HospitalInspections.org

Based on observation, record review and interview, the hospital failed to ensure patients received care in a safe setting by failing to mitigate a known elopement risk. This deficient practice is evidenced by having patients elope by jumping fences surrounding exterior patient areas for 7 (#3, #5, #R1, #R2, #R3, #R4, #R5) of 9 (#3, #4, #5, #R1, #R2, #R3, #R4, #R5, #R6) patients reviewed for elopements since 1/24/17.

Findings:

Observations beginning on 12/18/17 at 2:20 p.m. of the exterior patient areas of the hospital's 3 units revealed the following:
Unit A: The outside area was surrounded by a 6-foot wooden fence on 3 sides and a chain link fence on 1 side. A brick ledge protruded from the exterior of the building near the corner of the wooden fence.
Unit B: The outside area was surrounded by a 6-foot wooden fence on 1 side and chain link fence on the other 3 sides. The chain link section had 2 gates with bars across the middle which could facilitate climbing. A brick ledge protruded from the exterior of the building near the corner of the fence.
Unit C: The outside area was surrounded by a 6-foot wooden fence on 3 sides and a chain link fence on the 1 side. A brick ledge protruded from the exterior of the building near the corner of the wooden fence and the chain link fence.

Review of a hospital document titled Elopement Performance Improvement Data revealed since 1/25/17, 9 patients (#3, #4, #5, #R1, #R2, #R3, #R4, #R5, #R6) had eloped from the hospital. Further review revealed 7 (#3, #5, #R1, #R2, #R3, #R4, #R5) of the 9 had jumped a fence outside of one of the 3 units. The most recent elopement by jumping a fence was on 11/11/17.

Review of the hospital's quality improvement data since July 2017 revealed no documented evidence of how the hospital was going to mitigate the risk of elopements caused by patients climbing the exterior fences other than trying to identify patients at a higher risk.

In an interview on 12/19/17 at 9:25 a.m. with S2RiskMgt, she said the hospital did not identify that elopements by patients jumping the exterior fences was a problem until July 2017. S2RiskMgr said the only interventions the hospital had put into place to stop elopements were to educate employees on elopement risks and to try and identify patients who might be elopement risks. When asked how many of the 7 patients that had jumped the fence were determined to be elopement risks prior to elopement, she replied 1 (Patient #3). She said the hospital had not increased supervision when patients were outside or changed any of the fence heights. S2RiskMgr said during risk assessments at the hospital it was determined the exterior fences were not tall enough to ensure some patients could not easily climb over them. S2RiskMgr said the fences were scheduled to be changed with a large renovation the facility was planning to do which was scheduled to begin next year and not be completed until 2019. S2RiskMgr agreed the exterior fences were an elopement risk.

In an interview on 12/19/17 at 12:40 p.m. with S3MHT, he said Patient #R5 had jumped the fence when they were outside together. When asked how Patient #R5 was able to get over the fence, he said the fence was only 6 feet tall so he was able to pull himself over it. S3MHT said to stop patients from eloping, the hospital would need a taller fence.

In an interview on 12/19/17 at 1:00 p.m. with S4MHT, she said if patients were tall it was easy to jump over the fences because the fences were only about 6 feet tall.

In an interview on 12/19/17 at 2:05 p.m. with S1CEO, he stated the hospital removed a rail from unit B that acted as a step to jump the fence. He verified the hospital had not changed the fences or increased supervision while patients were outside the units to decrease elopement risks. S1CEO agreed the fences were not tall enough to prevent all patients from crawling over them.