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Based on document review, observation, and interview, it was determined that the Hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure patients exhibiting elopement behaviors were monitored to ensure safety of the patient. (See A-144)

The immediate jeopardy began on 2/13/2024, due to the Hospital's failure to ensure patients exhibiting elopement behaviors were monitored, allowing a patient to pull the fire alarm and elope from the Hospital; and was identified on 2/22/2024 at 42 CFR 482.13, Patient Rights. The IJ was announced on 2/22/2024 at 1:35 PM during a meeting with the Chief Executive Officer, Chief Quality Officer, Director of Regulatory, Chief Medical Officer and Clinical Services Administrator and was not removed by the survey exit date of 2/22/2024.

Based on document review, observation, and interview, it was determined that for 1 of 1 (Pt. #1) behavioral health patients involved in an elopement, the hospital failed to ensure patients exhibiting elopement behaviors were monitored to ensure the safety of the patient. Subsequently, Pt. #1 eloped from the hospital. This could potentially affect the current 14 behavioral health patients on census who are on elopement precautions.

Findings include:

1. The hospital's policy titled, "Precaution (9/3/2021)" was reviewed on 2/20/2024 and required, "The patient admitted to Behavioral Health will be placed on elopement precautions as part of standard admission precautions.
... Patients on any special precautions (suicide, elopement, assault, ...) will be monitored every 15 minutes and the patient status will be documented by the staff on the Observation Flow Sheet. ... There will be a staff member assigned to observe the hallways and bathrooms."

2. The clinical record of Pt. #1 was reviewed on 2/20/2024. Pt. #1 presented to the emergency department on 2/9/2024 with complaints of paranoia, increased auditory hallucinations and medication noncompliance. Pt. #1 was admitted to the locked behavioral health unit and placed on suicide, elopement, and assault precautions, requiring every 15-minute observations.

The BHU (behavioral health unit) Observation Record, dated 2/13/2024, indicated that Pt. #1 was not observed from 2:45 PM to the time of elopement at 3:35 PM (50 minutes).

A nurse's note, dated 2/13/2024 at 2:47 PM included, "Patient [Pt. #1] visible in hallway. Patient had to be redirected away from the nurse's station multiple times. Patient is demanding to see nurse practitioner [NP#1] regarding discharge. [NP#1] talked to [Pt. #1] several times and [Pt. #1] continues to request to see [NP#1] and constantly asks the nurses about discharge.

The discharge summary (NP#1), dated 2/14/2024 at 10:03 AM included, " ... Patient [Pt. #1] was seen by the nurse practitioner [NP] during morning rounds, patient was preoccupied with discharge all day, asking to be discharged home today [2/13/2024] ... Patient was told by the NP that [Pt. #1] will be discharged home when stable. During quiet time, it was reported that patient [Pt. #1] pulled the fire alarm and ran out of the unit and made it out of the hospital building. Patient was not properly discharged from the unit. Patient is safe and is currently at home with family."

3. The hospital's incident report dated 2/14/2024 included, "This writer heard alarms and immediately performed nursing rounds, noted Patient [Pt. #1] not in assigned room. Security arrived on site. MHA's and nursing started searching for patient in and around facility. Staff monitoring exit doors for safety and to prevent other patients from leaving unit and or eloping. Patient unable to be located at this time. Cause: Hallways were not covered."

4. On 2/20/2024 at 10:00 AM, an observational tour was conducted on the BHU (2nd floor). The BHU census was 14 adults (male and female). There were 14 patients on elopement precautions. There were 2 hallways (one long hallway and one short hallway). Pt #1's room (2024 -private room) was located on the long hallway.

5. A video review of February 13th from 3:34 PM to 3:37 PM (time of reported elopement) was conducted on 2/20/2024 at 8:50 AM with the clinical services administrator (E#1).
The video included:
3:34 PM - staff taking vital signs of a patient outside the nurse's station, three staff seen in the hallway.
3:35:34 (hour, minute, second) - Pt. #1 seen walking down a hallway (behind nurse's station) with blanket wrapped around body and head - no staff visible in the hallway.
3:35:50 PM - Pt. #1 at end of hallway, pulled alarm by door and blanket fell to floor, Pt. #1 was gone out the back door.
3:36:03PM - a MHA (mental health associate - E#3) entered the hallway, went to door at end of hallway, turned around and began a room-to-room search. Two additional staff entered hallway and began room to room search. Exit door was left unattended.

3:33:56 PM [Camera time based on different camera settings, but time was after elopement]:
- A different camera from outside of the hospital shows Pt. #1 running east down the street in front of the hospital.

6. The MHA (E#8), who was assigned to monitor the short hallway, was interviewed on 2/20/2024 at 12:10 PM. E#8 stated that E#8's assignment was to watch the short hallway. E#8 stated, "I went on break, told another MHA that I was leaving." E#8 stated that the other MHA was busy and never went to the short hallway to take E#8's place.

7. The risk compliance manager (E#9) was interviewed on 2/20/2024 at 12:45 PM. E#9 stated that an incident report was completed, and interviews of the staff were started to determine the cause. E#9 presented the investigation that included:
Findings:
Patient was released from quiet room and was not monitored by assigned staff.
No Code Grey was called for elopement.
Staff was not posted in the corridor.
Documentation of patient being in quiet room without notes of behavior issue warranted.
Minimal MHA documentation on patient behavior changes

Recommendations and Corrective Actions:
Disciplinary action determined by BHU manager.
Education and training regarding coverage of unit.
Assign coverage for lunch and breaks.
Review and update policy - elopement risk patient process, precaution policy, safety rounds, MHA documentation process, Lunch/break protocol, staffing assignment process.
Education and training on policies and procedures listed above.
E#9 stated that E#9 was unclear as to what has been completed from the recommendation list as of 2/20/2024.

8. The interim Nurse manager of Behavioral Health (E#4) was interviewed on 2/20/2024 at 11:10 AM. E#4 stated, "When a fire alarm goes off, the exit doors automatically unlock. Staff are required to go to all exits. I heard someone say, 'A patient eloped'. They found a blanket by the door, looked down the stairs and noticed the outside door was open. Once the staff figured out who was missing, they went back to the stairway with security and went outside to see if they could see the patient. The patient was not found." E#4 stated that an elopement had never happened before. The staff have been in serviced on environmental rounds [every 15 minute monitoring and documentation] and the requirement to not leave a hallway unattended. No policies have been reviewed or revised yet. E#4 stated, "Approximately 50 % of the staff have been reeducated. I'm also working on redoing the assignment sheet to include and clarify who should cover when breaks are taken. There should have been someone in the hallway and the monitoring rounds should have been completed and documented. That is a requirement.