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Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.13, Patient Rights.

Findings include:

1. The hospital failed to ensure its interventions to prevent elopement were effectively implemented. See deficiency at A-144.

2. The hospital failed to ensure that a patient was monitored as required. See deficiency cited at A-175.



The Immediate Jeopardy began on 09/19/23 due to the Hospital's failure to: ensure its interventions to prevent elopement were effectively implemented and failure to ensure that a patient was monitored as required, and was identified on 01/11/24, at 42 CFR 482.13, Patient Rights. The IJ was not removed by the survey 01/11/24.

Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient with a Patient Safety Attendant (sitter). the hospital failed to prevent one patient, who presented with suicidal ideations and required a one to one sitter, from eloping from the ED twice in less than 4 hours (5:13 PM and 8:49 PM) and jumping off a bridge into a river. These failures put the patient, other patients, staff, and community at large at risk for harm.

Findings Include:

1. The Hospital policy titled, "Patient Safety Attendant (PSA) and Remote Companions" (last reviewed 4/19/2022) was reviewed. The policy stated, "Constant Observation is performed by a PSA inside the room in immediate proximity with continuous visual observation to immediately intervene."

2. The procedure titled "Patient Safety Attendant (PSA) Assignment and Expectations" (effective 7/27/2022) was reviewed. The procedure required that Patient Observation Expectations, include: "Always maintain DIRECT Visual observation. Patient room door to always remain open with light on and PSA to sit in line with door, MUST fully visualize patient."

3. The clinical record for Pt #1 was reviewed on 11/28/23 and included that the Pt presented to the emergency department (ED) on 9/19/2023 at 12:50 PM. Pt # 1 was placed in ED Room #10, the Safe Room (ligature free room where mental health pts are placed for safety) and 1:1 monitoring started at 1:00 PM.

Pt #1's nursing notes stated:
- 1:43 PM stated, "Patient arrived to ED per EMS (Emergency Medical Services) for suicidal thoughts with previous suicide attempt ... Patient is CAO x 4 (alert and oriented to person, place, time, and situation) ... Pt given ... scrubs to change into .... Spoke with (House Supervisor) ... States patient is under constant supervision due to SI (suicidal ideations) and with allegations about (Developmental Center where pt lives) staff then (Developmental Center) staff should be sent back to the facility." [staff from facility had arrived at the hospital, and the hospital was indicating they sent the facility staff back]."
- 5:21 PM "Pt seen running out of room down hallway. This nurse and (another RN) ran after patient .... Security with pt and pt moved x 4 staff (with 4 staff) back to ED room 10. Pt screaming out during incident 'I don't wanna go back, I'd rather go to jail. I want to run into traffic and get hit by a car please don't send me back.' ED MD notified."
- 5:56 PM "2E (behavioral health) staff (Social Worker - E #6) at bedside, speaks with (Psychiatrist - E #16) who states that pt can be admitted overnight. Per (E #6) who spoke with their director it was recommended that pt return to (Developmental Center) if possible. Concern for pt safety voiced by several ED RNs. (House Ops) here at bedside also, states he will make some calls and update ED on next steps ..."
- 8:45 PM - "(ER MD - E #3) states patient being discharged after discussion with (E #16). Patient ran out of ER. Security notified."
- 9:03 PM "Unable to find patient at this time. (local city police) notified and looking for patient."

4. The "Security Daily Shift Summary" for the event was reviewed on 1/10/24 at 3:30 PM. The report stated, "(8:51 PM) Security received a call from ED Nurse about an eloped Pt (Pt #1). Pt escaped out of ED bed 10 and was running down the hallway towards MRI ...When reviewing camera #33 West Pavilion Roof you can see Pt (Pt #1) coming out the MRI Emergency exit doors heading down the stairs.. Also running across the street by a two story white house ... Pt was not located on hospital property. Security cleared the call around (9:36 PM). HOA (House Operations Administrator) contacted us around (5:00 AM) saying the Pt jumped in the river and is now at (other local hospital) seeking medical attention."

5. An interview was conducted with the Patient Safety Specialist (E #14) on 01/10/24 at approximately 2:00 PM. E #14 stated, "There were 2 event reports filed (09/20 and 09/21) in the event reporting system regarding the potential elopement and the elopement of (Pt #1). Risk and I evaluated them and took them the week after to the Safety Event Report Team to determine the harm level. They deemed it was not a safety event. They felt that the staff followed policy and did not see any concerns. Therefore, at that time, no RCA (root cause analysis) was needed. There has been no education or re-education following the event until the state investigation was started. We are currently working on an RCA."

Based on document review and staff interview, it was determined that for 1 of 3 patients (Pt. #1) clinical records reviewed regarding 1 to 1 monitoring for suicide precautions, the hospital failed to ensure that a patient was monitored as required.

