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Based on observation, interview, record review, policy review, the facility failed to:
- Follow their internal policy regarding elopement (patient leaving a facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) prevention and close observation (a level of supervision provided to patients with an increased risk for injury) to prevent one discharged patient (#10) of one reviewed elopement from the facility;
- Elicit additional, helpful information from staff overhearing a possible elopement plan by Patient #10, to possibly prevent the elopement;
-Follow their internal suicidal (SI, thought of killing self) precautions policy by not providing constant line-of-sight observation on one current patient (#1), and one discharged patient (#10) of six patients on suicidal precautions; and
-Follow their internal suicidal precautions policy by removal of the patient's personal belongings and change the patients into a paper gown/scrubs for two current patients (#3, and #9) of six patients on suicidal precautions.
Please refer to A-395.

These deficient practices resulted in the facility's non-compliance with specific requirements with nursing oversight found under the Condition of Participation: Nursing Services. The facility census was 452.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 05/23/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 05/24/18, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
- The nursing manger educated 3B unit nursing and sitter staff involved in the 05/17/18 elopement event on the following elements: suicide precautions, sitter and nursing responsibilities, frequent rounding and support for coworkers, appropriate escalation of concerns to engage manager or house supervisor and public safety;
- The Suicide Precautions policy was revised to include:
-clinical hold order will be placed in the electronic health record (EHR) when a patient was placed on suicide precautions. The patient will be changed into paper gown/scrubs;
-the patient will be under continuous observation by a coworker at all times, if the patient enters the bathroom or shower the patient will remain under direct observation;
-patient belongings will be removed from the patient's room including cell phones. In an emergency situation, the sitter will pull the call light cord which alerts throughout the nursing unit;
-the nurse will conduct hourly rounds to evaluate the patient and the sitter will complete the sitter checklist at the beginning and end of their shift/time and the primary nurse will review the checklist during the shift;
- The elopement policy was revised to include: the type of patients, who were at risk for elopement, controls that were initiated to prevent elopement to include notification of charge nurse, nurse leader, and public safety, moving the patient closer to the nursing station, rounding by public safety, and not ambulating patient near exits. Immediate actions when a patient on a clinical hold was missing;
- Education began to all facility staff and medical staff according to the newly revised policies. Education will commence for all staff currently in the facility, and will continue until completed for all staff at their next scheduled shift. Staff will not be allowed to begin shift until training was completed and documented; and
- Direct observation audits with the sitter in the patient room will be conducted on 100 percent of patients who were on suicide precautions.

Based on observation, interview, record review, policy review, the facility failed to:
- Follow their internal policy regarding elopement (patient leaving a facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) prevention and close observation (a level of supervision provided to patients with an increased risk for injury) to prevent one discharged patient (#10) of one reviewed from elopement from the facility;
- Elicit additional, helpful information from staff overhearing a possible elopement plan by Patient #10, to possibly prevent the elopement;
-Follow their internal suicidal (SI, thought of killing self) precautions policy by not providing a constant line-of-sight observation on one current patient (#1), and one discharged patient (#10) of six patients on suicidal precautions; and
-Follow their internal suicidal precautions policy by removal of the patient's personal belongings and change the patients into a paper gown/scrubs for two current patients (#3, and #9) of six patients on suicidal precautions.

These failures had the potential to affect all patients in the facility, as elopement allows patients at risk to harm themselves and/or others. The facility census was 452.

Findings included:

1. Review of facility policy titled "Suicide Precautions Acute Care", dated 10/2017, showed the direction for staff:
- To place any patient on suicidal precautions in a paper gown or paper scrubs, the only exception would be those patients in the Intensive Care Unit (ICU).
- Place a sitter with the patient, effectively making them a 1:1 observation.
- That all patients on suicide precautions require continuous visual observation.

Review of facility policy titled, "Sitter Use", dated 10/2017, directed clinical and non-clinical sitters to monitor the safety of patients by direct observation of all activities.

