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This condition is not met as evidenced by:

Based on the seriousness of the noncompliance, the facility failed to substantially comply with this condition.

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to comply with this condition.

These following standards were cited and show a systemic nature of noncompliance with regards to patient rights as follows:

482.13 (c)(2) Tag A-0144 The information reviewed during the survey provided evidence that personnel failed to ensure visual observation of behavioral health patients, failed to provide constant visual observation per physician orders, resulting in behavioral health patient elopement, for two medical records reviewed, failed to follow security procedures of patients with intent to harm themselves or others for two behavioral health patient medical records reviewed, failed to notify the police of homicidal patient elopement for one medical record reviewed, in which patient expressed homicidal threats towards neighbors, and failed to initiate an elopement response for three medical records reviewed.

Based on review of facility documents, medical records (MR), and interview with facility staff (EMP), it was determined that the facility failed to provide care in a safe setting by failing to ensure personnel followed adopted processes relative to constant visual observation of behavioral health patients, by failing to provide constant visual observation per physician order in two of three medical reviewed (MR1, MR6), by failing to follow adopted policies related to patients with intent to harm themselves or others in two of 18 medical records reviewed (MR1, MR6), by failing to follow adopted policies related to a homicidal behavioral health patient elopement for one of one medical records reviewed (MR6), and by failing to follow patient elopement policy, by initiating a Code Walker response, for three of three medical records. (MR1, MR2, MR6)

Findings include:

Review of policy entitled "Security Procedures for Patient with Intent to Harm Themselves or Others", dated June 2022, revealed "... Purpose: To provide adequate safety and security for the patient, staff members, and visitors ... Policy: For any patient presenting determined to at risk of harming himself or others, procedures are taken to ensure patient and staff safety. Procedure: 1. The environment is cleared of items which could potentially be a threat to patient safety. 2. The bedside stand is closed and verified as locked. If unable to lock, the bedside stand is removed from the room. 3. The patient is escorted to a patient room or seclusion room. 4. The Security officer is present to screen the patient with a metal detector device (wand). 5. It is the responsibility of the nursing staff to disrobe the patient ... 7. The belongings are removed from the room and placed in plastic bags. The belongings will be kept in the main nurse's station ... 8. If the patient requires observation, the security officer/observation assistant/RN completes the observation activity on the Observation Record ... Non-homicidal/Non-suicidal Admissions ... Security may be contacted for observation, based upon the patient assessment. Security presence is not always required for observation. Not all patients may require constant security until placement on the Mental Health Unit. This decision is made by the attending physician and Emergency Room nurse. If the Security Officer still feels in his/her opinion that Security should be present, they may stay in attendance at their own discretion. 1. The medical staff places an order for observation. 2. When needed for observation, the officer closest to the vicinity of the Emergency Department is located for direct observation. Homicidal/Suicidal Admissions. For homicidal/suicidal admissions the Security Officer must be notified upon arrival of the patient. When notified the Security Officer completes steps 1-4. 1. Responds to the location. 2. The Medical staff enters an order for observation. 3. Completes steps 1-9 of the initial procedure. 4. Nursing staff is present when the patient uses the bathroom. 5. The physician then conducts the examination ... 8. Not all pateints may require constant security until placement on the Mental Health Unit. This decision is made by the attending physician and Emergency Room nurse. If the Security Officer still feels in his/her opinion that Security should be present; they may stay in attendance at their own discretion. 9. In the event that a patient makes a threatening comment toward the welfare of another person, the Emergency Department staff will notify the local police department. 10. An observation assistant, sitter, or clinical staff may replace the role of Security officer, when appropriate, to maintain observation ... ."

Review of policy entitled "Suicide Assessment and Precautions (Clearfield), dated September 24, 2021, which stated "... Units Primarily Affected: Penn Highlands Clearfield ... Purpose: To describe the process of suicide assessment, implementation of appropriate interventions, and communication of suicide risk to staff members in order to proactively maintain patient safety ... Procedure: 1. Risk level while in the Emergency Department or community may differ from the level of risk determined for the inpatient unit. The level of risk (routine, moderate or high,) upon admission is based on psychiatrist determination of the presenting clinical information ... High Suicide Risk ... Interventions ... 1:1 observation will be implemented for patients on high risk for suicide unless otherwise indicated by the psychiatrist. Interventions include, but are not limited to the following. Routine and Moderate Suicide Risk Interventions. All personal items removed from patient's room. Hygiene products put into disposable cups. Patient given a suicide proof blanket, remove all blankets and linens. The door to the patient's room is to be opened at all times unless patient is bathing or changing clothes, under 1:1 observation. Placed into hospital garments or paper scrubs, per physician's discretion ... ."

Review of policy entitled "Patient Bill of Rights", dated July 17, 2021, which stated "... Patient Rights ... You have the right to good quality care and high professional standards that are continually maintained and reviewed ... You have a right to receive care in a safe environment ... ."

