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Based on observation, interview, record review and review of the facility's policies it was determined the facility failed to ensure its patients were receiving care in a safe environment as evidenced by: 1) one (1) patient (Patient #1) eloping while on a trial visit to a Personal Care Home (PCH) and 2) one (1) patient (Patient #2) eloping while on an outside, supervised break on the facility grounds.

The findings include:

1. The facility's policy "General Hospital Policies, Section 2, Discharge and Leave Policies, Subsection E, Home Visits," undated, listed the procedure for a voluntarily admitted patient to have a home visit for periods of twelve (12) consecutive hours or more. The procedure stated the visit must be thirty (30) days or less; medications should accompany the patient; home visit status could be converted to discharge status if the patient adjustment was satisfactory; and if the patient returned to the facility, a search would be conducted prior to entry into the facility. According to the document "Process for Eastern State Patients going on home visit/visit to personal care home," FAXED to the Eastern Enforcement Branch of the Office of the Inspector General (OIG) on 09/29/11 at 09:56 AM and requested to be received from the Hospital Administrator by the OIG Surveyor, the process for sending patients for a trial visit for placement in a PCH, was similar to the process for a home visit. Additions to the above procedure would be the recovery team assessed patient's readiness for discharge; unit Social Worker (SW) made contacts to appropriate facilities, including Personal Care Home (PCH's); PCH's evaluated whether or not the patient is an appropriate fit for their environment; in some instances, the PCH requested a trial visit of one (1) day up to thirty (30) days to fully evaluate the patient in their setting; the hospital kept the patient on the census but indicated the patient was on a home visit; neither the hospital nor the PCH charged the patient during the visit; the PCH maintained contact with the hospital staff regarding the progress and condition of the patient; the PCH notified the hospital when they reached a decision to keep the patient or return the patient to the hospital; if the PCH kept the patient, the hospital discharged the patient from the census and advised the psychiatrist to complete the discharge summary; and if the patient was returned to the hospital, they would be sent through the Central Triage Center (CTC) for a search, to secure their valuables, and if necessary, to have their medications re-ordered. However, these additions were not formally written in the "Discharge and Leave Policies." The PCH where Patient #1 had the trial visit had a policy, "Leaving Premises Without Notice Policy." This policy stated that the PCH will not accept responsibility for the resident who left the premises of the facility.

Interview with the two Risk Managers and the Nurse Leader, on 09/28/11 at 4:45 PM, revealed all three (3) believed the facility with physical custody of the patient had responsibility for the safety of the patient when the patient was on a trial or "guesting" period. Interview with PCH Administrators #1,2,3,4, per telephone, on 09/28/11 from 12:20 PM to 1:40 PM, revealed they all believed the responsibility for the safety of the patient rested with them as long as they had the patient in their facility. However, the question of who had responsibility for the patient during a trial visit is not addressed in a written form; there is also no written contract between the facilities.

Interview with the Director of Social Work, on 09/28/11 at 2:10 PM, verified the procedure Social Worker (SW's) use to contact PCH's. She revealed some of the facilities preferred to do trial visits, but most of the PCH's did not require trial visits and relied on SW information and FAXED information on whether to accept the patient. She stated the facility might be able to place more difficult patients if the PCH's knew the patient could be returned to the facility if the placement did not work. She revealed she would expect the patient to be on self or support supervision level when going on a trial or home visit. However, this level of supervision was not addressed in the "Discharge and Leave Policies."

Interview with Patient #1, on 09/27/11 at 4:30 PM, revealed he/she had no complaints about treatment at the PCH but felt he/she was given too much independence and started misbehaving. He/she stated the PCH let him/her come and go as much as desired. He/she also revealed his/her destination from the elopement was the facility (hospital), but the police found him/her in a field and returned him/her to the facility (hospital).

