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Based on medical record review, hospital policy review, and staff interview, it was determined the hospital failed to ensure patients' rights were protected and promoted. This directly impacted the safety of 2 of 3 patients (Patient #6 and #3) who eloped from the hospital and whose records were reviewed. This resulted in patients not being kept safe from themselves and had the potential to affect all patients receiving care at the hospital. Findings include:

1. Refer to A 144 as it relates to the failure of the hospital staff to ensure facility policy was followed for patients who were at risk for elopement.

The cumulative effects of these systemic practices seriously impeded the ability of the hospital to protect and promote patient rights and provide care in a safe setting.

Based on medical record review and staff interview, it was determined the hospital failed to ensure care was provided in a safe setting. This directly impacted the safety of 2 of 3 patients (Patient #6 and #3) who eloped from the hospital and whose records were reviewed. This resulted in patients not being kept safe from themselves and had the potential to affect all patients receiving care at the hospital. Findings include:

A facility policy titled "Elopement Precautions", dated 1/2021 included, "Restrict patient to the unit. Patient may access outside covered area with appropriate staffing and clinical presentation." This policy was not followed. Examples include:

1. Patient #6 was a 27 year old male who was admitted to the hospital on an involuntary hold on 8/11/21, with a presenting diagnosis of unspecified psychosis. An additional diagnosis included major depressive disorder.

Patient #6's medical record included a document titled "Inpatient Admission Orders," dated 8/11/21, signed by the physician. The form included that Patient #6 was placed on elopement precautions upon admission.

Patient #6's medical record included a form titled "High Risk Notification Alert." It included a checked box that Patient #6 was an elopement risk, and he had eloped from the Emergency Department he was transferred from prior to being admitted to the hospital.

Patient #6's medical record included a form titled "nursing flow sheet," dated 8/11/21. The narrative section included a note from the charge nurse which stated, "pt was outside at activity group in the generations courtyard pt had agreed to stay where A.T. [activity technician] could see him but the pt walked out of line of sight of the A.T. and jumped the fence."

The charge nurse was interviewed on 9/14/21 beginning at 2:45 PM and Patient #6's record was reviewed in her presence. When asked about Patient #6's elopement, she stated she was not on the unit at the time of the elopement and was not made aware of the elopement until she heard the code orange (code for patient elopement) called on the overhead pager. She stated staff did not notify her Patient #6 was going outside for group activity. She confirmed facility policy was patients on elopement precautions were not to go outside.

The medication nurse working on the generations unit during the time of the elopement was interviewed on 9/14/21, beginning at 3:18 PM and Patient #6's medical record was reviewed in her presence. She confirmed Patient #6 eloped from the unit from the courtyard. When asked if patients could go outside on elopement precautions, she stated patients on elopement precautions were kept inside and staff did not let them go outside in groups without MD approval. When asked about the elopement of Patient #6, she stated herself and the activity technician discussed Patient #6 was an elopement risk and shouldn't go outside. She stated the activity technician was holding the door open for the patients to go into the courtyard and Patient #6 went out the door with the group of patients.

The Activity Technician was interviewed 9/15/21 at 11:00 AM and Patient #6's medical record was reviewed in his presence. When asked about Patient #6's elopement, he stated if patients were on elopement precautions they were not supposed to go outside. He stated he knew Patient #6 was on elopement precautions. He said the psychiatric technician and medication nurse had a conversation about it. He said he told them he did not think Patient #6 was going to join group therapy outside. He stated he did not know who made the decision for Patient #6 to join group outside. He stated when he saw Patient #6 outside, he told Patient #6 to "stay near me." The Activity Technician stated he was helping another patient and he lost sight of Patient #6, and when he saw him, he was up over the fence.

The Activities Director was interviewed 9/15/21 beginning at 11:36 AM. She stated it was facility policy and expectation that before patients were taken outside for group, the activity technician had to check the census for precautions and have a conversation with the nursing staff about any precautions including elopement precautions.

The Director of Risk Management and Compliance was interviewed on 9/13/21 beginning at 12:39 PM. He confirmed facility staff did not follow policy regarding elopement precautions for Patient #6.

The facility staff failed to prevent patient elopement.



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2. Patient #3 was a 15 year old female admitted to the hospital on an involuntary hold on 6/04/21, with a presenting diagnosis of unspecified psychosis. Additional diagnoses included substance-induced psychosis (provisional), intermittent explosive disorder, and oppositional defiant disorder.

Patient #3's medical record was reviewed. Patient #3's medical record stated she attempted to elope from the emergency department from which she was transferred prior to being admitted to the hospital, as well as a documented elopement attempt during her transport to the hospital. Patient #3's medical record included a form titled "Initial Treatment Plan," dated 6/04/21. It included "Reason for Hospitalization: EL (Elopement)." The form titled "Master Treatment Plan," included "Master Problem List: EL ( Elopement)."

Patient #3's medical record included a form titled "Nursing Flow Sheet," dated 6/04/21. At the top of the form was a section labeled "Patient Monitoring, Precautions and Alerts." The "Elopement" box had been checked. The form titled "Interdisciplinary Treatment Notes," dated 6/04/21, included a narrative that stated "[patient] tried all exit doors on unit. Pt then tried to go through open door when meal cart arrived."

Patient #3's medical record included a form titled "Nursing Flow Sheet," dated 6/05/21. At the top of the form was a section labeled "Patient Monitoring, Precautions and Alerts." The "Elopement" box had been checked. The form titled "Interdisciplinary Treatment Notes," dated 6/05/21, included a narrative that stated "Pt attended PM [afternoon] therapy group but did not engage or participate. Pt left group and tried to get out of doors on unit again."

Patient #3's medical record included a form titled "Nursing Flow Sheet," dated 6/06/21. At the top of the form was a section labeled "Patient Monitoring, Precautions and Alerts." The "Elopement" box had been checked. The form titled "Interdisciplinary Treatment Notes," dated 6/06/21, included a narrative that stated "Pt went to group outside. At 1015 pt climbed up gate and onto building. Code orange was called. Pt jumped off of building on Newstart side. Pt ran to [nearby apartments], pt was caught by staff at the end of complex. Pt transferred [local hospital]."

The Activity Aide present during Patient #3's elopement was interviewed by phone on 9/15/21, beginning at 11:17 AM along with the Director of Clinical Services. Patient #3's medical record was reviewed. The Activity Aide confirmed Patient #3 was outside for a group session on 6/06/21 and subsequently eloped. The Activity Aide stated, "we were outside for 10 minutes...one of the girls said she was trying to get out, so I ran over there...she was climbing up there." When the Activity Aide was asked about review of patient elopement precautions, she stated, "generally the techs [psychiatric technicians] let me know." When asked if she checked to see if anyone was on elopement precautions prior to leading the group outside, she stated, "no I did not ask that question, they [psychiatric technicians] are supposed to double check."

The Psychiatric Technician who was present during the elopement of patient #3 was interviewed on 9/15/21, beginning at 8:32 AM. When asked if she was aware that patient #3 was on elopement precautions on 6/06/21, she stated, "not at that time." When asked who was responsible for ensuring no patient on elopement precautions was allowed outside, she stated, "I believe it is everyone's responsibility."

The Activities Director was interviewed on 9/15/21, beginning at 11:47 AM. She confirmed that her staff was trained on elopement precautions. When asked how her activities aides and activities technicians would know a patient was on elopement precautions, she stated "They would look at the nursing census and then ask nursing staff to be sure no changes have occurred before we start the group."

The facility staff failed to prevent patient elopement.