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Based on observation, interview, and record review, the hospital failed to ensure that two of three patients (Patient 1 and 2), who were at risk for suicide (or other forms of self-harm) received care in a safe setting by failing to follow policy to provide fifteen minute checks or have an associate to remain with the patient(s) and failed to provide appropriate safety measures to prevent elopement for one of three patients (Patient 1), that had a previous history of eloping, failed to make reasonable efforts to locate the patient after elopement, and failed to document and communicate the elopement. The hospital failed to ensure a legal guardian was notified of Patient Rights for one of one patients, (Patient 1) reviewed , and failed to thoroughly investigate, resolve or provide verbal and/or written communication to the patient/representative regarding a grievance for one of one patients, (Patient 1) reviewed.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

On 12/09/21 at 3:50 PM, Staff A, Hospital President and Staff E, Director of Quality and Patient Safety, was notified that an immediate jeopardy (IJ) existed related to 42 CFR 482.13 Patient Rights.

The hospital submitted a plan of removal that was accepted on 12/13/21 at 4:20 PM, that included the following:

Re-educating Emergency Department associates, Mental Health Protection Workers, and Security personnel on "Suicide Prevention" Policy and requiring acknowledgement.

Reviewed and revised "Patient Elopement" Policy.

Re-educating Emergency Department associates, Mental Health Protection Workers, and Security personnel on "Patient Elopement" Policy and requiring acknowledgement.

Re-educating Emergency Department associates, Mental Health Protection Workers, and Security personnel on "Incident Reporting and Disclosure" Policy and requiring acknowledgement.

Implementing the following process changes in the Emergency Department to prevent patients presenting with complaints of suicidal and/or homicidal ideation from eloping:

Placing a triaged patient with primary complaint of suicidal and/or homicidal ideation in a ligature resistant exam room, located behind secured doors; or

Placing a triaged patient with primary complaint of suicidal and/or homicidal ideation in the behavioral health quiet room, behind secured doors, if a ligature resistant exam room is unavailable; or

Placing a triaged patient with primary complain of suicidal and/or homicidal ideation in a ligature-resistant with video monitoring in close proximity to the nurses' stations if secured areas have reached capacity; or

Placing a triaged patient with primary medical complaint and secondary suicidal and/or homicidal ideation in a medical room with video monitoring.

Compliance Monitoring:

The ED manager or their designee will conduct and document real time, unannounced observations daily to ensure compliance with [The Hospital] process for the monitoring of suicidal and/or homicidal ideation patients.

The Risk Manager or designee will conduct a weekly review of the Event Reporting System to compare entries of patient elopement to the discharge disposition documentation of elopement in the medical record. This will ensure all episodes of elopement were documented in the Event Reporting System.

Audits will be conducted for two consecutive weeks and beyond or until sustained compliance has been demonstrated.

Re-educate all House Supervisors, Mental Health Protection Workers, Emergency Department, and Security personnel about the changes by 12/11/21 or prior to their next scheduled shift.

The hospital's plan of removal was validated by the surveyor prior to survey exit on 12/13/21 at 4:45 PM.


Findings Include:


The hospital failed to ensure that a patient's legal guardian/representative was informed of patient's rights in advance of furnishing care to one of three patients reviewed (Patient 1). (Refer to A-0117)

The hospital failed to complete a thorough investigation of a grievance, failed to resolve a grievance, and failed to provide verbal and/or written communication to the patient/representative the steps taken on behalf of the patient to investigate the grievance, the results of the grievance, and the date of completion of a grievance, as required for one of three patients (Patient 1). (Refer to A-0123)

The hospital failed to ensure that two of three patients (Patient 1 and 2), who were at risk for suicide (or other forms of self-harm) received care in a safe setting by failing to follow policy to provide fifteen minute checks or have an associate to remain with the patient(s) and failed to provide appropriate safety measures to prevent elopement for one of three patients (Patient 1), that had a previous history of eloping, failed to make reasonable efforts to locate the patient after elopement, and failed to document and communicate the elopement. (Refer to A-0144).

Based on record review, document review, and interview, the Hospital failed to ensure that a patient's legal guardian/representative was informed of patient's rights in advance of furnishing care to one of four patients reviewed (Patient 1). The Hospital's policy and procedures failed to provide a method of identifying patients that have or require a legal representative/guardianship for acknowledgement of patient rights and consent for treatment. This deficient practice has the potential to place any incapacitated patient with a legal representative at risk of not understanding their Patient Rights and/or making uniformed medical decisions.

