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Based on observations, interviews and record reviews the facility failed to provide sufficient protective oversight and care in a safe setting for an adult Psychiatry Unit patient (who had demonstrated prior elopement attempts, was diagnosed with suicidal ideation and was on a ninety six hour hold, a probate court ordered detention) to prevent an elopement from the facility Radiology Service area.

The facility failed to:

-Ensure effective communication between Psychiatry Unit staff members was routinely used for passing essential information including the requirement for the patient to be dressed in a hospital gown for chest x-rays.
-Develop and maintain consistent, effective procedures and hand-off tools with complete information, including level of precaution for Psychiatry patients.
-Develop, maintain and implement effective policies and procedures clearly directing specifics for oversight of the Psychiatry Unit patients while off-unit for testing or medical procedures.
-Effectively train Psychiatry Unit staff to ensure consistent levels of precaution were provided during off-unit care (x-ray in Radiology Department).
-Ensure any special precautions patients were not placed in environmentally unsafe areas such as toileting areas that contained structures, equipment and other items that could be used to harm self or others.

The cumulative result of these failures resulted in noncompliance with the Condition of Participation: Patient Rights.

At the time of exit on 08/11/10, the facility was able to provide documentation of actions implemented sufficient to abate the immediate jeopardy situation.

Based on observations, interviews and record reviews facility staff failed to provide one patient (Patient #1), who demonstrated prior elopement attempts, was diagnosed with suicidal ideation and was under ninety six hour hold, a probate court ordered detention, with sufficient protective oversight and care in a safe setting preventing elopement through:

-failure to ensure the requirement for the patient to be dressed in a patient gown for a chest x-ray was effectively communicated between Psychiatry staff members.
-failure to develop and maintain an effective procedures and hand-off tools with complete information, including level of precaution between Psychiatry Staff members.
-failure to develop, maintain and implement effective policies and procedures clearly directing specifics for oversight of the patient off-unit.
-failure to effectively train Psychiatry Unit staff to ensure consistent level of precaution was provided during off-unit care (x-ray in Radiology Department).
-failure to ensure the special precautions patient were not placed in environmentally unsafe areas (containing items that could be used to harm self or others).

The facility (North Campus Psychiatry Unit) census was 43 which included three patients identified with primary or secondary diagnosis of suicidal ideation and two other patients under ninety six hour hold.

Findings included:

1. Review of the facility policy titled, Patient Elopement, #Treatment 14; approved 06/07 directed in part, the following:
-The purpose of the policy was after a patient eloped, inform the Psychiatrist, the family and if appropriate, law enforcement.
-The policy directed staff to try to locate the patient and inform appropriate persons listed as:
-1. Security,
-2. Psychiatrist to determine further actions,
-3. The family,
-4. The Police or Sheriff's department, if the patient was admitted on Police or Court Order
-5. The Unit Manager.
-Document the incident in the patient's medical record, complete an incident report and if the patient was not returned in a reasonable time {not stated} a Psychiatrist's order should be obtained for discharge of the patient.

2. Review of the facility policy titled, Program Procedures for Patients, Visitors, Staff and Property, #SMP3, effective date 01/08 directed, in part, the following:
-Under the paragraph subtitled, Security of Patients, the policy directed all patients receiving any services at the facility whether inpatient or outpatient would be issued {the policy does not specify staff who would issue} an Identification Tag to be kept on their person at all times.
-Under the paragraph subtitled Patient Elopement, the policy directed patients who lacked the mental capabilities to make informed judgments and may endanger themselves by leaving the facility were housed and treated in areas with alarm systems (wander guards) which alert staff if they attempt to leave the housing or treatment areas. If those patients were taken to an area which does not have an alert system, they were closely monitored by staff.
-Under the paragraph subtitled Patient Elopement, the policy further directed staff to search the area and after fifteen minutes, call Security staff and the Nurse Manager.
-under the paragraph subtitled Patient Elopement, the policy further directed all staff who observe unusual activity such as small children, wandering, confused adults attempting to exit etcetera, should stop and see if the person needed help. Check the person for an identification band and call the appropriate unit.

3. Review of the facility policy titled, Precautions: Adult I and II and Senior Adult Inpatient Psychiatry, #Treatment 1; approved 05/10 directed in part, the following:
-The purpose of the policy was to establish guidelines for precautions used on the Adult and Senior Adult Inpatient Psychiatry Units.
-The policy directed staff to use three levels of precautions; including:
-1. Close Observation,
-2. Intense Monitoring,
-3. 1:1 {one to one} Observation.
-The policy directed the team leader was responsible to ensure monitoring and documentation occurred for any patient on any level.
-The policy directed the patient with an established history of significant self harm or harm to others would be placed on intense observations {not one of the levels listed above in the policy} at time of admission. The assigned Psychiatrist may reduce the level as safe behavior was demonstrated by the patient.
-The policy directed documentation consisted of a form called a Precaution Flow sheet, a form initiated by the Psychiatry staff when a physician ordered precautions.
-The policy directed the Physicians {Psychiatrists} will order the level of precaution with a reason for the level of precaution. The Registered Nurse may initiate or increase the level based on patient behaviors. The Psychiatrist will be contacted and documentation will be made in the patient's progress notes.
-The policy directed in the event there was difficulty in accommodation of staff required for the ordered precaution level, the Charge Nurse will first ensure the 1:1 have staff provided and the remaining staff will have assignments re-assigned.
-The policy further directed the Charge Nurse or the Nurse Manager will be notified to make any adjustments to staffing to allow for unit personnel to cover the constant observation status {not one of the levels listed above in the policy}.
-The policy further directed for Tests and Procedures:
-1. Will be completed on the unit whenever feasible,
-2. Patients on precautions requiring a test or procedure that required leaving the unit, a physician's order must be obtained prior to the patient leaving the unit. The policy further directed staff will accompany and remain with the patient one on one at all times.
-The policy defined the levels of precautions as:
-1. Close Observation included staff observation of the patient every fifteen minutes, private toileting for the patient, patient may sleep in their assigned room, patient may wear their own clothing and the patient was encouraged to participate in unit activities;
-2. Intense Monitoring was defined as a patient who required more than close observation and less than constant supervision {supervision not defined in the policy}. The policy further provided examples may include self-mutilation, threatening, hostile, aggressive or combative behavior, or suicidal gestures. The policy directed staff to provide care which included patient was transferred to a more restrictive area {not defined in the policy}, the patient will be under constant observation {not defined in the policy or differentiated from constant supervision stated in the preceding sentence}, patient was placed in hospital gown/scrubs, diet would be finger foods, no utensils, a same sex staff member will monitor patient showers and toileting, the bathroom door would be left partially open to ensure safety and the patient would sleep in an audio and video monitored room with the door open.
-3. One to one (1:1) was defined as the highest level of precaution and included patient was transferred to a more restrictive area {not defined in the policy}, patient was placed in hospital gown/scrubs, the patient will be under constant observation by psychiatry staff, the assigned staff member remained with the patient and the patient was in full view, the staff assigned completed documentation {unclear what documentation was done}, staff member could not leave the patient unless relieved by another staff, staff must sit in the room when the patient was sleeping or resting, staff member assigned to 1:1 will not have any other patient responsibilities, same sex staff member will monitor the patient during showering and toileting, the bathroom door would be left partially opened while the patient was in the bathroom and the diet would be finger foods without utensils.

