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Based on interview, record review, and review of the facility's policies entitled "Patient Rights and Responsibilities," and "Supervision of Patients," it was determined the facility failed to ensure patient rights were protected and failed to have mechanisms in place to ensure one (1) of ten (10) sampled patients was free from neglect (Patient #1). Patient #1's physician had written an order for facility staff to monitor Patient #1 every fifteen (15) minutes to ensure the patient's safety. On 06/06/14 at 1:30 PM, Nurse Aide #1 escorted Patient #1 to the facility's Recovery Center located on another floor of the facility for counseling/therapy and signed the patient in to the Recovery Center. However, interviews and review of the facility's investigation revealed at approximately 2:00 PM, Patient #1 requested to be excused from the Recovery Center to go to the restroom. The investigation also revealed, based on observation of the facility's video footage, Housekeeper #1 and Housekeeper #2 exited the locked Recovery Center through double doors at 2:15 PM and did not ensure the doors locked behind them as they exited. The investigation revealed Patient #1 exited the Recovery Center at 2:15 PM through the same double doors the housekeepers exited, and walked out of the hospital to a nearby gas station. Interviews and review of documentation revealed that even though staff on Patient #1's nursing unit had not contacted staff in the Recovery Center to determine Patient #1's status and/or whereabouts while the patient attended counseling/therapy, staff on the nursing unit had documented every fifteen (15) minutes, from 1:30 PM until 3:00 PM, that Patient #1 was in the Recovery Center.

Interviews and continued review of the facility's investigation revealed Patient #1 was taken to the Emergency Department of another acute care facility, Facility #2, on 06/08/14 at 5:27 PM due to a drug overdose and was admitted to that facility. The interview also revealed Facility #2 transferred Patient #1 back to the facility on 06/11/14 at 2:11 PM for continued treatment.

The failure of the facility to identify and protect patients from neglect, failure to provide a safe environment, and failure to ensure mechanisms were in place to ensure staff monitored patients in accordance with physician orders, placed patients at risk for serious injury, harm, impairment, and/or death. Immediate Jeopardy was identified on 06/17/14, was determined to exist on 06/17/14, and is ongoing. The facility was notified of the Immediate Jeopardy on 06/17/14.

Refer to A0145.

Based on interview, record review, and review of the facility's policies entitled "Patient Rights and Responsibilities," and "Supervision of Patients," it was determined the facility failed to have mechanisms in place to ensure one (1) of ten (10) sampled patients was free from neglect (Patient #1). Patient #1's physician had written an order for facility staff to monitor Patient #1 every fifteen (15) minutes to ensure the patient's safety. On 06/06/14 at 1:30 PM, Nurse Aide (NA) #1 escorted Patient #1 to the facility's Recovery Center located on another floor of the facility for counseling/therapy and signed the patient in to the Recovery Center. However, at 3:20 PM (approximately two hours after staff signed the patient in to the Recovery Center) facility staff discovered Patient #1 had left the Recovery Center, had not returned, and could not be located in the facility. Interviews revealed staff in the Recovery Center had not monitored and/or documented the patient's whereabouts. However, interviews and review of documentation revealed that although staff on Patient #1's nursing unit had not contacted staff in the Recovery Center to determine Patient #1's status and/or whereabouts while the patient attended counseling/therapy, staff on the nursing unit had documented every fifteen (15) minutes that Patient #1 was in the Recovery Center. Interview with the facility's Investigator revealed Patient #1 presented to the Emergency Department of Facility #2 on 06/08/14 (approximately two days after the patient left the Recovery Unit). A copy of Patient #1's medical record from Facility #2 revealed Patient #1 had presented him/herself to the police on 06/08/14, informed them that he/she thought he/she had overdosed, and the police took Patient #1 to the Emergency Department of Facility #2. Documentation by the physician at Facility #2 revealed the patient had a drug overdose of "cocaine, opiates, and benzodiazepines," and was admitted to that facility for further treatment. Continued interview with the facility's Investigator revealed Facility #2 transferred Patient #1 back to the facility's psychiatric unit on 06/11/14 at 2:11 PM for further psychiatric treatment.