Review of Patient #1's medical record, revealed he/she was admitted on 08/12/11 under a seventy-two (72) hour court ordered involuntary admission from a PCH, not the one where the trial visit occurred. The admitting diagnoses were impulse control disorder and mental retardation. Further review of the record revealed the "Patient Check-Out Form," the "Nursing Discharge Information" sheet and the "After-Care Instruction" sheet were completed on 09/08/11 when Patient #1 went for the two (2) week trial visit to the PCH. It was also checked that Patient #1 received his/her medication to go along with the visit and left at 2:40 PM via the facility transport. The "Shift Assessment/Daily Notes" sheet for Patient #1 on 09/08/11 indicated Patient #1 was on self supervision; had no self harm ideation; had no acting out behavior and was goal directed and cooperative. According to the facility policy "General Hospital Policies, Section 3, Risk Management and Safety, Subsection F, Supervision of Patients," undated, self level supervision allowed patients to be off the unit for a limited period of time without staff supervision; support level supervision allowed patients to leave the unit escorted by staff; and safety level supervision restricted patients from leaving the unit. A Progress Note written by the Physician, on 09/07/11 at 2:50 PM, stated Patient #1 to go to PCH on 09/08/11 for a two (2) week visit and that he/she was stable psychiatrically and medically and not at risk for harming self or others. A Progress Note written by the SW, on 09/12/11 at 2:00 PM, stated the PCH called and stated Patient #1 was on his/her way back to the facility from the home visit because Patient #1 had experienced a bad weekend with "breaking stuff and getting arrested for theft." A Progress Note by the SW, on 09/12/11 at 3:00 PM, stated that the PCH had called to inform that Patient #1 could not be found and was considered absent without leave (AWOL). CTC form "Return from Leave" indicated Patient #1 was returned to the facility by the police on 09/12/11 at 10:03 PM. The "Shift Assessment/Daily Notes" for 09/12/11 indicated Patient #1 arrived back on the unit at 10:55 PM in a pleasant, friendly, good mood. A Progress Note written by the Physician on 09/13/11 stated Patient #1's home visit ended due to his misconduct, such as shop lifting and running away from the PCH. The Physician Note also stated his level of supervision was changed to safety upon his/her return to the facility.

Review of the medical records of nine (9) other trial home visit patients, revealed three (3) were returned to the facility because of incidents at the PCH. Patient #4 was admitted 05/11/11 under a seventy-two (72) hour court ordered involuntary admission. The admitting diagnoses were impulse control disorder, hypertension and diabetes. He/she was admitted from a Supported Community Living (SCL) facility. According to the Discharge Summary dated 06/03/11, he/she was given a trial visit to the SCL, but had to return to the facility because he/she attacked one of the staff at the SCL. However, he/she was able to return to the same SCL in seventeen (17) days. Patient #8 was admitted 10/13/10 under a sixty (60) day request from an acute care facility; he/she was originally from home. The admitting diagnosis was a schizophrenic disorder. Patient #8 went for a trial home visit at a PCH but, according to SW Note of 05/02/11, had to return because he/she had attempted to elope from the PCH multiple times. Patient #11 was admitted 10/15/10 under a seventy-two (72) hour court ordered involuntary admission. The admitting diagnosis was psychosis. The patient had been a resident of a "rest home" and had walked away from it and broken into a number of residences in the area. Nurses Notes from 03/02/11 and 03/08/11 stated he/she left on a trial home visit on 03/02/11 and returned 03/08/11 due to Patient #11 leaving the PCH.

2. The facility's policy "General Hospital Policies, Section 3, Risk Management and Safety, Subsection F, Supervision of Patients," undated, stated that on support level supervision, patients could leave the unit escorted by staff, and staff may not supervise more than five Patients during this time if in an unsecured area. The facility document "ESH Nursing Policy Update," April 2011, also lists this ratio as a minimum guideline.

Observation of Wendell 3 Unit, on 09/28/11 at 3:25 PM, revealed the doors to the unit were locked with only nursing staff having a key. Patients were in the hallway being attended by Mental Health Associates (MHA). There were no outside breaks going on at this time. There was no acting out behaviors observed from the patients at this time.

Review of Patient #2's medical record revealed he/she was admitted on 09/10/11 from home with an admitting diagnosis of psychosis. He/she was admitted under a seventy-two (72) hour court order. The supervision level for Patient #2 initially was safety with fifteen (15) minute checks which is patient on the unit with observation and documentation by the staff every fifteen (15) minutes. On 09/12/11 at 7:05 PM, per Physician Order, the level of supervision was changed to support. Per Nurses Notes, on 09/13/11 at 5:45 PM, Patient #2 went on an outside break with MHA #1 and four (4) other patients. Patient #2 went over to the swing set area. When it was time to end the break, Patient #2 was not present. After a search of the unit and the outside grounds again, an "Absent Without Leave" (AWOL) protocol was initiated. The "Discharge Data Form" completed by the SW on 09/14/11 stated Patient #2 was determined to have returned to his home. Patient #2 was discharged due to his voluntary status and because he/she was not considered a danger to him/herself or others. Patient #2 was brought back by the police for another admission to the facility on 09/17/11.

