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Based on observations, interviews, and record reviews, the hospital failed to ensure that its governing body provided effective oversight of the functions of the hospital on the following Conditions of Participation:

1. To protect and promote each patient's rights. Refer to A- 0115.

2. To ensure that the hospital's Quality Assessment and Performance Improvement Program reflects the complexity of the hospital's organization and services. Refer to A- 0263.

The cumulative effect of these systemic problems resulted in the inability of the hospital to meet the Condition of Participation for Governing Body.

Based on observations, interviews and record reviews, the hospital failed to protect and promote each patient's right for safety and confidentiality of records as evidenced by failure to:

1. Ensure that Patient 1 and other patients are protected from elopement. Patient 1 eloped from the hospital, on 3/19/18, and was returned to the hospital. As of 3/26/18, the hospital did not assess, plan or correct its physical environment and patient care practices to prevent future elopement. Refer to A-144.

This failure resulted in an Immediate Jeopardy (IJ) situation. The hospitals' administrator was notified, on 3/27/18 at 2:41 p.m. The hospital submitted an acceptable Plan of Correction on 3/27/2018 at 3:50 p.m.; the IJ situation was removed.

Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

2. Ensure the safety of Patient 24 when he had an incorrect identification wrist band and medical record of Patient 10, when he was transferred from the Psychiatric Emergency Services of Campus A to the Emergency Department of Campus B. Refer to A-144.

These failures represented a systemic problem which resulted in the hospital's inability to meet the Condition of Participation for Patients's Right.

Based on observation, interview, and record review, the hospital failed to provide care in a safe setting for three (1, 2, and 24) of thirty patients.

1. For Patient 1 the facility failed to provide adequate supervision to prevent elopement, and did not establish measures to minimize potential future elopements.

These failures resulted in an Immediate Jeopardy to the health and safety of the patients. The Immediate Jeopardy was called, on 3/27/18 at 2:41 p.m., in the presence of hospital administrative staff.

2. For Patient 2 the facility failed to provide adequate supervision to prevent elopement when Patient 2 exited open patio doors and a gate left open.

These failures had the potential to result in harm to Patient 1 and Patient 2 after elopement, and had the potential for recurrent patient elopements.

3. For Patient 24 the facility failed to correctly identify Patient 24, when the Psychiatric Emergency Services (PES) at Campus A, substituted Patient 10's medical record and placed an incorrect wrist name band when Patient 24 was sent to the Emergency Department (ED) of Campus B (receiving hospital).

These failures had the potential for Patient 24 receiving medications and treatments meant for another patient and experiencing a possible allergic reaction.

Findings:

1. Review of the Psychiatric Emergency Services (PES) Evaluation, dated 3/12/18, showed Patient 1 entered the facility on a 72-hour involuntary psychiatric hold after he superficially cut his throat during a family argument. The physician ordered Patient 1 to be admitted for inpatient treatment, on 3/12/18, because he was a danger to himself. The Psychiatrist Intake, dated 3/13/18, reflected Patient 1 needed stabilization treatment for depression and substance abuse causing "grave disability." The court ordered continuation of Patient 1's involuntary commitment for 14 more days on 3/14/18.

The Physician Note dated 3/18/18 at 12:58 p.m., indicated Patient 1 continued focusing on his desire for discharge, but had no plan for self-care. The Note further indicated Patient 1 would, "likely walk away from any unlocked placement at this time and put himself in dangerous situation ..."

The Nurses' Shift Summary, dated 3/19/18 at 11:42 a.m., reflected Patient 1 eloped from the facility during courtyard recreation time.

During an interview on 3/26/18 at 1:05 p.m., Director of Acute/Crisis Behavioral Health Operations (ACO) said up to nine patients, from each from each of three units, had supervised courtyard time for 45 minutes, twice a day. ACO said Patient 3 assisted in Patient 1's elopement over the fence, in the garden area, during courtyard recreation time. ACO said the facility did not yet identify any concerns or possible corrective actions to prevent future elopements; the facility scheduled the committee analysis of Patient 1's elopement for tomorrow (3/27/18).

Review of the Daily Census Report, dated 3/26/18, reflected Patient 3 entered the facility for mental health issues the previous month. The court ordered an involuntary commitment for Patient 3, effective until 4/4/18.

During an observation with ACO, on 3/27/18 at 10:25 a.m., the courtyard was a fenced-in area, roughly egg shaped, with the large end at the north side. The courtyard had a northern grassy area, and a southern grassy area, separated by a central concrete patio. (The following measurements are approximations measured by facility Maintenance Staff 1.) The total length of the courtyard was 260 feet long (north to south), with a southern width of 40 feet and a northern width of 70 feet (east to west). The northern grassy area included a garden area (approximately 25 feet long by 22 feet wide) which was enclosed on two sides: on the south by the side of a building, and on the west side by a concrete wall. The concrete wall was approximately 25 feet long, 22 inches wide, and 11 feet high. The wall was adjacent to a 15 feet high cyclone fencing, leaving four feet of fencing, along the length of the top of the wall above a 10.5 inch wall ledge. The concrete wall also had a one inch deep groove extending the length of the wall at a level of 6 feet and 10 inches.

