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Based on document review, and interviews the hospital failed to protect the rights of patient #1, when patient #1 was able to elope from a locked unit of the facility. Patient #1 left the facility in subzero temperatures, and stated she went to a party and was raped by multiple men at the party. This failure places the Condition of Participation of Patient Rights out of compliance.


Refer to A144.

Based on intervew and record review the facility failed to provide a safe environment for 1 of 10 patients (patient #1) who eloped from an unsecured area of the facility. This failure resulted in potential harm to patient #1. Findings include:The hospital is a 16 bed secured adolescent psychiatric hospital with three locked units. The Parent and Patient Information, Rules, and Expectations documents the unit doors are locked at all times to reduce the risk of "running away, unwanted visitors, and protections during dangerous weather." All staff providing patient care carry a panic alarm ( emergency alarm when pushed alerts staff in the building of need for assistance). When staff are with a patient off of the unit they also carry a hand held radio to keep in contact of other staff in the building.

A review of patient #1's medical record documents that she has diagnoses including Complex Pediatric Trauma, major depressive disorder, generalized anxiety disorder, and self-injurious behaviors. The Minnesota Department of Human Services State Operated Services Psychiatric Assessment, dated 1/21/2014 documents prior to admission, patient #1 engaged in self injurious behaviors of cutting herself, head banging, and assaultive behaviors toward staff at a previous hospital. Patient #1 was admitted to the facility for continued mental health care, stabilization and development of a long term treatment plan. The medical record includes documentation that patient #1 has a history of elopement from previous placements. Patient #1 was on routine level supervision status which allows unrestricted movement on the secured unit and able to go off of the secured unit with staff supervision. Progress notes dated 2/1/2014, document that patient #1 was in the hallway when a Human Service Technician (HST) dropped a door key onto the floor. Patient #1 grabbed the keys and ran to the exit door. The HST was standing in front of the door to prevent patient #1 from accessing the lock on the door with the key. The HST negotiated with patient #1 to give her back the keys. Progress notes dated 2/7/2014 at 9:56 p.m. document that staff overheard patient #1 talking to another patient (patient #2) about which staff would not be able to catch her if she ran from the facility. No evidence of reassessment of patient #1's supervision status was completed following the talk of elopement. Progress notes dated 2/8/2014 at 8:45 p.m. document that at 8:00 p.m., patient #1 requested to get a blanket out of the south back hallway. (unsecured area of the hospital with an unlocked fire exit door) HST-E told patient #1 that she was not allowed back there, and she would get patient #1 a blanket. Patient #1 requested several more times to pick out a blanket, saying another staff let her pick out her own blanket. HST-E repeated that patient #1 was not allowed in that area, and patient #1 again asked to get a blanket. HST-E agreed that patient #1 could pick out one blanket and then needed to get back to the unit. HST-E opened the door to the south hall, and patient #1 walked to the closet where the blankets are stored. Patient #2 knocked on the unit door, and patient #1 opened the door, and let patient #2 into the south hall. HST-E again stated that patient #1 and #2 were not allowed in the south hall. Patient #1 and #2 picked out their blankets and patient #1 hugged patient #2. Patient #1 ran around HST-E and out of the (unlocked fire door) exit door. HST-E pushed the panic alarm, which did not sound, and ran back to the unit with patient #2 to alert staff that patient #1 had eloped. The charge nurse and police were notified. Hospital records, dated 2/9/2014 revealed that patient #1 was accompanied to the hospital by her stepmother. Patient #1 reported to hospital staff that after leaving the facility, she walked to a gas station, and called a friend. The friend brought her to a party where she reported being physically and sexually assaulted by seven men. A sexual assault examination was attempted by the Sexual Assault Nurse Examiner(SANE), but patient #1 would not allow photographs or a visual inspection of her body. The SANE nurse was able to visualize the vaginal area, and noted redness around the vaginal opening. No active bleeding was noted at the rectum, and no signs of trauma were found. Vaginal and rectal swabs were obtained for culture.Patient #1 was unable to be interviewed due to her medical condition.

LPN-G was interviewed on 4/17/2014 at 11:35 a.m. and stated on 2/7/2014 she overheard patient #1 talking to patient #2 about eloping from the facility. LPN-G reported the conversation to RN-H. She was unsure if the information was passed on in shift report for more than one shift. Patient #1's supervision status did not change after the conversation regarding elopement was reported. She also stated that she has witnessed staff take patients to the south hallway to get linens. She was not aware the south hallway was not a patient access area. HST-E was interviewed on 4/14/2014 at 12:43 p.m. and stated she worked with patient #1 on the evening of 2/8/2014. During the shift (unsure of exact time) patient #1 asked HST-E to take her off of the unit to get a blanket. HST-E stated she was not aware that the area was not a patient access area, so she accompanied patient #1 off of the secured unit to the south hall for a blanket. While they were in the south hallway, patient #2 knocked on the unit door and patient #1 opened the door. Patient #1 gave patient #2 a hug, and patient #1 ran past HST-E out of the unlocked fire exit door. HST-E pushed her panic alarm, but the alarm did not sound. HST-E ran back to the unit with patient #2, and reported the incident to HST-I and called the charge nurse and the police. HST-E stated that both patient #1 and patient #2 were on routine supervision status, so were able to go off of the unit with a staff person present. HST-E did not alert the nurse that she was leaving the unit with patient #1. She was unaware that patient #1 talked about elopement on 2/7/2014.
HST-I was interviewed on 4/24/2014 at 10:55 a.m. and stated after dinner on 2/8/2014, HST-E came into the hall of the unit and stated that patient #1 eloped. HST-I notified the charge nurse, and went outside to look for patient #1. He was unable to locate her. HST-I stated patient #1 was on routine status, so was able to go to the south hallway with a staff person present. He was not aware the area was not a patient access area. HST-I was aware that patient #1 had a history of elopement, but was not aware of the elopement conversation with another patient on 2/7/2014.
RN-C was interviewed on 4/14/2014 at 1:30 p.m. and stated only staff has access to the south hallway. The area is an unsecure area, and unsafe for patients to be in the area, due to the unlocked fire door, and the risk of elopement. RN-C was aware that patient #1 was a high risk of elopement, and has eloped from other facilities on the past. No policy was found which documented specific areas of the hospital which are not patient access areas, and therefore off limits to patient access.