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Based on review of facility documents, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to maintain a safe environment for one patient identified with impulse control disorder and one patient identified with depression for two of eight medical record reviewed (MR1 and MR7).

Findings include:

Review of facility policy "Patient Rights and Responsibilities," last revised on October 9, 2013 , revealed that the component, related to the patient having the right to receive care in a safe setting, was omitted from the policy.

Review of facility policy "Continual Observation Policy [D-02]," last revised March 2014, revealed "I. Policy ... Continual Observation protects the immediate physical safety of the patient, staff members, or others ... The purpose of this policy is to provide a therapeutically and maximally safe environment for the patients who have been determined to need continual observation. ... III. Education, Training & Competence A. Assigned staff members who perform Continual Observations participate in education, training, and assessment of competence at the following intervals: 1. at orientation 2. before participating in Continual Observation 3. on a periodic basis thereafter B. Education, training, and competence focus on the following: 1. Strategies to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require Continual Observation. 2. Methods for choosing alternatives based on an assessment of the patient's status or condition. 3. Clinical identification of specific behavioral changes that indicate that Continual Observation is no longer necessary. 4. Monitoring the physical and psychological well-being of the patient under Continual Observation. 5. Recognizing and reporting safety concerns. 6. Appropriate clinical documentation. C. Education, training, and competence is documented. D. LIP (Licensed Independent Practitioner) / other qualified healthcare personnel training- LIPs/other qualified healthcare personnel have working knowledge of the hospital policy regarding Continual Observation ... IV. Continual Observation Procedure ... C. Implementation 1. Scope of Responsibility a. Continual Observation for Non-Suicidal Patient: Continual observation for a non-suicidal patient is performed by an assigned staff member who: will maintain visual contact with the patient at all times; can not be distracted while performing the observation (i.e. by television, computer, phone); and can deliver patient care in accordance with their role ..."

1) Review of MR1 physician progress notes, dated/timed June 4, 2014, 9:00 AM, by OTH 5 revealed "... Improved behavior No restraints for 48 hours will continue to work on dispo plan with CM (case manger). Have meeting with nurses/ administration/ security to discuss plan of care while here in hospital..."

Review of MR1 nursing progress note, dated/timed June 4, 2014, 11:20 AM, by EMP 41, revealed "... pt. asked to go for a walk. pt ambulated with nurse and security. pt. ambulated with no assistance ... walked 2 laps around ICU."

Review of nursing progress note, at 13:45 by EMP40, revealed "returned from break found security staff and nurses in pt. room, observed broken bathroom window... rapid response and security alert had been already activated assisted in transporting patient to trauma bay with [OTH 5] in attendance ..."

Review of a physician progress note, at 3:00 PM, by OTH5, revealed "Had conversation with patient's father to discuss that patient locked [self] in the bathroom, broken window and jumped out. I immediately helped to transport patient to trauma bay and initiate trauma alert ..."

Interview on June 6, 2014, at 11:00AM, with EMP7 confirmed he was assigned to complete Continual Observation/ one to one to MR1 on June 3, 2014. EMP7 revealed that on June 3, 2014, the patient wanted to go for a walk, however a second staff was not available. The patient wanted to use the phone, but it was charging. At 1:39 PM, the patient became agitated and started walking from the bed, to the chair, to the bathroom located in the patient's room. The patient then went into the bathroom closed the door and locked the door. EMP7 heard the patient banging on the wall and called for EMP9. EMP7 stated that EMP7 tried to unlocked the bathroom door with EMP7 keys but was unsuccessful. EMP7 stated hearing the glass shatter. At that time, EMP7 called the control team. EMP7 did not recall how the door got unlocked.

Observation on June 6, 2014, at 10:00AM, of the ICU revealed that the patient rooms on that unit were not specifically outfitted to accommodate patients with active behavioral symptoms, such as aggressive and impulse behavioral disturbances.

Interview on June 6, 2014, at 1:00 PM, with EMP6 confirmed that security staff did not attend or receive Continual Observation training

Interview on June 6, 2014, at 2:50 PM, with EMP1, revealed that staff were not trained on how to utilize the safety release feature on the bathroom door locks.

2) Review of MR7 physician orders, dated May 28, 2014, revealed a diagnosis of "Depressive disorder." Further review of physician orders, dated May 28, 2014, revealed "Behavioral Observations [Nursing] q15 minutes."

Review of MR7 admission assessment, dated May 28, 2014, revealed "Symptoms Patient passively suicidal, wishes [patient] were dead but has no plan to kill self."

