HospitalInspections.org

Based on observation of video surveillance, interview and record review, the facility failed to securely protect 1 of 10 sampled patients admitted to their care (#1).

Findings:

Record review revealed patient #1 was a 14 year old male brought to the facility under a Baker Act. He was admitted as a voluntary admission on 12/02/12 with an Axis I diagnosis of depressive disorder, not otherwise specified and adjustment disorder with mixed anxiety and depressed mood. Physician orders dated 12/02/12 revealed the patient was admitted with routine safety, suicidal, and elopement precautions, which included physician ordered observations of every 15 minutes.

Review of patient #1's record revealed a nurse's entry dated 12/03/12 at 7:30 p.m. which documented "client was seen on the unit by staff-no sign of distress...."

Nursing documentation on 12/03/12 at 7:45 p.m. documented "upon 7:15 p.m. check, staff noted that patient was [nowhere] to be found after a total unit search. Supervisor, law enforcement officer, and father were notified regarding client missing off unit. Administrator on call and physician were also made aware."

Review of the "Patient Observation/Rounds Form" on 12/03/12 at 7:15 p.m. and 7:30 p.m. documented the patient was observed on the unit with a location code of "DA" (day area).

On 12/07/12, a review of the facility video surveillance of 12/03/12 was completed with the facility Risk Manager/Patient Safety Officer (RM/PSO), the Information Technologist and the Chief Executive Officer (CEO). At 7:24 p.m., the video showed patient #1 walking up the hallway towards the nurse's station with a mental health technician (MHT). Following the staff intervention, the video showed the patient turned and walked back down the hallway and stood by the unit entrance door.

The 12/03/12 video at 7:25 p.m. showed a male adult, identified as a medical physician by the Chief Executive Officer (CEO), swipe his badge outside the unit door, open the unit door and walk inside the unit, past the patient, and down the hallway. The video showed, following the entrance of the physician, the patient inserted his left foot in the doorway which disabled closure. The video showed the client looking down the unit hallway and then using both hands on the door push bars to open the door at which time he exited the unit to the outside. Video surveillance was unable to show how the patient eloped over the facility 12 foot fence due to tree coverage. The video continued to show the patient running across the facility parking lot and crossing the street until he was out of sight of the facility cameras.

Nursing documentation in the patient record on 12/04/12 documented "Not yet returned to unit, remains eloped."

Interview on 12/07/12 at approximately 1:30 p.m. with the facility CEO and RM/PSO, revealed the facility immediately searched for the patient, enacted a Code Yellow, an elopement alert, and the patient's representative family member and law enforcement were informed. They further related no other patient was determined to be involved or missing. Facility investigation revealed the cause of the elopement was identified and immediate education was given to staff, the identified physician, and other physicians regarding elopement and appropriate safety measures including proper usage and closing of secured/locked doors. The CEO further revealed she had counseled with the identified physician's superior and further corrective measures are scheduled to include reporting to the facility Medical executive board for action.

Interview with the identified physician on 12/07/12 at approximately 3:30 p.m., regarding the patient's elopement, revealed he did not remember seeing the patient by the door and had not seen the surveillance video, but had discussed the elopement with the facility CEO to include elopement precautions and proper entrance and closure of secured/locked doors. The physician stated he had not been to the facility since 12/03/12.