The failure of the facility to identify and protect patients from neglect, failure to provide a safe environment, and failure to ensure mechanisms were in place to ensure staff monitored patients in accordance with physician orders, placed patients at risk for serious injury, harm, impairment, and/or death. Immediate Jeopardy was identified on 06/17/14, was determined to exist on 06/17/14, and is ongoing. The facility was notified of the Immediate Jeopardy on 06/17/14.

The findings include:

Review of the facility policy titled, "Patient Rights and Responsibilities," dated 02/10/11, revealed patients have the right to be free from verbal or physical abuse, negligence, or harassment while hospitalized.

Review of facility policy titled, "Supervision of Patients," revised May 2012, revealed patients should be placed on the appropriate level of supervision to assure the safety and well-being of the patient and others. Level of supervision will determine the frequency and proximity of patient observation and are as follows: 30-minute checks; 15 minutes checks; within eyesight; and 1:1 observation. Upon admission patients are placed on suicide, assault, and/or elopement precautions for the first 24 hours. Precautions may be continued or later reinstated at the discretion of the attending physician and/or treatment team. All patients admitted to the Psychiatric Center will be monitored every 15 minutes for at least the first 72 hours and at least every 30 minutes for the remainder of the admission. Further review of the policy revealed that patients attending programming in the Recovery Center will be continuously monitored by group facilitators or hall monitors and will be escorted by a member of the staff between their patient care unit and the Recovery Center. However, the policy failed to state how the patient will be monitored in the Recovery Center or how the staff will document the monitoring to ensure patient whereabouts and safety.

Review of medical record revealed the facility admitted Patient #1 on 06/04/14 to a locked behavioral health unit with diagnoses that included Suicidal Ideation, Major Depressive Disorder, Polysubstance Abuse, and Substance Mood Disorder and was to be monitored every 15 minutes in accordance with facility policy. Continued review of the record revealed on 06/06/14 Patient #1's physician requested for staff to continue to monitor the patient every 15 minutes for safety. On 06/06/14 at 1:30 PM, Nurse Aide #1 escorted Patient #1 to the facility's Recovery Center located on another floor of the facility for the purpose of counseling/therapy and signed the patient in to the Recovery Center. However, at 3:20 PM (approximately two hours after staff signed the patient in to the Recovery Center) facility staff discovered Patient #1 had left the Recovery Center, had not returned, and could not be located in or outside the facility.

Review of the facility's investigation revealed at approximately 2:00 PM Patient #1 requested to be excused from the Recovery Center to go the restroom. The investigation also revealed, based on observation of the facility's video footage, Housekeeper #1 and Housekeeper #2 exited the locked Recovery Center through double doors at 2:15 PM and did not ensure the doors locked behind them as they exited. The investigation revealed Patient #1 exited the Recovery Center at 2:15 PM through the same double doors the housekeepers exited, and walked out of the hospital to a nearby gas station. However, review of the medical record revealed staff on the nursing unit had documented Patient #1 had been in the Recovery Center from 1:30 PM until 3:00 PM.

Interview with the facility's Investigator on 06/16/14 at 12:00 PM confirmed he had investigated the incident when Patient #1 had left the facility on 06/06/14 and acknowledged the information in the written investigation was accurate. Interview with the facility's Investigator also revealed Patient #1 presented to the Emergency Department of Facility #2 on 06/08/14 (approximately two days after the patient left the Recovery Center) and Facility #2 transferred Patient #1 back to the facility's psychiatric unit on 06/11/14 at 2:11 PM for further psychiatric treatment.

A copy of Patient #1's medical record from Facility #2 revealed Patient #1 had presented him/herself to the police on 06/08/14, informed them that he/she thought he/she had overdosed, and the police took Patient #1 to the Emergency Department of Facility #2. Documentation by the physician at Facility #2 revealed the patient had a drug overdose of "cocaine, opiates, and benzodiazepines," and was admitted to that facility for further treatment.