Findings Include:

Review of a policy titled, "Patient Rights and Responsibilities," revised 01/14/20, showed, " ...Written information containing a copy of patients' rights and patients' responsibilities related to their rights is provided upon admission. If the patient is a minor or incapacitated, the rights are communicated through a parent, guardian, or designated representative ..."

Review of a document in Patient 1's medical record, from a District Court, dated 07/10/20, showed legal guardianship of the patient was assigned to the [Named Person] "with the full powers and authority as provided for in KSA 59-3075...(Patient 1) is an adult with an impairment who is in need of a guardian...lacks the capacity to meet essential requirement for her physical health or safety...should not be permitted to make any decisions which affect her person or estate..."

Review of a document in Patient 1's medical record titled, "Admission Consent & Agreement," dated and signed 10/12/21 at 4:17 PM, showed that Patient 1 signed the document to consent to medical treatment.

Review of an ED (Emergency Department) physician note, dated 10/12/21 at 3:58 PM, showed, " ... [Patient 1] w/a hx (history) of schizoaffective disorder (a mental health disorder) and intellectual disability who presents to the ED for suicidal ideation ..."

Review of Patient 1's medical record for the date 10/12/21 showed, " ...Social history ...Guardian(s) Information, Legal Guardian is [Named Person], Phone #: [number] ..."

There was no documented evidence to show Patient 1's guardian was notified of Patient Rights.

During an interview on 12/08/21 at 9:47 AM, Staff G, Licensed Specialist Clinical Social Worker (LSCSW), stated "I think [Patient 1] has had the same guardian for some time ...I don't know if there is a certain place in the chart for information on guardianship/DPOA. I don't know who asks for this information or who is responsible for inputting the information in the medical record ...I believe [Patient 1] has intellectual disabilities. I don't know if she has the mental capacity to seek treatment or deny treatment ..."

During an interview on 12/07/21 at 5:24 PM, Staff E, Director of Quality and Patient Safety, stated that the facility does not have any policies in place for patients with legal guardians/representatives, or Durable Power of Attorney (DPOA). She was unable to state where the information should be entered into the patient's electronic medical record or how staff would identity a patient with a legal representative or guardianship.

Based on record review, document review, and interview, the hospital failed to complete a thorough investigation of a grievance, failed to resolve a grievance, and failed to provide verbal and/or written communication to the patient/representative the steps taken on behalf of the patient to investigate the grievance, the results of the grievance, and the date of completion of a grievance, as required for one of three patients (Patient 1). This deficient practice fails to protect and promote patient rights and places patients at potential risk of serious harm, injury or death by failing to identify and mitigate possible patient safety issues identified through the grievance process.


Findings Include:

Review of a policy titled, "Grievance Resolution/Patient Feedback/Complaint Resolution," revised 04/16/18, showed, "Per CMS' Condition of Participation 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance ...When staff present are unable to resolve the complaint the issue is communicated to an authorized representative as defined above, a Feedback Ticket is generated in the Event Reporting System (ERS) and the grievance process begins ...The patient or their representative filing a grievance that was not resolved by staff present receives an acknowledgement (written or verbal), within seven (7) working days of receipt of the grievance. Verbal responses are provided by authorized representatives and the interaction is documented on the Feedback Ticket by the authorized representative. Written responses to the appropriate parties are sent by the Risk Management Department. If necessary, the written acknowledgement of a grievance includes a time frame for a complete response, not to exceed 30 working days, as well as hospital contact information. If the investigation is not or will not be completed within 30 working days, the Risk Management Department or designee will inform the patient or patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy. The hospital must attempt to resolve all grievances as soon as possible ...A letter is sent to patients and/or their representatives at the conclusion of all grievance investigations. The letter is sent by the Risk Management Department or designee following the receipt of the investigative findings, conclusions and actions from the involved department(s') leadership. If a representative of the patient filed the grievance, the results of the investigation are also communicated to them ...Although personal meetings or other informal communication may occur, a final letter to the patient and/or their representative is sent at the conclusion of the grievance investigation. The response letter includes the name of the hospital's authorized representative, the steps taken on behalf of the patient to investigate the grievance, the results of the investigative process and date of completion. If the response is written in answer to a letter that was sent to a specific person, that person receives a copy of the letter sent to the patient ..."