4. Review of an undated facility single paged document titled Unit Specific Precautions Policy and Procedure Review Adult Psychiatry I and II, provided during the survey and identified as information used to train and re-train staff directed, in part, the following:
-The levels of precaution were:
-Close observation, self-harm or elopement, or specified by Dr. {physician/psychiatrist},
-Intense monitoring
-1:1 observation
-Review of the levels of precaution directed in part:
-Close observation patients may wear their own clothing and if the patient was allowed off the unit for a test/procedure, Psychiatry staff was to accompany the patient and remain with the patient one to one. {The review does not direct staff to have patients wear hospital gowns/scrubs when off the unit as specified in the policy titled Precautions: Adult I and II and Senior Adult Inpatient Psychiatry, #Treatment I, approved 05/10.}

5. Review of Patient #1's Emergency Medical Services (EMS) record dated 07/25/10 from 12:20 PM through 12:57 PM revealed paramedics/ambulance staff responded to a call from a county jail for the following:
-An unconscious patient found by jail staff, hanging from top bunk of a jail cell.
-A sheet had been used to hang the patient and the patient appeared to have ingested a bottle of shampoo.
-Patient had refused noon meal, covered the window of the cell and when jail staff entered the cell found the patient hanging.
-When EMS arrived, the patient had been moved to the floor, found to be unresponsive, pulse less and apneic (absence of breathing).
-Jail staff had started CPR (cardiopulmonary resuscitation) and upon arrival of the EMS, the patient had pulses and spontaneous respirations, remained unresponsive with posturing (abnormal movement of the limbs) and a c-collar (cervical collar, head/neck support) was placed by EMS.
-The patient had eyes fixed and to the left, continued posturing during transport, vomited and was suctioned through the nasal airway due to the patient's teeth being clenched.
-The patient maintained spontaneous pulses, respiration and blood pressures during transport to the Emergency Department (ED) of the South campus of the facility.

Record review of the patient's ED physician documentation dated 07/25/10 at 01:00 PM revealed the physician assessed following:
-The patient was found hanging at a county jail.
-Injuries sustained were loss of consciousness, severe respiratory distress, injury to the head and neck (bruising).
-Patient was intubated and put on a ventilator.
-Patient was discharged from the ED to the Cardiac Care Unit at the South campus for diagnoses of respiratory arrest after hanging, encephalopathy (brain damage), hypoxia (decreased oxygen to body cells) and ischemia (decreased blood supply to body cells).

Record review of the patient's admission history and physical dated 07/25/10 revealed the physician assessed the patient with diagnosis of anoxic (lack of oxygen) brain injury due to hanging and was on a ventilator.

Record review of the patient's physician's orders dated 07/25/10 directed staff to maintain the ventilator, keep the patient NPO (nothing by mouth), maintain intravenous (IVs) access, maintain the naso-gastric suction tube (tube through the nose to the stomach to suction out contents), maintain the cervical collar, obtain lab tests, perform neurological tests, maintain a urinary (tube from the bladder to excrete urine) catheter, apply soft wrist restraints and administer sedation and pain medication.

Record review of the facility Law Enforcement Personnel Time Log, provided during the survey revealed county law enforcement officers were present at Patient #1's bedside, the patient remained in law enforcement custody and the patient was restrained with metal restraints (cuffs) from 07/26/10 at 6:00 AM continuously through 07/27/10 at 10:48 AM. During an interview on 08/11/10 at approximately 12:29 PM the Director of Security, Staff N stated a county judge had released the patient from custody on 07/27/10 at 10:48 AM, county law enforcement officers had left the facility however, no paper documentation of the release was provided to the facility.

Record review of the patient's physician's orders dated 07/27/10 at 10:54 AM directed staff to maintain suicide precautions with a one to one sitter and obtain a psychology consultation.

Record review of the patient's Special Events Set, nursing notes dated 07/27/10 revealed:
-At 8:00 AM the patient had a sitter at the bedside.
-At 9:00 AM the patient pulled the naso-gastric tube out of his/her nose.
-At 9:30 AM the patient threatened to pull the cervical collar off so the nurse obtained a physician's order to remove it.
-At 12:30 PM the patient had called his/her parent to come pick him/her up from the facility, staff told the patient and the parent the patient was on a ninety six hour hold {no documentation or physician's orders were noted in the medical record to support this}. The patient could not leave. Security was called. All personal belongings were removed from the room. The parent and the sitter remained in the room with the patient. The patient removed the telemetry monitoring (wires), continuous pulse oximetry (clip to the finger), was attempting to pull out the urinary catheter and IV access.
-At 5:15 PM the patient ran from the room to the elevator, was returned to the room by multiple {nursing} staff, was agitated and vocal stating he/she would leave no matter what the staff said. Staff reinforced with the patient there was a ninety six hour hold in place {no documentation or physician's orders were found to support this}.
-At 8:40 PM the patient was escorted by Security staff to an ambulance and transported by ambulance to the Psychiatry Unit at the North campus.