Interview with Nurse Aide (NA) #1 06/16/14 at 2:15 PM revealed she escorted patients, including Patient #1, to the Recovery Center on 06/06/14. The NA stated she did not document supervision of the patients other than to sign them in when they escorted them downstairs and to sign them out when they took them back upstairs to the patient care area.
According to NA #1, on 06/06/14, she remained at the Recovery Center and was assigned to monitor the bathrooms, but had switched assignments that afternoon with NA #2 and had monitored the facility's cafeteria area. NA #1 stated the Recovery Center staff monitored the hallways, bathrooms, and outside area. According to NA #1, patients were not allowed outside without supervision and the bathrooms are locked. The interview further revealed that the Patient Monitoring Sheets remained up on the units with the nurses when the patients come downstairs to the Recovery Center.

Interview with Housekeeper #1 on 06/16/14 at 2:05 PM revealed on 06/06/14 he took a break and went outside to smoke around 2:00 PM on 06/06/14 and returned to the Recovery Center around 2:15 PM with Housekeeper #2. He stated they exited the Recovery Center through the double doors beside the House Supervisor's office and had not observed Patient #1 in the hall or anywhere in the area at that time. Housekeeper #1 stated although it was facility policy, he could not remember if he looked to see if the doors closed and locked behind him. In addition, Housekeeper #1 stated as a result of the incident, he received disciplinary action for failing to ensure the doors in the Recovery Center had locked when he exited the facility.

Interview with the Chief Nursing Officer (CNO) on 06/17/14 at 11:45 AM revealed staff in the Recovery Center do not monitor and/or document the patients' whereabouts and stated hall monitors escorted patients to and from the Recovery Center. According to the CNO, the staff on the nursing units maintains documentation of the patients' whereabouts on and off of the nursing unit. Further review of the policy revealed that patients attending programming in the Recovery Center would be continuously monitored by group facilitators or hall monitors.

Interview with the Counselor on 06/16/14 at 2:10 PM revealed that on 06/06/14 at 1:30 PM she conducted a group session that Patient #1 attended. Continued interview revealed that she remembered letting Patient #1 leave group "a couple of times" to go to the bathroom, unescorted. She stated the last time she let him/her go, he/she didn't return to group, but she was not alarmed because it was approximately 2:10 PM and near the end of the session. She also stated she had a census sheet that contained the names of the group participants and if a patient did not attend, she was not concerned or did not call upstairs to ask where a patient was.

Interview with the Manager of the Recovery Center on 06/16/14 at 2:45 PM revealed that on 06/06/14, at approximately 3:30 PM, he received a telephone call at the desk for Patient #1. He stated he looked for Patient #1 in the Recovery Center but was unsuccessful in locating the patient. The Manager stated he called staff on the patient's nursing unit to see if the patient had been escorted back there without his knowledge, spoke with NA #3, and was informed Patient #1 was not on the unit. Continued interview revealed at that time, he notified the House Supervisor, Director of Nursing, and Security that Patient #1 could not be located. According to the Manager, staff escorted patients to the unit, signed the patient in to the unit, signed them out of the Center when the session was over, and escorted the patient back to the nursing units. The interview further revealed each patient's monitoring sheet remained at the patient's nursing unit. He stated he, along with the nurse aides and group facilitators, monitored the patients while they were in the Recovery Center as per the facility policy. However, he stated they did not document the monitoring of the patients anywhere.

Interview with the Director of Nursing (DON) on 06/16/14 at 3:30 PM revealed it was the practice of the facility to leave the 15-minute monitoring sheets on the nursing unit of the patient care area with nursing staff when patients attend group or activities in the Recovery Center. She also stated when a patient goes to another part of the hospital (e.g., Emergency Department) the staff takes the monitoring sheet with the patient. She stated because monitors were in the hallways and facilitators were in the classrooms when patients attended counseling in the Recovery Center, she felt the patients were always monitored. However, the DON acknowledged there was no documented evidence that Patient #1 had been monitored every 15 minutes on 06/06/14 as requested by the physician.