Review of a document titled, "Complaint/Grievance Log," dated 12/2020-12/02/21, showed an entry on 10/14/21, "Patient's guardian called to file a complaint against ER at [Hospital]. She states that she is the guardian for [Patient 1]. She reports that the patient had eloped out of the ER on 10/12. No one called or made her aware that the patient was missing until the following morning on 10/13. Also reports that the patient was found at [Hospital B (a hospital 3 miles away)]. The patient herself reported that the security of [Hospital] took her to [Hospital B]. She requests a follow up call to discuss further concerns."


Review of a document from the hospital's Safety Event Manager (SEM) titled, "General Investigation," failed to show documentation that the hospital's investigation addressed immediate actions to prevent elopements, failed to provide risk mitigation or recommendations as a result of the elopement, failed to resolve the complainant's grievance, and failed to provide verbal or written communication to the patient or patient's representative of the steps taken on behalf of the patient to investigate the incident, results of the investigation, and/or the date of the grievance completion prior to the date of survey on 12/03/21.


During an interview on 12/02/21 at 9:58 AM, P1's legal guardian stated that on 10/12/21, Patient 1 was transported to the hospital for suicidal ideation and that Patient 1 had eloped from the hospital during the evening. P1's guardian stated that the hospital made no attempt to call or inform her of the elopement. She stated she has received no follow-up communication from the hospital since filing the grievance.


During an interview on 12/08/21 at 1:22 PM, Staff C, Director of Risk Management, stated the process for grievance resolution is to conduct an investigation into the event and respond within 30 business days to the patient or the patient's representative. Staff C stated that reviews may take longer than expected, and in those cases, they must reach out to the patient or representative and inform them when a written response will be provided. Correspondence with the patient or representative is to be recorded and entered in the hospital's SEM Feedback Manager program. Staff C stated that it was his opinion the investigation did not address Patient 1's elopement and stated that the hospital did not follow its Grievance Resolution policy and verified there had been no communication with the complainant until the date of this survey on 12/03/21.

Based on observation, interview, and record review, the hospital failed to ensure two of three patients (Patient 1 and 2), who were at risk for suicide (or other forms of self-harm) received care in a safe setting by failing to follow policy to provide fifteen minute checks or have an associate to remain with the patient(s); failed to provide appropriate safety measures to prevent elopement for one of three patients (Patient 1), that had a previous history of eloping, failed to make reasonable efforts to locate the patient after elopement, and failed to document and communicate the elopement. This deficient practice has the potential to place patient(s) at risk for serious harm, injury, or death.


Findings Include:


Review of a policy titled, "Suicide Prevention," revised 04/14/20, showed, " ...The intent of identifying a patient with suicide risk is to discern the imminent need for environmental safety measures to reduce potential attempts and to activate level of care necessary to mitigate the overall risk ...Patients at risk of suicide are placed in a safer environment. Environmental risk assessments identify features in the physical environment that could be used to attempt suicide. Necessary actions are taken to minimize the risks ...Inpatient and noninpatient nonbehavioral health settings that provide care to those at risk of harm to self or others, e.g. emergency departments, intensive care units, medical-surgical units and other inpatient and outpatient locations: "Safer" environment. Remove objects from the room that can be used for self-harm and monitor the patient per patient observation orders while awaiting transfer to a higher level of care ...Patient observation (Observation Levels) ...Level 1: Fifteen-minute checks ...Level 2: In visual premise (i.e. toileting, bathroom and patient sleeping) ...Level 3: Within arms-length requires that a staff member be within the arms-length of a patient to immediately intervene to prevent any self-harming behaviors ...Minimum documentation is at 15-minute increments for all observation levels ..."

Review of a policy titled "Patient Elopements," revised 08/24/21, showed, " ...If a patient elopes or attempts to elope, all reasonable efforts should be made to locate, redirect, and if necessary, detain the patient for his or her safety and so that treatment can be provided or resumed ..."


Patient 1

Review of a document titled, "Complaint/Grievance Log," dated 12/2020-12/02/21, showed an entry on 10/14/21, "Patient's guardian called to file a complaint against ER at [Hospital]. She states that she is the guardian for [Patient 1]. She reports that the patient had eloped out of the ER on 10/12. No one called or made her aware that the patient was missing until the following morning on 10/13. Also reports that the patient was found at [Hospital B (a hospital 3 miles away)]. The patient herself reported that the security of [Hospital] took her to [Hospital B]. She requests a follow up call to discuss further concerns."

