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Based on observation, interview, record review and policy review, the hospital failed ensure that psychiatric patients were appropriately observed for safety to prevent elopement, and failed to provide a physical re-assessment and psychiatric risk re-assessment for one patient (#13) of one patient reviewed who had eloped from the hospital and returned. The lack of observation and assessment had the potential to be detrimental to all patients in the hospital at risk for suicide and elopement. The hospital census was 95.

The severity and cumulative effects of these practices that resulted in the overall non-compliance with 42 CFR §482.23, Condition of Participation (CoP): Nursing Services.

Please refer to A-0395.

Based on observation, interview, record review and policy review, the hospital failed ensure that psychiatric patients were appropriately observed for safety to prevent elopement, and failed to provide a physical re-assessment and psychiatric risk re-assessment for one patient (#13) of one patient reviewed who had eloped from the hospital and returned. The lack of observation and assessment had the potential to be detrimental to all patients in the hospital at risk for suicide and elopement. The hospital census was 95.

Findings included:

1. Review of the hospital's policy titled, "Precautionary Levels," dated 09/25/19, showed that patients placed on Suicide Precautions Level 2 with Unit Restriction (SP2/UR) Moderate Risk, were to be observed every 15 minutes by staff, and provided unit restriction with supervised courtyard privileges. Patients placed on Suicide Precautions and Ligature (anything which could be used for the purpose of hanging or strangulation) Risk (SPL), were patients who presented with a past history of self-harm by choking, strangulation, asphyxiation or hanging.

Review of the hospital's undated document titled, "Columbia-Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self inflicted harm and desire to end one's life))," showed the following directive for moderate suicide risk:
- Unit restriction with supervised courtyard privileges;
- Suicide Risk assessed daily by the patient's nurse; and
- 15-minute observation rounds.

Review of Patient #13's Court order, dated 11/22/19, showed that he was placed on a medical furlough (leave of absence) from jail to be admitted to the hospital for inpatient treatment, and directed to stay there unless otherwise authorized by the court. Upon treatment completion, Patient #13 was to be returned to jail.

Review of the hospital's document titled, "Assessment Consent and Initial Patient Questionnaire," dated 11/22/19, showed that Patient #13 stated he had hallucinations (seeing or hearing things which were not there) of things that seemed very real and he heard thoughts that persuaded him to hurt himself. He also stated that he had two manic episodes (elevated or excited mood or behavior) recently, that resulted in his wife and kids leaving him.

Review of Patient #13's Psychiatric Admission Evaluation, dated 11/23/19 at 2:19 PM, showed:
- The patient's chief complaint was that he heard voices, had visual hallucinations and had suicidal ideation (SI, thoughts of causing one's own death).
- The patient complained of depression and anxiety since he had been in jail for stalking his wife.
- The patient felt that his skeleton was trying to pull out of his skin.
- A recent suicide attempt on 10/01/19.
- The patient's admitting diagnosis was bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) with a current episode of depression with some psychotic features (characterized by false ideas about what is taking place or who one is).

Review of Patient #13's C-SSRS Risk Assessment dated 11/22/19 at 12:48 PM showed that:
- He had an actual suicide attempt in the past three months.
- He wished to be dead.
- He had suicidal intent with a specific plan to end his life.
- He had a recent loss or significant negative event (his wife and kids had left him).
- He was pending incarceration or homelessness.
- He had hopelessness.
- Protective factors were a safe and secure environment.
- Based on the answers to this assessment, the patient was placed on moderate suicide risk precautions.

Review of Patient #13's follow-up C-SSRS Risk Assessment Scale for the following dates showed:
- 11/22/19 at 4:30 PM, the patient remained on moderate suicide risk precautions.
- 11/23/19 at 10:13 AM, the patient answered "no" to assessment questions and the risk level was left blank.
- 11/23/19 at 2:56 PM, showed Staff XX, Licensed Professional Counselor and the patient reviewed the C-SSRS Scale and the patient remained on moderate suicide risk precautions.

