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Based on interview, record review, review of Patient Rights and Patient Handbook, review of Root Cause Analysis Reports, review of Interdepartmental e-mails, and review of the facility's policies, it was determined the facility failed to ensure patients were provided care in a safe setting for three (3) of fourteen (14) sampled patients, Patient #3, #4 and #5. Patient #3 and #5 were not provided adequate supervision to prevent them from exiting their respective locked Units and then exiting the facility through exterior secured doors and making their way off facility grounds.

Patient #4 was on one-to-one (1:1) supervision and was able to self-harm his/her left arm, requiring seven (7) staples. He/she accomplished the self-harm with a piece of broken plastic spoon.

The findings include:

Review of the facility's policy Number 108, titled "Patient Rights and Responsibilities", reviewed April 2021, revealed patients could expect care to be provided in a safe setting.

Review of the facility's policy Number 301b, titled "Accountability of Patients", revised August 2022, revealed the facility utilized an interdisciplinary system to account for patients. The policy included that Nursing staff were to make rounds every fifteen (15) minutes to verify the whereabouts of patients on the unit.

Review of the facility's policy Number III-D (2), titled "24-Hour Patient Monitoring", revised May 2022, revealed patient safety and health would be maintained by the provision of twenty-four (24) hour Nursing supervision. The policy included that patients would be monitored and their location would be legibly documented every fifteen (15) minutes. Per the policy, the monitoring would be completed by walking rounds every fifteen (15) minutes to observe both the patient and the environment.

Review of the facility's policy Number 112, titled "High Risk Situations: Psychiatric Missing Person Management", revised March 2023, revealed the facility would make every effort to locate any patient believed to be absent without leave (AWOL) approval. Continued review revealed the facility defined AWOL as an event in which a patient was not accounted for when he/she was expected to be present. Additional review revealed when a patient was not located in the facility by Unit staff or Security, the individual in charge would notify the switchboard, and the switchboard would make the necessary notifications.

Review of the facility's policy Number 339, titled "1:1 Supervision", reviewed August 2021, revealed patients that were placed on one-to-one (1:1) supervision were monitored constantly to ensure they received care in a safe setting. Per the policy, a patient could be placed on one-to-one (1:1) supervision for exhibiting self-harm behaviors. Further review revealed one-to-one (1:1) supervision included observing the patient's head, neck, and hands, which were to be visible at all times, including when the patient was in the bathroom, shower room, and bedroom. Also, per the policy, staff assigned to monitor a patient on one-to-one (1:1) supervision, would place him/herself approximately three (3) feet from the patient and conduct him/herself in a manner that would ensure patient safety at all times.

Review of the facility's document Performance Improvement Plan for SOP 203-Professional Appearance and Dress Code, revision date 01/2017, revealed it was given to staff to correct performance in this area that needed improvement. Further review revealed employee responsibilities included that identification badges must be worn at all times. In addition, it stated that badges were to be prominently displayed above the waist in such a fashion that the employee readily could be identified by anyone.

During a facility tour, on 06/20/2023 at 9:11 AM, Investigator #3 stated there were no video cameras anywhere on the interior/exterior of the facility.

1. Review of Patient #3's medical record revealed the facility admitted the patient via a seventy-two (72) hour Court ordered hold, on 03/21/2023, with diagnoses that included Unspecified Schizophrenia Spectrum and Other Psychotic Disorders.

Review of the facility's final expanded investigation summary, Case Number WSH 23014, dated 04/13/2023, revealed that on 03/27/2023, at approximately 7:27 PM, a Code Black (missing patient) was called related to Patient #3 being unaccounted for during Unit checks. Continued review revealed Investigator #3 interviewed nursing staff present on the Unit and Patient #3 (upon return to the facility three (3) days later, on 03/30/2023). Per the investigation, all staff reported that Patient #3 was transferred to the Unit at approximately 5:15 PM and was last observed on the Unit at approximately 6:35 PM to 6:40 PM.

Further review of the facility's final expanded investigation summary, dated 04/13/2023, revealed staff reported that on 03/27/2023 between 6:45 PM and 7:15 PM, during shift change, there was a lot happening on the Unit, with vital signs being obtained and fifteen (15) minute checks being completed. Per the summary, staff stated Therapeutic Recreation was on the Unit and was cutting hair, doing nails, and playing music; patients were dancing; and Nurses were getting change-of-shift report. The summary stated it was during this time that a Code "D" (Patient Emergency) was also called.

Further review of the facility's final expanded investigation summary, dated 04/13/2023, revealed Investigator #3 substantiated the allegation of neglect related to Patient #3 eloping from the facility. Investigator #3 documented in the summary that the facility, as a whole, failed Patient #3 by creating an environment that allowed him/her to elope.

