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Based on observation, interview, and document review, the hospital failed to protect a patient's rights by ensuring patients with acute mental health illnesses remained safe in a secured setting. The hospital was found not in compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

The hospital failed to promote each patient's right to receive care in a safe environment for 1 of 21 patients reviewed (P1), when staff failed to ensure the mental health unit's door was secured and P1 eloped from the ICU mental health unit/NE 4. Refer to the deficiency issued at 42 CFR 482.13 (c) (2), A-144.

Based on observation, interview, and document review, the hospital failed to promote each patient's right to receive care in a safe setting for 1 of 21 patients reviewed (P1), when staff failed to ensure the mental health unit's door was secured and P1 eloped from the ICU mental health unit/NE4.

Findings include:

Observations on 02/01/16 at 9:50 a.m. indicated that the door to enter NE4 was locked and secured by a badge-entry system. Only personnel whose badges are programmed with the appropriate code can enter NE4. The door to the unit had a window for personnel to observe whether any patients are near the door before the door is opened. Once personnel open the door, personnel are required to maintain contact with the door handle until the door latches closed. Personnel entering NE4 are required to observe that the door is secured before walking away from the door. During the onsite investigation, this was the observed practice by NE4 staff. Inside NE4, a nook, with a bench is located on the same wall as the NE4 door, within one foot of the NE4 door handle. The nook is not visible from the window in the NE4 door nor is it visible from the nurse's station. NE4 has 15 video surveillance cameras that are located throughout the unit. The monitors are located at the nurse's station and in the main Security office of the hospital. NE4 has 20 beds and the patients have the highest acuity mental health needs of the hospital's five mental health units. During the tour, all beds were filled.

P1's medical record was reviewed and revealed that P1 was brought by the to the emergency department at 11:41 a.m. on 01/06/16, after P1's family member called for police help due to P1's uncontrolled agitation and terrorist threats at home. In the ED, P1 made suicidal and homicidal statements. ED staff observed that P1 had a stab wound to his abdomen which had been treated at another hospital. A crisis assessment was completed and a 72-hour hold was initiated due to suicidal and homicidal statement, terroristic threats and uncontrolled agitation. At 2:51 p.m. on 01/06/16, P1 was admitted to NE4. P1 immediately told all the NE4 staff, "I don't need to be here, I need to leave as soon as possible." P1's agitation escalated and P1 was restrained from 3:45 p.m. to 6:30 p.m. with 1:1 staffing. When restraints were discontinued at 6:30 p.m., P1 was secluded from 6:30 p.m. to 8:45 p.m. P1 was calm after seclusion was discontinued and 15-minute checks of P1's whereabouts were initiated. The following morning of 01/07/16, P1 stated "I feel better today, I need to leave as soon as possible." P1 repeatedly talked about how he needed to leave because he had a 1:00 p.m. police appointment. At 1:00 p.m., P1 was in the dining room at the time of P1's fifteen-minute check. At 1:10 p.m., P1 eloped from the unit, wearing green scrubs. No one saw P1 leave the unit.

An interview with registered nurse (RN)/H was conducted on 02/01/16 at 10:30 a.m. RN/H stated that P1 was angry about the 72-hour hold and involuntary hospitalization. P1 insisted that he needed to be released so could help the police identify the attacker. When P1 first arrived to NE4 on 01/06/16, several different interventions were undertaken to de-escalate P1's agitated behavior. P1's agitation increased again the next morning of 01/07/16. P1 paced NE4 that morning and perseverated about how he needed to leave for a 1:00 p.m. police appointment. P1 was on 15-minute checks, which is the minimum safety check for all patients on NE4. At the 1:00 p.m. check, P1 was observed in the dining room. Before the 1:15 p.m. check was due, NE4 received a call from security asking if all patients were accounted for. An immediate count was done. P1 was missing. No one observed P1's elopement from NE4.

