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Based on record review and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by the hospitals failure to ensure Unit B's exterior, patient courtyard was properly secured (see Findings in A-0144).

Based on observation, medical record review and interview, the hospital failed to ensure the patient's right to received care in a safe setting. This deficient practice was evidenced by the hospitals failure to ensure Unit B's exterior, patient courtyard was properly secured.
Findings:
Observations during a facility walk though on 04/07/2025 at 10:02 AM revealed Unit B's exterior, patient courtyard, used by the patients who smoke, enclosed by a 10 - 12 foot tall wood fence. The emergency exit gate from this courtyard was not secured when pushed on by the surveyor. The latch on the wood fencing gate was missing 1 of 2 screw fasteners and the remaining screw fastener was loosely secured to the wood fencing. Further, the magnetic locking system on this wood gate was not functioning. This gate opened to the rear parking area and service entry/delivery area of the hospital. The area in which the gate opened was not secured or enclosed.

A review of Unit B's bed board provided by S2DON revealed 13 (#1 - #12, #14) of 16 (#1 - #16) patients with altered mental status related to dementia and 1 (#5) of 16 (#1 - #16) patients had elopement precautions assigned. 4 (#2, #14 - #16) of 16 (#1 - #16) patients were identified as patients whom would use this courtyard 5 times per day for cigarette smoking. 2 (#2, #14) of 4 (#2, #14 - #16) patients identified on the bed board as cigarette smokers, had a diagnosis related to dementia and were not on elopement precautions. Although these patients were being monitored by mental health techs (MHT) while in this courtyard area, the MHTs do not maintain a position at the gate. The potential for these patients to wander or attempt elopement via the unsecured gate existed and could potentially place all patients in an unsafe situation with the potential for harm and/or injury.

In an interview on 04/07/2025 at 1:15 PM and present during the facility walk through, S2DON confirmed the above mentioned findings and the potential for patient(s) accessing the exterior, patient courtyard for the purpose of smoking cigarettes would be in an unsafe situation if they successfully wandered off or eloped via the unsecured gate.