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Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to ensure patients received care in a safe setting as evidenced by failure to mitigate known elopement risks by failing to secure air conditioner units in patients' rooms to ensure they could not be removed to allow a route to elope for 6 (#R1, #R2, #1, #2, #3, #4) of 6 patients reviewed who had eloped through removal of AC units, failing to ensure exterior windows were not breakable allowing elopement of 1 (#5) of 1 patients reviewed who had eloped by breaking a window, and by failing to prevent a patient elopement by jumping a fence which surrounded an exterior patient area for 1 (#6) of 1 total patients reviewed who had eloped by jumping a fence; (See findings under tag A-0144).


An Immediate Jeopardy situation was identified on 11/19/18 at 5:02 p.m. and reported to S1Adm and S2DON. The Immediate Jeopardy situation was a result of the hospital failing to prevent elopements and failure to mitigate known elopement risks for patients admitted for being a danger to themselves or others.


On 11/20/18 at 10:00 a.m. S1Adm presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:

1. Installation of metal straps to all air conditioners to be completed before 11/21/2018.

2. Maintenance staff will add an extension to the Unit #1 smoking deck gate to be completed on 11/20/2018.

3.Maintenance staff will lower the AC in the Unit # 2 exam room where it cannot be used as an elopement point in the smoking area to be completed by 11/20/2018.

4. Maintenance staff will install anti-ligature safety deadbolts without an internal locking mechanism to all rooms that can be locked when rooms are unoccupied for safety reasons.

5. Administrators will begin conducting administrative rounds on each shift. These rounds will be to assess the general safety of the hospital environment. These rounds will include observing Q15 minute checks to ensure they are being performed correctly, monitoring rooms to ensure that patients are only in designated areas, monitoring the physical environment to ensure that environmental risks are mitigated (e.g. ligature points, elopement risks), monitoring of elopement precautions to ensure that they are being conducted, and ensuring that all rooms that are unoccupied are locked.

6.Effective immediately, November 19, 2018. there must always be two technicians when escorting patient to smoke/clean air breaks and the cafeteria.

7.Effective 11/19/18 Patients on elopement precautions will not be allowed in the smoking patio area. Patients who have attempted elopement will be evaluated for 1:1 patient observation. All patients that sign a 72 hour request for discharge will be classified as an elopement risk. Like other high risk patients, they will not be allowed onto outside decks.


8. 11/20/18 educational in-services will be held for all nursing staff, licensed and non-licensed, to discuss the elopement policy, precautions and prevention of patient elopement. Identification of patients on elopement precautions will be identified on the patient's bed board, reported during the nurse to nurse report, and "Elopement" will be stamped on the Patient Observation 15 minute flow sheet.

9. An Elopement Risk Assessment policy and Elopement Risk Assessment form was developed and approved by Corporate for immediate implementation on 11/19/18. The Elopement Risk Assessment will determine the level of elopement risk of patients and patients will be placed on Elopement precautions and 1:1 Observation depending on the level of risk.

10. RN Supervision of MHT Patient Observation revised to require an RN to supervise the MHT by performing random checks, every 2 hours, on the flow sheet by initialing the form to ensure that the MHT is providing patient observation as ordered by the physician.

11. On 11/20/18 all Nursing staff were re-educated regarding compliance with the completion of MHT Flow sheet for patient observation per the physician order. Educational in services and re-trainings were held to ensure that patient observation is completed by staff every 15 minutes and/or per the physician order and the MHT must document appropriately on the flow sheet. The Director of Nursing will perform random chart reviews to ensure that the RN is providing supervision of MHT's observations of patients per physician order.

12. Staff will be reeducated on elopement precautions, ligature risks, and securing of the physical environment (e.g., locking doors of unoccupied rooms.).

13.One additional staff person will be brought to perform patient checks and to monitor and observe the environment of care. This person will be educated to observe environmental risks such as ligature points, unlocked doors, and other environmental hazards. Technicians will immediately begin communicating through two-way radios to prevent leaving patients unattended.


Documentation of staff training content and the accompanying sign in sheets was given to the survey team as part of the process for lifting the IJ. The training content was as referenced in the plan for lifting when it was reviewed on 11/2018.


Observations conducted on 11/20/18 1:15 p.m. - 1:50 p.m. revealed the fence where Patient #6 eloped over on 11/19/18 had been reinforced, closing the gap where the patient had jumped over the fence.


