HospitalInspections.org

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Haven Behavioral Hospital failed to ensure the protection and promotion of the rights of patients by failing to provide care in a safe setting.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this Condition.

Cross reference:
482.13(c)(2) Patient Rights: The patient has the right to receive care in a safe setting.

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that Haven Behavioral Hospital failed to ensure the protection and promotion of the rights of patients by failing to prevent elopment from the facility for two of ten medical records reviewed (MR1 and MR2).


Findings include:

On March 1, 2022, review of facility Safety Management Plan last approved March 2021, revealed, "Purpose-To promote a culture of safety to eliminate preventable patient harm by engaging, educating and equipping patient-care staff, patients, and visitors to safe practices through identification of safety risks and the planning and implementing of processes to minimize the likelihood of those risks...Risk Management Which Pro-Actively Evaluate the Impact of Buildings, Grounds, Equipment, Occupants and Internal Physical Systems on Patient and Public Safety- The Risk Management Program is designed to pro-actively evaluate the risks that may have an impact on patient care, staff and visitors as it relates to the safety of the buildings, grounds, equipment, occupants, internal physical systems and the safe practices of hospital employees."

Review of facility Incident Log documented May 24, 2021, revealed, " On May 5, 2021, at 1658 patient eloped behind staff member exiting door. Code called. Supervisor, CEO, AOC, ND ( Chief Executive Officer, Administrator On Call, Nursing Director) aware. Building searched by staff, security. 1740 Reading police called by RN (Registered Nurse) Supervisor: police given information. 2045 Wife notified. 2115 EMP7 spoke with patient's mother and wife again - patient had called into home to check on children."

Review of facility Elopement Follow Up Summary documented February 23, 2022, revealed "Patient was rounded on at 0745 and in bathroom by EMP4. During 0800 rounds EMP4 reported unable to locate patient, but patient did hide from staff the previous day in a childlike manner. Once unit searched nurse manager was contacted to request video be reviewed. It was discovered that patient eloped by following EMP5 out the stairs that are closest to the dayroom. Police and St. Joseph security contacted, given information about what the patient was wearing. Police also given patient's mother's contact information. Patient's mother was not contacted by facility since release not signed. EMP6 contacted patients BCC (Board of Childcare) case manager to report elopement."

On March 1, 2022, review of MR 1 revealed that Patient was admitted on May 4, 2021, under voluntary commitment status with admitting diagnosis of Schizoaffective Disorder, Bipolar Type. Upon admission, Patient reported feeling very tired with severe fatigue, not sleeping and having vague auditory hallucinations and paranoid symptoms. The patient reports in the last couple of days of feeling very depressed and admitted to putingt a rope around their neck. Patient observation sheet for May 5, 2021, revealed, "Patient observed in room sleep at 1630, entry at 1645 and 1700 noting patient eating in dining room has been crossed out and a note is written 1645: RN called elopement."

Further review of MR1 Progress Note documented May 6, 2021, 0330 noted by EMP 8 revealed, "Telephone call from Reading police at 0203 regarding patient. They stated that patient was found at home and will be transported to OTH1 (other hospital).

On March 1, 2022, review of MR2 revealed "Patient was admitted on January 14, 2022, under 201 (voluntary commitment) status with admitting diagnosis: Schizoaffective Disorder, Bipolar Type. On January 19, 2022, status was changed to 304 (commitment in which testimony is provided stating that the patient is still suffering from mental illness and needs further treatment) where EMP6 noted in petition, Patient has been noncompliant with medications prior to inpatient (IP) and continues to refuse medication. While IP patient has poor judgement, insight, is paranoid, delusional and not caring for self...Patient Observation Sheet for February 18, 2022, revealed patient was rounded on at 0745 and noted to be in the bathroom in room and at 0800 patient's status was noted as elopement.

Further review of MR2 BIRP (Behavior Intervention Response Plan) Progress Note documented on February 18, 2022, 1000 noted by EMP9 revealed, "During 0800 rounds BHT ( Behavioral Health Technician) reported unable to locate patient. Staff began to search for patient during rounds when unable to locate contacted nurse manager to review cameras. Nurse manager reported patient had left the unit by waiting for a EMP5 to exit and held the door just slightly, waiting for EMP5 to be out of site, and then exited via stairs near dayroom."

Interview with EMP1 on March 1, 2022, EMP1 confirmed that both patients eloped; MR1 eloped on May 5, 2021, and MR2 eloped on February 18, 2022, through secure doors after following facility staff members.