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Based on record review and staff interviews, it was determined that the hospital failed to ensure housekeeping personnel followed standard patient safety practices relative to patients leaving a unit unattended which resulted in a patient eloping from the hospital against medical advice for 1 of 4 patients reviewed for elopement, (Patient ID #1).

Findings are as follows:

On 11/12/2024, the Rhode Island Department of Health received a report from the hospital which indicated that on 11/7/2024, a patient eloped from the hospital after a housekeeper opened the unit door and allowed the patient to leave the unit.

Record review revealed that Patient ID #1 presented to hospital in November of 2024 seeking detox and was subsequently admitted on a voluntary basis. His/her diagnoses include, but are not limited to, alcohol use disorder, methamphetamine use disorder and marijuana use.

On 11/7/2024, the patient's record indicated she/he was on 15-minute safety checks with physician orders indicating she/he was restricted from leaving the unit.

Record review of nursing progress notes from 11/7/2024 revealed that the patient was agitated and wanted to leave. Additionally, the note indicated that the patient had been pacing on the unit and was observed by staff near a doorway telling staff to let him/her out.

Further review of nursing progress notes from 11/7/2024 revealed that the Charge Nurse was informed by staff at 11:16 AM that Patient ID #1 could not be located on the unit during the 11:15 AM observation checks and that a housekeeper had allowed the patient to leave the unit when she opened the door to the unit.

During a surveyor interview on 11/19/2024 at 11:42 AM with Employee A, Mental Health Worker, she revealed that on 11/7/2024 at around 11:00 AM, she was conducting observation checks when she noticed that Patient ID #1 was gathering his/her belongings. Employee A then stated that at 11:08 AM, she asked the nurse if the patient was being discharged to which the nurse replied that the patient was not. Employee A indicated that she then was unable to locate the patient during the 11:15 AM observation checks after checking all areas of the unit. Employee A stated that she had seen the Housekeeper "come in and out of the unit" multiple times and asked the Housekeeper if she had seen the patient to which the Housekeeper replied that the patient left the unit as "[she/he] was all set to go."

During a surveyor interview on 11/19/2024 at 10:38 AM with Employee B, Housekeeper, she revealed that on 11/7/2024 she entered the unit through the main double doors and heard the patient say, "bye" as she/he exited through the doors. Employee B indicated that she did not say anything to the patient as she/he exited because she thought she/he had been discharged. When asked if it is routine for nursing staff not to walk out of the unit with patients upon discharge, she stated that nursing staff only do this "sometimes."

During a surveyor interview on 11/19/2024 at approximately 11:15 AM with the Nurse Director of D3, Employee C, she stated that upon discharge, patients are always escorted out of the unit by nursing staff since they have to open the door for the patient to exit.

During a surveyor interview on 11/19/2024 at 11:15 AM with Employee D, Housekeeper, outside of the D3 unit, she revealed she heard about the patient elopement from other staff and indicated that her managers did not personally talk to her about what to do or what not to do upon entering a patient unit. When asked what precautions she is taking specific to ensuring no patients elope form the unit, she stated that the day after the elopement occurred, her and other Housekeeping staff would follow behind one another when entering the unit, but they do not do this anymore.

Following the above-mentioned interview, another Housekeeper, Employee E, was observed entering the D3 unit through the main double doors at 11:18 AM using his own fob key, to electronically unlock the doors.

During a surveyor interview with Employee E on 11/19/2024 at approximately 11:35 AM, he indicated that he has been instructed to ring the doorbell upon entering the unit via the main double doors and acknowledged that earlier, he did not ring the doorbell to enter the unit via the double doors as expected.

During a surveyor interview on 11/19/2024 at approximately 1:20 PM with Employee F, Environmental Services Manager, he revealed that Housekeeping staff have been told numerous times not to let anyone out of the unit as they are entering the unit unless that person has a hospital badge and stated that this has been their usual practice. In addition, Employee F indicated that Housekeeping staff have been instructed to always use the employee entrance, not the main double doors, to enter the units unless they have a cart or big equipment for which they would have to ring the doorbell and wait for staff to let them in.