Record review of the patient's physician's orders revealed:
-Dated 07/27/10 at 7:40 PM the psychiatrist admitted the patient to the Psychiatry Unit with diagnoses of bipolar disorder, depression with hanging attempt and directed staff to provide testing, medication, diet and a precautions level of close observation {least restrictive level of precaution described in the policy} for risk of harm.
-Dated 07/28/10 at 7:50 PM the psychiatrist wrote an order for suicide precautions {not described in the facility policy} and noted the patient was on ninety six hour hold.
-Dated 07/28/10 at 8:13 PM the psychiatrist ordered one to one intense {most restrictive level of precaution as described in the policy} observation and suicide precautions.
-Dated 07/28/10 at 8:43 PM the psychiatrist ordered the patient must wear hospital gowns {a requirement under the 1:1 observation precaution of the facility policy}.

Record review of the patient's nurse's notes dated 07/28/10
-At 10:00 PM revealed staff permitted the patient to wear his/her own gowns {facility policy directed hospital gowns and the psychiatrist also ordered the staff to place the patient in hospital gowns}.
-At 10:14 PM revealed the staff assessed the patient as unreliable after the ninety six hour hold was processed, the patient was on one to one intense observations. Staff assessed the patient was aggressive, agitated, angry, impulsive, oppositional, restless with poor boundaries. Staff assessed the patient was a threat to self and others and noted the ninety six hour hold was processed at 8:00 PM. The staff also noted the patient was quite upset after a visit with his/her parent, friends and child, cursed, made threats and cried.

Record review of the patient's physician's orders revealed the following:
-Dated 07/29/10 at 7:15 AM the psychiatrist directed staff to change the patient to intense suicide precautions only. No need for one to one. Obtain a repeat chest x-ray, two views due to {patient had a} fever.
-Dated 07/30/10 at 10:08 AM the psychiatrist directed staff to discontinue the intense suicide precautions and change the patient to close {observation} suicide precautions.

Record review of the patient's nurse's notes dated 07/30/10 revealed:
-At 12:15 PM the patient cursed the staff about having to sleep in the time-out room.
-At 12:20 PM the patient walked up and down the halls, cursed loudly, refused oral medications to help calm down and staff tried verbal de-escalation.
-At 12:25 PM the patient threatened physical harm to the staff, hit the side of the water fountain with a hand, staff called a code (man power) and Security staff came to the unit.
-At 12:30 PM the patient had to be held by three Security Officers and three Psychiatry Technicians while the RN administered an injection of a medication to calm the patient. The staff attempted to release the patient, the patient continued to flail arms and kick legs so staff held the patient for another fifteen minutes.

Record review of the patient's physician's orders dated 07/31/10 revealed the following:
-At 9:28 AM the psychiatrist directed staff to obtain a consult from Family Practice physicians regarding the patient's abnormal chest x-ray results and questioned if the patient had pneumonia.
-At 11:00 AM another physician ordered two view chest x-ray for diagnosis of perihilar opacities (irregularities seen on the x-ray that may indicate lung disorders/diseases).

Record review of the patient's nurse's notes dated 07/31/10 revealed:
-At 10:16 AM staff assessed the patient stated he/she felt ready to be discharged the first of the week.
-At 1:09 PM the staff documented the patient went to x-ray in a wheel chair for a chest x-ray.
-At 1:50 PM staff documented the patient eloped from the x-ray department bathroom that had a second door. Staff documented Security and the Charge nurse were notified.

6. During an interview on 08/09/10 from 2:47 PM to 3:45 PM, Psychiatry Technician, Staff A stated the following, he/she:
-Had been employed in the facility Psychiatry Unit for two years.
-Had eight years experience working with psychiatry patients in another facility prior to coming here.
-During the previous employment experience did not have contact with suicidal patients however, there was a hanging (a patient returned from a weekend pass and hung themselves).
-Was experienced with ninety six hour hold and court ordered admissions here at this facility.
-Felt the fifteen minute checks of patients was a big priority here.
-One of the RN's had instructed the fifteen minute checks were to be staggered and not on the exact minute.
-Knew all patients were kept on fifteen minute checks after admission.
-Knew after admission if the patient does something to show harm to self or others they were changed to a different status like one to one observation or close observation.
-Knew a patient on one to one was allowed to be in hospital gowns only, was on finger foods diet, had to be in line of sight, were never left alone, had female to female or male to male monitoring in the shower or bathroom. Those patients were on the "G" side (locked hall) inside the locked adult unit.
-Knew a patient on close observation was monitored with recording of whereabouts on a check sheet, had to stay inside, were kept in hospital gowns, and couldn't recall all the other restrictions but, the rest of the restrictions were listed on the reverse side of the check sheets for easy reference.
-Thought training provided here was mostly on-line {computerized} and covered non-violent crisis interventions and medication reactions. There were no set classes or classroom sessions. "My supervisors usually just tell me what I need to know."
-Knew the patient who eloped {Patient #1} was an inpatient for a few days and was fine at first. Then, the patient was put on a hold {ninety six hour} due to yelling after a visit with family members.
-Found out about the patient through listening to report (was in jail, found unconscious, hanging in a cell, the patient stated that didn't happen).
-Was the staff person who worked 11:00 AM to 7:00 PM on the Saturday {07/31/10} the patient eloped. I was called in to work extra because someone called in and the unit was short of help.
-Didn't get regular report. I just got a verbal report on the patient from other staff. They said she was fine through the day before I came on duty.
-Knew Wednesday {07/28/10} before, the patient had an upset, and was medicated. The patient was told to change into hospital gown and did it. The patient was on close observation and just went to bed.
-Knew on Thursday {07/29/10} the patient was off close observation and was okay.
-Knew on Friday {07/30/10} the patient was doing the {prescribed} programs.
-Knew on Saturday {07/31/10}, the patient was fine through the day, there were no warning signs at all.
-When I came in I was told the patient needed an x-ray so, I got the patient's chart {medical record}, woke the patient up and into a wheelchair and wheeled the patient down to the Radiology department on the first floor.
-Recalled the patient was sleepy so, there was no conversation or comments.
-Recalled in Radiology, the x-ray technician, saw the patient was in street clothes, got a hospital gown and asked the patient to change into the hospital gown. The patient went into the bathroom off the x-ray room and closed the door for privacy. {The Psychiatry Technician and the Radiology Technician were not the same sex as the patient.}
-Recalled the Radiology Technician opened the chart {medical record} and saw the patient had been a jail inmate then, shouted to me to check on the patient.
-Recalled I knocked on the door and when there was no answer, I opened the door and saw the other door into the hallway.
-Recalled the Radiology Technician said he/she would call Security.
-Ran down the hall to the Emergency Room registration desk and the ambulance entrance. None of the staff in Emergency Department, Registration or a Environmental Services saw the patient.
-Felt it all happened in a minute or two.
-Did not think we have a search {for a missing Psychiatry patient} guide. We don't have any drills on that and there was no on-line education of searching for a missing {eloped} patient.
-Felt communication was the problem. "It was the perfect storm." No one ever told me the patient had to be in a gown to leave the unit. I think it was the policy in the past. The x-ray room used was the one with two doors. The x-ray room used was selected by the Radiology Technician. I've only taken maybe ten patients off the unit to x-ray in the last six months.
-Could not recall any recent staff meetings or training. It was an unspoken policy of having the one to ones with a same sex Psychiatry Technician.