Review of Patient #10's medical record showed that:
- She was a direct admit to third medical unit on 5/16/18 at 9:07 PM.
- She had been transferred from another facility (Facility A) for medical stabilization and admission to an inpatient psychiatric treatment facility.
- Prior to transport to Facility A, she had been found by a guard in jail, hanging, six inches off the floor, cyanotic (the bluish or purplish discoloration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation), and was cut down.
- She had a history of a previous suicide attempt in August 2010, by jumping/lying before a moving vehicle.
- She was transferred to current facility (Facility B) for treatment of rhabdomyolysis (muscle damage releases a protein, myoglobin, into the blood stream, this is filtered by the kidneys, the breakdown of the substance results in damage to kidney cells, and ultimately kidney failure) and stabilization of kidney damage prior to placement for psychiatric treatment.
- Patient #10 was placed on Suicide Precautions with a sitter at bedside.
- On 5/17/18 at 6:26 PM, while being ambulated in the hallway, Patient #10 eloped, she ran to the elevator when the doors opened, and left the facility.

Record review of Public Safety Event Detail report dated 5/17/18 at 3:07 AM; showed that security responded to unit third medical unit, room 3152, for Patient #10's repeated threats to leave facility.

Record review of State of Missouri Department of Mental Health Affidavit dated 5/17/18, and signed by Staff KK, Psychiatrist, showed that Patient #10:
- Was found hanging in jail, six inches off the floor, and cut down;
- Had a previous suicide attempt;
- Had a history of illicit drug use, and poor insight;
- Was known to carry a weapon (knife);
- Was placed in solitary while in jail for fighting with other inmates; and
- Needed inpatient psychiatric assessment and treatment.

During a telephone interview on 05/23/18 at 11:40 AM, Staff NN, Sitter, stated:
- She had been the sitter assigned to watch over Patient #10 on 05/17/18 dayshift, when Patient #10 eloped from the facility.
- She had informed the professional staff twice during her shift that Patient #10 had potential for eloping from the facility.
- The patient had been ambulating in the hallway frequently, and she (Patient #10) had approached Staff MM, the Charge nurse, at the hall desk to discuss handing off her belongings to her sister around 4:00 PM.
- She informed, Staff MM, Charge nurse, during the same interaction, that Patient #10, had been expressing wanting to leave the facility, and staff should be careful, which Staff MM acknowledged saying okay.
- She informed Staff LL, RN and Staff JJ, LPN, of Patient #10's potential plan to elope during change of shift and walking rounds, around 6:30 PM.
- That she had stuck her head out of Patient #10's room to talk to the nurses, while the patient was in the bathroom, and that she did not maintain line of sight.
- When Patient #10 jumped on the elevator, she did not respond and follow her; she froze, and then yelled for assistance.

During a telephone interview on 05/23/18 at 11:00 AM, Staff MM, RN, Charge Nurse, stated that:
- She was not aware of the potential elopement risk that Patient #10 posed.
- Around 2:30 PM, Staff KK, Psychiatrist, had rounded on Patient #10, and stated to her that, he felt she was going to try to leave.
- She did not ask the Psychiatrist for any orders, and never recommended to him that Patient #10 might require a Clinical Hold.
- She did not initiate Elopement Precautions for Patient #10.
- Staff cannot prevent patients on Suicide Precautions from leaving facility unless they have a Clinical Hold in place.
- She felt that Patient #10 attempted to hang herself in an attempt to "get out of jail free".

During an interview on 05/23/18 at 9:25 AM, Staff KK, Psychiatrist, stated:
- Patient #10 had previously attempted to commit suicide.
- Completed an affidavit for a 96 hour hold.
- She had not specifically been placed on a Clinical Hold, that had been an oversight, and she was on Suicide Precautions.
- He had recommended inpatient psychiatric treatment, and was reluctant to release Patient #10 due to the seriousness of both suicide attempts.
- He had been aware of the several attempts to elope during the previous night shift, but had not ordered a Clinical Hold.
- That any patient whom attempts to hang themselves, are not safe to discharge to home, and the nursing staff should have intervened to ensure patient safety.

