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Based on review of Governing Board Meeting Minutes, policy and procedures, patient occurrence data, and staff interviews, it was determined that the Governing Body failed to provide oversight and ensure that measures were taken to mitigate elopements. From 5/6/22 to 5/1/23 there were ten patient incidents (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#10) of elopement from the facility that were not returned. Seven (P#3, P#4, P#5, P#6, P#7, P#9 and P#10) of the ten elopement incidents occurred by scaling or jumping a fence.

Findings included:

A review of the Governing Board Meeting Minutes from second quarter 2022 through first quarter 2023 revealed that one elopement incident was discussed in the August 2022 meeting.

A review of an 'Ad-Hoc Meeting of the Governing Board Meeting Minutes' dated 5/10/23 at 5:35 p.m. revealed that the CEO informed the Governing Board of a trend in elopements over the past 12 months and that 75% of the elopements were related to GLC fencing. Continued review of the minutes revealed that corrective actions taken in response to the most recent elopement included re-education of the nursing staff on patient observations and elopement precautions. Nurse Supervisor audits, Charge nurse checks of rounds and the current leadership round sheet was discussed. The CEO reported that three quotes were being sought for an evaluation of the current fencing and options to replace or fortify current fencing. The CEO would forward the quotes to the CFO for evaluation. Continued review of the meeting minutes revealed that the adult courtyard would be taken offline because it was the most accessible fence. The CEO was to notify the leadership of this action. The CNO would educate the nurse supervisors on BHA positioning on outdoor breaks and the CEO would modify the leadership rounds. The leadership team will report in daily flash meetings. The CEO would provide weekly updates to the Board.

A review of the "Elopement Precautions and Response" policy #CTS-022, revealed that staff would provide appropriate assessment and observation of inpatients who had either verbally or non-verbally expressed a desire to elope from the hospital. The psychiatric practitioner would order observation and precautions consistent with the assessed level of risk. Elopement risk, level of observations and/or placement on Elopement Precautions would be communicated to all staff. Patients who left the hospital without a discharge order were considered to have eloped. This included patients who were requesting Against Medical Advice (AMA) discharge but had not completed the discharge process. In order to provide protection to patients who were at high risk for elopement, Risk of Elopement would be added to the Interdisciplinary Treatment Plan. The patient would be placed in a patient room in close proximity to the nurse's station away from exit doors and observed for changes in behavior. At-risk patients would be observed more during activities where the doors to the units were opened.

At the time of discovering a patient was missing, staff would search the hospital and immediate hospital grounds. In the event that a patient left the hospital grounds, the police were to be contacted immediately if the patient met the following conditions:

i) Involuntarily committed.
ii) Minor status
iii) Determined to be dangerous to themselves or others.

Staff would follow the patient at a safe distance and attempt to keep the patient in their eyesight. Staff were not to lay hands on the patient or attempt to physically force the patient to return to the hospital. Staff could verbally communicate with the patient in an effort to encourage the patient to return to the hospital.

Staff would notify the physician, Chief Executive Officer, Director of Nursing, Police, Family, and the Director of Risk Management of the patient's elopement. Documentation would include the date, time, circumstances, action taken to locate the patient, information related to notifications, and the disposition (status) of the patient. An Incident Report would have been completed and submitted to the Director of Risk Management. The physician would have discharged the patient AMA if the patient did not return.


A review of an Occurrence Summary report dated 5/1/2022 through 5/1/2023 revealed that there were ten (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#10) patient elopements that had not been recovered or returned to the facility. Continued review of the occurrence summary report revealed that seven (P#3, P#4, P#5, P#6, P#7, P#9 and P#10) of the ten elopements involved patients jumping or scaling a fence.

During an interview with the Risk Manager (RM) BB on 5/10/23 at 2:05 p.m. in the Conference Room, RM BB said the trend concerned the fence. Expansion and renovation were in progress. Improvements in the fence height were suggested to corporate leadership and it would happen over the next 18 months.

An interview took place with the Chief Executive Officer (CEO) on 5/10/23 at 3:05 p.m. in the Conference Room. The CEO said that with a recent elopement, she asked staff to get quotes for improvements of the fence to send to corporate leaders. She explained that Level I and Level II incidents were typically communicated to the Governing Body through emails and phone calls. The CEO failed to confirm that elopements were being discussed during the board meetings.