7. Observations in the facility Radiology department bathroom off the x-ray room where Patient #1 eloped revealed Psychiatry Unit staff failed to assess multiple environmental risk factors that could be used by a patient with suicidal ideation or suicide attempt to harm self.

Observation on 8/9/10 at 3:20 PM showed a non-suicide resistant toilet room adjoining Radiology Suite #5. The room measured five feet wide by six feet deep and was sufficient for use by one person capable of toileting without staff assistance or supervision. The toilet room had a suspended ceiling, with walls that extended to the roof deck. The roof deck and interior portions of the inner wall were sealed with a heavy metal or lead derivative designed to block or mitigate any scattered radiation. Exposed plumbing fixtures on the toilet commode and below the hand wash sink offered several potential binding points. The walls were sheet rock gypsum material; the floor was vinyl tile and cove base. The room was originally accessible from two sides, either the corridor or from within the radiology suite. The door opening into the toilet from the radiology suite had a bayonet-type handle on both sides and could be latched in the door facing, however, it could not be locked. The door from the toilet room into the service corridor of radiology was firmly latched into the door frame and the handle removed. This corridor door could no longer be opened and cover plates on both sides of the door obscured the hole. The waste paper basket was lined with a thin plastic bag liner. A standard glass mirror, plastic liquid soap dispenser, metal paper towel dispenser, metal toilet paper dispenser and plastic toilet seat cover dispenser were mounted to the wall surfaces behind the toilet and hand sink. A grab bar was mounted on the east wall next to the toilet.

The room was equipped with a call light tied to three and a half (3.5) feet of cord that could be untied and detached for use in strangulation or self-induced hanging from either the toilet or hand sink plumbing fixtures. The metal paper towel holder could be opened without a key and exposed sharp metal edges of the mounting bracket. The thin plastic bag liner from the wastepaper basket could be easily removed and placed over a person's head to suffocate or asphyxiate a victim.

8. During an interview on 08/09/10 from 3:46 PM to 4:10 PM Psychiatry Technician, Staff B stated the following:
-He/she had been a Psychiatry Technician for eight years on the same unit.
-He/she had a bachelor's degree in psychology.
-Patients who were actively suicidal were on the "G" side which was the locked side of the unit.
-He/she had escorted one to three patients per week to Radiology and was unaware of the second door into the bathrooms adjacent to the x-ray rooms.

9. Observation of the Emergency Department (ED) public entrance on 8/9/10 at 4:00 PM showed a waiting room and reception vestibule where walk-in patients entered through a revolving door. Incoming patients were triaged and issued a temporary green badge. A sliding door, operated by a swipe card reader separated the ED from the reception vestibule. The sliding door was the secure barrier. Patients or family were not allowed beyond the door without a green badge. A reception desk just inside the sliding door was manned by two Registrars who ensured insurance and administrative paperwork was completed on each patient prior to discharge.

During an interview on 08/09/10 from 4:45 PM to 5:08 PM Emergency Department (ED) Registrar, Staff D stated the following:
-He/she had been in the position for about one year.
-He/she worked 6:30 AM through 5:00 PM.
-When a person comes in, I register them, verify their insurance information, address and emergency contact information.
-There were usually two staff on per day until 12:00 noon then, another staff comes in to work.
-I see some patients leave. When they leave they were supposed to have a green "GO" card.
-When they leave, I ask them if they had verified their information.
-On Saturday, 07/31/10 I was called into work from 12:00 noon until 5:00 PM.
-I was coming in and a person was coming out the door so, I asked if someone had gotten their information.
-On Monday, 08/02/10, I was told I was the one who let the psychiatry patient out the door.
-I still cannot recall anything about it. We were busy or it seemed busy.
-I was out at the triage desk. I went to the sliding door. There was a person just inside the door.
I swiped my badge and the door opened. I asked the person if someone had verified their information.
-The person didn't look any different than anyone else.

10. Review (reviewed on 08/10/10 at 8:35 AM) of the Security Services video monitoring tape of Patient #1's elopement, time stamped 07/31/10 at 1:17 PM revealed the following:
-Patient #1 dressed in street clothing, patient ran down a hallway into an area staffed by a facility clerical person (in a blue smock and badge).
-The clerical staff had his/her head down and failed to acknowledge the patient in front of the desk. The video tape showed no verbal exchange between the clerk and the patient.
-The patient momentarily stood in front of a glass door looking outward.
-A second staff person (with a blue smock and badge) outside the doors to swipe his/her badge, the door opened and the patient walked past the second staff person. The video tape showed no verbal exchange between the second clerk and the patient.
-The second staff person who opened the door, turned his/her back to the patient and continued a conversation with a facility housekeeper (in a pink uniform and with a badge).
-The patient exited through a revolving glass door then, ran through a parking lot.

