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Based on observation, interview, and record review, the hospital failed to provide a safe setting for one of 30 sampled patients (Patient 3) when a door that led from the cafeteria into the kitchen was propped open. This failure enabled Patient 3 to elope (the act of leaving without supervision and without authorization) from the hospital.

Findings:

Review of Patient 3's clinical record indicated he was admitted on 2/3/25 and had diagnoses including psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with reality).

Review of Patient 3's Progress Notes, dated 2/9/25, indicated, "Patient was at dinner today and eloped from the dining room through the kitchen." The Progress Notes further indicated, "Patient was in the cafeteria and went in through the kitchen and out the maintenance door."

During an interview with the Interim Facility Risk Manager (IFRM) on 3/10/25, at 9:49 a.m., the IFRM explained Patient 3 went into the kitchen through a door that was propped open. The IFRM further explained Patient 3 was able to open two more doors because these doors did not need to be unlocked in order to be opened.

During an observation and concurrent interview with the Director of Quality and Performance Improvement (DQAPI) on 3/10/25, at 10:10 a.m., the location of Patient 3's elopement was inspected. There was a door that led from the cafeteria into the kitchen. The DQAPI confirmed that if this door was closed, it would have locked. Inside the kitchen, the was a door that led to an adjacent hallway. The DQAPI confirmed this door did not need to be unlocked in order to be opened. At the end of the hallway, there was a door that led to the outside. The DQAPI confirmed this door was not alarmed and did not need to be unlocked in order to be opened.

During an interview with Behavioral Health Associate A (BHA A) on 3/11/25, at 2:30 p.m., BHA A confirmed he was assigned to Patient 3 during the elopement incident on 2/9/25. BHA A stated Patient 3 was standing in the cafeteria waiting for lunch to be served and another patient asked BHA A for some coffee. BHA A stated he went into the kitchen to get the coffee, and when he came back into the cafeteria, he noticed Patient 3 was not there anymore. BHA A stated the door that led from the cafeteria into the kitchen was already open when staff and patients arrived in the cafeteria. BHA A confirmed this door remained open while he was in the kitchen getting coffee for another patient. BHA A confirmed this door was typically supposed to remain closed.

During an interview with the DQAPI on 3/12/25, at 9:12 a.m., the DQAPI confirmed the door that led from the cafeteria into the kitchen should not have been propped open. The DQAPI stated the hospital did not have a policy that specified this, but the safety protocol was to not leave doors propped open.

Review of the hospital's Incident Investigation Report, dated 2/17/25, indicated, "On Sunday, February 9, 2025, [Patient 3] eloped from the facility during dinner time." "The investigation revealed that the patient was able to elope from the dining hall through the kitchen, as the kitchen door had been propped open. This allowed the patient to walk out through the kitchen and into the maintenance hallway. It was determined that staff failed to monitor the door closely due to a sense of complacency, as they had become accustomed to the door being closed and did not anticipate it being left open. This lack of situational awareness contributed to the patient's ability to elope."