The Administrator of the facility was out of town and unavailable for interview.

Based on interview, record review, and review of the facility's policy, "Supervision of Patients," it was determined the facility failed to ensure that a Registered Nurse (RN) supervised the nursing care and protected and promoted patient rights for one (1) of ten (10) sampled patients (Patient #1). The policy revealed all patients admitted to the Psychiatric Center would be monitored every fifteen (15) minutes for at least the first seventy-two (72) hours and at least every thirty (30) minutes for the remainder of the admission. In addition, the policy revealed group facilitators or hall monitors would continuously monitor and supervise patients that attended programming in the Recovery Center. However, the facility failed to ensure written policies and/or procedures were developed to ensure the care of each patient was supervised, on an ongoing basis, by a Registered Nurse, particularly when patients attended the programming at the Recovery Center.

Patient #1 was admitted on 06/04/14 to a locked Behavioral Health Unit with diagnoses that included Suicidal Ideation, Major Depressive Disorder, Polysubstance Abuse, and Substance Mood Disorder. On 06/06/14, even though Patient #1 remained on 15-minute checks for safety, Patient #1 was escorted to the Recovery Center at 1:30 PM, and at 3:20 PM the facility staff discovered Patient #1 had left the facility. Although staff could not provide documentation that Patient #1 had been monitored every 15 minutes while the patient attended the Recovery Center, nursing staff that remained on the nursing unit documented every 15 minutes, from 1:30 PM to 3:00 PM, that Patient #1 was in the Recovery Center. However, the facility's video footage revealed Patient #1 left the Recovery Center at approximately 2:15 PM, 45 minutes before the facility learned the patient had left the facility. Interview with the facility's Investigator revealed Patient #1 presented to the Emergency Department of Facility #2 on 06/08/14 at 5:27 PM due to Benzodiazepine and Opioid poisoning and was admitted to that facility.

Based on the survey findings it was determined the Conditions of Participation at 42 CFR 482.23 Nursing Services was not met.

The failure of the facility to ensure that a Registered Nurse supervised the nursing care for patients of the facility, and to ensure mechanisms were in place to ensure staff monitored patients in accordance with facility policy and physician orders, placed patients at risk for serious injury, harm, impairment, and/or death. Immediate Jeopardy was identified on 06/17/14, was determined to exist on 06/17/14, and is ongoing. The facility was notified of the Immediate Jeopardy on 06/17/14.

Refer to A0395.

Based on interview, record review, and review of the facility's policy, "Supervision of Patients," it was determined the facility failed to ensure that a Registered Nurse (RN) supervised the nursing care for one (1) of ten (10) sampled patients (Patient #1). Review of the policy revealed all patients admitted to the Psychiatric Center would be monitored every fifteen (15) minutes for at least the first seventy-two (72) hours and at least every thirty (30) minutes for the remainder of the admission. Further review of the policy revealed that patients that attended programming in the Recovery Center would be continuously monitored by group facilitators or hall monitors and would be escorted by a member of the staff between their patient care unit and the Recovery Center. Patient #1 was admitted to the psychiatric facility on 06/06/14. According to facility policy and a review of physician orders, staff was to monitor the patient every fifteen (15) minutes to ensure the patient's safety. On 06/06/14 at 1:30 PM, Nurse Aide (NA) #1 escorted Patient #1 to the facility's Recovery Center located on another floor of the facility for counseling/therapy and signed the patient in to the Recovery Center. However, at 3:20 PM (approximately two hours after staff signed the patient in to the Recovery Center) staff in the Recovery Center discovered Patient #1 had left the Recovery Center, had not returned, and could not be located inside or outside of the facility. Interviews revealed staff in the Recovery Center did not monitor and/or document patients' whereabouts and that the staff on the nursing units maintains the documentation. Interviews and review of documentation revealed that although staff on Patient #1's nursing unit had not contacted staff in the Recovery Center to determine Patient #1's status and/or whereabouts while the patient attended counseling/therapy, staff on the nursing unit had documented every fifteen (15) minutes that Patient #1 was in the Recovery Center.