Review of the Timeline for the elopement of Patient #3, given to the State Survey Agency (SSA) Surveyor by the facility, revealed that on 03/27/2023 at 6:45 PM, documentation on the Hall Monitoring Form indicated Patient #3 was awake on the Unit, with ceiling tiles intact. On 03/27/2023 at 7:00 PM, Patient #3 was noted missing. A ward search began, and the Coordinator was made aware. The Hall Monitoring Form indicated Patient #3 was in AWOL status. Further review revealed on 03/27/2023 at 7:27 PM, a Code Black was called, and an entire facility-wide search was conducted. Also, all appropriate notifications were made such as with the Police, the Administrator on Duty (AOD), and Physicians.

Additional review of the Timeline revealed on 03/27/2023 at 8:30 PM, according to the notes of the Switchboard, the Risk Manager was on the grounds of the facility. Per the timeline, on 3/27/2023 at 9:17 PM, the Risk Manager and Investigator #3 were on the grounds, made rounds, and secured all doors. Also, an email was sent to all users in the building regarding the facility's policy SOP 203-Professional Appearance and Dress Code to re-educate all staff. The Timeline stated no staff members were pulled at this time due to the inability to identify any specific staff responsible. Further review of the Timeline revealed, on 03/30/2023 at 1:53 PM, Patient #3 was returned to facility. Per the Timeline, on 03/31/2023, Patient #3 was interviewed by Risk Management, and it was determined that Patient Aide (PA) #8 and #9 needed to be pulled until the investigation could be completed. Both staff members were pulled from patient care on 3/31/2023.

Continued review of the Timeline revealed, on 04/10/2023, Nursing was made aware by Risk Management that both Patient Aides were released to nursing but required re-education on twenty-four (24) hour monitoring. The employees remained out of patient care until training could be provided. The Timeline stated, on 04/10/2023, PA #8 was given a Performance Improvement Plan and was provided re-education. She was then released to patient care. For PA #9, this occurred on 04/11/2023, and she was then released to patient care. The Timeline stated, on 04/18/2023, re-education for all Nursing staff on maintaining a safe environment was initiated to include a power point and a quiz.

Patient #3 was not interviewed by the SSA Surveyor because the facility's provider, Advanced Practice Registered Nurse (APRN) #1 requested the patient not be interviewed.

During an interview with Security #1, on 06/20/2023 at 4:34 PM, he stated that on 03/27/2023, he saw a woman running down the hallway but was unable to make out who it was (observations revealed staff wore street clothing, as did patients). He continued by stating since the elopements, there had been education on securing doors and making sure keys were secured.

While interviewing Registered Nurse (RN) #3, on 06/22/2023, at 9:01 AM, she stated it was chaotic during the time Patient #3 was discovered missing (approximately 7:15 PM). She stated Therapy Recreation was on the Unit and was engaged in various tasks with the patients; shift change tasks were being done; and a Code "D" had been called. She stated she had been notified by a PA (patient aide), while the PA was doing vital signs, that Patient #3 could not be found for the fifteen(15) minute checks. RN #3 stated that a search was conducted of the Unit without Patient #3 being located; so, at approximately 7:30 PM, a Code Black (missing patient) was called. She stated notifications were made to authorities, Risk Management, and medical staff. She stated there had been education on elopements, since both incidents, that included making sure keys and doors were secured.

Review of the Root Cause Analysis (RCA) Findings for Patient #3, no date, revealed there were several deviations from established facility policies and procedures that contributed to Patient #3's elopement. Per the RCA, the deviations included staff not appropriately conducting and documenting hall checks and poor communication between floor staff coming on and leaving shifts during the event. Also included in the RCA were that staff conducted a "headcount" instead of actually visualizing patients to identify, and staff and patients were dressed in similar street clothing, without staff appropriately wearing facility badges.

Continued review of the RCA Findings revealed there were human factors which contributed to the elopement event. These included the failure to follow established facility policies and procedures as well as staff rushing to complete a task. It was determined staff failed to ensure the door exiting a Unit was appropriately latched and secured when they left that Unit to attend to a Code "D" (patient emergency) in another area of the facility, thus allowing Patient #3 to exit the Unit and ultimately the facility.

2. Review of Patient #5's clinical record revealed the facility admitted the patient on 04/13/2023 with diagnoses that included Unspecified Bi-Polar and Related Disorders.

Review of the facility's Final Expanded Investigative Report, dated 05/08/2023, revealed a Code Black (missing patient) was called at approximately 6:00 AM on 04/23/2023, when Patient #5 was discovered to be missing from the Unit. The report stated a search of the facility and campus was conducted without Patient #5 being located. Further review revealed Investigator #1 documented that Patient #5 stated he/she had removed PA #6's badge and keys while she was asleep at the desk. The report stated the facility substantiated the allegation of neglect, related to Patient #5's elopement. Per the report, Investigator #1 documented in the report that staff failed to appropriately monitor patients while completing twenty-four (24) hour monitoring; and thus, Patient #5 was able to elope from the facility.