Findings include:

1. On 11/29/2023, the Hospital policy titled, "Patient Safety Attendant (PSA) and Remote Companions" (last reviewed 4/19/2022) was reviewed. The policy stated, "Constant Observation is performed by a PSA inside the room in immediate proximity with continuous visual observation to immediately intervene." The procedure titled "Patient Safety Attendant (PSA) Assignment and Expectations" (effective 7/27/2022) was reviewed. The procedure required that Patient Observation Expectations, include: "Always maintain DIRECT Visual observation. Patient room door to always remain open with light on and PSA to sit in line with door, MUST fully visualize patient."

2. On 11/28/2023 the clinical record of Pt #1 was reviewed. Pt #1 presented to the emergency room 9/19/2023 with a chief complaint of Suicidal thoughts with previous attempt. A Columbia Suicide risk assessment indicated a high risk for suicide. Pt # 1 was placed in ED Room #10, the Safe Room and 1:1 monitoring started at 1:00 PM.

3. On 11/29/2023 the video of Pt #1's 1st attempt for elopement on 9/19/2023 at 5:13 PM and Pt #1's successful elopement from the hospital on 9/19/2023 at 8:45 PM was reviewed with the Patient Safety Specialist (E #14) and the Quality (E #2). The video showed on 9/19/2023 at 5:13 PM- ER room #10 approximately 4 foot from nursing station, Patient Safety Attendant (E #11) sitting at nursing video monitor approximately 15 foot from ED room #10. There is no direct path from the video monitoring desk to ED Room #10. Pt #1 seen running out of ED Room #10 wrapped in a blanket, no staff exited room, On 9/19/2023 at 8:50 PM ED RN (E #5) is seen exiting
Pt #1's room ED #10 and walks to video monitoring desk (approximately 15 foot from ED Room #10) and sits down. Pt #1 is seen peering out of door window, Pt #1 comes out of door wrapped in blanket, drops blanket and starts running toward hallway. No other staff exit ED Room #10. There is no direct path from the video monitoring desk to ED Room #10. E #5 gets out of chair (approximately 15 foot from Pt #1) leaves nursing station and starts to pursue Pt #1 but stops as ER RN (E #13) pursued Pt #1 down hall. Pt #1 observed running out MRI exit door. Pt #1 ran down steps. No staff in pursuit.

4. On 11/29/2023 interview was conducted with the Safety Specialist (E #14) and Director of Quality and Patient Safety (E #2). E #2 explained ED Room #10 is the "Safe Ligature Free" room we use for 1:1 patient's. The door on ED Room #10 is kept shut, if you open the door then you are obstructing the hallway. The sitter does not sit in the hallway as it would be again obstructing the hallway. The sitter can not sit in the room with the patient with the door closed as it is unsafe. E#2 agreed the Patient Safety Monitor is sitting at the video monitoring desk and there is no direct path from the video monitoring desk to ED Room #10. No staff were present in Pt #1's room.

5. On 11/29/2023 the Hospital Policy titled, "Initial Suicide Screening and Assessment Process (ED and Non-Behavioral Health Inpatients) (last reviewed 4/19/2022) was reviewed. The policy required, "Precautions: High Risk: Hourly rounds will be documented."

6. On 11/29/2023 the "Patient Safety Monitoring Log" dated 9/19/2023 from 12:50 PM to 8:45 PM for Pt #10, was reviewed. The "Patient Safety Monitoring Log" lack documentation of hourly rounding for 5:00 PM thru 8:00 PM. Lacked required hourly documentation for 4 hours.

7. On 11/30/2023 an interview was conducted with the Director of Quality and Patient Safety (E #2). E #2 review the "Patient Safety Monitoring Log" and agreed the required hourly documentation was not completed.

8. On 11/29/2023 the Hospital Policy titled, "Patient Safety Attendant (PSA) and Remote Companions (last reviewed on 4/19/2022) was reviewed. The policy required, "The Emergency Department/Inpatient Environmental Safety Checklist will be utilized anytime a patient is placed in such observation. This is to be done on admission, when visitors leave and at the change of shifts during hand off."

9. On 11/30/2023 the "Patient Safety Monitoring Log" dated 9/19/2023 for Pt #10 was reviewed. The "Patient Safety Monitoring Log" lack documentation a safety check was completed upon change of shift/upon hand-offs.
Pt #10's "Patient Safety Monitoring Log" lack documentation the required Safety Checks (Activity Code #8) was
performed at change of shift/upon hand-offs at 1:45 PM, 3:15 PM, and 6:30 PM.

10. On 11/30/2023 an interview was conducted with the Director of Quality and Patient Safety (E #2). E #2 review the "Patient Safety Monitoring Log" and agreed the required Safety checks were not documented as required by policy.





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