During an interview on 05/23/18 at 10:45 AM, Staff LL, RN, dayshift nurse, stated:
- She had been informed by Staff JJ, LPN, nightshift nurse, that Patient #10 had attempted to elope on 05/17/18 around 3:00 AM, and security had been notified.
- No one had spoken to her about elopement concerns until Staff NN, sitter, stuck her head out to let her and Staff JJ know about the potential for elopement.
- She did not feel that the elopement of Patient #10 was an imminent threat, so she did not enter the room to assess or evaluate the situation.
- She returned to the desk, along with Staff JJ, to discuss the situation with Staff MM, Charge nurse, and develop a plan to prevent elopement.
- The primary goal for nursing staff would be to keep their patient safe, and in hindsight, one nurse would stay with the patient, and the second would seek help.

During a telephone interview on 05/23/18 at 08:40 AM, Staff JJ, Licensed Practical Nurse (LPN), stated:
- During change of shift bedside report, Staff NN, sitter, stuck her head out of Patient #10's room, to let her and Staff LL, RN, know that she felt the patient was planning on leaving the facility with the visitor that just left.
- She continued on to complete shift report, and proceeded to the nurses' desk, to discuss a plan with the charge nurse, Staff MM.
- She believed that Patient #10 had already been placed on a Clinical Hold, but wanted to verify that information with Staff MM, and to obtain more information before approaching the patient.
- The sitter's responsibility was to inform the licensed staff of any concerns regarding suicidal patients, she had been informed of the elopement risk, and she would have been responsible for assessing the situation with the patient and ensuring her safety.
- She had not been aware of previous attempts to leave facility, even though she was the nurse that had contacted security the previous early morning for assistance with same patient.
-She believed that the patient put on "a good show, she was ok, and the suicide attempt was just to get out of jail".

During an interview on 05/22/18 at 3:00 PM, Staff V, RN, Nurse Manager, stated that:
- She was present when Staff JJ and Staff LL approached the desk to inform the charge nurse, Staff MM, of their concerns that Patient #10 had potential to elope.
- Simultaneously, she heard Staff NN, the sitter, state that the patient was gone.
- She was not aware that Patient #10 had attempted to leave during the previous night.
- The expectation would be that the staff nurse would be responsible for maintaining the safety of the suicidal patient, and detaining them if necessary.
- Staff nurses are able to initiate Clinical Holds if necessary, and should be aware that a patient on Suicide Precautions would not be able to leave without a Psychiatrist order.

During an interview on 05/23/18 at 9:55 AM, Staff PP, Executive Director of Behavioral Health, agreed that the nursing staff should have intervened to prevent Patient #10 from eloping from the facility, she needed inpatient psychiatric treatment.

The fact that Patient #10 was on Suicide Precautions and allowed to elope from the facility, due to lack of nursing oversight and inability of staff to recognize the potential for elopement, places all patients at risk.

2. Review of Patient #1's medical record showed that:
- He was a 48 year old male that presented to the ED for evaluation of behavior problems;
- The State of Missouri Department of Mental Health Affidavit dated 5/21/18 showed he had history of unpredictable behavior, noncompliant with medications, and was unable to take care of himself;
- The patient had erratic and agitated behavior. On evaluation, the patient appeared delusional (fixed false belief) and psychosis (disconnection from reality) with agitation;
- The patient had history of schizoaffective disorder (mental health condition characterized by hallucinations or delusions), Bipolar disorder (disorder associated with mood swings), and manic phase (unusually irritable mood);
- A clinical hold was ordered and the patient was placed with a sitter at bedside;
- The elopement risk assessment showed the patient was high risk and a yellow elopement sticker was placed on the patient's door;
- On 5/21/18 at 6:50 PM, the patient became agitated that required de-escalation and medication; and
- On 5/21/18 at 8:20 PM, the patient tried to elope that required de-escalation and medications were given.