A second interview took place with the Risk Manager (RM) BB on 7/5/23 at 3:03 p.m. in the Conference Room. RM BB said incidents are scored I-IV, with I (one) being the most severe and IV (four) being the least severe. Anything Level I or II required an investigation. RM BB said an elopement for an involuntary patient, or an adolescent was a Level II, regardless of whether or not the patient returned. Elopement of a voluntary patient was Level III. Returning or not returning did not affect the severity level. An injury during elopement would increase the incident to a Level II. Adolescents who returned within 30 minutes would be a Level III. RM BB said police would only be called for an adolescent or involuntary patient. Staff would walk the property and would verbally redirect the patient, if located. Once a patient left the property, the staff could not put hands on them. The staff would document the elopement of a voluntary patient with no other actions.

Based on review of the occurrence summary, review of policy and procedures and staff interviews it was determined that the facility failed to ensure that care and treatment was rendered in a safe setting that included a physical environment constructed and maintained with respect to the patient population served when of ten elopement incidents from 5/6/22 through 5/1/23, seven (P#3, P#4, P#5, P#6, P#7, P#9 and P#10) happened by patients climbing or scaling fencing.

Findings included:

Cross refer to A0144 as it relates to the facility's failure to ensure that patients received care in a safe setting.

Based on review of the occurrence summary, review of policy and procedures and staff interviews it was determined that the facility failed to ensure that patients received care in an environment constructed and maintained specific to the patient population served. Specifically, from 5/6/22 through 5/1/23, ten patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#10) eloped and failed to return to the facility. Seven (P#3, P#4, P#5, P#6, P#7, P#9 and P#10) of the ten elopement incidents happened by patients climbing or scaling fencing.

Findings included:

A review of an Occurrence Summary report dated 5/1/2022 through 5/1/2023 revealed that revealed that seven (P#3, P#4, P#5, P#6, P#7, P#9 and P#10) elopement incidents occurred that involved patients jumping or scaling a fence. Specifically,
P#3 eloped from the Adult Unit and was not returned on 6/7/22 at 3:45 p.m. P#3 went on smoke break with staff and other patients and jumped the fence.
P#4 eloped from the Adult South unit courtyard on 1/30/23 at 11:33 a.m. and was not returned.
P#5 eloped from the Sub-acute unit on 3/17/23 at 4:00 p.m. by jumping the fence.
P#6 eloped from the Adult Unit Courtyard by jumping a fence and did not return on 6/8/22 at 11:20 a.m.
P#7 was outside for smoke/fresh air break and jumped over the fence eloped from the Adult South Unit on 12/12/22 at 10:50 a.m.
P#9 eloped from the PICU Courtyard and did not return on 6/5/22 at 9:27 a.m. by scaling the fence.
On 12/3/22 at 9:51 a.m. P#10 scaled the fence in the pool area and eloped.

Review of the "Rights and Responsibilities of Individuals" policy, last revised 7/22, revealed that the hospital protected and promoted patients' rights that were extended to all patients. Patients had the right to be protected by the hospital from neglect and physical, verbal, and emotional abuse.

Review of the "Elopement Precautions and Response" policy #CTS-022, revealed that staff would provide appropriate assessment and observation of inpatients who had either verbally or non-verbally expressed a desire to elope from the hospital. The psychiatric practitioner would order observation and precautions consistent with the assessed level of risk. Elopement risk, level of observations and/or placement on Elopement Precautions would be communicated to all staff. Patients who left the hospital without a discharge order were considered to have eloped. This included patients who were requesting Against Medical Advice (AMA) discharge but had not completed the discharge process. In order to provide protection to patients who were at high risk for elopement, Risk of Elopement would be added to the Interdisciplinary Treatment Plan. The patient would be placed in a patient room in close proximity to the nurse's station away from exit doors and observed for changes in behavior. At-risk patients would be observed more during activities where the doors to the units were opened.

At the time of discovering a patient was missing, staff would search the hospital and immediate hospital grounds. In the event that a patient left the hospital grounds, the police were to be contacted immediately if the patient met the following conditions:

iv) Involuntarily committed.
v) Minor status
vi) Determined to be dangerous to themselves or others.

Staff would follow the patient at a safe distance and attempt to keep the patient in their eyesight. Staff were not to lay hands on the patient or attempt to physically force the patient to return to the hospital. Staff could verbally communicate with the patient in an effort to encourage the patient to return to the hospital.

Staff would notify the physician, Chief Executive Officer, Director of Nursing, Police, Family, and the Director of Risk Management of the patient's elopement. Documentation would include the date, time, circumstances, action taken to locate the patient, information related to notifications, and the disposition (status) of the patient. An Incident Report would have been completed and submitted to the Director of Risk Management. The physician would have discharged the patient AMA if the patient did not return.

