HospitalInspections.org

Based on video review, document review and staff interview it was determined the facility failed to provide adequate safety measures to prevent a patient from eloping while he was outside in the fresh air area (Patient #1). This failure has the potential to negatively impact the mental and/or physical health of the patient if he/she elopes.

Findings include:

1. In an interview with Behavior Health Technician (BHT) #1 on 3/5/18 at approximately 2:05 p.m. it was determined he was playing ball with one (1) of the patients with his back to Patient #1 when he heard another patient yell his name; he turned around and realized what was happening. He stated the patient was already "on the roof, so I started running telling him to stop. He was over the gate and gone before security could get the gate unlocked for me to go after him". BHT #1 stated a new facility policy was now in effect stating that one (1) BHT is to be on one (1) end of the fresh air area and another BHT is to be on the other with their backs against the fence to visualize all patients.

2. A review of the facility policy entitled "Yard Outdoor Activities", last revised 6/7/17, revealed it states, in part: "Staff is to always be aware of where the patients are and what they are doing...Staff are to stay with the patients and do not sit apart from the group."

3. An interview with Security Guard #1 was conducted on 3/6/18 at approximately 10:20 a.m. During the interview it was discovered he was 'always walking along the fence to make sure no metal was along the fence'. He stated he heard one (1) of the patients yell to the BHT and saw the BHT start running. He stated he called 'Code MIA' while 'he was still on the roof'. He stated by the time everyone was able to get there the patient had already 'ran over the hill'. The security guard stated he was not aware the patient was a known 'flight risk'.

4. In an interview with the Captain of Security on 3/6/18 at approximately 10:35 a.m. it was revealed security is not notified when patients are considered a 'flight risk'.

5. In an interview with Security Guard #2 on 3/6/18 at approximately 10:50 a.m. it was revealed when the 'Codes' were called he was unable to understand initially what was being said. He stated, "The only thing I heard the first time was static, the second time I heard something at the end but couldn't really understand what he said and the third time I finally understood and took off trying to get to the fresh air area." He denied that security is made aware of potential 'flight risk' patients.

6. In an interview with the Nursing Supervisor on 3/7/18 at approximately 9:45 a.m. it was revealed she heard the page overhead when the 'Codes' were called. The police had been notified before she even arrived in the fresh air area. She stated multiple staff members were looking for the patient and she was not made aware the patient was a 'flight risk'.

7. A video of the incident that occurred on 2/22/18 was reviewed and revealed Patient #1 was walking back and forth by the gate in the fresh air area. The two (2) BHT's, the security guard and three (3) other patients are noted to be on the other end of the fresh air area. The video revealed the facility staff was not following the "Yard Outdoor Activities" policy.

8. A joint interview was conducted with the Director of Quality Assessment/Performance Improvement and the Director of Nursing on 3/7/18 at approximately 1:45 p.m. and they concurred with the above findings.

Based on document review, video review and staff interview it was determined the facility failed to provide adequate supervision of a patient while he was in the fresh air area (Patient #1). This failure has the potential to result in patients eloping from the fresh air area or other patient harm.

Findings include:

1. A review of the facility policy entitled "Yard Outdoor Activities", last revised 6/7/17, revealed it states, in part: "Staff is to always be aware of where the patients are and what they are doing...Staff are to stay with the patients and do not sit apart from the group."

2. A video of the incident that occurred on 2/22/18 was reviewed and revealed Patient #1 was walking back and forth by the gate in the fresh air area. Two (2) Behavior Health Technicians (BHT), a security guard and three (3) other patients are noted to be on the other end of the fresh air area. The video revealed the facility staff was not following the "Yard Outdoor Activities" policy.

3. In a discussion with BHT #1 on 3/5/18 at approximately 2:05 p.m. it was determined he was playing ball with one (1) of the patients with his back to Patient #1 when he heard another patient yell his name; he turned around and realized what was happening. He stated the patient was already "on the roof, so I started running telling him to stop. He was over the gate and gone before security could get the gate unlocked for me to go after him". BHT #1 stated a new facility policy was now in effect stating that one (1) BHT is to be on one (1) end of the fresh air area and another BHT is to be on the other with their backs against the fence to visualize all patients.

4. A joint interview was conducted with the Director of Quality Assessment/Performance Improvement and the Director of Nursing on 3/7/18 at approximately 1:45 p.m. They concurred with the above findings.