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Based on observation, interview and record review, the facility failed to provide a safe setting for 2 (Patient #1 and Patient # 4) of 10 patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and Patient #10) as evidenced by one successful elopement from the facility (Patient #1) and one successful elopement from the unit (Patient #4).

TX 00230240

Findings included:

Observation on 12/02/2016 at 0845 of the Psychiatric Intensive Care Unit revealed an entrance into the unit from the facility courtyard. That entrance was a double metal door with glass panes. The door itself was warped resulting in an approximate 3-inch gap at the bottom of the door between the door and the door frame.

In interviews with MHT #54, MHT #55, RN #56 and RN #57, they stated they had concerns that the door had been compromised to the point that another patient would be able to get through the door again.

In an interview with RN #60 on 02/10/2016 at 1055, she stated:
· The door from PICU to the courtyard had plywood on it Patient #4 had broken out the glass with a chair about a week earlier.
· She was outside the building and saw Patient #1 kicking the door.
· Patient #1 busted the wood and went through the hole he created " legs first ... in seconds, he was on his feet and off. "
· Patient #1 eloped from the facility by going over a fence.

In an interview with Plant Ops Director #61 on 02/10/2016 at 1010, he stated:
· The glass had been broken in the door about a week before Patient #1 eloped. That incident involved Patient #4.
· During the incident with Patient #4, she broke out the glass panes of the door into the courtyard with a chair.
· The door was repaired that night by Maintenance Technician #62 with plywood.
· Patient #1 broke through the plywood.

Record review of the Initial Psychiatric Evaluation by MD #64 on 12/01/2015 at 1300 revealed a 19-year-old male was admitted on 11/30/2015 with an emergency detention warrant. He presented with auditory and visual hallucinations and bizarre behavior. His sister stated he had been talking to deceased family members and spirits and demons that encouraged him to kill himself. He denied these allegations but admitted to smoking synthetic marijuana. His admitting diagnoses were psychosis, not otherwise specified (NOS); rule out drug induced psychosis (marijuana, synthetic marijuana) and rule out schizophrenia, paranoid type.

Record review of Progress Notes by MHT #58 dated 12/02/2015 [no time] revealed: " At 1920 patient was walking around ... The patient began towards the door. Patient looked back and started to charge at patient and MHT. Patient proceeded into the door kicking it and running out the door. "
In an interview with Plant Ops #61 on 02/11/2016 at 1130, he stated that there were doors with glass panes on the adolescent and general adult units that have tempered glass in them. He also stated that once the glass shatters, this creates an elopement safety risk. " We have decided to replace broken glass with 1/4-inch Lexan, a polycarbonate material which does not break. "