Review of the Timeline for the elopement of Patient #5, given to the State Survey Agency (SSA) Surveyor by the facility, revealed on 04/23/2023 at 6:00 AM, Patient #5 was noted missing from the Unit. A Unit search was conducted, and keys to the locked door on the Unit were noted to be missing. Further review revealed all following actions were on 04/23/2023: at 6:10 AM, the Administrator on call (AOD) was notified; at 6:14 AM, State Police were made aware; at 6:20 AM, the local sheriff was made aware; at 6:40 AM, the facility was made aware Patient #5 had been located and was being transported back to the facility; and Risk Management conducted an expanded investigation and at 11:30 AM, notified Nursing management to remove PA #5 and PA #6 from patient care. Neither staff members were present in the building but were notified by phone.

Further review of Patient #5's Timeline revealed, on 4/23/2023, to implement re-education, all staff members were required to review and sign the acknowledgment forms for the facility's policies "Environmental Safety" and "General Hospital SOP 339 1:1 Supervision". The Timeline stated, on 04/24/2023, PA #5 was returned to care due to no evidence of involvement; and on 05/01/2023 at 9:51 AM, Nursing Management was notified by Risk Management via email that neglect was substantiated against PA #6. The Timeline stated PA #6 was terminated on 05/01/2023 and was listed as not re-hirable.

Review of the Root Cause Analysis (RCA) Findings, no date, revealed the human factors involved in the elopement included staff failure to follow facility established policies. The RCA determined the PA assigned to hall monitoring at the time of the elopement failed to properly monitor patients per the facility's policy. That infraction allowed Patient #5 to access PA #6's badge and keys and use them to leave the locked Unit and exit via secured exterior doors. Additionally, fatigue was identified as a human factor that resulted in the outcome. Continued review revealed there were several deviations from defined policy as well as performance variances that were revealed during Risk Management's investigation.

Patient #5 was not interviewed by the SSA Surveyor because the facility's provider, APRN #1 requested the patient not be interviewed.

While interviewing PA #6, on 06/27/2023 at 2:12 PM, she stated the facility had suspended and terminated her. PA #6 denied being asleep, as alleged, and stated Patient #5 could have slipped the Unit keys out of her pocket when Patient #5 was "all up in his/her space" while Patient #5 was being weighed.

During an interview, on 06/27/2023 at 2:33 PM, PA #5 stated he did not see PA #6 asleep, he just tapped her shoulder to get her attention because she was behind PA #5. He notified PA #6 that Patient #5 was missing, and a search began.

On 06/27/2023 at 2:40 PM, while interviewing Registered Nurse (RN) #6, she stated she observed Patient #5 on the Parkway on 04/23/2023 at about 6:30 AM while she was coming into work. She stated at the time of observation, she was two and three-tenths (2.3) miles from the facility per, and this was verified by the State Survey Agency (SSA) Surveyor. She stated notifications were made as soon as she got to work.

During an interview with the Therapy Program Coordinator Assistant, on 06/27/2023 at 2:53 PM, he stated he was working in the Coordinator's Office at the time of Patient #5's elopement but was unable to remember how he found out about the elopement. He stated protocol was followed in that a Code Black was called, the facility and grounds were searched, and notifications were made.

While interviewing RN #7, on 06/27/2023 at 5:11 PM, she stated that on 04/23/2023, she was covering two (2) Units with a total of twenty-nine (29) patients. She described the work intensity of the night as steady. She stated that at approximately 6:00 AM, she returned to Patient #5's Unit just as PA #5 was receiving a call from the Coordinator's Office asking if Patient #5 was on the Unit. She stated that she, PA #5, and PA #6 then searched the Unit, without finding Patient #5. She stated she remembered PA #6 looking in her jacket for her keys, which she could not find, and PA #6 saying she thought Patient #5 took them.

During an interview with the Director of Security, on 06/23/2023 at 7:22 AM, she stated that she had already left for the day when both elopements occurred. She stated the process for a Code Black was for the facility and campus to be searched, and law enforcement would also be notified if the patient was not found on the grounds. She stated Security did not document events because Nursing did. She stated all three (3) shifts had assigned tasks which included ensuring doors were secured. She stated staff had received education that included emails and Survey Monkey (a software program). On 06/28/2023 at 2:46 PM, during re-interview for clarification of Security assignment sheets for the days of both elopements, she confirmed that the form, for either day, was not filled out correctly. Therefore, she stated there was no documented evidence the tasks, which included checking interior/exterior doors to ensure they were locked, had been completed.

During an interview, on 06/29/2023 at 2:17 PM, the QAPI Coordinator stated Risk Management would send their preliminary investigation. Then, she stated the preliminary investigation would be reviewed with the Executive Director, Nursing and Charge Nurse of the involved Unit. She stated this review would lead to the development of the Action Plan.

