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Based on record review, interviews and observations, the hospital failed to ensure patients determined to be a danger to themselves or others received care in a safe setting as evidenced by:
1)failing to ensure a PEC patient (#1) was not allowed to elope from the hospital, off of hospital property, requiring police involvement, for 1 (#2) of 1 patients reviewed for elopement out of a total sample of 5 patients.
2) failing to ensure a PEC patient with a history of " cutting " and self-injury was not allowed to insert foreign objects into a pre-existing leg wound for 1 (#1) of 1 patients reviewed for self injury out of a total sample of 5 patients.
3) failing to ensure the physical environment did not provide opportunities for self-harm of the psychiatric patients determined to be a danger to themselves or others.

Findings:
1) Failing to ensure a PEC patient was not allowed to elope from the hospital, off of hospital property, requiring police involvement.

Review of the hospital policy titled, Levels of Patient Observation, Policy Number: PC-1013, effective 01/18/12, revealed in part: Purpose: To maintain safety of each patient and the stability of the therapeutic milieu. The degree of this monitoring is dependent upon the individual patient ' s assessed psychiatric condition.
Procedure: The charge RN, in conjunction with other staff providing direct patient care, is responsible for assessing the observation status of all patients and increasing the level of observation when required, until Physician ' s orders can be obtained. Any decrease in observation level requires a physician ' s order prior to decrease in status. All patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation.
A) Routine level of Observation: 1. All patients are monitored a minimum of once every fifteen minutes. 2. Location of patients is monitored at each change of shift by a staff member from the off going shift together with a member of the on-coming shift. Location is noted on the observation sheet for appropriate shift.
B) Special Levels of Observation: An increased degree of monitoring is applied to patients whose psychiatric conditions is assessed as needing more intense external controls and/or increased frequency of staff contact for patients to be able to maintain their internal controls. Patients assessed as needing any of the following increased levels of observation are to be maintained in the hospital.

Review of the hospital ' s policy titled, Elopement Precautions. Policy Number: PC-1015, effective date: 10/18/12, revealed in part:
Policy: Patients that are at high risk for elopement will be placed on elopement precautions at the order of their attending physician.
Procedure: 1) A patient is placed on elopement precautions by the physician on admission or anytime during hospitalization when there is an indication that the patient is high risk. 2) The patient is restricted to the safe environment. 3) Patients placed on elopement precautions will have every 15 minute observation documented.

Review of the hospital ' s incident reports revealed a report documenting Patient #2 ' s elopement from the hospital on 9/11/16 at 8:20 a.m. (7 hours after admission to the hospital).

Review of Patient #2 ' s medical record revealed the patient was admitted on 9/11/16 at 1:20 a.m. with an admission diagnosis of psychosis. Further review revealed the patient was PEC on 9/10/16 at 8:05 a.m. (prior to admission to this hospital) due to being a danger to self, gravely disabled, and unable to seek voluntary admission. Additional review of Patient #2 ' s record revealed an admission order for the patient to be placed on every fifteen minute observations. The patient was not on elopement precautions.

Review of Patient #2 ' s admission nurses note dated 9/11/16 at 1:30 a.m. revealed in part: Patient is a 25 y/o African American male that was transferred from a hospital in New Orleans. Patient was brought to ER by his mother and grandmother for increasing bizarre behavior. He is reported to have not slept for 2-3 days. His mother says that he tried to jump out of a moving car and that he thinks " it is all going to end " . He asked his grandmother to remove all of the pills out of her house because he is afraid of what he might do. The patient was very tearful on admission to this facility. He was calm one moment and very upset the next.
Further review of Patient #2 ' s nursing notes revealed the following entry dated 9/11/16 at 7:46 a.m.: Pt. in dayroom. Pt. reports " I attempted to commit suicide by drinking a whole bottle of wine and taking melatonin, but right after I told my Mom. I also tried to get out of car, but I jumped back, too. I don ' t know if I really want to die or if I am doing it for attention. Pt. verbally contracts for safety. Pt. rates depression 4/10 and anxiety 10/10. Pt. reports having racing thoughts. Pt. reports " I did not sleep last night " will continue to monitor pt. for safety and changes in condition.