An interview with RN/G was conducted on 02/01/16 at 9:00 a.m. RN/G stated that she watched the video surveillance tapes pertaining to P1's activity on NE4 on 01/07/16 prior to the elopement. The video surveillance tapes showed that ten minutes before P1 eloped from NE4, P1 turned every door knob on the NE4 unit. P1 then covered himself from head to toe with a blanket and sat in the nook by the NE4 door. A housekeeper (Housekeeper/P) entered NE4 shortly after 1:00 p.m. Housekeeper/P did not check to see that the NE4 door closed behind him. Housekeeper/P entered NE4 and walked straight ahead. Housekeeper/P's back was toward P1, who was sitting in the nook within a foot of the NE4 door. P1 extended his arm and stopped the door before it completely closed. P1 went out the door at 1:10 p.m. and went into a bathroom that is in the foyer right outside the door entrance. P1 waited a few seconds in the bathroom and then left the bathroom and got on the elevator, ten feet away. P1 went down to the first floor and quickly walked down a hallway approximately 150 feet, with a blanket draped over his head and body. P1 walked past a security guard, then walked another 100 feet, and exited the main south hospital door onto a busy street. The hospital immediately notified the police that P1 had eloped and was missing from NE4. P1 was not located for 24 hours. The police found P1 at another hospital the following day of 01/08/16 when P1 presented there seeking pain medication for his stab wound. The police escorted P1 back to Regions Hospital. At 7:51 p.m. on 01/08/16, P1 was re-admitted directly to NE4 and placed on a 72-hour hold.

An interview with Housekeeper/P was conducted on 02/02/16 at 9:30 a.m. Housekeeper/P stated he has worked at the hospital for 16 years as a float housekeeper on all five mental health units. On 01/07/16, Housekeeper/P was assigned to NE4 from 7:00 a.m. - 3:30 p.m. During any given shift, Housekeeper/P badges in and out of the mental health units approximately 12 times. When Housekeeper/P badges into one of the mental health units, he is supposed to look through the door window and make sure no patients are near the door before he opens it. Once Housekeeper/P has opened the door, he is supposed to hold onto the door handle until the door closes and make sure he hears it click closed. On 01/07/16, he entered NE4 around 7:00 a.m. to clean the unit per usual. He badged in and out several times to bring in supplies and take his cleaning cart out of NE4. He noticed P1 was laying in the nook all covered up with a blanket. P1's head was also covered with the blanket. He thought P1 was sleeping. He badged out to exit with the garbage (time not recalled) and was gone several minutes. When Housekeeper/P came back to re-enter NE4, he looked through the window and did not see any patients near the door. Housekeeper/P re-entered NE4 but he did not think to check the nook when he opened the door. Housekeeper/P did not hold onto the door handle until the door closed. Housekeeper/P thought he heard the door click closed but he did not look back to see if the door closed. Housekeeper/P knows the safety protocol for the mental health doors and did not know why he didn't follow the protocol on 01/07/16.

An interview with Director of Housekeeping (DH)/N was conducted on 01/01/16 at 2:35 p.m. DH/N stated that each of the five mental health units has a consistent full-time housekeeper ten days a pay period from 7:00 a.m. - 3:30 p.m. The hospital has approximately ten housekeepers who float to the five mental health units to cover days off, call-ins, or to clean spills or discharge rooms after 3:30 p.m. Housekeeper/P routinely floats to the mental health units. All of the housekeepers are trained at their time of hire about door security and the patient safety procedure for badging in and out of high-risk units. Although there is no specific plan regarding the frequency of door security review with employees, Housekeeper/P was last trained in 2013 and then again in 2016 after P1's elopement.

An interview with Program Manager (PM)/D was conducted on 02/01/16 at 2:15 p.m. PM/D stated that the hospital conducted a root cause analysis (RCA) regarding P1's elopement. The RCA identified that Housekeeper/P did not follow the proper procedure to ensure that the door on NE4 was securely closed after he entered NE4 on 01/07/16. The RCA identified a need for planned training of all staff who have access to secured mental health units to ensure door closure protocols were understood and followed. The RCA also identified an action issue necessary to address line of sight of patients who are sitting in the nook inside the NE4 entrance. The RCA identified that although P1 passed by a security officer during the elopement who recognized that P1 was a patient, the security officer's first action was a phone inquiry to NE4 rather than immediately pursuing P1. P1 had already left the hospital before Security staff began a search for P1.

The hospital did not have a written policy that addressed the safety protocol for door closure into high-risk units which is limited to only those personnel who possess the required badge access card. The hospital had a Key Request Form and a Door Access Request Form, but no documented procedure that described the staff expectations to maintain patient safety when entering or exiting high-risk areas of the hospital, such as the mental health units, Pod G in the Emergency Department, and the Birthing Center.