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SWEDISH HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on document review and interview, it was determined that for 1 of 10 patients' (Pt. #1) clinical records reviewed in the psychiatric unit, the Hospital failed to ensure that the patient received care in a safe setting.
Findings include:
1. On 2/2/2022, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted on 1/26/2022 with a diagnosis of acute psychosis. Pt. #1 was admitted in room A202 of the adult behavioral health unit until 1/29/2022. On 1/29/2022, Pt. #1 eloped from the Hospital through the window in room A202.
2. On 2/2/2022, the Hospital's policy titled, "Patient Rights" (revised on 4/2021) was reviewed and included, "... All patients at (Name of the Hospital) are granted the rights and responsibilities which are enumerated herein... Patient Rights... 6. Personal Safety - the right to receive care in a safe setting..."
3. On 2/2/2022, the Hospital's root cause analysis conducted by E #1 (Senior Director of Nursing), dated 2/1/2022, was reviewed and included, "... (On 1/29/2022 at approximately 3:37 PM), staff entered (Pt. #1's) room and found that (Pt. #1) was missing, the lower part of the window was broken. (Pt. #1) was able to get out through the window (in room A202)... Conclusion... An issue related to the lower part of the window glass in patient room A202 resulted the ability of the patient (Pt. #1) to break the glass..."
4. On 2/4/2022, the Hospital's environmental assessment of the adult behavioral health unit conducted with the Hospital's Engineering Department, dated 5/3/2021, indicated that the window glass in patient room A202 was tamper-resistant..."
5. On 2/4/2022, the Hospital's email communication with (Name of the Glass Company) dated 2/4/2022 indicated that the bottom section of the glass window in room A202 did not meet safety glazing code.
6. On 2/4/2022 at approximately 12:00 PM, and on 2/8/2022 at approximately 10:30 AM, interviews were conducted with E #1. E #1 stated that according to the assessment by the glass company, the lower section of the glass window in Pt. #1's room was not tamper resistant, which allowed Pt. #1 to break the glass and escape from the Hospital. E #1 stated that the issue about the glass window was missed by the Hospital.