Observations of the metal strap reinforcements on the exterior portion of the air conditioning units in the patient rooms revealed 2/3 of the rooms had reinforcements leaving 1/3 of the air conditioning units without reinforcements to mitigate elopements. Further observation revealed the re-installation of the locks on the individual patient room doors had not been completed at the time of the observation leaving the rooms accessible to patients who had a desire to elope.


Due to the continued environmental risks related to elopement the IJ remained in place on 11/20/18 pending completion of the above referenced environmental corrective actions.


On 11/21/18 at 8:20 a.m. an observation was conducted of Units 1 and 2. Metal strap reinforcements were observed on all air conditioning units, completing the reinforcement of all 37 units in patient rooms. The air conditioning unit had been removed from the consultation room where Patient #5 had eloped and the opening had been glassed in. Unoccupied patient rooms were observed to have been locked.


On 11/21/18 beginning at 8:30 a.m. interviews were conducted with direct care staff (MHTs and Nurses) regarding training referenced in the IJ plan for lifting.


In an interview on 11/21/18 at 8:30 a.m. with S7RN, she reported she had received training regarding elopement policy, precautions and prevention of patient elopement. She further reported the hospital had initiated an Elopement Risk Assessment tool. S7RN also indicated nursing staff was to sign off on MHT observation sheets every 2 hours and to observe the MHTs to ensure they were supervising patients as ordered. S7RN was knowledgeable about the policy changes and was able to describe the changes.


In an interview on 11/21/18 at 8:40 a.m. with S8RN, she reported she had received training regarding elopement policy, precautions and prevention of patient elopement. S8RN indicated nursing staff was to sign off on MHT observation sheets every 2 hours and to observe the MHTs to ensure they were supervising patients as ordered. She further reported the hospital had initiated an Elopement Risk Assessment tool. S8RN was knowledgeable about the policy changes and was able to describe the changes.


In an interview on 11/21/18 at 8:50 a.m. with S9MHT, she reported she had received training regarding elopement policy, precautions and prevention of patient elopement. She further reported the hospital had initiated securing patient rooms when patients were not in them and having 2 staff members out with patients on smoke breaks/fresh air at all times. S9MHT was knowledgeable about the policy changes and was able to describe the changes.


In an interview on 11/21/18 at 8:55 a.m. with S10MHT, he confirmed he had received training regarding elopement policy, precautions and prevention of patient elopement. He further reported the hospital had initiated securing patient rooms when patients were not in them and having 2 staff members out with patients on smoke breaks/fresh air at all times. S10MHT was knowledgeable about the policy changes and was able to describe the changes.


In an interview on 11/21/18 at 9:00 a.m. with S11MHT, she confirmed she had received training regarding elopement policy, precautions and prevention of patient elopement. She further confirmed the hospital had begun securing patient rooms when patients were not in them and having 2 staff members out with patients on smoke breaks/fresh air at all times. S11MHT was knowledgeable about the policy changes and was able to describe the changes.


In an interview on 11/21/18 at 9:10 a.m. with S12RN, she indicated she had received training regarding elopement policy, precautions and prevention of patient elopement. S12RN reported nursing staff was to sign off on MHT observation sheets every 2 hours and to conduct observations of the MHTs to ensure they were supervising patients as ordered. She further reported the hospital had initiated an Elopement Risk Assessment tool. S12RN was knowledgeable about the policy changes and was able to describe the changes.


No issues with patient supervision were noted during the observations conducted on 11/21/18 from 8:20 a.m. - 9:10 a.m. on both Unit 1 and Unit 2.


The Immediacy was lifted on 11/21/18 at 9:43 a.m. at survey team exit. However, there was not enough evidence to determine sustainability of Compliance for the Condition of Patient Rights to be cleared. Noncompliance remains at the Condition Level.

Based on record review, observation, and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by:

1) failing to mitigate known elopement risks as evidenced by failing to secure air conditioner units in patients' rooms to ensure they could not be removed to allow a route to elope for 6 (# R1, #R2, #1, #2, #3, #4) of 6 patients who had eloped through removal of AC units, failing to ensure exterior windows were not breakable allowing elopement of 1 (#5) of 1 patient reviewed who had eloped by breaking a window, and by failing to prevent a patient elopement by jumping a fence which surrounded an exterior patient area for 1 (#6) of 1 total patients reviewed who had eloped by jumping a fence; and

2) failing to maintain a safe environment for patients admitted for being at risk for harm to self and/or others.

