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Based on record review and interview, the psychiatric hospital failed to provide care in a safe setting. This deficient practice is evidenced by:
1) failure to observe/monitor patient per physicians orders in 1 (#3) of 3 (#1-#3) medical records reviewed;
2) failure to implement elopement precautions as per hospital policy in 1 (#3) of 1 (#3) patients reviewed for elopement precautions;
3) failure to implement seizure precautions as per hospital policy in 1 (#3) of 1 (#3) patients reviewed for seizure precautions.
Findings:

1) Failure to observe patient per physicians order in 1 (#3) of 3 (#1-#3) medical records reviewed.
A review of psychiatric hospital policy titled "Levels of Observation" revision 09/25/2020, revealed, in part: Policy, in part: Note: The level of Observation may never be decreased without an order from an authorized licensed prescriber. Electronically Enhanced Observation, in part: ...both Line of Sight and 1:1 Observation require continuous observation ...Procedure, in part: Upon admission or when warranted by a change in the patient's condition, a registered nurse may assign a Level of Observation, followed immediately by obtaining an order for a Level of Observation from an authorized licensed prescriber. The Level of Observation may never be decreased without an order from an authorized licensed prescriber. Line of Sight, in part: Line of sight is defined as maintaining visual observation of a patient at all times.

Review of Patient #3's medical record revealed a document titled "Orders for Patient #3", start date 10/06/2023 at 10:22 a.m.; discontinued on 10/07/2023 at 22:33 p.m. Continued review revealed order #6 which read as follows: Line of Sight Daily, Request Type: Now, Comments: Line of sight monitoring until discontinued by physician.

Review of Patient #3's medical record revealed a document titled "Behavioral Health-Patient Observation Sheet", dated 10/06/2023. Further review revealed a notation stating Patient checked in on 10/06/2023 at 10:35 a.m. with an observation interval of every 15 minutes.

Review of Patient #3's medical record revealed a document titled "Note Discipline: Licensed Practical Nurse", dated 10/07/2023 at 4:00 p.m. Further review revealed the following note: It was noticed during the 15-minute rounding that patient was not in her room. Patient was not in the facility and had eloped around 3:50 p.m. Coroner found patient and brought her back to facility at 4:10 p.m. At 4:50 p.m., Patient noted running down hall and busted open back door and left facility. Sheriff's Office A contacted, patient was brought back to facility.

Review of Patient #3's medical record revealed a document titled "Note Discipline: Registered Nurse", dated 10/07/2023 at 5:28 p.m. Further review revealed the following note: At around 3:50 p.m. on every 15-minute rounding patient was noted not in facility. Patient eloped from facility around 3:50 p.m., patient was found by coroner around 4:10 p.m. and brought back to facility.

In an interview on 11/06/2023 at 11:28 a.m., S1DON confirmed there was no evidence that this patient was on line of sight precautions as ordered by physician. S1DON stated the patient should not have been on every 15-minute rounding as noted in medical record but should have been on line of sight observation level as per physician order.

2) Failure to implement elopement precautions as per hospital policy in 1 (#3) of 1 (#3) patients reviewed for elopement precautions.
Review of psychiatric hospital document titled" Precautions", revised 03/21/2028, revealed, in part: Standardized Precautions used by Hospital include, in part: Elopement. Note: Precautions may never be discontinued without an order from an authorized licensed prescriber. Elopement precautions, in part: applied when a patient presents a risk of eloping (i.e. leaving without authorization) from the hospital or an area within the hospital. The following are components of Elopement Precautions, in part: Unit Restriction ...In the event that the patient must leave the unit the patient will be placed on at least 1:1 Observation when off the unit (2:1 Observation should be considered if the patient is physically strong and /or highly motivated to elope). 1-Foot Door Parameter-A patient on Elopement Precautions must remain at least 10 feet away from any access door on the unit.

