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Based on record review, policy and procedure review and staff interview, the governing body failed to ensure that the facility was in compliance with State of Georgia laws, the Rules and Regulations for Hospital Required Reporting under 111-8-40-.07, the facility failed to report "reportable" incidents for four (4) patients (#8, 9, 10 and A) which included elopement and unexpected death.

Findings include:
1. A review of facility records revealed, three (3) patients eloped from the facility on 5/12/2014 at 11:45 p.m.. Local law enforcement, and the guardians of the patients were immediately notified of the incident. One of the three (3) patients #9 was located on May 17, 2014, five (5) days later in Florida, the other two patients, #8, and #9 were located on May 19,2014, seven (7) days later also in Florida.
A review of facility documentation and incident reporting revealed, no evidence of a self-report to the Department of Community Health as required in Chapter 111-8-40-07 Rules and Regulations for Hospital Required Reporting, patient missing greater than eight (8) hours.
A review of facility policy and procedure, Policy # PI00.02.0 titled, "Observation Reporting of Medical Errors, Adverse, Sentinel, and Near Miss Events" revealed the facility is to report any patient that is missing for more than 8 hours to the Department.
Interview with the facility administrator on May 22, 2014 at 2:00 p.m. confirmed the above finding. The administrator stated, in the past 90 days, as of February 27, 2014 there have been no self reports sent to the Department, including the incident of elopement that occurred on May 12,2014.
2. Record review for patient "A" revealed an admission date of 5/7/2014 with diagnosis of Manor Depression, Suicidal, Alcohol Withdrawal and Prescription Drug Abuse. Continued review of the record revealed that on 5/12/2014, patient "A" was found unresponsive and expired.
3. In addition, from January 2014 to current that facility failed to report six (6) other reportable incidents.

Based on record review policy and procedure review,and staff interview the Governing Body failed to ensure that the facility was in compliance with the Condition of Participation found at 482.11 Compliance with State Laws, and 482.13 Patient Rights, Care in a Safe Setting.

Cross Reference:
482.11 Compliance with Laws
482.13 Patient RIghts

Based on observation, record review and staff interview, the facility's noncompliance with one or more requirements of participation caused potentially serious harm to three (3) patient (#8, 9 and 10) patients who eloped of ten (10) sampled patients.

Based on implementation of the AoC, including:
Action Plan related to elopement occurring on 5/12/14. The following actions are a result of several team meetings which occurred during the time period of 5/12/14 through 5/22/14.
1. The gap in the fence was repaired on 5/13/2014, and eight (8) foot fence was installed;
2. A new security system was installed on 5/20/14, which included a two (2) step process for entering and exiting the building. This included a swipe Idenitfcation bade, with a four (4) digit code to be entered to open and close the doors;
3. All staff upon arriving to the facility are being educated on the new security system, effective 5/20/14 and on-going.
The immediacy of the deficient practice was determined to have been removed as of 5/22/14. However, to ensure ongoing compliance, Condition Level noncompliance continues.

Cross Reference:
482.11 Compliance with Laws
482.12 Governing Body
482.13 (c) (2) Patients Rights: Care in Safe Setting

Based on record review and staff interview the facility failed to prevent patients from elopement for three (3) patients (#8, 9, and 10) of ten (10) sampled patients.

Findings include:

Review of facility accident and injury reports from 1/1/2014 to 5/22/2014 revealed an incident of patient elopement that occurred on 5/12/2014 at 11:45 p.m.. Three patients #8, #9, and #10 eloped from the adolescent residential unit, and left the facility grounds through a gap in the facility fencing.

The incident report revealed the following:

? The three patients were sleeping in their bedrooms last checked at 11:30 p.m. as ordered for 15 min safety checks while sleeping;
? At 11:45 p.m. the three patients ran into the hallway and obtained Mental Health Technician (MHT) #4;
? The three patients removed the ID badge of MHT #4;
? The three patients used the ID badge to open the fire exit door of the building to leave, and;
? The three patients left the facility grounds escaping through a gap in the temporary fencing surrounding the building.

The incidents reports further revealed that local law enforcement and the guardians of the patients were immediately notified of the incident. One of the three (3) patients #9 was located on May 17, 2014, five (5) days later in Florida, the other two patients, #8, and #9 were located on May 19,2014, seven (7) days later also in Florida.
A record review of facility maintenance records revealed, the facility is under construction and expansion of beds for a Certificate of Need. The fencing that the three patients eloped through was identified as temporary fencing in place with zip ties that allowed for gaps to be present and the fencing not to be secure.
A review of facility policy and procedure revealed, policy # RM 00.11.0 titled Conducting a Failure Mode Effect Analysis (FMEA) that documented the facility tool utilized to identify events, and facility failures prior to occurrence to ensure patient safety. There was no evidence that the facility utilized the FEMA tool to identify safety risks, including the gaps in the fencing that occurred during construction.
Interview while touring on 5/22/2014 at 6:15 p.m. the Director of Nursing (DON) confirmed the above findings and stated the three patients were able to elope from the facility due to a gap in the fencing created during the construction.