Review of MR7 "FlowSheet Behavior Safety," dated May 29, 2014, revealed "Q15min Checks 00:20 for 11-7 Shift Suicide Risk."

Review of MR7 nursing progress note, dated/timed May 29, 2014, 02:00, revealed "the patient said that [patient] was hungry and requested a snack. Yogurt and milk provided."

Review of MR7 nursing progress note, dated/timed May 29, 2014, 02:21, revealed "the patient c/o feeling very anxious, can not sleep; pacing the hallways of the unit. PRN ativan given. The patient was encourage to distract self from distressing thoughts, reading a book."

Review of MR7 nursing progress note, dated/timed May 29, 2014, 02:45, revealed "the patient came to the nurses station after receiving a snack and said ' I tried to stab myself with the spoon.' The patient pulled ... shirt up and revealed abrasion area covering the right lower quadrant of [patient's] abdomen. These self inflicted wounds were cleansed and dressing applies. All articles by which the patient could harm self were removed from [patient's] room."

Review of MR7 revealed "Behavior Safety" checks were only documented once per shift at various times. There was no documented evidence that this"behavioral observations" on this patient were completed every 15 minutes in accordance with the physician's order.

3) Review on June 10, 2014, of "Security Department Meeting," minutes from June 12, 2013, September 10, 2013, January 29, 2014 and May 28, 2014 revealed no evidence that Continual Observation of patients was addressed or discussed during any of these meetings.

Review on June 6, 2014, at 10:00 AM, of PF4, PF11, PF12, PF13, PF14, PF15, PF16, PF17, PF18, PF19, PF20, PF21, PF22, PF23, PF24 and PF24 revealed no documented evidence that these staff members participated in education, training, and assessment of competence of Continual Observation at the following intervals: 1. at orientation 2. before participating in Continual Observation 3. on a periodic basis thereafter.

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to identify and provide adequate justification for the use of medications as a chemical restraint for one of two restraint records reviewed (MR7).

Findings include:

Review of facility policy "Restraint Use [D-32]," revised March 2014, revealed " Policy ... During the treatment of specific conditions or when certain behaviors are exhibited, caregivers use a variety of interventions that promote patient safety and decrease the risk for interruption of medical healing or behaviors which may cause harm to patients, staff, and others. Restraint or seclusion will not be used as a means of coercion, discipline, convenience or retaliation by staff ... Restraint or seclusion is only used after alternatives have been considered and/or determined to be infective. Staff uses the least restrictive form of restraint or seclusion necessary to protect the patient, staff, or others. ... II. Definitions Restraint ... 2. A drug or medication, when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition (chemical restraint). ... III. Restraint for Non-Violent/Non Self-Destructive Behaviors A. Assessment and Restraint Criteria 1. The RN assesses the behaviors the patient is exhibiting in order to determine the need for restraint. This assessment includes: a. behavior that is harmful to self, others, or the environment b. behavior that may interfere with necessary medical treatment c. behavior that indicates the patient is unable to follow directions to avoid self-injury 2. The assessment of the patient needs to determine that the risks associated with the use of the restraint are outweighed by the risk of not using it. 3. The patient is restrained only after alternatives to restraint are considered and/or are determined to be ineffective. B. Restraint Order 1. There is a written/electronic, time-limited, order for restraints. ... 3. Standing orders or PRN (also known as "as needed") orders for restraint are prohibited. ... F. Documentation 1. The RN documents completed assessments and reassessments to validate the continued need for restraint. 2. Patient care staff documents the following in the patient's medical record: a. any alternatives attempted. b. A description of the patient's behavior and staff concerns regarding safety risks to the patient, staff, or others that warranted the use of the restraint. c. The restraint type used. ... IV Restraint for Violent or Self- Destructive Behavior All information included in Section III A-F also applies to restraint used for violent or self- destructive behavior; specific and additional requirements follow. A. Assessment and Restraint Criteria (See also Section III, A.) Patient is exhibiting violent/self-destructive behavior and/or is at risk of placing others at risk and/or is exhibiting severely violent/aggressive behavior and/or is an immediate danger to self or others. ... "

Review of MR7 "Discharge Summary," dated June 5, 2014, revealed " Reason for Admission Anxiety and depression."