Findings:

1.Failing to mitigate known elopement risks.

Review of the hospital policy titled, "Sentinel or High Risk Events and Root Cause Analysis", policy number: RM-022, revealed in part: It is the policy of this hospital that when a crisis and/or sentinel event occurs, it is necessary that appropriate individuals within the organization be aware of the event, investigate, and understand the causes that underlie the event, and make changes in the organization's systems and processes to reduce the probability of such an event in the future. I. Definitions: 1. Action Plan: The product of root cause analysis that identifies the facility intends to implement to reduce the probability of Sentinel of High Risk Events from occurring in the future. The action plan addresses responsibility for implementation, oversight, timelines, and strategies for measuring the effectiveness of the actions. 7. High Risk Event: May be a potential sentinel event and includes the following events as part of the risk thereof: f. Elopement of a unit restricted client.


Review of the hospital policy titled,"Reduction of Elopement", Policy Number: SEC-017, revealed in part: It is the policy of this hospital to establish safeguards to follow to prevent elopements and procedures to follow in the event of an elopement. Procedure: 1. The safety officer will make periodic reviews of the hospital to identify potential systems and equipment that may contribute to preventing an elopement. 2. The risk manager will trend for patterns and will make recommendations for improvement to the safety officer and safety committee.


Review of the hospital's elopement documentation revealed the following:

In 2017 there were 13 total elopements from the hospital and the means of elopement were as follows:

5 over the fence; and 2 through AC Units on 9/22/17 and 12/18/17.

Further review revealed there was a number documented monthly from 1/2017-7/2017 indicating the number of elopements per month with no means of elopement listed.


As of 11/19/18 there had been 12 documented elopements from the hospital and the means of elopement were as follows:

3 over the fence;

3 through AC Units;

2 through the unit doors;

1 through the emergency door; and

1 through the attic.


Review of a self report of a patient elopement by removing the AC unit submitted to LDH- HSS on 7/15/18 revealed the plan of action to address patients eloping by removing AC units was to have been addressed by encaging the AC units from the outside.


Review of a self report of a patient elopement by removing the AC unit submitted to LDH- HSS on 9/26/18 revealed the completion date for encaging the AC units from the outside was listed as 10/31/18.


Elopement 9/22/17

Patient #R1

Review of Patient #R1's medical record revealed an admission date of 9/20/17 with admission diagnoses of Suicidal Ideation, history of depression and Detox off of Heroin. Further review revealed the patient's legal status was PEC due to having attempted suicide by cutting into his abdomen to puncture his lung.

Review of Patient #R1's MD admission orders, dated 9/20/17, revealed the patient was placed on Level III Opioid Detox Protocol. Further review revealed the patient was on suicide precautions and his level of observation was close observation with every 15 minute staff checks. Additional review revealed an order, dated 9/22/17 indicating Patient #R1 had been discharged due to leaving AMA with elopement.

Review of Patient #R1's Q (every) 15 minute observation sheets, dated 9/22/17, revealed the last time the patient had been documented on was at 5:15 p.m. and the patient had been observed in his room.

Review of the Nurse Psychiatric Notes revealed the following entry, in part: 9/22/17 5:30 p.m.: Approached at nurses' station by MHT. Reported pt. (#R1) not being in room or dayroom during dinner time round-up. Checked room and AC unit was detached from the wall. Unable to locate inside or outside the facility. Q 15 min observations completed, last observation noted at 5:15 p.m. patient seen lying in bed.


Elopement 12/15/17

Patient #R2
Review of Patient #R2's medical record revealed an admission date of 12/13/17 with an admission diagnosis of Opioid Dependence. Further review revealed the patient's legal status was Formal Voluntary Admission.

Review of Patient #R2's MD admission orders, dated 12/13/17 at 10:35 p.m., revealed the patient had been placed on Level III Opioid Withdrawal Protocol. Further review revealed the patient's level of observation was close observation with every 15 minute staff checks. Additional review revealed an order, dated 12/15/17, indicating Patient #R2 had been discharged due to leaving AMA with elopement.