11. During an interview on 08/10/10 from 9:00 AM through 9:42 AM Radiology Technician, Staff E stated the following:
-He/she had been a Radiology Technician for nineteen years at the facility.
-The Radiology Services area had five rooms to take x-rays. Four of the rooms had bathroom adjacent to the x-ray room and one did not have a bathroom adjacent.
-the Radiology Services had two working portable x-ray machines however the quality of the finished film may not be as good as a film done in the department.
-He/she usually performed x-rays for approximately ten Psychiatry Unit patients per month.
-He/she had performed x-rays for some psychiatric patients who were referred from the Emergency Department.
-Each Psychiatry Unit in-patient was accompanied by a Psychiatry Unit Technician for monitoring.
-The Radiology Services staffing for weekends was usually two technicians for x-rays and CTs {computer tomography, specialized imaging} and one clerk.
-On 07/31/10, I was "swamped". I didn't have two or three patients waiting but I did have a difficult procedure.
-Usually in-patients from the Psychiatry Unit come down here with one staff member.
-The staff person brings the chart {medical record} so I can check for the physician's order and check for any past testing.
-On 07/31/10, the Psychiatry Technician brought the patient to Room #5. I don't use #5 a lot. I like to use the digital imaging equipment in Room #1 however, since the Psychiatry Technician brought the patient into #5, I was going to use that room.
-The patient was in street clothes. I provided a hospital gown and asked the patient to change into the gown for the chest x-ray. The patient took the gown, went into the bathroom and shut the door. The Psychiatry Technician remained in the x-ray room.
-The patient seemed like any other patient. There was no verbal discussion or change in demeanor.
-I took the chart and went to the counter to review the orders and diagnoses. I opened the chart and saw the patient was from a jail and yelled to the Psychiatry Technician to check on the patient. The Psychiatry Technician knocked on the door and after there was no answer opened the door to the bathroom.
-The other bathroom door into the hallway was opened and the Psychiatry Technician yelled that the patient was gone. It all happened in maybe twenty seconds.
-I yelled for the other Radiology Technician to call Security and I and the Psychiatry Technician ran down the hall. It was the only way the patient could have gone because the doors to the Radiology Ultra sound rooms were locked.
-The Psychiatry Technician and I ran through the Emergency Department to the doors where the Registrars sit. We asked the Registrar if he/she had seen anyone leave and they responded, no.
-All of the Radiology rooms do have good line of sight into the room but no line of sight into the bathrooms.
-Other than removing the door knob from the second door in the bathroom, the Radiology Technician had not heard of any procedural changes implemented for Psychiatry Unit patients undergoing radiology tests.

During another interview on 8/10/10 at 9:00 AM, Radiology Technician, Staff E said he/she sets up and conducts x-rays of multiple types of patients, including patients from the emergency department and Psychiatric patients several times a week. He/she said some radiology staff prefer to bring patients to Room #5 because it is digital and there was no wait time for film development. He/she said it was more open, but less secure for "eyes on" patients than some of the other rooms in the department since there was no observation window and only one door. He/she preferred to use Room #1 for patients who were difficult or needed 1:1 supervision or prisoners with a police escort, because the patient bed may be viewed from the control station as well as a glass window in the service corridor. He/she said a lot of the direct care staff and doctors do not like Room #1 because it still used conventional x-ray plates and took time to develop the prints.

He/she said sometimes the patient was gowned and ready, other times he/she had to ask them to change into a gown. He/she said they were able to do some "pictures" (of extremities) without having the patient remove or change clothing.

12. Review of the Security Services video monitoring tape of Patient #1's elopement, in the Security Offices reveal

Based on observation, interview and record review facility staff failed to ensure Psychiatry Unit staff focused quality improvement study priorities on high risk, problem prone admissions including patients (such as Patient #1) with suicidal ideation and/or on ninety six hour holds, probate court ordered detention for treatment, which had direct impact on patient safety and failed to prevent elopement.

The facility staff failed to proactively use the quality improvement program to review, revise and ensure policies and procedures addressed prevention of elopement, directing consistent procedural steps to communication between Psychiatry Unit staff, between Psychiatry and other departments who provide care for Psychiatry patients and other staff in the North Campus building to ensure safe patient care and safe environment.

The facility staff also failed to proactively use the quality improvement program to ensure all Psychiatry Unit staff, off unit staff who provide care and any other staff who work in the North Campus building were provided education, training and periodic re-training in recognition of possible problem situations and preventative measures to use to protect patients.

The facility (North Campus Psychiatry Unit) census was 43 which included three patients identified with primary or secondary diagnosis of suicidal ideation and two other patients under ninety six hour hold.

Findings included:

1. Review of the facility policy titled, Patient Elopement, #Treatment 14; approved 06/07 directed in part, the purpose of the policy was to protect the patient after he/she eloped which staff could not perform if the patient was not in the facility. The policy failed to discuss measures, actions, care planning to prevent elopement of a suicidal patient, patients held under ninety six hour holds or any other psychiatry patient who required hospitalization on any of the locked units.

During an interview on 08/09/10 from 2:47 PM to 3:45 PM, Psychiatry Technician, Staff A stated the following:
-Did not think we have a search {for a missing Psychiatry patient} guide. We don't have any drills on that and there was no on-line education of searching for a missing {eloped} patient.
-Could not recall any recent staff meetings or training. It was an unspoken policy of having the one to ones with a same sex Psychiatry Technician.

During a telephone interview on 08/10/10 from 3:45 PM through 4:00 PM Security Officer, Staff M stated the following:
-He/she had been a Security Officer for the facility for the last three and a half years.
-He/she was making rounds and heard a door alarm in back of the ED. The doors in the back were accessed by employee badge only and alarmed when opened without a badge.
-Security Officer, Staff I called on the radio and stated a patient had escaped from the Radiology department.
-I searched the area. No one said they saw a person fitting the description. It all happened over three or four minutes.
-I am not sure what the policy and procedure is for a patient elopement. The Security policy is the ED Security Officer stays in the ED.

2. Review of the facility policy titled, Program Procedures for Patients, Visitors, Staff and Property, #SMP3, effective date 01/08 directed, in part, under Security of Patients; all patients receiving any services at the facility whether inpatient or outpatient would be issued an Identification Tag to be kept on their person at all times.

Further, the policy directed under Patient Elopement; patients who lacked the mental capabilities to make informed judgments and may endanger themselves by leaving the facility were housed and treated in areas with alarm systems (wander guards) which alert staff if they attempt to leave the housing or treatment areas. If those patients were taken to an area which does not have an alert system, they were closely monitored by staff.

Further, under the same paragraph subtitled Patient Elopement, the policy directed staff to search the area and after fifteen minutes, call Security staff and the Nurse Manager.

The policy was not enforced and failed to direct interventions for patient who would not be wearing a wander guard or other alert devices. The policy does not address measures for staff to take (a specified search grid or organized search pattern with specific assignments once an elopement was suspected). The policy does not direct staff to be alert and aware of any suspicious persons in their work areas which were located inside the building. The policy also allowed for an extended period of time (fifteen minutes) to elapse before calling Security staff.