Review of "Penn Highlands Clearfield Manual: PHC Emergency Department / Provision of Care Treatment and Services Units Primarily Affected: Emergency Department Title: Behavioral Health Elopement (Clearfield)" dated June 2022, revealed "Purpose: To provide a consistent response for Emergency Department patients that has eloped either during the medical evaluation and or pending a voluntary or involuntary commitment. Policy: Elopement events are managed with the intent of minimizing the potential for adversity to patients, staff and the community. Procedure: 1. When a patient elopes from the Emergency Department, the following person are notified: *Security. *Mental Health Therapist. *Behavioral Health Intake. *Emergency Department Physician. * Police. *Family (when appropriate). * Inpatient Manager or Supervisor (after hours). *Risk Management. *Any individual who had been subject of a personal threat by the patient ... 4. In cases of a Mental Health patient having made a direct threats to harm a specific person, the police are notified to con-tact(sic) the person at risk for harm ... ."
Review of "Penn Highlands Clearfield Manual: PHC Administrative / Provision of Care, Treatment and Services Units Primarily Affected: All Departments Title Code Walker - Missing Adult Patient / Elopement (Clearfield), dated May 30, 2023, revealed "Purpose: To define staff response to a situation where a patient may wander from their assigned room or floor ands is considered missing. Policy: In the event that you discover that a patient is missing from their room and/or nursing unit floor, immediately notify the unit charge person of the missing person. Procedure: Step 1 a. Immediately call 1-3-7-9-# to access the hospital paging system to place a missing adult patient/elopement. With the paging system accessed, announce the incident in the following manner. Code Walker, nursing unit name, specific sex, race ... b. Emergency Department, Patient Access and Pharmacy will depress the panic button to alert Security and 911 ... ."
1. A tour of the Emergency Department was conducted on May 17, 2023, with EMP3. Surveyor observed both H1 and H2 behavioral health rooms, either of which can be occupied by a patient that requires constant visual observation. Observation of rooms/area revealed that a patient in Behavioral Health Room H1, would not be able to visualized from the hallway. EMP3 stated that security tends to sit between the two rooms in the hallway and stated that if patients are ordered to be in direct line of view, that needs to occur, and stated that security can be defiant, and they have had issues with security stating they aren't going into the room.
2. Review of MR1 revealed the patient presented to the Emergency Department with homicidal threats, on April 18, 2023, with a physician's order dated April 18, 2023, at 10:23 PM for Constant Visual Observation and Suicide Precautions. Patient was in Behavioral Health Room, H2. Documentation in the medical record dated April 19, 2023 stated that the patient was being watched by security as a one-to-one sitter, however, at approximately 8:10 PM, security guard stepped outside because a helicopter was landing, and patient subsequently eloped from the Department.
Observation records in MR1, also revealed no documentation of constant visual observation between April 18, 2023, at 10:23 PM to April 19, 2023, at 6:00 PM.
Telephone interview with EMP3 on May 23, 2023, revealed that security refused to fill out the form relative to observation.
Documentation in MR1, dated April 18, 2023, at 10:21 PM, revealed the patient was changed in hospital scrub pants only.
Review of Video Footage, relative to MR1 elopement dated April 19, 2023, 8:06 PM, patient was observed to be dressed in hospital scrub pants only, and dressed in long sleeve street shirt and socks, and walked out of the Emergency Department via ambulance entrance.
3. Review of MR6 revealed the patient presented to the Emergency Department on June 19, 2023, at 11:17 AM. Documentation stated that the patient made homicidal threats to neighbors, which included one neighbor identified by first name. Physician orders dated June 19, 2023, at 11:27 AM, for High Risk Precautions and Constant Visual Observation were noted. Patient subsequently eloped from the Department on June 19, 2023, at approximately 6:00 PM.
There was no documentation present in MR6, that any security procedures for patients with intent to harm themselves or others were executed, no documentation that patient was ever placed on Constant visual observation, or changed into hospital scrubs, and no documentation that police were notified that patient had made direct threats to harm neighbors.
4. Review of Video Footage, relative to MR6 elopement dated June 19, 2023, 6:05 PM, revealed patient was observed noted to be dressed entirely in street clothes, and walked out of the Emergency Department via ambulance entrance.
Interview with EMP1 on June 23, 2023, confirmed the patient was not placed on 1:1 observation per order, no sitter was watching patient, and that policy relative to security of patients with intent to harm themselves or others was not followed.
Interview with EMP1 on June 27, 2023, confirmed that there is no documentation in MR6 that police were advised of patient's homicidal statements towards neighbors.
5. Review of MR1, MR2, and MR6 all revealed documentation of behavioral health elopements. A Code Walker was not initiated for any of the elopements, which was confirmed by EMP3 on June 27, 2023.