Review of MR7 physician orders, dated May 28, 2014, revealed " ... Haldol (a antipsychotic medication used to treat psychosis and that can have sedating effects) 2 MG IM-Intramuscular Every Two Hours PRN (as needed) Severe Agitation; Ativan (a anxiolytic medication used to treat anxiety and that may cause drowsiness) 0.5 MG IM- Intramuscular Every Four Hours PRN Agitation; Ativan 0.5 MG Oral Every Four Hours PRN Agitation ... "

Review of MR7 nursing progress note, dated/timed May 30, 2014 at 18:26, by EMP48, revealed " Tray with burger and ice cream came up, brought into patient's room along with glucometer, patient took a bite of the burger and spit it out, patient then stated that since [patient] did not eat we cannot check [patient's] sugar, also stated that [patient] will not take any meds and wants another doctor, patient very upset and told us to get out of [patient's] room."

Review of MR7 medication administration record, dated May 30, 2014, revealed patient was administered Ativan 0.5 MG orally at 19:15, by EMP48.

Review of MR7 medication administration record, dated May 31, 2014, revealed patient was administered Ativan 0.5 MG orally at 19:33, by EMP47.

Review of MR7 nursing progress note, date/timed May 31, 2014 at 20:27, by EMP47, revealed "Patient demonstrating a sense of entitlement, making demands, screaming, throwing tantrums, challenging staff to call security, demanding to have a snack before group because [patient] is 'not going to group'. Patient walked up close to staff and said '[expletive] you!' Accusing staff at this hospital of 'starving' [patient]. Patient was reminded that a tech called dietary for a requested sandwich because [patient] did not like the hummus/vegetable/pita plate [patient] ordered, then patient ended up slamming the sandwich in the garbage in front of staff because it was 'dry.' Patient rang [patient's] bed alarm to request a soda and was also reminded the bell is used for help. Patient continues to believe [patient] is being mistreated and that [patient] is only here for 'rest.' Patient was asked to stay calm in [patient's] room for an hour and [patient's] request for a soda and snack would be obliged like normal milieu routine. At one hour of passing time, patient came out of [patient's] room to this nurse demanding a snack and firmly stating [patient] was not going to group. Patient was redirected, [patient] walked back to [patient's] room and began screaming and creating a scene looking out to see if the patients in the common room were looking. Patient given IM- PRN and [patient's] wish to go into the quiet room was granted. Patient offered toilet, watch and necklace removed for safety-patient voluntarily handed to this nurse. Patient screamed to turn out the light which stayed on to observe. Door is unlocked, patient can come out at any time. Patient currently laying down and quiet. "

Review of MR7 medication administration, dated May 31, 2014, revealed that the patient was administered Ativan 0.5 MG IM, by EMP47. A review of the "Admin Note," dated/timed May 31, 2014 21:57 revealed that this medication was "given at 2000."

Further review of the medication administration, dated May 31, 2014, revealed that the patient was also administered Haldol 2 MG IM, by EMP47. A review of the "Admin Note," dated/timed May 31, 2014 23:36 revealed that this medication was "given at 2000."

Review of documentation provided on June 10, 2014, by EMP1, revealed that the patient had an order for Ativan q 4 hours as needed, therefore the facility did not consider this a restraint order. Further review of documentation revealed that these medication were administered during the patient's "acting out" episodes, such as "spitting out food, rapid pacing, and tantrums."

Based on review of facility documents, review medical records (MR) and interviews with staff (EMP), it was determined the facility failed to implement performance improvement measures related to inpatient elopements to ensure that the facility provided a safe setting for eight of eight medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, and MR8).

Findings include:

Review on June 6, 2014 of the facility's "Performance Improvement Plan," last revised March 15, 2013, revealed "... III. Procedure: A. Leadership Roles and responsibilities: The Network's leadership is responsible for: setting executions, planning and managing processes to measure assess, and improve the Network's governance, management , clinical and support activities with a goal to achieve performance excellence.../Measuring and assessing the effectiveness of the performance improvement and safety activities B. Authority and Accountability: 1. Board of trustees a. The authority and responsibility for establishment maintenance, support and evaluation of the performance improvement, patient safety and risk management programs is vested in the St. Luke's University Health Network Board of trustees. b. The Board , through a designated quality committee will delegate to Administration and the Medical Staff the responsibility for implementation and reporting of the activities and mechanisms for monitoring and evaluating the quality of patient care, identifying opportunities to improve patient care, and identifying and resolving problems. c. The designated quality committee of the board will receive reports from administration to monitor quality review activities and results. ..."

Review on June 6, 2014 of "Quality and Medical Education Committee Meeting," minutes from January 17, 2014 to March 14, 2014, and the "Network Patient Safety Committee Report," from the First Quarter of 2014, revealed that inpatient elopements were not investigated at the Quality Assurance Performance Improvement committee meetings.

Review on June 6, 2014, of MR1 revealed the patient eloped from the hospital twice within a 24 hour period on May 25, 2014.

