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8550 HUEBNER ROAD

SAN ANTONIO, TX 78240

PLAN BASED ON INVENTORY OF STRENGTHS/DISABILITIES

Tag No.: B0119

Based on a record review of facility documentation and staff interviews, the facility failed to ensure patients had an appropriate comprehensive treatment plan implemented based on the patient's needs identified on assessments for 2 of 3 patients reviewed (Patient's #1 and #2); and failed to update the treatment plans in accordance with the facility's policy.

Specifically, Patient #1 and Patient #2 had a known history of elopement; "runaway" behaviors that were safety risks identified through intake; and in addition, an incident that occurred on 4/21/18. The facility failed to ensure Patient #1 and #2's MTP addressed Elopement/Run Away risks in order to support and implement a treatment care plan for this problem.

Findings included:

Review of the facility's Policy titled, Master Treatment Plan (MTP), last revised 1/25/2017 indicated in part, that every patient shall have an individualized, comprehensive MTP based on the needs identified on assessments and developed by the multi-disciplinary team, in conjunction with the patient and family/significant others.
Procedures included: A. A Registered Nurse (RN) initiates the Treatment Plan within eight hours of admission, based on the findings of the Intake Assessment, Physician Screening Evaluation, and Nursing Assessment.
B. When initiating the treatment plan, the RN shall include at least the following:
1. A problem list identifying: ... ... ....
c. safety issues not included in the principal psychiatric problem or identified medical problems.
C. Within 72-hours of admission, the multi-disciplinary team shall complete the MTP.

Review of the facility's self-reported incident to the Department of State Health Services dated 4/25/18 revealed a Mental Health Tech (MHT) was with patients (Patient #1, #2, and #3) at the gym and was walking them to the adjacent cafeteria to get a drink of water. As they were leaving the cafeteria, one of the patients grabbed the MHT's badge. MHT attempted to retrieve the badge but was unsuccessful. The patients ran down the hall and used the badge to release the lobby doors. The MHT was able to detain Patient #2, but Patient's #1 and #3 got away. The Police were notified.

Patient #1

Review of Patient #1's Intake High Risk Alert red form dated 4/17/18 revealed "High risk issues/concerns" identified included "Elopement" with a check for a History of eloping from treatment/home. It was documented by the intake staff that Patient #1 had "runaway numerous times." Other high risk issues included suicide.

Review of the Nursing Admission Assessment dated 4/17/18 documented Patient #1 having drug use, runaway, truancy, issues with authority figures, blaming others and attempts to hurt self (superficial scratches) when he does not get his way.

Review of Patient #1's MTP established 4/17/18 revealed the Problem list was as following:
1. Suicidal/Danger to self, established 4/17/18
2. Substance abuse, established 4/18/18

Patient #1's MTP did not contain the identified problem of elopement in order to implement treatment interventions.

Review of the facility's Incident Report for Patient #1 dated 4/21/18 at 15:30 revealed Patient #1 was being escorted back to the unit from the gym; accompanied by staff. It was reported that he grabbed a badge from a staff member and then ran out of the hospital through the lobby and out the admission/intake area doors. He was accompanied by another patient (Patient #3). Facility administrative staff were notified and the local police department of the "elopement."

Patient #2

Review of Patient #2's Intake Assessment dated 3/9/18 documented Patient with a plan to "runaway" and get shot by a neighbor.

Review of Patient #2's Psychosocial Assessment dated 3/10/18 revealed "Acute Symptoms Requiring Hospitalization: included "Runaway Behavior" checked.

Review of Patient #2's MTP established 3/9/18 revealed the Problem list was as following:
1. Danger to self- Suicidal, established 3/9/18
2. Danger to others- Aggression, established 3/9/18
3. Sexual Acting Out, established 3/9/18
4. Infection, established 5/23/18

Further review of the MTP indicated the reason for admission was that Patient #2 stated, "I was suicidal, I told placement I am going to run away and get shot." Patient #2's MTP did not contain the identified problem of elopement in order to implement treatment interventions. In addition, the MTP was not revised, reviewed, or updated following the attempted elopement from the facility on 4/21/18.

Review of the Seclusion/Restraint Physician Order and Record dated 3/13/18 documented Patient #2 attempted to elope from unit briefly.

Review of the facility's Incident Report for Patient #2 dated 4/21/18 at 15:15 revealed Patient #2 attempted to elope from the facility with 2 other peers (Patient's #1 and #3) through the front doors and Patient #2 required physical restraint in the reception area to prevent his departure from the hospital.


During an interview on 10/9/18 at 11:05 AM with the Charge Registered Nurse (RN) from the adolescent unit stated that if a patient comes to the unit with a known elopement issue then; "elopement goes onto the MTP" to be addressed as a problem.

During an interview on 10/09/18 at 1:05 PM with the Regional Director of Risk Management (DRM) confirmed the above findings that Patient #1 and Patient #2 had identified risks of elopement/run away issues identified during intake. The Regional DRM also confirmed that Patient #1 and Patient #2's MTP's did not include elopement/run away addressed in order to support and implement a treatment care plan for this problem and stated that Elopement/Run Away should have been addressed and/or added to Patient #1 and #2's MTP's.

During an interview on 10/9/18 at 1:50 PM with Licensed Professional Counselor (LPC)-A; previously the Director of Clinical Services, stated she was assigned to Patient #2 following his challenging behaviors displayed and implemented a "Specialized Treatment Program" for Patient #2 that included a point system/reinforcements to address his significant maladaptive behaviors. The LPC-A was not able to obtain the evidence of Patient #2's Specialized Treatment Program from his master record or from medical records. LPC-A provided the facility's Level System draft regulations that was not specific to Patient #2.