Registered Nurse (RN) #1 was Patient #2's nurse on 09/13/11 at the time of the elopement. Interview with RN #1, on 09/28/11 at 3:30 PM at the Unit Nurses Station, revealed Patient #2 was on a support level of supervision, and there were four (4) other patients with Patient #2 that went on an outside break with MHA #1 on 09/13/11. RN #1 got back to the unit around 6:00 PM and discovered that Patient #2 was missing. Another search was done; when he/she still was not found, the AWOL protocol was put in place. RN #1 further revealed that Patient #2 had exhibited no behaviors to be considered an AWOL risk. Interview with Patient #2, on 09/28/11 at 3:45 PM in the unit conference room, revealed he/she was hearing voices and stated the staff told him/her to hop the fence, and it had something to do with Judgment Day. He/she further revealed the other patients told him to leave, not verbally, but in other ways. He/she stated that someone picked him/her up and drove to his/her home and that nothing bad happened during the elopement. Telephone interview with MHA #1, on 10/04/11 at 12:40 PM, revealed the break area for Patient #2's unit was bounded by walls and a chain link fence that was approximately eight (8) feet high. He further stated there was a generator with a fence around it and a swing set in this area. The generator with the fence blocked the view of the patients in the swing set area. MHA #1 further revealed he did not hear the chain link fence rattling or see Patient #2 elope. He further revealed he was very surprised that Patient #2 did elope. He confirmed that AWOL procedures were put in place when Patient #2 could not be found, and also that there were four (4) other patients with him and Patient #2 on the outside break. Interview with the two (2) Risk Managers and the Nurse Leader, on 09/28/11 at 4:45 PM, revealed the facility tried to locate the patient and notify authorities with elopements. They revealed there was no way to prevent elopements when the patient was on self supervision and that this supervision was necessary to transition the patients to discharge. They further revealed that elopement data was trended and benchmarked with other facilities, both statewide and nationally. Finally, they revealed the highest number of elopements per month would have been three (3).

Based on observation, interview, record review and review of the facility's policies it was determined the facility failed to ensure its patients were receiving care in a safe environment as evidenced by: 1) one (1) patient (Patient #1) eloping while on a trial visit to a Personal Care Home (PCH) and 2) one (1) patient (Patient #2) eloping while on an outside, supervised break on the facility grounds.

The findings include:

1. The facility's policy "General Hospital Policies, Section 2, Discharge and Leave Policies, Subsection E, Home Visits," undated, listed the procedure for a voluntarily admitted patient to have a home visit for periods of twelve (12) consecutive hours or more. The procedure stated the visit must be thirty (30) days or less; medications should accompany the patient; home visit status could be converted to discharge status if the patient adjustment was satisfactory; and if the patient returned to the facility, a search would be conducted prior to entry into the facility. According to the document "Process for Eastern State Patients going on home visit/visit to personal care home," FAXED to the Eastern Enforcement Branch of the Office of the Inspector General (OIG) on 09/29/11 at 09:56 AM and requested to be received from the Hospital Administrator by the OIG Surveyor, the process for sending patients for a trial visit for placement in a PCH, was similar to the process for a home visit. Additions to the above procedure would be the recovery team assessed patient's readiness for discharge; unit Social Worker (SW) made contacts to appropriate facilities, including Personal Care Home (PCH's); PCH's evaluated whether or not the patient is an appropriate fit for their environment; in some instances, the PCH requested a trial visit of one (1) day up to thirty (30) days to fully evaluate the patient in their setting; the hospital kept the patient on the census but indicated the patient was on a home visit; neither the hospital nor the PCH charged the patient during the visit; the PCH maintained contact with the hospital staff regarding the progress and condition of the patient; the PCH notified the hospital when they reached a decision to keep the patient or return the patient to the hospital; if the PCH kept the patient, the hospital discharged the patient from the census and advised the psychiatrist to complete the discharge summary; and if the patient was returned to the hospital, they would be sent through the Central Triage Center (CTC) for a search, to secure their valuables, and if necessary, to have their medications re-ordered. However, these additions were not formally written in the "Discharge and Leave Policies." The PCH where Patient #1 had the trial visit had a policy, "Leaving Premises Without Notice Policy." This policy stated that the PCH will not accept responsibility for the resident who left the premises of the facility.