Interviews with multiple staff working in Psychiatry Unit, Emergency Department Registration and Security revealed either no knowledge of the policy, misunderstanding of the policy or failure to follow the policy.

During an interview on 08/09/10 from 2:47 PM to 3:45 PM, Psychiatry Technician, Staff A stated the following:
-Thought training provided here was mostly on-line {computerized} and covered non-violent crisis interventions and medication reactions. There were no set classes or classroom sessions. "My supervisors usually just tell me what I need to know."
-Felt communication was the problem. "It was the perfect storm." No one ever told me the patient had to be in a gown to leave the unit. I think it was the policy in the past.

During an interview on 08/09/10 from 3:46 PM to 4:10 PM Psychiatry Technician, Staff B stated he/she had escorted one to three patients per week to Radiology and was unaware of the second door into the bathrooms adjacent to the x-ray rooms.

During an interview on 08/09/10 from 4:45 PM to 5:08 PM Emergency Department (ED) Registrar, Staff D stated the following:
-I see some patients leave. When they leave they were supposed to have a green "GO" card.
-When they leave, I ask them if they had verified their information.
-I was coming in and a person was coming out the door so, I asked if someone had gotten their information.
-I was out at the triage desk. I went to the sliding door. There was a person just inside the door.
-I swiped my badge and the door opened and the person (a psychiatry patient) left.

During an interview on 08/10/10 from 9:00 AM through 9:42 AM Radiology Technician, Staff E stated the following:
-He/she usually performed x-rays for approximately ten Psychiatry Unit patients per month.
-Each Psychiatry Unit in-patient was accompanied by a Psychiatry Unit Technician for monitoring.
-Usually in-patients from the Psychiatry Unit come down here with one staff member.
-I took the chart and went to the counter to review the orders and diagnoses. I opened the chart and saw the patient was from a jail and yelled to the Psychiatry Technician to check on the patient.
-Other than removing the door knob from the second door in the bathroom, the Radiology Technician had not heard of any procedural changes implemented for Psychiatry Unit patients undergoing radiology tests.

During an interview on 08/10/10 at 10:22 AM Registration Specialist, Staff F stated the following:
-One of the duties of the ED Registrar was to check for a badge on anyone coming in or going out of the department.
-He/she did not see everyone so, there was a possibility that a person could be in the ED without a badge.

During a telephone interview on 08/10/10 at 11:50 AM Security Officer, Staff I stated the following:
-Thought Patients were usually in gowns. The Psychiatry Unit had reported the patient, who eloped, was in street clothes.
-He/she had never dealt with anything like that before.
-He/she reported it was routine to escort patients from the ED to the Psychiatry Unit and escorting patients from the Unit to x-ray was a possibility however the Unit had not called the Security Department.

During a telephone interview on 08/10/10 from approximately 1:15 PM to 1:40 PM the Psychiatry Unit weekend Charge Nurse, Staff J stated the following:
-Had been an RN since 1995 and had worked for the facility for the last six years.
-Had never had any specialized training in psychiatric nursing and has just had regular RN training.
-Told two Psychiatry Technicians on the unit that the patient who eloped had to be dressed in a hospital gown for the chest x-ray and Radiology would call when they were ready to take the patient.
-After the patient eloped, I confirmed with the two Psychiatry Technicians that I told both to dress the patient in a hospital gown for x-rays.
-I did not see the patient being taken off the unit. I was in report taping at 1:00 PM for the 3:00 PM to 11:00 PM shift.
-The Medication Nurse said he/she saw the patient and the Psychiatry Technician go downstairs but didn't think a thing about it (the patient not being in a gown).
-Patients do not routinely go to x-ray in a hospital gown.
-At the time the Psychiatry Unit did not have a policy and procedure about the patients on the unit going to x-ray in hospital gowns but now we do.
-Procedures are different now. Patients go to x-ray in hospital gowns and we send two with the patient. We call Security or if Security is not available we send one other staff with the patient.
-Our training for the Psychiatry Unit was just the normal training on suicide ideation, ninety six hour holds, non-violent crisis intervention, safety, restraints. It's all on the computer. We view it and take a test.
-We used to have a nurse educator but that position was lost about a year ago.

During an interview on 08/10/10 from 1:50 PM through 2:10 PM Psychiatry Technician, Staff K stated the following:
-Was assigned to perform the patient {fifteen minute} checks and ensure the well being of the patients.
-On the day Patient #1 eloped, Charge Nurse, Staff J told the other Psychiatry Technician, Staff L and myself that Patient #1 needed an x-ray and needed to go in a hospital gown.
-Psychiatry Technician and I didn't have a division of work so, we were both told and both knew what Charge Nurse, Staff J told us.
-Psychiatry Technician, Staff A came into work at 11:00 AM and relieved Psychiatry Technician, Staff L. Psychiatry Technician, Staff L went over to the "F" side of the Unit which was routine {not atypical}.
-Psychiatry Technician, Staff A said he/she would escort Patient #1 to x-ray and I assumed he/she knew the patient had to be in a gown. I saw Psychiatry Technician, Staff A take the patient's medical record and step off the "G" side with the patient in a wheelchair. Patient #1 was dressed in normal clothes and not a hospital gown.
-I didn't know if it was normal to take a patient to x-ray in a gown or street clothes. I'm unclear about a protocol for that. Charge Nurse, Staff J told me to put the patient in a hospital gown. I probably should have stopped Psychiatry Technician, Staff A and told him/her about the gown but I assumed he/she knew.
-There was no pre-planning because I just assumed I would be taking Patient #1 down to x-ray.
-I have taken other patients from the unit to x-ray and some were in gowns.
-I don't think there is a written policy and procedure on patients being in hospital gowns to go to x-ray.
-Everyone {on duty} was responsible for not changing the patient into a hospital gown before the x-ray. I was responsible {for the elopement} in that I did not pass along the information that the patient needed to be in a gown for x-ray.