Interview with the facility's Investigator and a review of the facility's investigation (which included a review of the facility's video surveillance) revealed at approximately 2:00 PM, Patient #1 requested to be excused from the Recovery Center to go to the restroom. The investigation revealed Housekeeper #1 and Housekeeper #2 exited the locked Recovery Center through double doors at 2:15 PM, did not ensure the doors locked behind them as they exited, and Patient #1 exited the Recovery Center at 2:15 PM through the double doors and walked out of the hospital to a nearby gas station.

Continued interview with the facility's Investigator revealed Patient #1 presented to the Emergency Department of Facility #2 on 06/08/14 at 5:27 PM due to Benzodiazepine and Opioid poisoning and was admitted to that facility.

The failure of the facility to ensure that a Registered Nurse supervised the nursing care for patients of the facility, and to ensure mechanisms were in place to ensure staff monitored patients in accordance with physician orders, placed patients at risk for serious injury, harm, impairment, and/or death. Immediate Jeopardy was identified on 06/17/14, was determined to exist on 06/17/14, and is ongoing. The facility was notified of the Immediate Jeopardy on 06/17/14.

The findings include:

Review of facility policy titled, "Supervision of Patients," revised May 2012, revealed patients should be placed on the appropriate level of supervision to assure the safety and well-being of the patient and others. The policy revealed the level of supervision would determine the frequency and proximity of patient observation as follows: 30-minute checks; 15 minutes checks; within eyesight; and 1:1 observation. Upon admission, patients are placed on suicide, assault, and/or elopement precautions for the first 24 hours; and precautions may be continued or later reinstated at the discretion of the attending physician and/or treatment team. In addition, the policy revealed all patients admitted to the Psychiatric Center would be monitored every 15 minutes for at least the first 72 hours and at least every 30 minutes for the remainder of the admission. Further review of the policy revealed that patients attending programming in the Recovery Center would be continuously monitored by group facilitators or hall monitors and would be escorted by a member of the staff between their patient care unit and the Recovery Center.

Review of facility policy titled, "ARH Recovery Center" revised March 2013 revealed patients would be continuously monitored while in the Recovery Center.

Review of medical record revealed the facility admitted Patient #1 on 06/04/14 to a locked behavioral health unit with diagnoses that included Suicidal Ideation, Major Depressive Disorder, Polysubstance Abuse, and Substance Mood Disorder. A review of facility policy revealed staff was to monitor the patient every 15 minutes. In addition, review of Patient #1's medical record revealed on 06/06/14 Patient #1's physician requested for staff to continue to monitor the patient every 15 minutes for safety. On 06/06/14 at 1:30 PM, Nurse Aide #1 escorted Patient #1 to the facility's Recovery Center located on another floor of the facility for counseling/therapy and signed the patient in to the Recovery Center. However, at 3:20 PM (approximately two hours after staff signed the patient in to the Recovery Center) facility staff discovered Patient #1 had left the Recovery Center, had not returned, and could not be located in or outside the facility.

Interview with the facility's Investigator on 06/16/14 at 12:00 PM and a review of documentation revealed at approximately 2:00 PM Patient #1 requested to be excused from the Recovery Center to go to the restroom. The investigation revealed Housekeeper #1 and Housekeeper #2 exited the locked Recovery Center through double doors at 2:15 PM, did not ensure the doors locked behind them as they exited, and Patient #1 exited the Recovery Center at 2:15 PM through the double doors. After the patient exited, he/she walked out of the hospital to a nearby gas station. However, review of the medical record revealed staff on the nursing unit had documented Patient #1 had been in the Recovery Center from 1:30 PM until 3:00 PM.