Review of the observation sheets for Patient #2, dated 9/11/16, revealed observations of Patient #2 were being documented every 15 minutes. Further review revealed the patient had been documented as being in the dining room immediately prior to elopement from the hospital at 8:20 a.m.

Review of the hospital ' s investigation/root cause analysis of the patient elopement revealed the following account of the incident, in part:
9/11/16 8:20 a.m.: Patient #2 had been in the hospital's dayroom, completing breakfast when he began asking S11MHT when he could go outside and how he could obtain a key to go outside. Further review revealed the patient told S11MHT he needed " that thing (door key card on a lanyard) around her neck ". S11MHT explained to Patient #2 that patients did not get a key. The patient grabbed the lanyard from the MHT's neck and ran to a porch exit, was stopped by 2 other patients, then turned and ran towards unit doors, swiped the key card and ran out the front door of the hospital. S6RN and S11MHT chased the patient as well as 2 other patients trying to catch the eloping patient. S6RN and S11MHT redirected the 2 patients back onto the unit. Patient #2 ran across the road towards a gas station and was then out of sight.
8:23 a.m.: S9LPN called the sheriff 's department to notify them of the elopement. A sheriff ' s deputy called S6RN shortly thereafter to advise that Patient #2 was at the gas station across the road and that 2 officers were en route. At this point the law enforcement officers apprehended the patient. A sheriff 's deputy notified S9LPN that the patient would be taken to the ED and then arrested as this was a felony.

Review of Patient #2's arrest report from the area sheriff ' s department revealed the patient had been arrested for carjacking, aggravated battery in the 2nd degree, theft (less than $750), and simple battery.

In an interview on 9/27/16 at 1:11 p.m. with S1IntCEO, she confirmed Patient #2 had eloped on 9/11/16 (a Sunday morning). She said the administrative staff conducted a verbal walk-through of the situation. She indicated the conclusion was that the patient had been watching staff, inquiring about keys /badges, asking about going outside to smoke. She said the patient had grabbed the key card lanyard from around S11MHT's neck in order to elope from the hospital. S1IntCEO indicated staff had called 911 to ask police for assistance in getting the patient back. She indicated the patient had been apprehended, arrested and taken to jail, according to the communication from the police department and information in Patient #2's arrest report. She confirmed the patient had not returned to the hospital after his arrest. S1IntCEO said staff training needs were identified in the analysis of Patient #2's elopement. S1IntCEO indicated staff needed additional training in securing of key cards, recognizing signs of elopement /elopement precautions and methods for staff to call for assistance.

In an interview on 9/27/16 at 1:37 p.m. with S2DON, she confirmed Patient #2 had eloped from the hospital on 9/11/16. S2DON also confirmed Patient #2 had obtained S11MHT's lanyard with her keycard from around the MHT's neck and had used the card to elope from the hospital. S2DON indicated staff had been instructed to call the police and to not chase eloping patients on foot. S2DON confirmed Patient #2 had not returned to the hospital for treatment after his elopement and subsequent arrest on 9/11/16.

In an interview on 9/28/16 at 9:26 a.m. with S6RN, she indicated she remembered Patient #2. She confirmed Patient #2 had eloped from the hospital on 9/11/16. S6RN indicated she was charge nurse on the day of the elopement. S6RN said at around 8:20 a.m. Patient #2 kept asking S11MHT about going out to smoke on the back patio. She said he was asking questions such as, "how do you get out of here" and "where do I get a key". S6RN also reported Patient #2 grabbed at S11MHT's keycard lanyard. S6RN said Patient #2 grabbed S11MHT's keycard lanyard as she was turning around to get away from him. S6RN said Patient #2 ran to the back patio door and 2 other patients tried to stop him. S6RN indicated she was running after Patient #2 and S11MHT was knocking on the front window of the nurses ' station to get help. S6RN said Patient #2 swiped the keycard, opened the double doors (entry to inpatient unit), exited and was past the hospital's main double doors by 8:23 a.m. S6RN said she had to stop to turn the patients trying to keep Patient #2 from eloping around to get them back into unit. S6RN said S9LPN called the police and S2DON was also called to notify her of Patient #2's elopement. S6RN said at 8:30 a.m. a deputy from the sheriff's department called and told them the patient was at the gas station and 2 officers were en route. S6RN reported the sheriff's department called at 8:43 a.m. to report the patient was in custody and possibly going to jail. S6RN further reported that at 8:49 a.m. the sheriff's department called the hospital and confirmed the patient had been arrested and was going to jail. S6RN indicated prior to his elopement Patient #2 had been on every 15 minute observations and had not been on elopement precautions or suicide precautions.