On 06/29/2023 at 2:39 PM, while interviewing the Executive Director (ED), she stated she had been at the facility ten (10) years, and it had been at least five (5) years since there had been an elopement. She stated both elopements, involving Patient #3 and Patient #5, were discussed in the Executive Committee (EC) with the RCA Findings included in the discussion. The ED stated the investigations, RCA Findings and EC discussions were really about future event prevention. She stated it had been a learning experience, and it caused staff to be more cautious about who might be following them through a door. Additionally, the ED stated that Patient #3's elopement was definitely a systems failure. However, she stated, with Patient #5, it seemed more like an opportunistic event. She stated Patient #5 saw an opportunity to remove the badge and keys from an allegedly sleeping staff member, and Patient #5 exited the Unit and the grounds of the facility. The ED voiced that Patient #5 watched the staff as much as staff watched the patients, and he/she was familiar with processes, shift changes, and facility tasks. The ED stated by Patient #5 taking both the badge and the keys, it revealed how long he/she had been a patient over the years; at one time, the badge was required but now it took keys to exit/open all facility doors. She stated there were only two (2) keys on the PA keyring, so it was not hard for Patient #5 to determine which one to use. The ED continued by stating that Patient #5 saw an opportunity and took it.

3. Review of Patient #4's clinical record revealed the facility admitted the patient, on 03/02/2023, with a diagnosis that included Unspecified Bi-Polar and Related Disorders.

Review of Investigator #3's preliminary report, initiated on 06/19/2023, with an extension granted on 06/29/2023, by the Department for Behavioral Health and Intellectual Disabilities revealed, on 06/09/2023, Patient Aide (PA) #2 was negligent in providing Physician ordered one-to-one (1:1) monitoring, thus allowing Patient #4 to self-harm his/her left arm, which required seven (7) staples.

Patient #4 declined to be interviewed.

During an interview on 06/22/2023, Security #1 stated he had been visiting with Patient #4 at the time the incident was discovered. He stated that at no time during the visit were there observations of blood and that Patient #4's hands, neck, and head were uncovered.

While interviewing PA #1, on 06/23/2023 at 8:37 AM, he stated he was familiar with Patient #4, who would self-harm when taken off one-to-one (1:1) supervision and when the patient did not get his/her way.

During an interview with Registered Nurse (RN) #5, on 06/26/2023 at 10:34 AM, she stated PA #3 reported that Patient #4 had harmed him/herself with part of a broken plastic spoon, and she went to investigate. She stated Patient #4's arm was not actively bleeding at that time, and Patient #4 refused to let RN #5 dress the wound but did let her clean it. She stated notifications were made to the State Police, Leadership, Physicians, and the local Police Department, and Patient #4 was sent to a local Emergency Department. RN #5 stated Patient #4 did relinquish the spoon parts. RN #5 further stated Patient #4 was frequently on one-to-one (1:1) supervision for different things such as not getting his/her own way, causing discord on the Unit, and self-harm by cutting. Additionally, RN #5, when asked how she ensured staff were not sleeping, were not on phones during care, and that rounds were being made, stated that she would make rounds at least every hour.

In an interview on 06/27/2023 at 9:07 AM with PA #4, she stated she was currently working away from patient care until Risk Management concluded their investigation.

On 06/26/2023 at 10:45 AM and 10:46 AM, the SSA Surveyor left voice mails for PA #2 and PA #3, respectively. No return calls were received on 06/26/2023 or 06/27/2023. On 06/28/2023, the SSA Surveyor again attempted to contact PA #2 and PA #3. PA #2's phone recording stated the mailbox was full. PA #3's phone recording stated she was not accepting calls at this time.

During an interview on 06/27/2023 at 9:07 AM, PA #4 stated she assumed the one-to-one (1:1) supervision with Patient #4 at 10:00 PM, on 06/09/2023. She stated Patient #4 was in bed on his/her side, with arms covered, hands together, and with head lying on exposed hands so they could be observed. She stated PA #2 came by asking Patient #4 if he/she wanted a snack. She stated Patient #4 sat up, and the covers fell off his/her arms and that was when the blood and cut was discovered. PA #4 stated she sent PA #2 for the nurse, and she did not leave Patient #4 alone. PA #4 stated Patient #4 said he/she got the spoon off supper tray. She stated supper was over prior to her coming on shift, and she had no knowledge of how or when Patient #4 obtained the spoon. She stated Patient #4 was not a body search, just one-to-one (1:1) supervision. PA #4 stated Patient #4 was frequently on one-to-one (1:1) supervision for causing disturbances or cutting. She stated plastic ware was only available on meal trays.

