HospitalInspections.org

Based on interview, record review, and review of facility policy, the facility failed to provide patient care in a safe setting related to environmental risks for 2 of 10 sampled patients, one who eloped from the facility (#2), and one who was found in the facility with a drawstring around her neck in a suicide attempt (#1).

Findings:

1. Review of patient #2's record revealed a 23 year old male admitted under a Baker Act to the hospital on 1/09/19 and discharged on 1/13/19, due to his elopement from the facility. Diagnosis wase Schizophrenia, chronic paranoid type. The patient's previous admission revealed he had a previous admission on 11/23/18 and a discharge on 12/02/18 due to an elopement off hospital grounds.

Review of physician's orders revealed a planned discharge on 1/12/19 that was later held by the physician, due to a change of medication and a need to monitor patient status. Patient discharge was expected to occur on 1/13/19 and the patient was waiting for the final discharge order from the physician on 1/13/19. The patient was documented on every 15 minute routine observations.

A nurse's note, dated 1/13/19 at 3:30 PM, read, "Two staff members took several patients outside to the play grounds [patient #2] is pending discharge home today or tomorrow and he questioned to go outside with staff for some fresh air [patient #2] has a history of elopement. When questioned about going outside, patient states "I'm leaving and will be discharged today or tomorrow so I'm not going to run off. I promise." Staff stated they will be watching [patient #2] closely. Patient eloped through bars in fence in the play ground and ran off. Staff attempted to chase him to no avail."

A nurse's note, dated 1/13/19 at 3:50 PM, read, "Patient eloped through the bars out in the yard during group. [staff] tried to stop the patient. 911 called, Dr. notified...administrator on call notified. Patient aware he was discharging today."

In an interview with the Chief Nursing Officer (CNO) on 1/29/18 at 3 PM, he related if a patient comes in and shows elopement risk, we could place him on unit restrictions. Patient #2 showed no evidence of elopement attempt, impulsivity or psychosis, therefore he was on routine every 15 minute observation. He related he was called regarding the patient elopement on 1/13/19. The facility began an investigation into the elopement event and found that the patient was outside with a group and appropriate staff supervision. He related when the staff member turned to assist another patient they saw him on the other side of the fence and tried to go after him but could not reach him. The CNO related upon video surveillance it was seen that the patient went through the 3 and 1/2 inch opening between the bars of the fence and not over the top. The CNO stated he examined the fence and tried to pull open the bars and found they would give minimally. There was no break or other openings observed in the fence as it was in good repair.

Review of the facility policy "Observation/Precaution", revised 10/2017, read, "Precaution Reminders...."When outside remember your perimeter." There was no documentation observed regarding patient supervision when outside the locked unit.

2. Patient #1's record revealed the patient was brought to the facility under a Baker Act by law enforcement on 12/05/18 for thoughts of harming herself and taking the razor out of a pencil sharpener to harm herself. Diagnoses included disruptive mood disorder, dysregulation disorder, and a previous diagnosis of Schizoaffective disorder. The patient was discharged to home with her parents on 12/19/18.

Review of the nurses' notes revealed an entry dated 12/11/18 at 5:30 PM which read that the patient "made an attempt to commit suicide, she was found by nurse in her room with a tied string around her neck, bleeding from nose, a small screw was found on her." The note documented the medical team was called, she was seen, and an order given to send her to an acute care hospital for medical clearance. The patient left around 5:30 PM and her mother notified. The patient was medically cleared and returned to the facility at 11:45 PM and placed on 1:1 observation. Documentation by the physician revealed the patient with a small laceration on her neck.

In an interview with the CNO on 1/29/18 at 1:45 PM regarding the suicide attempt of the patient, he revealed the patient was found in her room and she did not loose consciousness. He related an immediate investigation was done regarding the incident and it was found that the patient had a jacket that she came in with, that had a small hidden opening in the middle of the jacket that enclosed a drawstring of the same color of the jacket and it was missed by staff. He related it was suspected the screw that was found with the patient possibly came from a piece of furniture, as the patient would attempt to take apart the furniture. He related the bleeding from the patient's nose was expected to have come from the screw.

Review of the facility policy "Contraband/Searches", reviewed 12/09/2018, read, "Items that are considered contraband to be removed until discharge include....belts, drawstrings in any clothing item such as pants, shorts, shirts, pajamas."