Interview with the two Risk Managers and the Nurse Leader, on 09/28/11 at 4:45 PM, revealed all three (3) believed the facility with physical custody of the patient had responsibility for the safety of the patient when the patient was on a trial or "guesting" period. Interview with PCH Administrators #1,2,3,4, per telephone, on 09/28/11 from 12:20 PM to 1:40 PM, revealed they all believed the responsibility for the safety of the patient rested with them as long as they had the patient in their facility. However, the question of who had responsibility for the patient during a trial visit is not addressed in a written form; there is also no written contract between the facilities.

Interview with the Director of Social Work, on 09/28/11 at 2:10 PM, verified the procedure Social Worker (SW's) use to contact PCH's. She revealed some of the facilities preferred to do trial visits, but most of the PCH's did not require trial visits and relied on SW information and FAXED information on whether to accept the patient. She stated the facility might be able to place more difficult patients if the PCH's knew the patient could be returned to the facility if the placement did not work. She revealed she would expect the patient to be on self or support supervision level when going on a trial or home visit. However, this level of supervision was not addressed in the "Discharge and Leave Policies."

Interview with Patient #1, on 09/27/11 at 4:30 PM, revealed he/she had no complaints about treatment at the PCH but felt he/she was given too much independence and started misbehaving. He/she stated the PCH let him/her come and go as much as desired. He/she also revealed his/her destination from the elopement was the facility (hospital), but the police found him/her in a field and returned him/her to the facility (hospital).

Review of Patient #1's medical record, revealed he/she was admitted on 08/12/11 under a seventy-two (72) hour court ordered involuntary admission from a PCH, not the one where the trial visit occurred. The admitting diagnoses were impulse control disorder and mental retardation. Further review of the record revealed the "Patient Check-Out Form," the "Nursing Discharge Information" sheet and the "After-Care Instruction" sheet were completed on 09/08/11 when Patient #1 went for the two (2) week trial visit to the PCH. It was also checked that Patient #1 received his/her medication to go along with the visit and left at 2:40 PM via the facility transport. The "Shift Assessment/Daily Notes" sheet for Patient #1 on 09/08/11 indicated Patient #1 was on self supervision; had no self harm ideation; had no acting out behavior and was goal directed and cooperative. According to the facility policy "General Hospital Policies, Section 3, Risk Management and Safety, Subsection F, Supervision of Patients," undated, self level supervision allowed patients to be off the unit for a limited period of time without staff supervision; support level supervision allowed patients to leave the unit escorted by staff; and safety level supervision restricted patients from leaving the unit. A Progress Note written by the Physician, on 09/07/11 at 2:50 PM, stated Patient #1 to go to PCH on 09/08/11 for a two (2) week visit and that he/she was stable psychiatrically and medically and not at risk for harming self or others. A Progress Note written by the SW, on 09/12/11 at 2:00 PM, stated the PCH called and stated Patient #1 was on his/her way back to the facility from the home visit because Patient #1 had experienced a bad weekend with "breaking stuff and getting arrested for theft." A Progress Note by the SW, on 09/12/11 at 3:00 PM, stated that the PCH had called to inform that Patient #1 could not be found and was considered absent without leave (AWOL). CTC form "Return from Leave" indicated Patient #1 was returned to the facility by the police on 09/12/11 at 10:03 PM. The "Shift Assessment/Daily Notes" for 09/12/11 indicated Patient #1 arrived back on the unit at 10:55 PM in a pleasant, friendly, good mood. A Progress Note written by the Physician on 09/13/11 stated Patient #1's home visit ended due to his misconduct, such as shop lifting and running away from the PCH. The Physician Note also stated his level of supervision was changed to safety upon his/her return to the facility.

Review of the medical records of nine (9) other trial home visit patients, revealed three (3) were returned to the facility because of incidents at the PCH. Patient #4 was admitted 05/11/11 under a seventy-two (72) hour court ordered involuntary admission. The admitting diagnoses were impulse control disorder, hypertension and diabetes. He/she was admitted from a Supported Community Living (SCL) facility. According to the Discharge Summary dated 06/03/11, he/she was given a trial visit to the SCL, but had to return to the facility because he/she attacked one of the staff at the SCL. However, he/she was able to return to the same SCL in seventeen (17) days. Patient #8 was admitted 10/13/10 under a sixty (60) day request from an acute care facility; he/she was originally from home. The admitting diagnosis was a schizophrenic disorder. Patient #8 went for a trial home visit at a PCH but, according to SW N