Review of MR2, MR3, MR4, MR5, MR6, MR8 and MR9 revealed they were inpatients who had eloped from the hospital between February 17, 2014 to June 3, 2014.

Interview on June 6, 2014, at 12:55PM, with EMP2 confirmed that inpatient elopements are not discussed or investigated at Quality Assurance Performance Improvement. EMP2 revealed that only elopements from the Emergency Department are investigated.

Based on review of facility documents, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that behavioral observations were documented to reflect that behavior safety checks were completed every 15 minutes in accordance with the physician's order for two of two medical records (MR1 and MR7).

Findings include:

Review on June 6, 2014, of facility policy "Continual Observation Policy [D-02]," last revised March 2014, revealed ... D. Continual Observation: visual contact with patient at all times. ... 6. Documentation a. The RN documents completed assessments and reassessments to validate the need for Continual Observation. Reassessments for Continual Observation occur at frequent intervals, normally not to exceed four hours.

1) Review on June 12, 2013, at approximately 9:30 AM, of MR1 revealed physician orders dated on May 21, 22, 23, 24, 25 and , 27, 2014 for "Behavioral Observations pt risk to self and others Q 15 min." Further review of MR1 revealed behavior safety checks documented on May 21 at 0400, 0800,1200, 1600 and 1946. The patient was documented on May 22 at 0016, 0427, 0800, 1426, 1600, and 2000. The patient was documented on May 23 at 0000, 0400, 0737, 1200, 1600, and 2000. The patient was documented on May 24 at 0000, 0410, 0710, 0931, 1210, 1630, and 2000. The patient was documented on May 25 at 0002, 0509, 0800, 1200, 1600, and 2000. The patient was documented on May 27 at 0000, 0400, 0600, 0800, 1200, 1500, 1600, 1700, 1806, 2000, and 2200.

During an interview on June 30, 2014, at approximately 8:30 AM, with EMP1 revealed that the "Behavioral Observation Q15 min" was a physician's order and part of the nursing assignment sheets.

2) Review of MR7 admission assessment, dated May 28, 2014, revealed " Symptoms Patient passively suicidal, wishes [patient] were dead but has no plan to kill self."

Review of MR7 "FlowSheet Behavior Safety," dated May 28, 2014, revealed "Q15min Checks 15:37 for 3-11 Shift Suicide Risk."

Review of "FlowSheet Behavior Safety," dated May 29, 2014, revealed "Q15min Checks 00:20 for 11-7 Shift Suicide Risk, 06:57 for 7-3 Shift Suicide Risk, 14:33 for 3-11 Shift Suicide Risk."

Review of "FlowSheet Behavior Safety," dated May 30, 2014, revealed "Q15min Checks 00:24 for 11-7 Shift Suicide Risk, 06:52 for 7-3 Shift Suicide Risk, 14:56 for 3-11 Shift Suicide Risk."

Review of "FlowSheet Behavior Safety," dated May 31, 2014, revealed "Q15min Checks 03:29 for 11-7 Shift Suicide Risk, 06:23 for 7-3 Shift Suicide Risk, 14:23 for 3-11 Shift Suicide Risk."

Review of "FlowSheet Behavior Safety," dated June 1, 2014, revealed "Q15min Checks 01:18 for 11-7 Shift Suicide Risk, 06:25 for 7-3 Shift Suicide Risk, 15:19 for 3-11 Shift Suicide Risk."

Review of "FlowSheet Behavior Safety," dated June 2, 2014, revealed "Q15min Checks 00:41 for 11-7 Shift Suicide Risk, 06:27 for 7-3 Shift Suicide Risk, 14:01 for 3-11 Shift Suicide Risk."

Review of "FlowSheet Behavior Safety," dated June 3, 2014, revealed "Q15min Checks 00:25 for 11-7 Shift Suicide Risk, 06:48 for 7-3 Shift Suicide Risk, 14:02 for 3-11 Suicide Risk."

Review of "FlowSheet Behavior Safety," dated June 4, 2014, revealed "Q15min Checks 02:12 for 3-11 Shift Suicide Risk, 06:28 for 7-3 Shift Suicide Risk, 13:59 for 3-11 Shift Suicide Risk."

Review of "FlowSheet Behavior Safety," dated June 5, 2014, revealed "Q15min Checks 01:35 for 11-7 Shift Suicide Risk, 06:27 for 7-3 Shift Suicide Risk."

Review of MR7 revealed "Behavior Safety" checks were only documented once per shift at various times. There was no documented evidence that "behavioral observations" on this patient were completed every 15 minutes in accordance with the physician's order.