On 11/23/19, the patient's suicide risk level assessment was not documented by the patient's nurse, as directed in policy.

Review of Patient #13's "Clinical Status Report 15-Minute Rounds," dated 11/23/19, showed:
- Precaution levels were SP2 and SPL.
- At approximately 6:30 PM, he was located in the dayroom, and the documentation was initialed by Staff AA, Mental Health Technician (MHT).
- At 6:47 PM, he was located in the dayroom, and the documentation was initialed by Staff AA, with a line drawn through the documented times (as if in error).
- At 7:02 PM, he was located in the dayroom, and the documentation was initialed by Staff AA, with a line drawn through the documented times.

During an interview on 01/15/20 at 2:45 PM, Staff AA, MHT, stated that he worked the evening shift (3:30 PM - 11:00 PM) on 11/23/19, and provided care for Patient #13. He stated that some of the patients went outside to the courtyard, but he didn't notice Patient #13 in the courtyard and thought the patient had stayed inside. He documented Patient #13 was in the dayroom on the 15-minute rounds because he mistook another patient to be Patient #13, but Patient #13 was not in the dayroom.

Review of a hospital incident report, showed that the patient eloped on 11/23/19 at 7:20 PM.

During an interview on 01/15/20 at 11:52 AM, Staff HH, MHT, stated that he and Staff AA were the only MHTs working on the unit when Patient #13 eloped. He had taken approximately 12-14 patients outside to smoke, and did not notice Patient #13 in the courtyard. Staff HH added that the doors that led to the courtyard were locked at all times, and patients had to be let in and out, but they did not count the patients when they went outside or when they come back in. When patients left the courtyard while other patients remained, or if patients stayed inside, the MHTs were expected to continue the 15-minute rounds on all patents, even when the expectation was for the MHTs to remain outside in the courtyard with patients.

The hospital failed to accurately identify the patients they observed and documented on for 15-minute rounds, and failed to have a process to ensure the same amount of patients came in from the courtyard that went out to the courtyard.

Review of the hospital's documents titled, "Position Description for Mental Health Tech 1, 2 and 3," dated 10/01/18 showed that the MHTs worked under the direction of the Registered Nurses (RN).

During an interview on 01/15/20 at 12:10 PM, Staff GG, RN, stated that the MHTs were to perform rounds every 15 minutes in real time.

During an interview on 01/15/20 at 11:35 AM, Staff JJ, RN, stated that Patient #13 was her patient that evening, and she wasn't sure that the MHTs performed the rounds appropriately. She stated that the documentation showed the patient was in the dayroom and out in the courtyard at the same time, and that was not possible.

During an interview on 01/15/20 at 1:27 PM, Staff T, House Supervisor, stated that she responded to Patient
#13's elopement on 11/23/19, reviewed the 15-minute rounding sheets, and remembered conflicting stories about whether the patient was in the dayroom or in the courtyard.

During an interview on 01/16/20 at 12:35 PM, Staff G, Director of Nursing (DON), stated that the nurses should have made sure the MHTs completed the 15 minute rounds appropriately, and if the MHTs were unable to complete the rounding, they should have handed the rounding sheets to the RN.

2. Although requested, the hospital failed to provide a patient assessment/reassessment policy.

During an interview on 01/15/20 at 11:07 AM, Staff KK, RN, stated that:
- On 11/24/19 at approximately 7:00 AM, she saw Patient #13 knocking from outside, on the locked door of the courtyard.
- She let the patient inside and alerted the MHT who had informed her the patient had eloped.
- She cleaned an abrasion the patient had on his hand.
- She did not perform a full nursing assessment on the patient.

Review of the National Weather Services documented temperatures for 11/23/19 to 11/24/19, showed that the temperature lows were 32-33 degrees Fahrenheit.