During an interview with the Risk Manager (RM) BB on 5/10/23 at 2:05 p.m. in the Conference Room, RM BB said the trend concerned the fence. Expansion and renovation were in progress. Improvements in the fence height were suggested to corporate leadership and it would happen over the next 18 months.

An interview took place with the Chief Executive Officer (CEO) on 5/10/23 at 3:05 p.m. in the Conference Room. The CEO said that with a recent elopement, she asked staff to get quotes for improvements of the fence to send to corporate leaders. She explained that Level I and Level II incidents were typically communicated to the Governing Body through emails and phone calls. The CEO failed to confirm that elopements were being discussed during the board meetings.

A second interview took place with the Risk Manager (RM) BB on 7/5/23 at 3:03 p.m. in the Conference Room. RM BB said incidents are scored I-IV, with I. being the most severe and IV being the least severe. Anything Level I or II required an investigation. RM BB said an elopement for an involuntary patient, or an adolescent was a Level II, regardless of whether or not the patient returned. Elopement of a voluntary patient was Level III. Returning or not returning did not affect the severity level. An injury during elopement would increase the incident to a Level II. Adolescents who returned within 30 minutes would be a Level III. RM BB said police would only be called for an adolescent or involuntary patient. Staff would walk the property and would verbally redirect the patient, if located. Once a patient left the property, the staff could not put hands on them. The staff would document the elopement of a voluntary patient with no other actions.

Based on review of the facility's occurrence data, tour, policy, and procedures, and interviews it was determined that the facility failed to ensure that the facility's outside fencing was constructed in a manner to ensure the safety of behavioral health patients. Specifically, from 5/6/22 to 5/1/23, there were ten patient incidents (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#10) of elopement from the facility that were not returned. Seven (P#3, P#4, P#5, P#6, P#7, P#9 and P#10) of the ten elopement incidents occurred by scaling or jumping a fence.

Findings include:

Refer to A0701 as it related to the failure of the facility to ensure that fencing around the courtyards used for outside breaks by patients, was constructed in such a manner to prevent unauthorized departure.

Based on a review of the occurrence summaries, a tour of the facility, interviews, and other facility documentation it was determined that the facility failed to ensure that fencing around the behavioral health unit (BHU) was constructed in such a manner to prevent unauthorized departure. Specifically, from 5/6/22 to 5/1/23, there were ten patient incidents (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#10) of elopement from the facility that were not returned. Seven (P#3, P#4, P#5, P#6, P#7, P#9 and P#10) of the ten elopement incidents occurred by scaling or jumping a fence.

Findings included:

A review of an Occurrence Summary report dated 5/1/2022 through 5/1/2023 revealed that there were ten (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, and P#10) patient elopements that had not been recovered or returned to the facility. Continued review of the occurrence summary report revealed that seven (P#3, P#4, P#5, P#6, P#7, P#9, and P#10) of the ten elopements involved patients jumping or scaling a fence.

A review of an Incident Report Form for P#3 revealed that P#3 eloped from the adult unit and was not returned on 6/7/22 at 3:45 p.m. Witnesses to the incident were the Registered Nurse (RN) LLL, Behavioral Health Associate (BHA) MMM, and the RN NNN. P#3 went on smoke break with staff and other patients. P#3 jumped the fence outside. Code Green was called. Staff assessed facility grounds and the patient was not found. The police were contacted, and the physician was notified. The Director of Nursing, facility supervisor, and family were contacted on 6/7/22 at 3:50 p.m. Attempts to reach the patient's mother were unsuccessful. The severity level was classified as III by Risk Management.

A review of the Incident Report Form revealed that P#4 eloped from the Adult South unit on 1/30/23 at 11:33 a.m. and was not returned. The incident was witnessed by RN OOO. P#4 was in the gym and eloped from the area leaving the facility. P#4 was not on precautions at the time of elopement. The police were not involved. Risk Manager follow-up notes revealed that P#4 was on voluntary status. The physician was notified on 1/30/23 at 11:35 a.m. The Severity classification was Level III.

A review of the Incident Report Form revealed that P#5 eloped from the Sub-acute unit and did not return on 3/17/23 at 4:00 p.m. BHA PPP was a witness to the incident. The patient jumped the fence and fled the premises. Staff looked for her but could not find her. P#5 was not on precautions at the time of elopement. The police were not involved. Risk Manager notes stated that P#5 was on voluntary status and was observed leaving in a vehicle. The physician and Director of Nursing were notified on 3/17/23 at 4:20 p.m. The event was classified as a Level III severity by the Risk Manager.