Review of Patient #R2's discharge summary revealed during Patient #R2's admission he had been fixated on discharge and was relocated to Unit 2. Further review revealed the patient had become angry that he was transferred to Unit 2 and had requested to leave early. Patient #R2 later eloped and was discharged due to the elopement.

Review of Patient #R2's every 15 minute observation sheets, dated 12/15/17, revealed the last time the patient had been documented on was at 4:45 p.m. and the patient had been observed in his room. Further review revealed the following narrative note: At 5:00 p.m. I completed my rounds. I noticed patient air condition was removed from the wall. Techs and nurses initiated head count for the census and confirmed all other patients present but Patient #R2 had eloped.

Review of the Nurse Psychiatric Notes dated 12/15/17 5:00 p.m. revealed the following: Approached at nurses' station by MHT reporting that Patient #R2 had eloped. AC unit detached from the wall in Room "b". House Supervisor, DON, and MD notified.


Elopement 7/14/18

Patient #1
Review of Patient #1's medical record revealed an admission date of 7/13/18 at 3:52 p.m. with an admission diagnosis of Opioid Dependence. Further review revealed the patient's legal status was Formal Voluntary Admission.

Review of Patient #1's MD admission orders, dated 7/13/18 6:39 p.m., revealed the patient was placed on Level III Opiate Detox Protocol and his level of observation was close observation with every 15 minute staff checks. Further review revealed an order, dated 7/14/18 4:07 p.m. indicating Patient #1 had been discharged due to leaving AMA with elopement. Patient #1 eloped in less than 24 hours after admission.

Review of Patient #1's every 15 minute observation sheets, dated 7/14/18, revealed the patient had been documented on as having been in his room at 1:15 p.m. and the next entry was at 1:30 p.m. indicating the pt. had eloped. Further review revealed the following notation: Pt. eloped through AC unit in room.

Review of the Nurse Psychiatric Notes dated 7/14/18 revealed the following entry:
1:37 p.m.: Pt. eloped through Room "e". The AC Unit was pulled out of the wall and pt. escaped. Discharge order obtained.


Patient #2
Review of Patient #2's medical record revealed an admission date of 7/11/18 with an admission diagnosis of Heroin Dependence. Further review revealed the patient's legal status was Formal Voluntary Admission.

Review of Patient #2's MD admission orders, dated 7/11/18 11:22 a.m., revealed the patient was placed on Level III Opiate Withdrawal Protocol and his level of observation was close observation with every 15 minute staff checks. Further review revealed an order, dated 7/14/18 4:08 p.m. indicating Patient #2 had been discharged due to leaving AMA with elopement.

Review of Patient #2's every 15 minute observation sheets, dated 7/14/18, revealed the patient had been documented as having been in his room at 1:15 p.m. and the next entry was at 1:30 p.m. indicating the pt. had eloped. Further review revealed the following notation: Pt. eloped through AC unit in room.

Review of the Nurse Psychiatric Notes dated 7/14/18 revealed the following entry:
1:27 p.m.: Pt. eloped through Room "e". The AC Unit was pulled out of the wall and pt. escaped. Discharge order obtained.

Patient #1 and Patient #2 had shared a room (Room " e") and eloped from the hospital together.


Elopement 9/26/18

Patient #3
Review of Patient #3's medical record revealed an admission date of 9/20/18 with an admission diagnosis of Psychosis. Further review revealed the patient's legal status was PEC on 9/19/18 and 9/21/18 and CEC on 9/21/18 due to being aggressive/threatening to kill family, positive for hallucinations, currently homicidal, dangerous to others, and unable to seek voluntary admission

Review of Patient #3's MD admission orders, dated 9/20/18 at 4:25 p.m. revealed the patient had been admitted to Unit 2 with a Psychiatric/Detox dual diagnosis (urine drug screen had been positive for cocaine) and his ordered level of observation was close observation with every 15 minute staff checks.

Review of Patient #3's every 15 minute observation sheets, dated 9/26/18, revealed the patient had been documented on as having been asleep in his room at 5:45 a.m.

Review of the self-report of the elopement to LDH-HSS revealed the following, in part: While conducting environmental rounds in Patient #3's room (Room "c") at 6:00 a.m., S4RN discovered the AC unit was out of the space in the wall and lying on the floor. Patient #3 was not present. The outer perimeters of the facility were searched but the patient was not found. A count of the unit was done and showed Patient #3 was unaccounted for. The police were notified locally and in the patient's home town.