During an interview on 08/10/10 at approximately 3:25 PM Psychiatry Technician, Staff L stated the following:
-Charge Nurse, Staff J came over at about 10:30 AM and said Patient #1 had to go to x-ray and also told me to make sure the patient was in a gown.
-At 11:00 AM, Psychiatry technician, Staff A came in and I went to the "F" side.
-In the past, I have taken patients to x-ray, to ultrasound tests and CTs dressed in street clothes.
-I think it's normal to take patients from the Unit to x-ray in their clothes.
-When Charge Nurse, Staff J told me to take Patient #1 in a hospital gown, it didn't seem odd to me. I've taken other patients to x-ray and they were not asked to change into a gown.
-We didn't have a policy before that I was aware of that told us to take all patients to Radiology in gowns.

During a telephone interview on 08/10/10 from 3:45 PM through 4:00 PM Security Officer, Staff M stated the following:
-He/she was making rounds and heard a door alarm in back of the ED. The doors in the back were accessed by employee badge only and alarmed when opened without a badge.
-I searched the area. I am not sure what the policy and procedure is for a patient elopement. The Security policy is the ED Security Officer stays in the ED.

3. Review of the facility policy titled, Precautions: Adult I and II and Senior Adult Inpatient Psychiatry, #Treatment 1; approved 05/10 directed in part, the purpose of the policy was to establish guidelines for precautions used on the Adult and Senior Adult Inpatient Psychiatry Units and outlined specific actions directed by specific verbiage for levels of precaution.

Interview with Psychiatry Unit bedside staff revealed inconsistent interpretation of the requirement for each of the levels of precaution and lack of consistent, effective training regarding the policy. Further, the policy failed to direct staff to any visually checks for any environmental hazards that may cause harm to the patient or others, when escorting a patient to off-unit testing or procedures in the building.

During an interview on 08/09/10 from 2:47 PM to 3:45 PM, Psychiatry Technician, Staff A stated the following:
-Didn't get regular report. I just got a verbal report on the patient from other staff.
-Felt communication was the problem. "It was the perfect storm." No one ever told me the patient had to be in a gown to leave the unit. I think it was the policy in the past. The x-ray room used was the one with two doors.
-Could not recall any recent staff meetings or training. It was an unspoken policy of having the one to ones with a same sex Psychiatry Technician.

During a telephone interview on 08/10/10 from approximately 1:15 PM to 1:40 PM the Psychiatry Unit weekend Charge Nurse, Staff J stated the following:
-Had been an RN since 1995 and had worked for the facility for the last six years.
-Had never had any specialized training in psychiatric nursing and has just had regular RN training.
-Had told the two Psychiatry Technicians on the unit the patient had to be dressed in a hospital gown for the chest x-ray and Radiology would call when they were ready to take the patient.
-After the patient eloped, I confirm that I told both Psychiatry Technicians that they were told to dress the patient in a hospital gown for x-rays.
-The Medication Nurse said he/she saw the patient and the Psychiatry Technician go downstairs but didn't think a thing about it (the patient not being in a gown).
-Patients do not routinely go to x-ray in a hospital gown.
-At the time the Psychiatry Unit did not have a policy and procedure about the patients on the unit going to x-ray in hospital gowns but now we do.
-Procedures are different now. Patients go to x-ray in hospital gowns and we send two with the patient. We call Security or if Security is not available we send one other staff with the patient.
-Our training for the Psychiatry Unit was just the normal training on suicide ideation, ninety six hour holds, non-violent crisis intervention, safety, restraints. It's all on the computer. We view it and take a test.
-We used to have a nurse educator but that position was lost about a year ago.

During an interview on 08/10/10 from 1:50 PM through 2:10 PM Psychiatry Technician, Staff K stated the following:
-Was assigned to perform the patient {fifteen minute} checks and ensure the well being of the patients.
-On the day Patient #1 eloped, Charge Nurse, Staff J told the other Psychiatry Technician, Staff L and myself that Patient #1 needed an x-ray and needed to go in a hospital gown.
-Psychiatry Technician, Staff A said he/she would escort Patient #1 to x-ray and I assumed he/she knew the patient had to be in a gown. I saw Psychiatry Technician, Staff A take the patient's medical record and step off the "G" side with the patient in a wheelchair. Patient #1 was dressed in normal clothes and not a hospital gown.
-I didn't know if it was normal to take a patient to x-ray in a gown or street clothes. I'm unclear about a protocol for that. Charge Nurse, Staff J told me to put the patient in a hospital gown. I probably should have stopped Psychiatry Technician, Staff A and told him/her about the gown but I assumed he/she knew.
-There was no pre-planning because I just assumed I would be taking Patient #1 down to x-ray.
-I have taken other patients from the unit to x-ray and some were in gowns.
-I don't think there is a written policy and procedure on patients being in hospital gowns to go to x-ray.
-Everyone {on duty} was responsible for not changing the patient into a hospital gown before the x-ray. I was responsible {for the elopement} in that I did not pass along the information that the patient needed to be in a gown for x-ray.

During an interview on 08/10/10 at approximately 3:25 PM Psychiatry Technician, Staff L stated the following:
-Charge Nurse, Staff J came over at about 10:30 AM and said Patient #1 had to go to x-ray and also told me to make sure the patient was in a gown.
-At 11:00 AM, Psychiatry technician, Staff A came in and I went to the "F" side.
-In the past, I have taken patients to x-ray, to ultrasound tests and CTs dressed in street clothes.
-I think it's normal to take patients from the Unit to x-ray in their clothes.
-When Charge Nurse, Staff J told me to take Patient #1 in a hospital gown, it didn't seem odd to me. I've taken other patients to x-ray and they were not asked to change into a gown.
-We didn't have a policy before that I was aware of that told us to take all patients to Radiology in gowns.

4. Review of the Missouri Department of Mental Health, Division of Comprehensive Psychiatric Services, Quick Reference Guide for Civil Involuntary Detention, dated 08/08 revealed, in part, a person who represents a likelihood of serious harm to self or others as the result of mental disorder or alcohol or drug abuse may be involuntarily detained for evaluation and treatment at a mental health or alcohol/drug abuse facility. Further review revealed mental disorder was defined as any organic, mental or emotional impairment which has substantial adverse effect on a person's cognitive, volitional or emotional function and which constitutes a substantial impairment in a person's ability to participate in activities of normal living. Review of the quick reference guide also, in part, defined Likelihood of serious harm as a substantial risk that serious physical harm will be inflicted by a person upon his own person, as evidenced by recent threats, including verbal threats, or attempts to commit suicide or inflict physical harm on himself. Evidence of substantial risk may also include information about patterns of behavior that historically have resulted in serious harm previously being inflicted by a person upon himself.