During an interview and concurrent observation, 3/27/18 at 10:40 a.m., Mental Health Specialist 1 (MHS 1) said he was providing supervision during the courtyard activity period last week, when he noticed Patient 1 and Patient 3 walking close together and talking. MHS 1 said the patients were on the courtyard for about five minutes, when Patient 1 and Patient 3 arrived at the southwest corner of the garden area. MHS 1 said he was too far away to reach the patients before Patient 3 used his hands in a stirrup method to raise Patient 1 up the 11 foot concrete wall. Patient 1 used the groove in the concrete to help himself further up the wall to the ledge, and pulled himself up and over the fencing.

During interviews 3/26/18 at 1:55 p.m., and 3/27/18 at 10:30 a.m., Patient 3 said Patient 1 asked him for help to escape, so he hoisted Patient 1 up until he could climb out. Patient 3 said the event happened a few minutes after they went into the courtyard, and it happened too quickly for staff to get close enough to stop them.

During an observation of courtyard recreation time, on 3/27/18 at 10:46 a.m., four random patients were in the garden area, unaccompanied by staff, and one random patient walked alone along the north fence perimeter. A total of seven patients and five staff members were scattered around the courtyard. The southwest garden corner was not visible from areas south of the bordering building. No staff patrolled the garden area, or were within five feet of the eastern edge of the garden and 27 ft away from wall. One patient sat at a table in the middle of the northern grassy area with the closest staff member about 30 feet away on the concrete patio. In a concurrent interview, ACO said staff providing patient supervision did not have assigned areas to patrol during the courtyard recreation time.

The Immediate Jeopardy was removed, on 3/27/18 at 3:50 p.m., after approval of a plan of correction presented by hospital administrative staff.

2. Review of the, "Psychiatric Emergency Services Triage Form," dated 12/5/17 reflected Patient 2 had a history of schizophrenia, and came to the facility from jail for psychological evaluation after refusing release from jail.

During a previous staff interview, 12/8/17 at 4 p.m., Mental Health Specialist 1 (MHS 1) said Patient 2 went to the unit patio unsupervised and was able to exit through an emergency gate normally locked.

Review of the Alameda County Sheriff Office, "Incident/Criminal Report, Case Number 17-021412, Narrative, and Narrative Summary," reflected after Patient 2 eloped from the facility, he assaulted two visitors on hospital grounds, and was subsequently arrested after unsuccessfully attempting to run across the freeway and being hit by two cars.

Review of the hospital, "Discharge Summary," dated 12/12/17, showed Patient 2's injuries from his elopement attempt as a hand fracture of the long bone attached to the 5th digit (pinky finger), and multiple bites from the canine officer.

During a previous interview on 12/8/17 at 3:50 p.m., Director of Acute/Crisis Operations (ACO) said patients were not allowed on the patio without supervision, and was unable to explain how Patient 2 managed to elope through the locked patio gate.




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3. In an observation and concurrent interview on 3/26/18 at 2:10 p.m., Patient 24 was observed in the ED of Campus B. There were two law enforcement persons standing outside Patient 24's room in the ED. Patient 24 was observed talking to self and unable to answer questions.

A record review indicated Patient 24 was currently admitted at Campus A (sending facility), since 3/21/18, with diagnoses of schizophrenia, polysubstance use and incarcerated for battery. Patient 24 had allergies that included broccoli, Haldol and Primatene mist.

A record review indicated Patient 10 was admitted, on 3/16/2018, to Campus A with diagnoses that included schizoaffective disorder (mental disorder), 5150 hold, and had no known drug allergy.

Patient 24 was transferred to the ED of Campus B on 3/26/18 at 10:44 a.m., with a complaint of right shoulder pain. Registered Nurse (RN) 1, indicated on the clinical notes, dated 3/26/18 at 12:35 p.m.,"Hold paperwork not in chart, telephoned [Campus A], unit B clerk states will fax patient..Hold documentation. An incorrect ID [wrist band identification] and an incorrect patient chart arrived with patient... Telephoned [Campus B] to notify..." At 1:01 p.m., RN 1 added on the notes, "Pt. greeted, 2x ID check- discovered wrong ID, band removed, registration notified. Allergy check in wrist and leg shackles with deputies at bedside....Requesting food ".