In an interview on 11/20/18 at 2:30 p.m. with S4RN, she reported she had gone into Patient #3's room to draw labs. She further reported the patient had not been in his room and she had observed the AC unit pulled out from the wall, having left a hole in the wall. S4RN indicated she had notified staff that Patient #3 had not been in his room. She said the outer perimeter of the grounds and the unit were searched and a head count was taken. She reported the hospital verified Patient #3 was not in any of the areas searched and he had eloped.


Elopement 10/28/18

Patient #4
Review of Patient #4's medical record revealed an admission date of 10/26/18 at 3:10 a.m. with an admission diagnosis of Suicidal and a past medical history of Antisocial Personality Disorder, Bipolar Disorder and Poly-substance Abuse. Further review revealed the patient's legal status was PEC on 10/25/18 at 9:49 p.m. due to being suicidal, dangerous to self, and unable to seek voluntary admission and CEC on 10/26/18 at 8:15 a.m. due to being suicidal, dangerous to self, and unable to seek voluntary admission.

Review of Patient #4's MD admission orders, dated 10/25/18 at 4:30 a.m., revealed the patient had been placed on suicide precautions and his ordered level of observation was close observation with every 15 minute staff checks.

Review of Patient #4's every 15 minute observation sheets, dated 10/28/18, revealed rounds were not being conducted every 15 minutes as ordered. Further review revealed Patient #4 had last been documented on at 8:45 a.m. (1 hour prior to being seen running across the parking lot by S17MHT at 9:45 a.m.).

Review of the self-report of the elopement submitted to LDH-HSS revealed the following, in part: On 10/28/18 at approximately 9:45 a.m. while standing outside S17MHT saw Patient #4 run across the parking lot. The parking lot and perimeter were searched but Patient #4 was not found. A search of the unit was conducted. The air conditioner was discovered out of its space in the wall in Room "d" and lying on the floor. Staff searched for the pt. but he was not found. A unit head count was conducted by staff and Pt #4 was unaccounted for.

In an interview on 11/20/18 at 2:29 p.m. with S6MHT, he confirmed he had been assigned Patient #4 on the day of his elopement. S6MHT reported he had seen Patient #4 that morning around breakfast. He indicated Patient #4 had stayed on the unit and had not gone to breakfast. S6MHT reported he returned to the unit around 8:45 a.m. - 9:00 a.m. after taking patients to breakfast and he began supervising the patients on smoke break. He reported there were 2-3 MHTs on the unit and one of the MHTs was doing morning group. S6MHT reported no one assumed responsibility for his patients when he was outside for smoke break, and he further reported Patient #4 was not reassigned to another MHT for observation when he stayed behind on the unit and did not go to breakfast. S6MHT reported when he came back in he was checking on his patients and checked off the patients who were in group. S6MHT indicated he had then gone to check on the patients in their rooms. S6MHT said the nurses and S1Adm came into the hall and told them to get the pts. into the dayroom because someone had eloped. S6MHT reported when he came back down the hall he peeped his head into Patient #4's room and he saw the AC unit was out of the wall and the patient was not in his room or on the unit.


Elopements 11/15/18 and 11/18/18

Patient #5
Review of Patient #5's medical record revealed an admission date of 11/15/18 at 9:00 a.m. with an admission diagnosis of Suicidal and a primary diagnosis of Major Depressive Disorder, recurrent. Further review revealed the patient's legal status was PEC on 11/15/18 at 02:49 a.m. due to being suicidal, presenting with a plan to shoot self (he reported searching for someone with a gun), dangerous to self, and unable to seek voluntary admission. Additional review revealed the patient was CEC'd on 11/16/18 at 5:02 p.m. due to being suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission.

Review of Patient #5's MD admission orders, dated 11/15/18 1:15 p.m., revealed the patient had been placed on suicide precautions and his ordered level of observation was close observation with every 15 minute staff checks.