While interviewing the ED, on 06/29/2023 at 2:39 PM, she stated that she was very familiar with Patient #4. The ED stated Patient #4 would do just about anything, such as cutting and urethral insertion, to gain attention. She stated that she believed the behaviors typically reflected Patient #4's feelings of loneliness. She stated that Patient #4 did not have any predictability for behaviors for staff to expect a self-harm behavior. She continued by stating that because Patient #4's behaviors could not be predicted and in-spite of following the one-to-one (1:1) supervision protocol, Patient #4 was able to secrete a plastic spoon on his/her person. During further interview, the ED stated that because Patient #4 was an experienced self-harmer, hiding a spoon was nothing, even with one-to-one (1:1) supervision.

Based on interview, record review, review of Patient Rights and Patient Handbook, review of Root Cause Analysis Reports, review of Job Descriptions, and review of the facility's policies, it was determined the facility failed to ensure patients received adequate nursing supervision to provide a safe environment for three (3) of fourteen (14) sampled patients, Patient #3, #4 and #5. Patient #3 and #5 were not provided adequate supervision to prevent them from exiting their respective locked Units and then exiting the facility through exterior secured doors and making their way off facility grounds.

Patient #4 was on one-to-one (1:1) supervision and was able to self-harm his/her left arm, requiring seven (7) staples. He/she accomplished the self-harm with a piece of a broken plastic spoon.

The findings include:

Review of the facility's Standard of Practice (SOP) 1B, revised 08/2020, revealed the core features of the Nurse-Directed Care Model provided for continuity of care by having one (1) nurse in charge of the program area and provided for individual accountability of care by having a registered nurse (RN) directly supervise licensed practical nurses (LPN) and aides (E-Morris, et al., 2010). This was shown through the Nursing Department's chain of command structure where each program area was supervised by one (1) nurse program supervisor who was responsible for the twenty-four (24) hour care that was provided. Per the SOP, each shift, an RN was assigned to supervise the direct care that was provided by the LPNs, the therapeutic program supervisory assistants (TPSA), the patient aide II (PAII), the patient aide I (PAI), and the patient support aides (PSA).

Review of the facility's policy Number 108, titled "Patient Rights and Responsibilities", reviewed April 2021, revealed patients could expect care to be provided in a safe setting.

Review of the facility's policy Number 301b, titled "Accountability of Patients", revised August 2022, revealed the facility utilized an interdisciplinary system to account for patients. The policy included that Nursing staff were to make rounds every fifteen (15) minutes to verify the whereabouts of patients on the unit.

Review of the facility's policy Number III-D (2), titled "24-Hour Patient Monitoring", revised May 2022, revealed patient safety and health would be maintained by the provision of twenty-four (24) hour Nursing supervision. The policy included that patients would be monitored, and their location would be legibly documented every fifteen (15) minutes. Per the policy, the monitoring would be completed by walking rounds every fifteen (15) minutes to observe both the patient and the environment.

Review of the facility's policy Number 339, titled "1:1 Supervision", reviewed August 2021, revealed patients that were placed on one-to-one (1:1) supervision were monitored constantly to ensure they received care in a safe setting. Per the policy, a patient could be placed on one-to-one (1:1) supervision for exhibiting self-harm behaviors. Further review revealed one-to-one (1:1) supervision included observing the patient's head, neck, and hands, which were to be always visible, including when the patient was in the bathroom, shower room, and bedroom. Also, per the policy, staff assigned to monitor a patient on one-to-one (1:1) supervision, would place him/herself approximately three (3) feet from the patient and conduct him/herself in a manner that would always ensure patient safety.

Review of the Patient Aide (PA) job description, revised 09/16/2017, revealed there were no specific inclusions on patient supervision. The job description did include the PA's were to adhere to all facility policies and procedures.

During a facility tour, on 06/20/2023, at 9:11 AM, Investigator #3 stated there were no video cameras anywhere on the interior/exterior of the facility.

1. Review of Patient #3's medical record revealed the facility admitted the patient via a seventy-two (72) hour Court ordered hold, on 03/21/2023, with diagnoses that included Unspecified Schizophrenia Spectrum and Other Psychotic Disorders.

Review of the facility's final expanded investigation summary, Case Number WSH 23014, dated 04/13/2023, revealed that on 03/27/2023, at approximately 7:27 PM, a Code Black (missing patient) was called related to Patient #3 being unaccounted for during Unit checks. Continued review revealed Investigator #3 interviewed nursing staff present on the Unit and Patient #3 (upon return to the facility three (3) days later, on 03/30/2023). Per the investigation, all staff reported that Patient #3 was transferred to the Unit at approximately 5:15 PM and was last observed on the Unit at approximately 6:35 PM to 6:40 PM.

Further review of the facility's final expanded investigation summary, dated 04/13/2023, revealed staff reported that on 03/27/2023 between 6:45 PM and 7:15 PM, during shift change, there was a lot happening on the Unit, with vital signs being obtained and fifteen (15) minute checks being completed. Per the summary, staff stated Therapeutic Recreation was on the Unit and was cutting hair, doing nails, and playing music; patients were dancing; and Nurses were getting change-of-shift report. The summary stated it was during this time that a Code "D" (Patient Emergency) was also called.