Review of the Emergency Department (ED) medical record showed the hospital registered Patient 1 in the ED on 10/12/21 at 1:13 PM and discharged Patient 1 from the ED on 10/12/21 at 2:14 PM. The discharge disposition was coded as, "Left Without Being Seen."

Review of a document in Patient 1's medical record from the District Court, dated 07/10/20, showed legal guardianship of Patient 1 was assigned to the [Named Person] "with the full powers and authority as provided for in KSA 59-3075 ...(Patient 1) is an adult with an impairment who is need of a guardian ...lacks the capacity to meet essential requirement for her physical health or safety ...should not be permitted to make any decisions which affect her person or estate ..."

Review of security video footage from 10/12/21 showed Patient 1 entered the hospital alone through the ED entrance at 1:13 PM. The patient approached the registration desk and was given a wrist band. Patient 1 then seated herself in the ED lobby waiting area. Security footage showed a staff member identified as, Staff I, Mental Health Protection Worker (MHPW) visiting with the patient for several minutes before leaving the waiting room area. Patient 1 got up and walked out of the ED exit at approximately 1:35 PM and was observed walking south.

During an interview on 12/07/21 at 3:40 PM, Staff I, MHPW, stated that he noticed Patient 1 sitting in the ED waiting area and stopped to say hello and ask if she needed anything. Staff I stated that Patient 1 gave a brief history of why she was there and that she was tired of waiting and was going to leave. Staff I stated that he was aware of Patient 1's risk of elopement so told her not to leave and that he would talk to the ED charge nurse to see if they could get her seen sooner.

Further review of the hospital's security video footage on 10/12/21 showed that Patient 1 returned to the ED at approximately 3:45 PM.

Review of Patient 1's ED medical record dated 10/12/21 at 3:58 PM showed that Staff H, Registered Nurse (RN), documented the Columbia Suicide Severity Rating Scale (CSSRS) Risk Assessment placed Patient 1 at an observation level of 1, requiring documentation of a patient observation every 15 minutes. There was no documented evidence of any 15-minute observations between 3:58 PM to 5:46 PM (one hour and 45 minutes since the previous assessment/observation).

Review of Patient 1's ED medical record showed that at 5:46 PM, Staff L, RN documented an assessment of Patient 1 when she was taken to a room (Room 12). There was no documented evidence of any 15-minute observations between 5:46 PM and 7:00 PM (one hour and 15 minutes since the previous assessment/observation.)

Review of Patient 1's ED medical record dated 10/12/21, showed that Staff G, Licensed Specialist Clinical Social Worker (LSCSW), completed a CSSRS Risk Assessment on 10/12/21 at 4:27 PM. Review of this assessment showed that Staff G did not include Patient 1's previous elopement from the ED as a risk factor. The documentation showed a comment, "Patient has a long Hx (history) of SI (suicidal ideation)/threats and verbal/phys (physical) aggression toward others. She reports she will remain in the ED and not leave again ...Observation level-low/1."

During an interview on 12/08/21 at 9:47 AM, Staff G, LSCSW, stated "I had a conversation with the patient about her earlier elopement and she said she had gone across the street to [facility name] to visit ...I did not document about her homicidal ideation ..." Staff G stated that the CSSRS Risk Assessment considers elopement to be a risk factor for an observation at a Level 2 which would include constant eyes on monitoring of a patient. Staff G acknowledged her awareness of Patient 1's previous elopement and stated that she did not feel that Patient 1 was an elopement risk and rated Patient 1's observation requirement at a Level 1 (a lower risk requiring 15-minute observations).

Observation of the ED on 12/07/21 at 5:00 PM, showed Room 12 (Patient 1's assigned room) is not visible to any of the three nursing stations in the ED and is not equipped with cameras nor visible on any of the security cameras.

During an interview on 12/07/21 at 11:24 AM, Staff D, Director and Charge Nurse of the ED stated that the placement of a patient with suicidal/homicidal ideation would ideally be in one of the six secured (locked unit) observation rooms (Rooms 4, 5, 6, 7, 8, 9). If one of those beds is not available, the patient would be placed in an unsecured room near the nurses' station for visibility. Staff D stated that a suicidal ideation patient should be assigned a sitter if not able to be place in the locked unit. Staff D stated that Patient 1 was not assigned a sitter for 1:1 observation.