Review of a self-report of the elopement to LDH-HSS revealed in part: The patient was upset and wanted to see the MD because he wanted to be transferred to another city. The patient was an involuntary admit. The nurses had not yet completed the assessment. Because the patient was agitated, he was taken outside to the smoking area on Unit 2 to calm down. The patient jumped on top of the air conditioning unit and was able to pull himself up by the gutters and was able to get on the roof. While he was grabbing the gutters the MHT grabbed his legs and the patient kicked him in the face so he was unable to hold onto him. He eloped by jumping off of the roof. The police returned the patient in about 2 hours.

Review of Patient #5's orders, dated 11/15/18 3:00 p.m. revealed the patient had been placed on suicide/elopement precautions upon his return and placed on 1:1 supervision. Further review revealed 1:1 supervision was discontinued on 11/17/18 at 9:35 a.m.

Review of Patient #5's Nurse Psychiatric Notes dated 11/18/18 (no time documented) revealed in part: Patient expresses he is ready to leave, he states he voluntarily came in. Notified patient of PEC. Patient denies anxiety and depression, denies suicidal ideation and homicidal ideation. Patient states he is "thinking of a master plan." Patient is walking back and forth through the halls. Patient presented as very manipulative.

11/18/18 1:30 p.m.: Admissions notified us that patient was climbing out of the window. A code sky was called. Police department notified. The DON, CEO, MD notified. The patient went into Room ""a" (not his assigned room) and glass was noted inside of the room. There was a hole in the window and patient escaped through the window.

Review of Patient #5's every 15 minute observation sheets revealed the patient had last been documented on at 1:15 p.m. as being in the hallway/eloped. Further review revealed another entry at 1:30 p.m. indicating elopement.


In an interview on 11/19/18 at 8:20 a.m., with S1Adm, he confirmed Patient #5 had eloped from the hospital on 11/15/18, was returned 2 hours later by area police officers, and had eloped again on 11/18/18 by breaking out a window in Room "a" which was unsecured at the time. He confirmed Room "a" was not Patient #5's assigned room. S1Adm explained all patients had access to all patient rooms because they were not secured in any way when the patients were not in their rooms. S1Adm confirmed Patient #5 had not returned after the second elopement. He reported S2DON had felt the patient should not have been taken off of 1:1 supervision on 11/17/18 because the patient had told the staff he would play their game and when they weren't looking he would get over on them. S1Adm further reported S2DON had felt the patient was at risk for attempting elopement again, but the physician had felt he no longer needed 1:1 supervision. S1Adm acknowledged the hospital had a problem with elopements and reported he was not sure if it was the type of patients they admitted, the layout of the building, or a little of both, that was contributing to the issues with elopements.


On 11/19/18 at 8:30 a.m. an observation was made of the area where Patient #5 had eloped on 11/15/18. S1Adm described how the patient had climbed onto the elevated AC unit and had hoisted himself onto the awning, gaining access to the roof, and had jumped off of the roof.


On 11/19/18 at 8:35 a.m. an observation was made of Room "a" which was the room from which Patient #5 had eloped on 11/18/18 at 1:30 p.m. A large, oval shaped hole in the bottom pane of the window was noted. Jagged glass fragments were observed around the periphery of the break. The patient had broken through the plexi-glass sheeting (inside the room) and the glass pane (which was thin glass that was not shatterproof) that backed it. S1Adm reported, during the observation, that it was possible the patient had used a piece of wood (a detached shelf) to break the glass. S1Adm further reported another patient's family member had notified the front desk staff that someone had been climbing out through a broken window.


In an interview on 11/20/18 at 2:00 p.m. with S5MHT, he confirmed he had been assigned Patient #5 on 11/18/18. He reported the pt. had been in the television room watching a football game the last time he saw him prior to elopement. S5MHT reported he was doing every 15 minute checks as ordered. S5MHT explained he had left the television room and had gone to do another pt.'s vital signs and Patient #5 had eloped after he left the room. S5MHT confirmed the room Patient #5 had eloped from was not the room he was assigned to. S5MHT confirmed patient rooms were not locked during the day and that any patient had access to any room.


Elopement 11/19/18

Patient #6
Review of Patient #6's medical record revealed an admission date of 11/18/18 12:22 p.m. with an admission diagnosis of Opioid Dependence. Further review revealed the patient's legal status was Formal Voluntary Admission.

Patient #6 was a current patient who eloped while the surveyor was onsite. Patient #6 was not returned to the hospital after elopement and was discharged.