Further review of the facility's final expanded investigation summary, dated 04/13/2023, revealed Investigator #3 substantiated the allegation of neglect related to Patient #3 eloping from the facility. Investigator #3 documented in the summary that the facility failed Patient #3 by creating an environment that allowed him/her to elope.

Review of the Timeline for the elopement of Patient #3, given to the State Survey Agency (SSA) Surveyor by the facility, revealed that on 03/27/2023 at 6:45 PM, documentation on the Hall Monitoring Form indicated Patient #3 was awake on the Unit, with ceiling tiles intact. On 03/27/2023 at 7:00 PM, Patient #3 was noted missing. A ward search began, and the Coordinator was made aware. The Hall Monitoring Form indicated Patient #3 was in AWOL status. Further review revealed on 03/27/2023 at 7:27 PM, a Code Black was called, and an entire facility-wide search was conducted. Also, all appropriate notifications were made such as with the Police, the Administrator on Duty (AOD), and Physicians.

Additional review of the Timeline revealed on 03/27/2023 at 8:30 PM, according to the notes of the Switchboard, the Risk Manager was on the grounds of the facility. Per the timeline, on 3/27/2023 at 9:17 PM, the Risk Manager and Investigator #3 were on the grounds, made rounds, and secured all doors. Also, an email was sent to all users in the building regarding the facility's policy SOP 203-Professional Appearance and Dress Code to re-educate all staff. The Timeline stated no staff members were pulled at this time due to the inability to identify any specific staff responsible. Further review of the Timeline revealed, on 03/30/2023 at 1:53 PM, Patient #3 was returned to facility. Per the Timeline, on 03/31/2023, Patient #3 was interviewed by Risk Management, and it was determined that Patient Aide (PA) #8 and #9 needed to be pulled until the investigation could be completed. Both staff members were pulled from patient care on 3/31/2023.

Continued review of the Timeline revealed, on 04/10/2023, Nursing was made aware by Risk Management that both Patient Aides were released to nursing but required re-education on twenty-four (24) hour monitoring. The employees remained out of patient care until training could be provided. The Timeline stated, on 04/10/2023, PA #8 was given a Performance Improvement Plan and was provided re-education. She was then released to patient care. For PA #9, this occurred on 04/11/2023, and she was then released to patient care. The Timeline stated, on 04/18/2023, re-education for all Nursing staff on maintaining a safe environment was initiated to include a power point and a quiz.

Patient #3 was not interviewed by the SSA Surveyor because the facility's provider, Advanced Practice Registered Nurse (APRN) #1 requested the patient not be interviewed.

During an interview with Security #1, on 06/20/2023 at 4:34 PM, he stated that on 03/27/2023, he saw a woman running down the hallway but was unable to make out who it was (observations revealed staff wore street clothing, as did patients). He continued by stating since the elopements, there had been education on securing doors and making sure keys were secured.

While interviewing Registered Nurse (RN) #3, on 06/22/2023, at 9:01 AM, she stated it was chaotic during the time Patient #3 was discovered missing (approximately 7:15 PM). She stated Therapy Recreation was on the Unit and was engaged in various tasks with the patients; shift change tasks were being done; and a Code "D" had been called. She stated she had been notified by a PA (patient aide), while the PA was doing vital signs, that Patient #3 could not be found for the fifteen (15) minute checks. RN #3 stated that a search was conducted of the Unit without Patient #3 being located; so, at approximately 7:30 PM, a Code Black (missing patient) was called. She stated notifications were made to authorities, Risk Management, and medical staff. She stated there had been education on elopements, since both incidents, that included making sure keys and doors were secured. RN #3 stated she was aware of the facility ' s policy that stated rounds were to be completed and documented every fifteen (15) minutes. She stated she tried to make rounds at least hourly.

Review of the Root Cause Analysis (RCA) Findings for Patient #3, no date, revealed there were several deviations from established facility policies and procedures that contributed to Patient #3's elopement. Per the RCA, the deviations included staff not appropriately conducting and documenting hall checks and poor communication between floor staff coming on and leaving shifts during the event. Also included in the RCA were that staff conducted a "headcount" instead of visualizing patients to identify, and staff and patients were dressed in similar street clothing, without staff appropriately wearing facility badges.

Continued review of the RCA Findings revealed there were human factors which contributed to the elopement event. These included the failure to follow established facility policies and procedures as well as staff rushing to complete a task. It was determined staff failed to ensure the door exiting a Unit was appropriately latched and secured when they left that Unit to attend to a Code "D" (patient emergency) in another area of the facility, thus allowing Patient #3 to exit the Unit and ultimately the facility.

