 days prior to this admission for suicidal ideation and elopement. Patient #3 had been discharged from the other facility on 03/08/24 and within 2 hours made suicidal, self-harm, and elopement statements. Patient #3 was initially placed on elopement precautions and unit restrictions. The Physician's Orders on 03/09/24 did not evidence an order to continue or discontinue elopement precautions and unit restrictions. The Physician's Orders evidenced the elopement precautions had been continued on 03/10/24.
Patient #4, a 14-year-old female, was admitted to the facility on 03/09/24 for an attempted suicide. Patient #4 was not initially placed on elopement precautions or unit restrictions. The Physician's Orders on 03/11/24 evidenced the patient had been placed on elopement precautions. The medical record did not evidence an order for elopement precautions on 03/10/24 after the patient was returned to the facility after an elopement.
Patient #5, a 16-year-old female, was admitted to the facility on 03/02/24 after multiple incidents of sneaking out to use substances and sneaking her 20-year-old boyfriend into the family home. Patient #5 was not initially placed on elopement precautions or unit restrictions. The medical record did not evidence an order for elopement precautions on 03/10/24 after the patient was returned to the facility after an elopement. The 03/11/24 Physician's Orders evidenced Patient #5 was placed on unit restrictions but not elopement precautions. The Physician's orders for 03/12/24 and 03/13/24 did not evidence an order to continue or discontinue the unit restrictions; no elopement precautions were ordered.
Patient #6, a 16-year-old female, was admitted to the facility on 02/29/24 for suicidal ideation, self-harm, and medication noncompliance. Patient #6 was initially placed on elopement precautions and unit restrictions. The Physician's Orders from 03/01/24 through 03/04/24 did not evidence an order to continue or discontinue the elopement precautions or unit restrictions. The Physician's Orders dated 03/05/24 evidenced an order for elopement precautions. The Physician's Orders dated 03/06/24 Through 03/09/24 did not evidence an order to continue or discontinue the elopement precautions. Patient #6 was placed on elopement precautions on 03/09/24 after eloping from the facility. The Physician's Orders dated 03/11/24 through 03/13/24 did not evidence an order to continue or discontinue the elopement precautions.
The camera review for 03/09/24 reflected at 07:20 PM Patient #2 pulled a chair next to the nurse's station, jumped into the nurse's station, and pulled the fire alarm. Patient #2 and Patient #3 exited the adolescent girl's unit into a hallway and attempted to enter the lobby. Patient #2 and Patient #3 proceeded to a closed unit and Patient #3 pulled a second fire alarm. Patient #2 and Patient #3 were found hiding in the nurse's station of the closed unit and were escorted back to their unit. Patient #2 and Patient #3 then ran across the adolescent girl's unit out an exit door to a courtyard and eloped through an open gate. At 08:11 PM Patient #6 then runs through the exit door and eloped from the facility.
Patient #6 then walked to the front of the facility and was let back in. Patient #2 and Patient #3 returned to the facility on their own at 08:00 PM on 03/09/24.
The camera review for 03/10/24 reflected on 03/10/24 at 08:44 PM Patient #2 jumped over the nurse's station and pulled the fire alarm. At 08:45 PM Patient #2, Patient #3, Patient #4 and Patient #5 run over the staff guarding the exit door and elope from the facility through the courtyard. All patients returned to the facility 30 minutes later.
During a complaint survey on 03/13/24 Personnel #1 stated the plan of correction was to place an employee in front of the fire alarm pull until the locked fire alarm covers could be installed. During a tour of the facility on 03/13/24 at 12:35 PM there was not an employee stationed in front of the fire alarm pull.

During a facility tour on 03/13/24 at 12:35 PM Personnel #1 stated when Patient #2 pulled the fire alarm all magnetic door locks released and Patient #2, Patient #3 and Patient #6 eloped from the facility. Personnel #1 stated the previous Environment of Care Coordinator had changed the code to turn off the fire alarm and all the doors remained unlocked until the alarm could be turned off. The facility was able to fix that issue on 03/09/24. Personnel #1 stated the facility had ordered locking fire alarm covers but they were not installed yet. Personnel #1 stated the facility had placed an employee to stand by the fire alarm pull to stop the patients from pulling the alarm and eloping. While on the adolescent girl's unit on 03/13/24 at 12:35 PM this surveyor observed no employes were standing next to the fire alarm. Personnel #1 stated that the patient that had been pulling the fire alarm had been discharged from the facility, so they were no longer stationing an employee in front of the fire alarm. This surveyor confirmed with Personnel #1 that at least 2 of the 5 girl's that had eloped due to the fire alarm being pulled were still admitted to the facility.