Review of psychiatric hospital document titled "Hospital /Licensed Provider Abuse/Neglect Initial Report", dated 10/07/2023, revealed in part: Patient #3 eloped at 4:30 p.m. on 10/07/2023. Patient eloped again after powering through maglock door. Patient was pursued, obtained, and returned to the facility. Patient was placed in seclusion and medicated per orders. Patient soon after busted through the locked seclusion room door and ran to the exit door and powered through. Staff contacted the police for assistance and pursued looking though the area for patient. Search was conducted by staff, and local law enforcement, Sheriff's office A and Police Department B. Search by Sheriff's Office C, patient found safely with her mother and taken to local hospital for evaluation. Director of Plant ops contacted and on site to evaluate external door access for proper operation.

Review of Patient #3's medical record revealed a document titled "Orders for Patient #3" dated 10/06/2023, 10:21 a.m.-10/07/2023, 10:33 p.m. Further review failed to reveal Elopement Precautions were ordered and implemented following her first elopement on 10/07/2023 at 3:50 p.m..

In an interview on 11/06/2023 at 11:30 a.m., S1DON verified that documentation failed to reveal evidence Elopement Precautions were implemented as per policy. S1DON stated Elopement Precautions should have been implemented as per hospital policy immediately following the return of Patient #3 after her first elopement at 3:50 p.m. on 10/07/2023.

3) Failure to implement seizure precautions as per hospital policy in 1 (#3) of 1 (#3) patients reviewed for seizure precautions.
Review of psychiatric hospital document titled" Precautions", revised 03/21/2028, revealed, in part: Standardized Precautions used by Hospital include, in part: Seizure. Seizure Precautions are typically ordered for patient that have documented or verbalized) diagnoses of seizure disorders (such as Epilepsy) ...

Review of Patient #3's medical record revealed Patient #3 admitted on 10/06/2023 at 10:21 a.m. and discharged on 10/07/2023 at 10:33 p.m. after eloping to her mother's home. Further review revealed a document titled "History and Physical Examination" dated 10/07/2023 at 8:27 a.m. Further review revealed patient's past medical history included epilepsy and seizures. Patient reported before admission being hit across the head by her stepfather's hand, resulting in lightheadedness. Continued review revealed physician recommendations stating the following, in part: Seizures: Home Depakote and Seizure Precautions.

Review of Patient #3's medical record revealed a document titled "Orders for Patient #3" dated 10/06/2023, 10:21 a.m.-10/07/2023, 10:33 p.m. Further review failed to reveal Seizure Precautions were ordered and implemented.

In an interview on 11/06/2023 at 11:28 a.m. S1DON confirmed there was no evidence that this patient, diagnosed with seizures, was on seizure precautions. S1DON further stated the patient should have been on seizure precautions.

Based on record review and interview, the psychiatric hospital failed to obtain a physician's order for the use of the seclusion room for 1 (#3) of 1 (#3) patients reviewed for use of the seclusion room.
Findings:

Review of psychiatric hospital document titled, "Restraint or Seclusion", revised 03/21/2018 revealed, in part: Policy, in part: The use of ...Seclusion requires an order from an authorized licensed prescriber. Procedure, in part: 3. The registered nurse ensures that an order has been obtained from an authorized licensed prescriber and that all documents are accurately initiated.

Review of Patient #3's medical record revealed an admit date of 10/06/2023 with a primary diagnosis of Suicidal Ideations, Seizures, and Schizoaffective disorder, bipolar type.

Review of Patient #3's medical record revealed a document titled "Note Discipline: Registered Nurse" dated 10/07/2023 at 5:45 p.m. Further review revealed the following: Patient was noted using her body to ram up against seclusion door. Patient took 3 steps back 3 times then used her body to bust open the seclusion door. Once out of seclusion patient was not able to be redirected. Patient then proceeded past nurses station, started to run fast then busted out of back door that she had previously eloped out of within the last hour.

Review of Patient #3's medical record revealed a document titled "Orders for Patient #3" dated 10/06/2023, 10:21 a.m.-10/07/2023, 10:33 p.m. Further review of "Orders for Patient #3" failed to reveal physician orders for the use of the seclusion room.

In an interview on 10/06/2023 at 12:17 p.m., S1DON confirmed there was no order for Patient #3 for the use of the seclusion room and that there should have been an order obtained before patient was placed in seclusion.