5. Record review of Patient #1's ED physician's documentation dated 07/25/10 at 01:00 PM revealed the patient was found hanging in a county jail cell, had loss of consciousness, severe respiratory distress, injury to the head and neck (bruising), was intubated and put on a ventilator. The patient was transferred to the Cardiac Care Unit at the South campus with diagnoses of respiratory arrest after hanging, encephalopathy (brain damage), hypoxia (decreased oxygen to body cells) and ischemia (decreased blood supply to body cells).

Record review of the patient's admission history and physical dated 07/25/10 revealed the physician assessed the patient with diagnosis of anoxic (lack of oxygen) brain injury due to hanging and was on a ventilator.

Record review of the facility Law Enforcement Personnel Time Log, provided during the survey revealed county law enforcement officers were present at Patient #1's bedside, the patient remained in law enforcement custody and the patient was restrained with metal restraints (cuffs) from 07/26/10 at 6:00 AM continuously through 07/27/10 at 10:48 AM. During an interview on 08/11/10 at approximately 12:29 PM the Director of Security, Staff N stated a county judge had released the patient from custody on 07/27/10 at 10:48 AM, county law enforcement officers had left the facility however, no paper documentation of the release was provided to the facility.

Record review of the patient's nurses notes dated 07/27/10 revealed the patient pulled off monitoring tubes and equipment, tried to remove bladder and intravenous lines and at 5:15 PM the patient ran from the room to the elevator, was returned to the room by multiple {nursing} staff, was agitated and vocal, stating he/she would leave no matter what the staff said. Staff reinforced with the patient there was a ninety six hour hold in place. Further review revealed at 8:40 PM the patient was escorted by Security staff to an ambulance and transported by ambulance to the Psychiatry Unit at the North campus.

Record review of the patient's physician's orders dated 07/27/10 revealed he psychiatrist ordered close observation. On 07/28/10 the psychiatrist ordered suicide precautions, noted the patient was on ninety six hour hold, later ordered one to one intense, suicide precautions and ordered the patient must wear hospital gowns

Record review of the patient's nurse's notes dated 07/28/10 at 10:00 PM revealed staff permitted the patient to wear his/her own gowns and later described the patient as aggressive, agitated, angry, impulsive, oppositional, restless with poor boundaries. Staff assessed the patient was a threat to self and others and noted the ninety six hour hold was processed at 8:00 PM.

Record review of the patient's nurse's notes dated 07/30/10 revealed the patient paced the hallway, shouted, cursed, refused oral medications and threatened physical harm to the staff, struck a water fountain and staff called a code (man power). Security staff came to the unit and the patient required physical hold by three Security Officers and three Psychiatry Technicians while the RN administered an injection of a medication to calm the patient. When staff attempted to release the patient, the patient continued to flail arms and kick legs so, staff held the patient for another fifteen minutes.

Record review of the patient's physician's orders dated 07/31/10 revealed the physician ordered a chest x-ray for questionable pneumonia.

Record review of the patient's nurse's notes dated 07/31/10 revealed staff assessed the patient stated he/she felt ready to be discharged the first of the week, the patient was escorted off-unit to Radiology for chest x-ray and the patient eloped from the x-ay department.

6. Observations in the facility Radiology department bathroom off the x-ray room where Patient #1 eloped revealed Psychiatry Unit staff failed to assess multiple environmental risk factors that could be used by a patient with suicidal ideation or suicide attempt to harm self.

Observation on 8/9/10 at 3:20 PM showed a non-suicide resistant toilet room adjoining Radiology Suite #5. The room measured five feet wide by six feet deep and was sufficient for use by one person capable of toileting without staff assistance or supervision. The toilet room had a suspended ceiling, with walls that extended to the roof deck. The roof deck and interior portions of the inner wall were sealed with a heavy metal or lead derivative designed to block or mitigate any scattered radiation. Exposed plumbing fixtures on the toilet commode and below the hand wash sink offered several potential binding points. The walls were sheet rock gypsum material; the floor was vinyl tile and cove base. The room was originally accessible from two sides, either the corridor or from within the radiology suite. The door opening into the toilet from the radiology suite had a bayonet-type handle on both sides and could be latched in the door facing, however, it could not be locked. The door from the toilet room into the service corridor of radiology was firmly latched into the door frame and the handle removed. This corridor door could no longer be opened and cover plates on both sides of the door obscured the hole. The waste paper basket was lined with a thin plastic bag liner. A standard glass mirror, plastic liquid soap dispenser, metal paper towel dispenser, metal toilet paper dispenser and plastic toilet seat cover dispenser were mounted to the wall surfaces behind the toilet and hand sink. A grab bar was mounted on the east wall next to the toilet.

Room #5 bathroom was equipped with a call light tied to three and a half (3.5) feet of cord that could be untied and detached for use in strangulation or self-induced hanging from either the toilet or hand sink plumbing fixtures. The metal paper towel holder could be opened without a key and exposed sharp metal edges of the mounting bracket. The thin plastic bag liner from the wastepaper basket could be easily removed and placed over a person's head to suffocate or asphyxiate a victim.

7. During entrance conference into the facility on 08/09/10 survey staff requested facility staff provide Psychiatry Unit Quality Assurance and Performance Improvement committee minutes for the previous three month and evidence of active integration into the system wide Quality Assurance-Performance Improvement program. At the time the survey staff left the facility 08/11/10 at 1:00 PM no specifically identifiable documentation of Psychiatry Unit Quality Assurance and Performance Improvement projects were provided. Review of the Quality Improvement information provided by the facility was facility wide data collect from a standardized patient satisfaction form and did not specifically target high risk, problem prone issues for the safety of Psychiatry Unit patients.

Review of the Safety and Security Subcommittee meeting minutes dated 02/11/10 from 1:00 PM to 2:00 PM revealed, in part, the Administrative Director of the North Campus Psychiatry Unit was a member and staff discussed the following:
-Risk assessment at the North Campus Pharmacy.
-A recommendation to increase the height of the North Learning Center.
-An increase in the reports of work place violence from the North Campus.
-No discussions of prevention of patient elopement or safety of high risk patients such as those diagnosed with suicidal ideation