Review of Patient #13's record showed no indication that the patient's suicide risk was reassessed.

During an interview on 01/16/20 at 12:35 PM, Staff G, DON, stated that nursing should have performed a full nursing assessment on the patient when the patient returned.

During an interview on 01/15/20 at 1:27 PM, Staff T, House Supervisor, stated that upon Patient #13's return, she contacted Staff P, Physician, for direction, and Staff P gave her a telephone order to discharge the patient back to jail.

During an interview on 01/15/20 at 4:10 PM, Staff P, Physician, stated that he was Patient #13's primary physician and he discharged the patient to return to jail, but was unaware that the patient failed to receive a full assessment prior to discharge.

Patient #13 was court ordered for psychiatric care, and was sent to the hospital for treatment of suicidal ideation. The hospital failed to protect the patient, by not completing 15-minute rounds in a manner that ensured the accuracy of the patient's whereabouts, which resulted in the patient's elopement. The patient was missing from the hospital between 11/23/19 at approximately 6:45 PM and 11/24/19 at 7:00 AM (around 12 hours). The cold temperatures and the patient's mental health status warranted a nursing assessment which included the patient's suicide risk, before the patient was subsequently discharged to jail.

Based on interview, record review and policy review, the hospital failed to assess/re-evaluate the appropriateness of discharge for one psychiatric at-risk patient (#13) of one psychiatric at-risk patient reviewed, who had eloped and returned to the hospital. This failure had the potential to lead to the inability to recognize those patients in need of continued care, and result in poor discharge outcomes for all patients in the hospital. The hospital census was 95.

The severity and cumulative effects of these practices that resulted in the overall non-compliance with 42 CFR §482.43 Condition of Participation (CoP): Discharge Planning.

Please refer to A-0802.

Based on interview, record review and policy review, the hospital failed to assess/re-evaluate the appropriateness of discharge for one psychiatric at-risk patient (#13) of one psychiatric at-risk patient reviewed, who had eloped and returned to the hospital. This failure had the potential to lead to the inability to recognize those patients in need of continued care, and result in poor discharge outcomes for all patients in the hospital. The hospital census was 95.

Findings included:

1. Review of the hospital's policy titled, "Discharge and Continued Stay Criteria," dated 08/26/19, showed that patient's discharge criteria was met when:
- The goals of treatment had been met at that level of care (unless transfer to another hospital setting was indicated) and there was a discharge plan in place that met any continuing needs.
- Follow-up goals and treatment plans for a lesser level of care had been established.
- Releasing or transferring the patient did not pose a threat to them, others or property.

Review of the hospital's policy titled, "Discharge Planning," dated 09/04/19, showed that community resource information and referrals were a significant component of the discharge recommendations, and the discharge plans were to be continually reassessed by the multidisciplinary team and updated as needed.

Review of Patient #13's Court order dated 11/22/19, showed that he was placed on a medical furlough (leave of absence) from jail, to be admitted to the hospital for inpatient treatment, and directed to stay at the hospital unless otherwise authorized by the court. Upon treatment completion, Patient #13 was to be returned to jail.

Review of Patient #13's Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self inflicted harm and desire to end one's life) Risk Assessment dated 11/22/19 at 12:48 PM showed that:
- He had an actual suicide attempt in the past three months.
- He wished to be dead.
- He had suicidal intent with a specific plan to end his life.
- He had a recent loss or significant negative event (his wife and children had left him).
- He was pending incarceration or homelessness.
- He had hopelessness.
- Protective factors were a safe and secure environment.
- Based on the answers to this assessment, the patient was placed on moderate suicide risk precautions (interventions put into place to prevent self-harm or death).