In an interview on 9/28/16 at 10:23 a.m. with S11MHT, she indicated she remembered Patient #2. S11MHT confirmed the patient had eloped from the hospital. S11MHT indicated she had been getting a breakfast plate for a new patient when Patient #2 had begun asking when they were going outside to smoke. S11MHT said Patient #2 was standing in front of her and he asked her for a key. S11MHT said she told the patient only staff had keys. S11MHT said Patient #2 had grabbed at her shirt and asked if that was the key around her neck. S11MHT indicated the patient grabbed the keycard/lanyard from around her neck when she turned around to get away from him and ran to the back patio door. S11MHT said she knocked on the nursing station window and yelled for help, alerting the nursing staff that the patient was attempting to elope. S11MHT said Patient #2 tried to exit out of the back door and when he couldn ' t get out that way he turned and went out main doors. S11MHT confirmed the patient eloped off of the property and had not returned because he had gone to jail.

2) Failing to ensure a PEC patient with a history of "cutting " and self-injury was not allowed to insert foreign objects into a pre-existing leg wound.

Review of Patient #1 ' s medical record revealed an admission date of 9/17/16 with admission diagnoses including Depression, PTSD, and Social Anxiety Disorder. Further review revealed the patient ' s legal status was PEC (9/16/16 at 4:56 p.m.). Review of the PEC documentation revealed in part: History of Present illness: Pt. cut right leg again and stuck a metal woodscrew in it. Mental condition: Positive for depression, angry, suicidal with a plan to kill self, no hallucinations and no delusions.

Further review of Patient #1 ' s medical record revealed the patient had been transported to an area hospital on 9/18/16 (the day after his admission to this hospital on 9/17/16) for evaluation and treatment due to the patient stabbing himself with a broken plastic spoon and then inserting the pieces of the spoon into his pre-existing right leg wound. The patient had been on every 15 minute observations when the incident on 9/18/16 occurred.

On 9/26/16 at approximately 1:00 p.m. Patient #1 was observed being taken out of the hospital via ambulance.

On 9/26/16 at 1:05 p.m. an observation was made of Patient #1 ' s room (Room 101). The room was noted to have non-tamper resistant screws in the light switches located beside each bed, on the wall at room entry, and in the bathroom. There was also a solid metal faceplate near the floor in the bathrooms that did not have tamper resistant screws. Further observation revealed the screws in the deadbolt lock plate and the bathroom door closure plate also had screws that were not tamper resistant.

In an interview on 9/26/16 at 1:10 p.m. with S5RN, Charge nurse, she indicated Patient #1 was being transferred to the hospital for evaluation and treatment because he had stuck a pencil in a pre-existing wound in his leg while he was in the shower. She said Patient #1 had been irritable and became upset during treatment team. S5RN indicated the patient was on every 5 minute observations but had previously been on 1:1 precautions previously due to suicidal ideation. S5RN indicated patients are accompanied by MHTs while they are showering no matter what level of observation the patient is on. S5RN said the MHTs sit in a chair, outside the shower, while patients are in the shower. She indicated she did not have any idea how the patient had gotten the pencil into the shower.