2. Review of Patient #5's clinical record revealed the facility admitted the patient on 04/13/2023 with diagnoses that included Unspecified Bi-Polar and Related Disorders.

Review of the facility's Final Expanded Investigative Report, dated 05/08/2023, revealed a Code Black (missing patient) was called at approximately 6:00 AM on 04/23/2023, when Patient #5 was discovered to be missing from the Unit. The report stated a search of the facility and campus was conducted without Patient #5 being located. Further review revealed Investigator #1 documented that Patient #5 stated he/she had removed PA #6's badge and keys while she was asleep at the desk. The report stated the facility substantiated the allegation of neglect, related to Patient #5's elopement. Per the report, Investigator #1 documented in the report that staff failed to appropriately monitor patients while completing twenty-four (24) hour monitoring; and thus, Patient #5 was able to elope from the facility.

Review of the Timeline for the elopement of Patient #5, given to the State Survey Agency (SSA) Surveyor by the facility, revealed on 04/23/2023 at 6:00 AM, Patient #5 was noted missing from the Unit. A Unit search was conducted, and keys to the locked door on the Unit were noted to be missing. Further review revealed all the following actions were on 04/23/2023: at 6:10 AM, the Administrator on call (AOD) was notified; at 6:14 AM, State Police were made aware; at 6:20 AM, the local sheriff was made aware; at 6:40 AM, the facility was made aware Patient #5 had been located and was being transported back to the facility; and Risk Management conducted an expanded investigation and at 11:30 AM, notified Nursing management to remove PA #5 and PA #6 from patient care. The staff members were not present in the building but were notified by phone.

Further review of Patient #5's Timeline revealed, on 4/23/2023, to implement re-education, all staff members were required to review and sign the acknowledgment forms for the facility's policies "Environmental Safety" and "General Hospital SOP 339 1:1 Supervision". The Timeline stated, on 04/24/2023, PA #5 was returned to care due to no evidence of involvement; and on 05/01/2023 at 9:51 AM, Nursing Management was notified by Risk Management via email that neglect was substantiated against PA #6. The Timeline stated PA #6 was terminated on 05/01/2023 and was listed as not re-hirable.

Review of the Root Cause Analysis (RCA) Findings, no date, revealed the human factors involved in the elopement included staff failure to follow facility established policies. The RCA determined the PA assigned to hall monitoring at the time of the elopement failed to properly monitor patients per the facility's policy. That infraction allowed Patient #5 to access PA #6's badge and keys and use them to leave the locked Unit and exit via secured exterior doors. Additionally, fatigue was identified as a human factor that resulted in the outcome. Continued review revealed there were several deviations from defined policy as well as performance variances that were revealed during Risk Management's investigation.

Patient #5 was not interviewed by the SSA Surveyor because the facility's provider, APRN #1 requested the patient not be interviewed.

While interviewing PA #6, on 06/27/2023 at 2:12 PM, she stated the facility had suspended and terminated her. PA #6 denied being asleep, as alleged, and stated Patient #5 could have slipped the Unit keys out of her pocket when Patient #5 was "all up in his/her space" while Patient #5 was being weighed.

During an interview, on 06/27/2023 at 2:33 PM, PA #5 stated he did not see PA #6 asleep, he just tapped her shoulder to get her attention because she was behind PA #5. He notified PA #6 that Patient #5 was missing, and a search began.

On 06/27/2023 at 2:40 PM, while interviewing Registered Nurse (RN) #6, she stated she observed Patient #5 on the Parkway on 04/23/2023 at about 6:30 AM while she was coming into work. She stated at the time of observation, she was two and three-tenths (2.3) miles from the facility per State car odometer, and this was verified by the State Survey Agency (SSA) Surveyor. She stated notifications were made as soon as she got to work.

While interviewing RN #7, on 06/27/2023 at 5:11 PM, she stated that on 04/23/2023, she was covering two (2) Units with a total of twenty-nine (29) patients. She described the work intensity of the night as steady. She stated that at approximately 6:00 AM, she returned to Patient #5's Unit just as PA #5 was receiving a call from the Coordinator's Office asking if Patient #5 was on the Unit. She stated that she, PA #5, and PA #6 then searched the Unit, without finding Patient #5. She stated she remembered PA #6 looking in her jacket for her keys, which she could not find, and PA #6 saying she thought Patient #5 took them.