A review of the ED MD note, dated 3/26/18 at 3:27 p.m., indicated, "Patient initially registered under an incorrect name. Registration notified, [Campus A] unit B, and patient identifiers corrected. Patient [24] did not receive any treatment under the incorrect name".

In an interview on 3/26/18 at 3:05 p.m., the Patient Access Supervisor (PAS), of Campus B, stated she was not made aware Patient 24 had the wrong ID band and wrong patient information and that she (PAS) would follow up with registration.

In an interview on 3/28/18 at 2:10 p.m., RN 3 (Campus A) stated, on 3/26/18, Campus A's charge nurse prepared the transfer form for Patient 24 and gave verbal instruction to the Medical Clerk (MC) to prepare the rest of the chart to send with Patient 24. RN 3 stated he received the envelope packet from MC but he (RN 3) did not check the contents to verify the documents. He confirmed there was no checklist on the outside of the envelope. RN 3 then gave the envelope to the two law enforcement persons, who transported Patient 24 from Campus A to the ED of Campus B. RN 3 added that MC did not notify him (RN 3) that Campus B called MC after Patient 24 arrived in Campus B to report the medical records sent with Patient 24 were incorrect.

In a concurrent interview on 3/28/18 at 3:30 p.m., MC stated she worked at Campus A for ten years. On 3/26/18, MC stated she was on duty as medical clerk and RN 3 was the charge nurse in the B unit of Campus A. RN 3 gave MC instructions to send a patient out and verbally told MC the name of the patient. MC stated she prepared the documents, placed them in an envelope then gave the envelope to RN 3. MC confirmed she did not place the transfer information checklist on the outside of the envelope per facility policy, as she never used the checklist before. MC further added that sometime later after Patient 24 left, she received a telephone call from the ED of Campus B and was informed that Patient 24 arrived in the ED with the wrong ID band and medical record. MC was given Patient 24's name by Campus B then MC faxed Patient 24's medical records and afterwards shredded them and left unit B. MC confirmed she did not report this incident to the charge nurse or to any supervisors as per facility policy. The Psychiatric Emergency Services Manager (PESM) of campus A confirmed MC's failure to send the correct patient information to identify patients when transferred to another facility, and said MC should have reported the incident to the supervisors.

A review of the Campus A's Policy and Procedure titled,"Occurrence Reporting" date revised 12/2016, indicated..."Safety alert system will be used to identify, quantify, monitor, and report relevant data concerning important risks to the safety of patients, visitors and...Healthcare providers and other hospital employees are required to report and complete an on-line Safety Alert regarding any patient or visitor who, while within hospital jurisdiction and/or while in hospital premises, is involved in an occurrence or near miss...Example...Transfer incidents...For occurrences involving patients, the person completing the occurrences report should be the individual who witnessed, first discovered, or is most familiar with the event".

A review of the Campus A's Policy and Procedure titled, "Transfer Unit to Unit and Transport to other Facilities", revised date 3/2013, indicated...." Transfer to other Facilities...6. Obtain patient's permission to copy medical record. Copy the necessary information (refer to the transfer envelope) from the medical record. See Note Place information in the transfer envelope. The person placing the information in the envelope will place their initials in the space provided. The envelope will be sent to the receiving facility with the transporting. Personnel".

Based on observation, interview, and record review, the psychiatric hospital failed to initiate corrective action(s) after one of thirty patients, Patient 1, eloped, on 3/19/18, by being hoisted up to a ledge on a wall and jumping over a four foot fence above the wall. A quality process, (RCA or root cause analysis is a systematic process for identifying "root causes" of problems or events to prevent future recurrences) was scheduled for eight days after the event, on 3/27/18. The failure, to immediately conduct an RCA and implement a plan of correction, had the potential to result in repeated patient elopements from the psychiatric hospital, which had the potential to cause emotional and physical harm and death to patients who eloped.

Findings: Refer to tag A-0144.

During an interview and observation of the elopement site of Patient 1, on 3/26/18 at 1:05 p.m., Director of Acute/Crisis Behavioral Health Operations (ACO) said the area and supervisory procedures were unchanged since Patient 1 eloped over the wall over a week ago, on 3/19/18. ACO said the facility scheduled the RCA for Patient 1's elopement to take place on 3/27/18 (eight days after the elopement). ACO said since the RCA had not occurred yet, the hospital did not identify process changes to prevent future elopements.

During an interview and concurrent record review, on 3/27/18 at 8:39 a.m., Director of Accreditation and Risk Management (DARM) confirmed the RCA was scheduled, on 3/27/18, for Patient 1's, 3/19/18, elopement.

The cumulative effect of this systemic problem resulted in the inability of the hospital to meet the Condition of Participation of Quality Assessment and Performance Improvement.