Review of Patient 1's medical record showed, Staff M, ED physician, documented on 10/12/21 at 6:42 PM that Patient 1 had a diagnosis of excessive anger and suicidal ideations. " ...Psych eval - feels very angry and is already in trouble for hurting someone ...also is suicidal and tried to cut left wrist with a piece of metal ..."

During an interview on 12/09/21 at 8:23 AM, Staff M, ED physician, stated that he did not recall being notified of Patient 1's elopement on 10/12/21. He stated that a patient with a history of previous elopement should have an increased observation level with more security measures taken and that Patient 1's documented observations/assessments should have started upon Patient 1's initial assessment at 3:58 PM.

During an interview on 12/08/21 at 8:13 AM, Staff F, RN, stated that she was assigned Patient 1 for her shift on 10/12/21. She stated her last recollection of Patient 1 was at approximately 7:48 PM when she administered a nicotine patch. Staff F stated, "I think I was the one that discovered she was gone." Staff F was unable to state what actions she or any other staff took upon discovering the patient was missing. She stated that the patient was not assigned a 1:1 sitter.

Review of security video footage on 10/12/21 at 8:38 PM showed Patient 1 exiting the ED observation area and leaving the hospital's ED at 8:39 PM.

Review of Patient 1's ED medical record showed Patient 1's discharge disposition was coded as "Eloped" on 10/12/21 at 8:40 PM.

During an interview on 12/02/21 at 9:58 AM, Patient 1's guardian stated that the hospital did not notify her of Patient 1's elopement on 10/12/21.

The facility was unable to provide requested documentation that they notified security, police, the physician, or any of Patient 1's contacts or representative that Patient 1 eloped on 10/12/21 or that they made any attempts to locate the patient after she left the hospital.

During an interview on 12/08/21 at 1:22 PM, Staff C, Director of Risk Management, stated that he was not aware of Patient 1's elopement incident until surveyors arrived on 12/03/21. Staff C stated that his expectation would be that at the time of elopement the hospital would notify security and the police of the incident, particularly if a patient lacks decision making capacity and is in danger of self-harm or risk of harm to others. Staff C stated that there was no documentation in the medical record of any action taken by the facility in regard to the elopement.


Patient 2

Review of the Emergency Department (ED) medical record showed the hospital registered Patient 2 in the ED on 11/09/21 at 2:58 PM for suicidal and homicidal ideation and discharged Patient 2 from the ED on 11/09/21 at 10:00 PM. The discharge disposition was coded as, "Eloped."

Review of the ED medical record for Patient 2 on 11/09/21 showed, "ED Note-Physician ...Patient reported/exhibited symptoms indicating they are a danger to self or others during initial examination with ED Physician/APP. At time of evaluation, recommending following Observation level: LEVEL 2: Visual Premise - Patient must be within eyesight of staff at all times ...Patient has access to or owns firearms and/or stockpiled medications ..."

Review of the ED medical record for Patient 2 on 11/09/21 showed initial CSSRS Screen completed by Staff R, RN at 3:15 PM, " ...Suicide Risk Level Screen Result Adult: Moderate ..." An order for suicide precautions was entered on 11/09/21 at 3:18 PM. On 11/09/21 at 10:00 PM, Staff K, RN documented that Patient 2 left the hospital against medical advice.

Review of the ED medical record for Patient 2 failed to show evidence of any treatment or documentation of patient observation/assessment from 3:15 PM to 10:00 PM when patient left the facility, (a period of six hours and 45 minutes).

Review of the ED medical record for Patient 2 failed to show documented evidence that Patient 2 was placed in a "safer" environment (see Suicide Prevention Policy above) failed to show the hospital monitored Patient 2 per patient observation orders (Level 2) and failed to show the minimum 15-minute documentation/assessment required for all observation levels.

During an interview on 12/13/21 at 1:10 PM, Staff D, RN/ER Director, stated that review of Patient 2's ER medical record showed that discharge information and education was not completed and given to the patient. She stated that the medical record showed that Patient 2 was never placed in an ER observation room and appeared to be seated in the internal ER waiting area from 3:15 PM until patient left at 10:00 PM. She stated that medical record failed to show documentation of Level 2 observation and failed to show that Patient 2 was treated or assessed by any clinician between 3:15 PM and the time the patient left the ER at 10:00 PM.