A review of an Incident Report Form revealed that P#6 eloped from the Adult Unit Courtyard and did not return on 6/8/22 at 11:20 a.m. RN QQQ and BHA RRR were witnesses to the incident. During smoke break, P#6 jump the fence and eloped. The patient was not a current 1013. Supervisors were notified. The facility supervisor and Director of Nursing were notified on 6/8/22 at 11:30 a.m. The Risk Manager classified the event as Level III.

A review of the Incident Report Form for revealed that P#7 eloped from the South Unit and did not return on 12/12/22 at 10:50 a.m. The incident was witnessed by BHA SSS. P#7 was outside for smoke/fresh air break, at which time the patient jumped over the fence. Code Green was called. The supervisor was notified. P#7 was on voluntary status. P#7 was on suicide, elopement, and assault precautions. P#7 returned to get his belongings one hour later and refused treatment. The facility supervisor was notified on 12/12/22 at 10:52 a.m. The event was classified as a Level III severity by Risk Management.

Review of the Incident Report Form revealed that P#9 eloped from the PICU Courtyard and did not return on 6/5/22 at 9:27 a.m. P#9 was outside with staff for fresh air break. P#9 was interacting with peers and dancing to music when he suddenly grabbed the fence and pulled himself up and over. P#9 jumped to the other side and began to run away. P#9 refused to listen to staff verbal attempts to redirect him. P#9 was not on precautions at the time of elopement. The police were not involved. The facility supervisor was notified on 8/5/22 at 9:30 a.m. The event was classified as a Level III severity by Risk Management.

Review of the Incident Report Form revealed that P#10 eloped from the facility's Adult North pool area on 12/3/22 at 9:51 a.m. BHA UUU was a witness to the incident. During fresh air break at the pool, P#10 scaled the fence and left the facility. P#10 was on suicide precautions at the time of elopement. The police were not involved. The facility supervisor was notified on 12/3/22 at 9:51 a.m., and the family was notified on 12/3/22 at 10:01 a.m. The event was classified as a Level III severity by Risk Management. A witness statement by BHA UUU on 12/3/22 revealed that P#10 was outside pacing. Staff kept their eyes on him and then another patient asked a question. While the staff was answering the question, P#10 jumped the fence and took off running.

A tour of the Psychiatric Intensive Care Unit (PICU) took place on 5/11/23 at 9:20 a.m. with the Risk Manager and Director of Nursing. It was observed that an exit from the PICU led to an L-shaped hallway approximately 50 feet long with a locked door that led to a courtyard with a swimming pool, surrounded by other buildings or a fence. The fence to the courtyard was observed to be approximately 50 feet long and 15 feet tall, chain-linked, with a protective fabric covering to prevent climbing. There was a locked gate to the courtyard. It was further observed that there was a locked exit in front of the nurses 'station with a glass door surrounded by windows that led to an open area with benches and a covering. The area was used for smoke breaks and had two portable chairs next to the entrance where the BHAs would sit during smoke breaks. There was a wooden fence surrounding the courtyard approximately 12 feet high with horizontal 2 " x4 "supports every two feet and vertical 4 " x4 "posts approximately every 12 feet. There was a locked gate to the courtyard area. It was observed that there was an area near a building to the left of the entrance that was not visible from PICU door. The area was approximately 12 'x 12 '. Vertical slats approximately 15 feet tall had been attached to the fence in the area that was not visible. It was observed that the 2 " x4 "horizontal boards to the remaining fence were slanted to prevent a foothold. The fence to the courtyard was adjacent to a construction area.

The tour continued to the adult unit courtyard which was observed to be a large courtyard with a cinder-block fence approximately 9 feet high. The fence was adjacent to a parking lot and residential area. There was a gate to the courtyard with a lock box approximately 3 feet from the ground, next to the building and a window. The DON SS said that patients were easily able to step onto the lock box and over the fence, which was how patients had previously eloped. It was observed that the window ledge was near the lock box. RM BB said the courtyard was currently not in use due to the ease of elopement from that area due to the fence and the spread-out nature of the area. It was further observed that the doors to the PICU closed and locked without hesitation, except the door to the L-shaped hallway hesitated prior to automatically closing. The hallway where the door was located was surrounded by seclusion rooms or other unoccupied areas.

An interview took place with the Risk Manager (RM) BB on 5/9/23 at 2:00 p.m. in the Conference Room. RM BB said there were two recent incidents where patients eloped. P#2 was in the psychiatric intensive care unit (PICU). P#2 eloped when a BHA assumed he was in his room and wasn ' t properly performing observations every five minutes. P#2 either went out the back over the fence or followed a staff member off the unit. The facility ' s corrective action was related to both situations. RM BB said P#2 left on 4/30/23 and had not been found. P#2 did not have a contact number. As soon as P#2 eloped, law enforcement was notified and provided with a photo and a description. The staff could not tell RM BB the last time they had seen P#2, and RM BB asked the evening shift BHA EE if she had seen him at all that shift. BHA EE was terminated because she had marked off the rounds sheet and said she thought P#2 was in his room. RM BB said two BHAs said they saw P#2 inside after the smoke break. BHA EE did not put eyes on P#2 one time.