On 9/27/16 at 8:35 a.m. an interview was conducted with S1IntCEO and S2DON. During the interview S2DON confirmed Patient #1 had self injured with a wood screw prior to his admit and had stuck a broken plastic spoon in his leg on 9/18/16 (the next day after his admission). S2DON also confirmed Patient #1 had stuck a pencil in his pre-existing leg wound while showering on 9/26/16. S2DON indicated Patient #1 had been on every 5 minute observations when he stuck the pencil in his leg, in the shower. S2DON indicated the MHTs sit facing sideways in the shower room while the patient is showering to give them some privacy unless the patients are on line of sight or 1:1 observation. S2DON confirmed the showers have no curtains. S2DON was puzzled as to how the patient smuggled a pencil into the shower. S2DON confirmed patients are given pencils during group. S1IntCEO said the pencils are counted before and after they are given to patients and she is not sure how the patient managed to keep a pencil unless he is putting things in a body cavity. S2DON indicated staff counted pencils after group but could provide no documented evidence of staff maintaining counts of pencils. She confirmed the staff was not documenting pencil/pen counts.


In an interview on 9/27/16 at 8:46 a.m. with S13MHT, (assigned to the Patient #1 on 9/26/16)
she confirmed she had been assigned to observe Patient #1. She confirmed Patient #1 had been on every 5 minute observations. She indicated she was with Patient #1 in the shower room when he stuck the pencil in his leg wound. She said she was seated in a chair outside the shower. S13MHT indicated she was constantly talking to the patient. She indicated the patient had disrobed in the shower and had put his clothing on the floor right at the shower entrance. S13MHT reported she had asked, " Mr.(Patient #1) are you alright? " and he responded, " I ' m ok " , she said she told him, " when you are done with your shower the nurse will dress your leg " , she said patient said, " where is the nurse who is going to dress my leg because it is bleeding " She said when the patient said that he was leaning out the shower talking to her and she didn ' t see his leg, but the towel on the floor had a little blood on it. S13MHT said the nurse came to assess the wound. S13MHT indicated she had checked Patient #1 earlier in the day, because he was isolating, sitting by himself. She indicated she had patted his pockets and there was no pencil. S13MHT further indicated she was not sure where Patient #1 had hidden the pencil.


3) Failing to ensure the physical environment did not provide opportunities for self-harm of the psychiatric patients determined to be a danger to themselves or others.

On 9/28/16 from 9:10 a.m.-9:20 a.m. an observation was made on inpatient rooms 101, 107 and 104. The following findings were noted in all 3 rooms: light switches located beside each patient bed, on the wall at room entry, and in the bathrooms had screws that were not tamper resistant. There was also a solid metal faceplate near the floor in the bathrooms that did not have tamper resistant screws. Further observation revealed the screws in the deadbolt lock plate and the door locking mechanism plate also had screws that were not tamper resistant.


In an interview on 9/28/16 at 9:20 a.m. with S6RN, who was present during the observations, she confirmed the above referenced findings. She indicated all 8 of the hospital ' s patient rooms had the same hardware. She agreed the screws could provide a method for self harm or injury to patients admitted for being a danger to themselves or others.

Based on record reviews and interviews, the hospital failed to ensure a physical restraint used in a patient's care to administer an IM (intramuscular) injections as ordered by the nurse practitioner when the patient exhibited violent/destructive behavior was identified as a restraint for 1 of 1 (#3) patient who required a physical restraint during administration of an IM injection out of 5 sampled patients.

Findings:
A review of the hospital policy titled "Restraints and Seclusion", as provided by S2DON as the most current, revealed in part: A restraint is any manual method, physical or mechanical that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely. A physical hold is considered a restraint and requires adherence to the restraint policy and procedure.

A review of Patient #3's medical record revealed on 7/17/16 at 7:20 p.m., the patient began exhibiting threatening behavior to staff to include hollering, screaming, verbal treats, throwing objects and kicking staff with no success to calm the patient after multiple attempts of redirection. The nurse practitioner was notified and ordered an IM injection NOW. A further review of the patient's medical record revealed the patient required physical restraint using Edge technique to administer the IM medication.