Observation on 5/22/18 at 9:00 AM, in the Emergency Department (ED), showed Patient #1 in the restroom as the sitter was outside the door looking away from the restroom.

During an interview on 05/22/18 at 9:10 AM, Staff D, Sitter, stated:
- She was responsible for sitting with Patient #1;
- She did not keep the patient in line of sight while he was in the restroom;
- She was educated to just listen outside the door for any "unusual noises".

During an interview on 05/22/18 at 9:35 AM, Staff F, ED Technician, stated that it was the facility's policy to keep the patient in line of sight at all times. With the restroom door closed, the sitter could not visualize the patient at all times.

During an interview on 05/22/18 at 9:40 AM, Staff G, RN, stated:
- She was the nurse assigned to Patient #1;
- The patient was on clinical hold, had a sitter, and affidavit for danger to himself and others; and
- She was educated that you can close the restroom door and listen, and not keep them in line of sight.

During an interview on 05/22/18 at 9:50 AM, Staff K, ED Clinical Supervisor stated that it was not the facility's practice to leave patients on suicidal precautions unsupervised, and not in line of sight at all times.

3. Review of Patient #3's medical record showed that:
- He was a 65 year old male presented as a direct admit to sixth medical unit for behavioral changes;
- He had subsequent obsessive-compulsive disorder (OCD, anxiety disorder, characterized by the presence of obsessive thought and/or ritualistic behaviors) which began to get much worse;
- The patient had been in several psychiatric institutions;
- The patient had a suicide attempt last year, and was hospitalized;
- In the past six months the patient had become more aggressive to his wife and has struck her on numerous occasions;
- The State of Missouri Department of Mental Health Affidavit dated 5/21/18 showed history of unpredictable violence and aggression despite several recent psychiatric admissions and medication changes. The spouse was afraid to have the patient home due to the new personality dangers;
- The Columbia-Suicide Severity Rating scale (scale to evaluate a suicide risk) showed the patient answered yes that the visit was related to a suicidal behavior/attempt;
- A clinical hold was ordered and the patient was placed on suicidal precautions with a sitter at bedside;
- Psychiatry recommended admission to the inpatient psychiatric unit; and
- Safety interventions were suicide and elopement precautions.

Observation and concurrent interview on 5/22/18 at 10:05 AM, on six medical unit, showed Patient #3 sitting in a chair with street clothes on, cell phone and personal belongings within arm's reach. Staff M, PCA, stated that he was sitting with the patient because he was on suicidal precautions. Staff M acknowledge that Patient #3 had his cell phone, personal belongings, and his street clothes on. Staff M also stated he did not know why the patient had on his street clothes.

During an interview on 05/22/18 at 10:35 AM, Staff N, RN, stated:
- She was assigned to Patient #3;
- She had taken report and was informed that the patient was on suicidal precautions and had a sitter;
- When she went into assess the patient he had on his street clothes; and
- If the patient was on suicidal precautions, he should have been changed into green scrubs, and not be wearing his street clothes.

During an interview on 05/22/18 at 10:50 AM, Staff I, Charge RN, stated that Patient #3 had been in his street clothes for two days. With the patient on suicidal precautions, he should have been changed into green scrubs.

During an interview on 05/22/18 at 10:55 AM, Staff O, Clinical Supervisor, stated that patients that were on suicidal precautions should be changed into green scrubs. Patient #3 should not have his street clothes on or personal belonging in the room.

4. Observation on 5/22/18 on unit 3B at 10:50 AM showed Patient #9 resting in bed, with suicide sitter observing, dressed in a regular hospital gown.

During an interview on 5/22/18 at 10:52 AM, Staff V, Registered Nurse (RN), Manager Unit 3A/3B, stated that suicidal patients should be wearing paper gowns or scrubs, and there was no reason for Patient #9 to be in a regular medical gown.



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