An interview took place with BHA HH on 5/9/23 at 2:52 p.m. in the Conference Room. BHA HH said he worked the day P#2 eloped, but he was not on shift at the time. BHA HH said he saw P#2 walking in from smoke break and P#2 was in the building when BHA HH went home. BHA HH said the doors to the unit automatically locked when closed. BHA HH further said the staff stood at the door after smoke break and counted the patients until all of the patients were in the facility. Smoke break was in an area where everything was visible except one spot that had to be checked. BHA HH said that no concerns about elopement had been expressed by P#2. BHA HH further said there was a patient a month prior who jumped the courtyard fence. Police were called and picked up the patient.

An interview took place with BHA II on 5/8/12 at 3:00 p.m. BHA II said that on the day that P#2 eloped, she clocked in at 6:30 p.m. and met BHA HH as he was leaving the unit. At 6:45 p.m., BHA II was getting to the last of the patients who were supposed to get vital signs checked and noticed that four patients had not come to get vital signs. There were 15 patients on the unit. BHA II went to get all the people who were missing, and P#2 was not in his room. Staff began to search for P#2 and concluded that P#2 was gone. BHA II further said that BHA HH put on the observation sheet that he was on smoke break at 6:30 p.m., but BHA II met him in the hallway at 6:32 p.m. BHA II further said that SW AA said she let P#2 go back outside because BHA HH was outside smoking. The patients said the last time they saw P#2, he was outside. BHA II said the evening shift did not let anybody in or out of the unit and there was no way that P#2 left after evening shift got there. BHA EE wrote on the observation sheets that she was laying eyes on P#2 when she did not observe him. BHA II further said that P#2 was calm the day before he eloped and did not seem like a threat.

An interview took place with the charge nurse (RN) JJ on 5/9/23 at 3:10 p.m. in the Conference Room. RN JJ said it was very busy at the end of the shift. The medication nurse was busy bathing a patient and cleaning a room. RN JJ was on the phone trying to get medication for a patient. The last thing RN JJ remembered was P#2 coming inside after smoke break and leaning against a wall by the phone and nurses 'station. RN JJ got a patient to settle down and then left the unit. RN JJ was halfway home when she got a phone call from the supervisor asking if she knew where P#2 was. The supervisor called RN JJ between 7:20 p.m. and 7:30 p.m. RN JJ further said P#2 wearing street clothes when he eloped. P#2 was not on any precautions. P#2 had refused to sign paperwork and said the staff were trying to force him to take medications.

An interview took place with the Risk Manager (RM) BB on 5/9/23 at 2:00 p.m. in the Conference Room. RM BB said P#3 escaped from the van while he was being transported to the hospital. Law enforcement found him 5 days later. P#3 was in DFACS custody. RM BB further said that P#3 was being transported to the hospital on non-emergency transport for medical clearance. P#3 was not compliant with treatment and did not want to eat food or take medications. RM BB said that the transport personnel would typically take patients out on stretchers, but transport did not adhere to their policy. There were two BHA ' s with P#3. RM BB said that when a patient eloped, law enforcement would immediately be notified, and facility staff would keep an eye on the patient as long as possible. RM BB said the staff lost sight of P#3 relatively quickly. RM BB said that he was not aware of any previous elopements by P#3, but P#3 was very close to his sister and wanted to go see her.

During an interview with the Risk Manager (RM) BB on 5/10/23 at 2:05 p.m. in the Conference Room, RM BB said the trend concerned the fence. Expansion and renovation were in progress. Improvements in the fence height were suggested to corporate leadership and it would happen over the next 18 months.

An interview took place with the Chief Executive Officer (CEO) on 5/10/23 at 3:05 p.m. in the Conference Room. The CEO said that with a recent elopement, she asked staff to get quotes for improvements of the fence to send to corporate leaders. She explained that Level I and Level II incidents were typically communicated to the Governing Body through emails and phone calls. The CEO failed to confirm that elopements were being discussed during the board meetings.

A review of documents provided by the facility revealed:
Sims Fencing issued an estimate to replace/repair fencing on 5/24/23.
Sims Fencing Company issued an estimate on 5/31/23 for expansion to fencing.