In an interview on 9/26/16 at 2:50 p.m. with S2DON she indicated that the hospital had a restraint log book and that there were no recorded restraints in the log book for 2016. She further indicated that physical/therapeutic holds were not considered a physical restraint since it was only for a limited amount of time in order to give an IM injection safely to a patient exhibiting violence and/or destructive behavior. After reviewing the above hospital policy with S2DON, she indicated that a physical hold was considered a restraint.

Based on record reviews and interview the hospital failed to ensure the use of restraint was in accordance with a written modification to the patient's plan of care as evidenced by failure to have 1 of 1 (#3) patient's care plan revised for the use of restraints out of 5 sampled patient medical records reviewed.

Findings:
A review of the hospital policy titled "Restraints and Seclusion", as provided by S2DON as the most current, revealed in part: A restraint is any manual method, physical or mechanical that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely. A physical hold is considered a restraint and requires adherence to the restraint policy and procedure. A further review of the policy revealed in part: When restraint is used, there must be revisions to the care plan.

A review of Patient #3's medical record revealed on 7/17/16 at 7:20 p.m., the patient began exhibiting threatening behavior to staff to include hollering, screaming, verbal treats, throwing objects and kicking staff with no success to calm the patient after multiple attempts of redirection. The nurse practitioner was notified and ordered an IM injection NOW. A further review of the patient's medical record revealed the patient required physical restraint using Edge technique to administer the IM medication.

A review of Patient #3's care plan revealed no documented evidence that it was modified when restraints were initiated.

In an interview on 9/27/16 at 11:45 a.m. with S2DON she reviewed Patient's #3 care plan/treatment plan and indicated that there was no documented evidence that the plan had been revised to include a modification when the physical restraint was used on Patient #3. She indicated that the plan of care should have been revised after the use of a physical restraint.

Based on record reviews and interview the hospital failed to ensure when restraints were used for the management of violent/destructive behavior, the patient was seen face-to-face within 1 hour after the initiation of the intervention by a physician, nurse practitioner or trained registered nurse for 1 of 1 (#3) patient out of 5 sampled patients.

Findings:
A review of the hospital policy titled "Restraints and Seclusion", as provided by S2DON as the most current, revealed in part: A restraint is any manual method, physical or mechanical that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely. A physical hold is considered a restraint and requires adherence to the restraint policy and procedure. A further review of the policy revealed in part: When restraint is used for the management of violent/destructive behavior, the patient must be seen face-to-face within one hour by a physician, nurse practitioner or trained registered nurse.

A review of Patient #3's medical record revealed on 7/17/16 at 7:20 p.m., the patient began exhibiting threatening behavior to staff to include hollering, screaming, verbal treats, throwing objects and kicking staff with no success to calm the patient after multiple attempts of redirection. The nurse practitioner was notified and ordered an IM injection NOW. A review of the patient's medical record revealed the patient required physical restraint using Edge technique to administer the IM medication. A further review of the patient's medical record revealed no documented evidence of a face-to-face within one hour by a physician, nurse practitioner or trained registered nurse after the use of the physical restraint.

In an interview on 9/27/16 at 11:45 a.m. with S2DON she reviewed Patient's #3 medical record and indicated that there was no documented evidence that a face-to-face within one hour was conducted by a physician, nurse practitioner or trained registered nurse after the use of the physical restraint, as required by hospital policy.

Based on record review, observation, and interview, the hospital failed to ensure each patient had an individualized, comprehensive treatment plan as evidenced by failure of the hospital to address a patient's (#1) self injurious behavior of "cutting" and inserting foreign objects into a pre-existing leg wound in the patient's master treatment plan for 1 (#1) of 5 sampled patient records reviewed.

Findings:

Review of Patient #1's medical record revealed an admission date of 9/17/16 with admission diagnoses including Depression, PTSD, and Social Anxiety Disorder. Further review revealed the patient's legal status was PEC (9/16/16 at 4:56 p.m.). Review of the PEC documentation revealed in part: History of Present illness: Pt. cut right leg again and stuck a metal woodscrew in it. Mental condition: Positive for depression, angry, suicidal with a plan to kill self, no hallucinations and no delusions.

