HospitalInspections.org

482.13 Tag A-0115

The information reviewed during the survey provided evidence the facility failed to ensure an involuntary committed (302) suicidal patient a safe environment, as evidenced by the patient eloped the facility grounds.

A discussion took place with the survey team and the facility's administrative staff (EMP1), regarding the survey team's concerns related to Patient's Rights on September 9, 2021 at 1:56 PM.


Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting

Based on review of policies and procedures, facility documents, and medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow its own established policy by failing to ensure an involuntarily committed (302) suicidal patient was in a safe environment, as evidenced by the patient eloping from the facility property.
Findings include:

Review of MR1, on September 9, 2021 revealed, "Discharge Summary [dated September 3, 2021]...Pt [patient] removed IV [intravenous] and tele [telemetry] monitor ...Pt expressed being upset about 302 and not being discharged to [Outpatient Psychiatric Provider]. Crisis and Nurse Supervisor spoke to patient. Pt. on continuous 1:1. Pt. escaped unit. Code Yellow called. Pt. off hospital grounds. Police called by security. [P]atient was admitted for fentanyl overdose withdrawl [withdrawal] symptoms and psychiatry was consulted for the same, apparently noted to have had attempted suicide with fentanyl overdose and 302 was petitioned since he refused to get into inpatient psychiatric facility for treatment."
Review of Patient Rights and Responsibilities pamphlet, on September 9, 2021, revealed, "...You have the right to:...Receive care in a safe setting...Receive kind, respectful, safe, quality care delivered by skilled staff..."
Review of security department incident report, on September 9, 2021, revealed, "On 9/1/21 at 2120 a Code Yellow was called for 3A. Units 27, 17, &21 responded. Patient...in room 305 (a 302 patient) ran out of his room prior to our arrival. Patient was found outside main lobby hiding behind a bush. When we attempted to speak to him[,] he fled up Lawn Ave.[avenue] toward 309. Police were notified."
Interview with EMP3 on September 9, 2021 at approximately 10:00 AM confirmed the patient eloped off the facility grounds and was unable to be found by staff. EMP3 further confirmed the patient was an involuntarily committed (302) suicidal patient.
Interview with EMP4 on September 9, 2021 at 10:43 AM, confirmed the patient eloped before the security officers could get to the floor. EMP4 confirmed there are no cameras in the hallway of the patient's room. EMP4 further confirmed the patient was an involuntarily committed (302) suicidal patient.