HospitalInspections.org

Based on seven (7) out of seven (7) observations, staff interviews, review of one (1) out of one (1) medical record (#1) and review of facility documents, it was determined that the facility failed to ensure patient care is provided in a safe setting.

Findings include:

1. The facility failed to mitigate the risk of elopement from within the facility's seven (7) courtyards, creating an unsafe and potentially dangerous environment for patients. Refer to Tag A-0144.

Based on seven (7) out of seven (7) observations, staff interviews, review of one (1) out of one (1) medical record (#1) and review of facility documents, it was determined that the facility failed to ensure patient care is provided in a safe environment, by mitigating the risk of elopement from within the seven (7) courtyards.

Findings include:

1. On 9/20/2021, during an interview, Staff #3 confirmed that on 9/8/2021 at 6:20 PM, a 27-year-old patient hoisted himself/herself onto the roof and eloped from the facility.

2. On 9/20/2021 at 10:46 AM, during review of Medical Record #1, in the presence of Staff #2, the following was revealed:

a. The patient was an involuntary commitment transferred from another facility (hospital) on 9/3/2021 at 8:50 PM, with a diagnosis of Bipolar disorder, MRE (Multiple Reoccurring Episodes) Manic, Severe w/o [without] psychotic features, ETOH [chemical title for ethanol alcohol] in remission.

(i) The medical record indicated that the patient was identified as an elopement risk as he/she attempted twice to elope from the sending facility with injury. There was a special precautions order for an "S2" entered on 9/3/2021 at 21:07 [9:07 PM] by the APN (Advanced Practice Nurse). Staff #2 stated that S2 is an observation status and means that the patient has to be visually observed every 5 minutes. The reason for the S2 observation status was marked as "unpredictable behavior and elopement."

(ii) The patients S2 status changed and there was a special precautions order for Q15 (every 15 minute) checks entered on 9/6/2021 at 20:16 [8:16 PM]. The reason for the Q15 observation status was marked as "unpredictable behavior and elopement."

b. On 9/8/2021 at 19:03 [7:03 PM], the Registered Nurse (RN) Note stated, "Patient was observed by two MHT [Mental Health Technicians] staff and multiple patients jumping onto roof in courtyard. Per MHT, patient stepped on chair, grabbed onto ledge and pulled [him/herself] up to the roof. Multiple MHT staff attempted to prevent [him/her] from hoisting [him/herself] on the roof but were unsuccessful. Security alert-elopement was called at 18:21 [6:21 PM]. Multiple staff members went to look for patient on (name of facility) property but was not located. ...Police was contacted by security. ...As of 19:08 [7:08 PM], patient was not located by police."

(i) On 9/20/2021, Staff #1 and Staff #3 confirmed that Patient #1 eloped while outside for a fresh air break in the courtyard of the Comprehensive Services Unit (CSU). Security was alerted at 6:21 PM and a search for the patient was unsuccessful. Township police were notified at 6:35 PM. To the facility's knowledge the patient has still not been located.

3. On 9/21/2021 at 11:40 AM, during an interview, Staff #5 stated that he/she was present during the incident and observed the patient stand onto a picnic table, that was located under the ledge of the roof, and flip him/herself up onto the roof of the facility and elope. Staff #5 confirmed that it was a picnic table and not a chair that the patient stood upon.

4. A review of elopements for the past six (6) months revealed that on 5/25/2021, another patient [Patient #2] on the General Adult Unit (GAU), who was out in the courtyard during music group, was found running on top of the roof by a staff member. A security alert was called, and the patient was located on the grounds and brought back to the unit.

5. On 9/20/2021, a tour of seven (7) of the facility's courtyards revealed picnic tables and chairs, in each of the courtyards, that if moved under the roof's ledge and stood upon, allows a patient to gain access to the roof, presenting a risk for elopement and patient safety.

a. At 12:39 PM, during a tour of the CSU courtyard, the following was revealed:

(i) There were picnic tables and moveable chairs throughout the courtyard.

(ii) There was a storage container (Deck box) that was directly under the ledge to the roof. Staff #4 confirmed the box contained bouncing balls.

(ii) There was another taller storage container located directly next to the fence.

b. At 1:45 PM, in the ACUE (Acute Care Unit East) and ACUW (Acute Care Unit West) courtyard, there were three (3) patients observed sitting in chairs directly under the roof's ledge. The chairs under the roof's ledge, if stood upon, allows a patient to gain access to the roof, presenting a risk for elopement and patient safety.

c. At 1:51 PM, in the courtyard of the Adult Psychiatric and Addictions Unit (APA), there were two (2) metal picnic tables that were directly under the roof's ledge and two (2) wooden picnic tables that were close to the roof's ledge.

d. At 2:57 PM, in the Intensive Treatment Unit (ITU) courtyard, there were two (2) round tables and five (5) moveable chairs.

e. At 3:02 PM, in the Older Adult Unit (OAU) courtyard, there were four (4) moveable chairs and (1) storage container (deck box).

f. At 3:05 PM, in the Adolescent Unit (AU) courtyard, there were three (3) picnic tables and five (5) moveable chairs.

g. At 3:11 PM, in the General Adult Unit (GAU) courtyard, there were six (6) picnic tables and multiple movable chairs.

6. On 9/21/2021 at 12:35 PM, a request was made for the facility elopement risk assessment. The risk assessment dated 5/26/21 was received and reviewed. The assessment described an elopement event that occurred on 5/25/21, indicating the population at risk included patients and the general public. The section Current Safeguard in place to prevent potential harm: stated, "1. 15 minute head check (minimum) 2. Elopement precautions for those at higher risk 3. Courtyard supervision 4. Staff education not to leave furniture near fence lines." The assessment indicated that the mitigation (potential strategies to reduce risk) plan was to consider the use of bolted down picnic tables, giving the patients the opportunity to sit comfortably without the risk of furniture being moved.

7. The facility failed to mitigate the risk of elopement from within the facility's seven (7) courtyards, creating an unsafe and potentially dangerous environment for patients.

The above findings resulted in an Immediate Jeopardy (IJ) under the requirement of 482.13 Patient Rights. The Vice President of Nursing, Staff #1 was informed of the IJ and provided with the IJ template on 9/21/2021 at 12:05 PM, and a removal plan was requested. An acceptable removal plan was provided by the facility on 9/21/2021 at 1:35 PM.

On 9/21/2021 while on-site, a tour of the seven courtyards was conducted, the facility removed all moveable chairs from within the courtyards and relocated the picnic tables and storage containers to the center of the courtyard, away from the walls and fences. Staff were educated to ensure that no furniture or tables are moved close enough to any wall or fence, so patients cannot use them to climb over a fence or onto a roof. Staff were also educated that no chairs are to be allowed in any courtyard. The facility was found to have implemented the IJ removal plan and the IJ was removed on 9/21/2021 at 1:51 PM.