Further review of Patient #1 ' s medical record revealed the patient had been transported to an area hospital on 9/18/16 (the day after his admission to this hospital on 9/17/16) for evaluation and treatment due to the patient stabbing himself with a broken plastic spoon and then inserting the pieces of the spoon into his pre-existing right leg wound.

On 9/26/16 at approximately 1:00 p.m. Patient #1 was observed being taken out of the hospital via ambulance for evaluation and treatment due to the patient stabbing himself (while showering) with a pencil in the pre-existing wound in his right leg.

In an interview on 9/26/16 at 1:10 p.m. with S5RN, Charge nurse, she indicated Patient #1 was being transferred to the hospital for evaluation and treatment because he had stuck a pencil in a pre-existing wound in his leg while he was in the shower.

Review of Patient #1's master treatment plan revealed no documented evidence of interventions to address/prevent the patient's self injurious behavior of "cutting" and inserting foreign objects into a pre-existing leg wound in the patient's master treatment plan.

On 9/27/16 at 8:35 a.m. an interview was conducted with S2DON. During the interview S2DON confirmed Patient #1 had self injured with a wood screw prior to his admit and had stuck a broken plastic spoon in his leg on 9/18/16 (the next day after his admission). S2DON also confirmed Patient #1 had stuck a pencil in his pre-existing leg wound while showering on 9/26/16. S2DON confirmed Patient #1's self injurious behavior had not been addressed on his master treatment plan prior to the incident on 9/26/16 when he stuck the pencil in his leg (second time since admission the patient had stuck a foreign object in his leg). S2DON confirmed the behaviors should have been addressed on the patient plan of care.

Based on record review, observation and interview, the hospital failed to ensure active treatment measures were initiated and documented in patient treatment plans to assure that the patient achieved his/her optimal level of functioning. This deficient practice was evidenced by failure of the hospital to document interventions to address/prevent a patient's (#1) self injurious behavior of "cutting" and inserting foreign objects into a pre-existing leg wound in the patient's master treatment plan for 1 (#1) of 5 sampled patient records reviewed. .

Findings:

Review of Patient #1's medical record revealed an admission date of 9/17/16 with admission diagnoses including Depression, PTSD, and Social Anxiety Disorder. Further review revealed the patient's legal status was PEC (9/16/16 at 4:56 p.m.). Review of the PEC documentation revealed in part: History of Present illness: Pt. cut right leg again and stuck a metal woodscrew in it. Mental condition: Positive for depression, angry, suicidal with a plan to kill self, no hallucinations and no delusions.

Further review of Patient #1's medical record revealed the patient had been transported to an area hospital on 9/18/16 (the day after his admission to this hospital on 9/17/16) for evaluation and treatment due to stabbing himself with a broken plastic spoon and then inserting the pieces of the spoon into his pre-existing right leg wound.

On 9/26/16 at approximately 1:00 p.m. Patient #1 was observed being taken out of the hospital via ambulance for evaluation and treatment due to the patient stabbing himself (while showering) with a pencil in the pre-existing wound in his right leg.

In an interview on 9/26/16 at 1:10 p.m. with S5RN, Charge nurse, she indicated Patient #1 was being transferred to the hospital for evaluation and treatment because he had stuck a pencil in a pre-existing wound in his leg while he was in the shower.

Review of Patient #1's master treatment plan revealed no documented evidence of interventions to address/prevent the patient's self injurious behavior of "cutting" and inserting foreign objects into a pre-existing leg wound.

On 9/27/16 at 8:35 a.m. an interview was conducted with S2DON. During the interview S2DON confirmed Patient #1 had self injured with a wood screw prior to his admit and had stuck a broken plastic spoon in his leg on 9/18/16 (the next day after his admission). S2DON also confirmed Patient #1 had stuck a pencil in his pre-existing leg wound while showering on 9/26/16. S2DON confirmed Patient #1's self injurious behavior had not been addressed on his master treatment plan prior to the incident on 9/26/16 when he stuck the pencil in his leg (second time since admission the patient had stuck a foreign object into his leg). S2DON confirmed the behaviors should have been addressed on the patient plan of care.