Review of Patient #1's medical record from Facility #2 revealed Patient #1 presented him/herself to the police on 06/08/14, informed them that he/she thought he/she had overdosed, and the police took Patient #1 to the Emergency Department of Facility #2. Documentation by the physician at Facility #2 revealed the patient had a drug overdose of "cocaine, opiates, and benzodiazepines," and was admitted to that facility for further treatment. Continued interview with the facility's Investigator revealed Facility #2 transferred Patient #1 back to the facility's psychiatric unit on 06/11/14 at 2:11 PM for further psychiatric treatment.

Interview with the Chief Nursing Officer (CNO) on 06/17/14 at 11:45 AM revealed the staff in the Recovery Center does not monitor and/or document the patients' whereabouts and stated hall monitors escorted patients to and from the Recovery Center. According to the CNO, staff on the nursing units maintains documentation of the patients' whereabouts on and off of the nursing units.

Interview with the Manager of the Recovery Center 06/16/14 at 2:45 PM revealed Nurse Aides escorted patients to the Recovery Center from the patient care areas, signed the patients in, and then signed the patient out and escorted the patient back upstairs to the patient care area when the Recovery Center session was completed. The interview further revealed that the nurse aides do not monitor the patients when the patients are at the Recovery Center and stated the monitoring sheets remained upstairs with the nursing staff.

Nurse Aide (NA) #1 stated in interview conducted on 06/16/14 at 2:15 PM that she escorted Patient #1 to the Recovery Unit on 06/06/14. The NA stated she did not document supervision of the patients other than to sign them in when they escorted them downstairs and to sign them out when they took them back upstairs to the patient care area. NA #1 stated on 06/06/14, she remained at the Recovery Center and was assigned to monitor the bathrooms, but had switched assignments that afternoon with NA #2 and had monitored the facility's cafeteria area. NA #1 stated the Recovery Center staff monitored the hallways, bathrooms, and outside area. According to NA #1, patients were not allowed outside without supervision. The interview further revealed that the patient monitoring sheets remained up on the units with the nurses when the patients came downstairs to the Recovery Center.

Interview with NA #3 on 06/16/14 at 2:30 PM revealed she had worked the patient care area on 06/06/14 where Patient #1 had been admitted and stated another nurse aide had escorted Patient #1 downstairs to the Recovery Center at approximately 1:30 PM. NA #3 stated the patient monitoring sheets remained upstairs with nursing staff and she had documented on the monitoring sheet every 15 minutes that Patient #1 was in the Recovery Center. Continued interview revealed that at approximately 3:00 PM, she received a phone call from the Recovery Center's Director and the Director asked if Patient #1 was upstairs in the patient care area. NA #3 stated she looked for Patient #1, could not locate him/her, and telephoned the Director to inform him the patient was not upstairs on the nursing unit. At that point, NA #3 stated she informed the Charge Nurse that Patient #1 could not be found.

Interview with the Counselor on 06/16/14 at 2:10 PM revealed Patient #1 had attended a group counseling session that she conducted on 06/06/14 at 1:30 PM. Continued interview revealed that when patients were in group the facilitators were supposed to monitor patients; however, she stated they did not keep written documentation of the patients' whereabouts every 15 minutes as indicated in the facility's policy.

Interview with the manager of the Recovery Center on 06/16/14 at 2:45 PM revealed Nurse Aides escorted patients down from the patient care area, signed the patients in and then when patients were finished for the day, the patients were signed out and escorted back upstairs to the patient care area by nurse aides. The interview further revealed the monitoring sheets were not brought to the Recovery Unit with the patients for monitoring to be documented.

Interview with the Director of Nursing (DON) on 06/016/14 at 3:30 PM revealed it was the facility's practice for staff to leave the monitoring sheets on the nursing unit with nursing staff when the patients attended group or activities in the Recovery Center. The DON stated monitors were in the hallways and facilitators were in the classrooms when patients attended the Recovery Center and patients were always monitored; however, the DON stated the facility did not maintain documentation of the monitoring. She stated the facility ensured monitoring of the patients in the Recovery Center with the signing in and out of patients by the nurse aides.

The Administrator of the facility was out of town and unavailable for interview.