On 06/29/2023 at 2:39 PM, while interviewing the Executive Director (ED), she stated she had been at the facility ten (10) years, and it had been at least five (5) years since there had been an elopement. She stated both elopements, involving Patient #3 and Patient #5, were discussed in the Executive Committee (EC) with the RCA Findings included in the discussion. The ED stated the investigations, RCA Findings and EC discussions were about future event prevention. She stated it had been a learning experience, and it caused staff to be more cautious about who might be following them through a door. Additionally, the ED stated that Patient #3's elopement was a systems failure. However, she stated, with Patient #5, it seemed more like an opportunistic event. She stated Patient #5 saw an opportunity to remove the badge and keys from an allegedly sleeping staff member, and Patient #5 exited the Unit and the grounds of the facility. The ED voiced that Patient #5 watched the staff as much as staff watched the patients, and he/she was familiar with processes, shift changes, and facility tasks. The ED stated by Patient #5 taking both the badge and the keys, it revealed how long he/she had been a patient over the years; at one time, the badge was required but now it took keys to exit/open all facility doors. She stated there were only two (2) keys on the PA ' s keyring, so it was not hard for Patient #5 to determine which one to use. The ED continued by stating that Patient #5 saw an opportunity and took it.

3. Review of Patient #4's clinical record revealed the facility admitted the patient, on 03/02/2023, with a diagnosis that included Unspecified Bi-Polar and Related Disorders.

Review of Investigator #3's preliminary report, initiated on 06/19/2023, with an extension granted on 06/29/2023, by the Department for Behavioral Health and Intellectual Disabilities revealed, on 06/09/2023, Patient Aide (PA) #2 was negligent in providing Physician ordered one-to-one (1:1) monitoring, thus allowing Patient #4 to self-harm his/her left arm, which required seven (7) staples.

Patient #4 declined to be interviewed.

During an interview on 06/22/2023, Security #1 stated he had been visiting with Patient #4 at the time the incident was discovered. He stated that at no time during the visit were there observations of blood and that Patient #4's hands, neck, and head were uncovered.

While interviewing PA #1, on 06/23/2023 at 8:37 AM, he stated he was familiar with Patient #4, who would self-harm when taken off one-to-one (1:1) supervision and when the patient did not get his/her way.

During an interview with Registered Nurse (RN) #5, on 06/26/2023 at 10:34 AM, she stated PA #3 reported that Patient #4 had harmed him/herself with part of a broken plastic spoon, and she went to investigate. She stated Patient #4's arm was not actively bleeding at that time, and Patient #4 refused to let RN #5 dress the wound but did let her clean it. She stated notifications were made to the State Police, Leadership, Physicians, and the local Police Department, and Patient #4 was sent to a local Emergency Department. RN #5 stated Patient #4 did relinquish the spoon parts. RN #5 further stated Patient #4 was frequently on one-to-one (1:1) supervision for different things such as not getting his/her own way, causing discord on the Unit, and self-harm by cutting. Additionally, RN #5, when asked how she ensured staff were not sleeping, were not on phones during care, and that rounds were being made, stated that she would make rounds at least every hour.

In an interview on 06/27/2023 at 9:07 AM with PA #4, she stated she was currently working away from patient care until Risk Management concluded their investigation.

On 06/26/2023 at 10:45 AM and 10:46 AM, the SSA Surveyor left voice mails for PA #2 and PA #3, respectively. No return calls were received on 06/26/2023 or 06/27/2023. On 06/28/2023, the SSA Surveyor again attempted to contact PA #2 and PA #3. PA #2's phone recording stated the mailbox was full. PA #3's phone recording stated she was not accepting calls at this time.

During an interview on 06/27/2023 at 9:07 AM, PA #4 stated she assumed the one-to-one (1:1) supervision with Patient #4 at 10:00 PM, on 06/09/2023. She stated Patient #4 was in bed on his/her side, with arms covered, hands together, and with head lying on exposed hands so they could be observed. She stated PA #2 came by asking Patient #4 if he/she wanted a snack. She stated Patient #4 sat up, and the covers fell off his/her arms and that was when the blood and cut was discovered. PA #4 stated she sent PA #2 for the nurse, and she did not leave Patient #4 alone. PA #4 stated Patient #4 said he/she got the spoon off supper tray. She stated supper was over prior to her coming on shift, and she had no knowledge of how or when Patient #4 obtained the spoon. She stated Patient #4 was not a body search, just one-to-one (1:1) supervision. PA #4 stated Patient #4 was frequently on one-to-one (1:1) supervision for causing disturbances or cutting. She stated plastic ware was only available on meal trays.

While interviewing the ED, on 06/29/2023 at 2:39 PM, she stated that she was very familiar with Patient #4. The ED stated Patient #4 would do just about anything, such as cutting and urethral insertion, to gain attention. She stated that she believed the behaviors typically reflected Patient #4's feelings of loneliness. She stated that Patient #4 did not have any predictability for behaviors for staff to expect a self-harm behavior. She continued by stating that because Patient #4's behaviors could not be predicted and in-spite of following the one-to-one (1:1) supervision protocol, Patient #4 was able to secrete a plastic spoon on his/her person. During further interview, the ED stated that because Patient #4 was an experienced self-harmer, hiding a spoon was nothing, even with one-to-one (1:1) supervision.