Review of Patient #13's Master Treatment Plan, dated 11/22/19 at 3:50 PM, showed that the patient was a danger to himself or others as evidenced by suicidal ideation with a plan to hang himself, sadness, and two previous suicide attempts. The short-term goals for the patient were to take medications daily as prescribed, attend three groups per day to learn to cope with depression and meet with clinical services to assess progress and develop a discharge plan. The target completion date was 11/29/19, and there were no updates since the treatment plan was developed.

Review of Patient #13's Psychiatric Admission Evaluation, dated 11/23/19 at 2:19 PM, showed:
- The patient's chief complaint was that he heard voices, had visual hallucinations (seeing or hearing things which were not there) and had suicidal ideation (SI, thoughts of causing one's own death).
- The patient complained of depression and anxiety since he had been in jail for stalking his wife.
- The patient felt that his skeleton was trying to pull out of his skin.
- A recent suicide attempt on 10/01/19 (one month and 22 days before admission).
- The patient's admitting diagnosis was bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) with a current episode of depression with some psychotic features (characterized by false ideas about what is taking place or who one is).

Review of Patient #13's follow-up C-SSRS Risk Assessment Scale showed that on 11/23/19 at 2:56 PM, Staff XX, Licensed Professional Counselor (LPC) and the patient reviewed the C-SSRS Scale, and the patient remained on moderate suicide risk precautions.

Review of Patient #13's "Clinical Status Report 15 Minute Rounds," dated 11/23/19, showed that 15 minute rounds to verify the patient was safe and accounted for, stopped at approximately 6:30 PM.

Review of a hospital incident report, showed that the patient eloped on 11/23/19 at 7:20 PM.

During an interview on 01/15/20 at 11:07 AM, Staff KK, Registered Nurse (RN), stated that:
- On 11/24/20 at approximately 7:00 AM, she saw Patient #13 knocking from outside on the locked door that led into the courtyard.
- She helped place the patient in paper scrubs, performed a body check, and cleaned an abrasion on the patient's hand.
- She did not perform a full nursing assessment.

Review of the National Weather Services documented temperatures for 11/23/19 to 11/24/19, showed that the temperature lows were 32-33 degrees Fahrenheit.

Although requested, no nursing progress notes were provided for Patient #13's return on 11/24/19.

Review of Patient #13's medical record showed no indication that the patient was assessed physically, or for current suicide risk or risk to others, after he eloped and returned to the hospital.

During an interview on 01/16/19 at 12:35 PM, Staff G, Director of Nursing, stated that nursing should have performed a full nursing assessment when the patient returned after his elopement.

During an interview on 01/15/20 at 1:27 PM, Staff T, House Supervisor, stated that upon Patient #13's return to the hospital, she contacted Staff P, Physician, for direction. She stated that Staff P gave her a telephone order to discharge the patient back to jail. She also stated that there was nothing more mentioned about continuation of care.

Review of Patient #13's discharge summary, dated 11/24/19, showed Staff P, Physician, documented that the patient was discharged into police custody to return to jail, because he felt the hospital was a less secure environment. He also documented that the patient was high-risk for elopement and possible violent or suicidal behavior.

During an interview on 1/15/20 at 4:10 PM, Staff P, Physician, stated that he was Patient #13's primary physician and when he discharged the patient to return to jail, he was unaware that the patient was not reassessed after his elopement, and prior to discharge.

During an interview on 1/27/20 at 8:45 AM, local Sheriff's Department Lieutenant YY, stated that they did not have mental health services at the jail, and that they sent mental health patients to the hospital for treatment.

Review of a county newspaper article dated 11/27/19, showed that Patient #13 was found on 11/25/19 at approximately 3:00 PM, hanging by a piece of bedding tied above his bunk, in the county jail.

The patient was missing from the hospital between 11/23/19 at approximately 6:45 PM and 11/24/19 at 7:00 AM (approximately 12 hours) and subject to extreme temperatures and possible physical injury. The patient was not reassessed physically, or for suicide risk or risk to others, after he eloped and returned to the hospital, and prior to his discharge to jail. The patient was found dead the following day.