Review of Patient #6's MD admission orders, dated 11/18/18 at 2:16 p.m., revealed the patient had been placed on Level III Opioid Detox and his ordered level of observation was close observation with every 15 minute staff checks.

Review of the Psychiatric Assessment Nurses' notes, revealed the following entries:

11/19/18 11:45 a.m.: 72 hour signed, Pt. states he wants to be home for Thanksgiving.

11/19/18 3:00 p.m.: Pt. jumped fence during smoke break. Code sky called. MD, Administrator, and DON notified.


Review of Patient #6's observation sheets dated 11/19/18 revealed the last time the patient had been documented on he was documented as being in the dining room with the MHT at 2:45 p.m. Further review revealed the next entry was at 3:00 p.m. indicating the patient had eloped.


In an interview on 11/19/18 at 3:02 p.m. with S16MHT, she confirmed she had been with Patient #6 in the smoking area. She reported Patient #6 had signed a 72 hour notice for discharge that morning because he wanted to be home for Thanksgiving. S16MHT confirmed Patient #6 had eloped by jumping the gate to the fence in the smoking area. She reported Patient #6 had climbed up onto the gate and she had asked him to please not jump over the gate, but he jumped over it and eloped. S16MHT indicated she had been responsible for a total of 7 patients on smoke break. S16MHT confirmed she had been on the patio alone with the 7 patients during smoke break.


In an interview on 11/19/18 at 1:00 p.m. with S1Adm, he confirmed 10 of the hospital's 37 rooms AC units had been outfitted with exterior metal straps as a method of elopement mitigation. He also confirmed the patient rooms had remained open at all times and patients had access to the rooms. S1Adm indicated the hospital did not currently have an elopement risk assessment tool in use. S1Adm showed the surveyors the method of repair for the broken window was to repair the window with the same materials that had been previously used and had been used as a means of escape by breaking the window covering.


In an interview on 11/19/18 at 2:00 p.m. with S3QA, she reported she had begun a list of the elopements that had occurred and methods used to elope. She confirmed she had not completed a root cause analysis related to elopements and had no performance improvement plan addressing elopements. S3QA reported there was a Quality Assurance meeting scheduled for the Wednesday after Thanksgiving to attempt to identify trends/causes of elopements.


In an interview on 11/19/18 at 3:35 p.m. with S1Adm, he reported none of the patients that had eloped had returned to the hospital except for the patient who eloped on 11/15/18, returned, and then eloped again on 11/18/18.


In an interview on 11/19/18 at 4:00 p.m. with S2DON, she confirmed the hospital had been working on an elopement risk assessment tool but had not initiated using the tool at present.


2) Failing to maintain a safe environment for patients admitted for being at risk for harm to self and/or others.

Observations conducted of the patient care units on 11/19/18 from 12:15 p.m. - 12:35 p.m. revealed the following risks to patient safety in the physical environment:

a. At the time of the observation, S1Adm confirmed only 10 patient rooms (Rooms 101, 102, 103, 104, 105, 106, 107, 108, 111, and 112) of the hospital's 37 rooms had metal reinforcement straps installed in order to deter elopement attempts. He reported there had been time constraints related to installation of the metal straps.

b. Rooms 106, 108, 121, and 123 were observed to have windows with non-shatterproof glass that was not reinforced with a second layer of plexi-glass that completely covered the glass. Shattering of glass afforded patients a means of elopement and for use for potential harm of self or others.

c. Room 106: a metal bar was observed to be secured vertically to the top and bottom of the window- potential ligature anchor point.

e. Television in commons area was observed to have exposed cords- potential ligature risk. Patients were noted in the room, unattended/unobserved by staff, at the time of the observation.

f. Dining room, unlocked with no staff present, with open framework metal tables with attached seating- potential ligature points. Further observation revealed large plastic garbage bags in the garbage can- could potentially be used for suffocation.

g. Restraint/seclusion room, unlocked with no staff present, with a blood pressure machine on a stand that had 3 long cords attached and the electrical cord- potential ligature/strangulation risk. Further observation revealed a restraint bed with 10 handleswas also present in the room - potential ligature anchor points/potential for strangulation.


On 11/20/18 at 9:30 a.m. a patient was again observed unattended/unsupervised by staff in the commons area with the television with exposed cords- potential ligature risk.


All above referenced potential safety risks in the patient care environment were confirmed by S1Adm during the observation.