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Based on staff interview, review of medical records, and review of facility documents, it was determined that the facility failed to ensure: 1.) implementation of their policy on assessing elopement risk and assigning level of observation (0144); 2.) accurate documentation of Q15 (every 15 minutes) observation for all patients (0144); 3.) a comprehensive risk assessment is documented involving all courtyards (0144); 4.) the safety risk assessment and PSS3/ESS6 screening tools are completed for all patients upon admission and defined in facility policy (0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

Findings include:

The facility was informed of the IJ and provided with the IJ template on January 2, 2024 at 4:20 PM. An acceptable removal plan was received on January 4, 2024, the last day of survey. The facility addressed the IJ findings by educating the Admissions Department Staff, the LIP's [Licensed Independent Practitioners], and the inpatient unit Registered Nurses on elopement risk assessment procedures and communication to the assigned providers with patient results, provided re-education to staff on all inpatient units for courtyard procedures and protocol, as well as implementation of a Courtyard Patient Roster/Tracking Sheet to be utilized during courtyard activities (smoke breaks, fresh air breaks, and group activities). The IJ was resolved on January 4, 2024, at 11:26 AM, after the State Survey Agency verified full implementation of the removal plan through staff interviews, document review, and review of staff education.

Based on review of medical records, staff interviews, facility documents, and tour of the facility inpatient units and courtyards, it was determined that the facility failed to ensure 1.) implementation of their policy on assessing elopement risk and assigning level of observation; 2.) accurate documentation of Q15 (every 15 minutes) observation for all patients; 3.) a comprehensive risk assessment is documented involving all courtyards; 4.) the safety risk assessment and PSS3/ESS6 screening tools are completed for all patients upon admission and defined in facility policy.

Findings include:

1. On 12/28/23, review of the medical record of Patient 1 (P1) revealed the following:

On 12/20/23 at 21:51 [9:52 PM], upon admission, Staff 28 (S28), the Associate Counselor, determined at screening that the P1 has a history of elopement, documenting, "Runaway behaviors from home and facility."

The medical record lacked documentation that an LIP (licensed independent practitioner) received a verbal agreement from the patient for elopement risk, and the patient was placed on Q15 observation.

On 01/02/2024 at 1:37 PM, S10 (Assistant Vice President of Nursing) verified that there was no documented acknowledgement from an LIP of the patient's elopement assessment, or of communication from S28 to the LIP for P1's history of elopement. S10 confirmed that there was no documented treatment plan or care plan addressing P1's history of elopement. S10 indicated that P1's level of observation was a standard level of every 15 minutes, and stated, "per facility 'Observation Status and Special Precautions Policy', the patient should have been on every five minute checks at minimum."

Facility policy titled, "Observation Status and Special Precautions" stated, "every 5-minute checks" will be done for patients at risk for elopement, even if they "verbalized agreement with current treatment plan and denies intent to elope."

2. On 1/2/24, during the review of the surveillance footage of the incident, P1 was observed eloping from the APA courtyard at 9:55 PM. A tree located near the fence in the APA courtyard was involved at the point of elopement.

Upon review of the facility document titled, "Carrier Clinic Q15 min Patient and Environmental Observation Form," it was documented that the patient was "calm" and "on unit" at 10PM, 10:15PM, 10:30PM, 10:45PM, and 11PM. Upon interview at approximately 1:37 PM, S2, the Assistant Vice President of Risk, verified that the facility video recordings were accurate, and that P1, as of 9:55 PM on 12/25/2023, was no longer on the APA Unit.

3. On 01/02/2024 at 11:30 AM, S2 provided documentation of a risk assessment from 12/26/23, following P1's elopement from the APA courtyard. The risk assessment identified the trees as high risk.

S2 provided documentation of a risk assessment completed on 6/12/23, following a patient elopement from another courtyard using a tree. The tree was removed as a mitigation plan, but no risk assessment was provided for other courtyard areas, including the APA courtyard.

S2 stated that following P1's elopement, all APA staff received re-education prior to their next working shift on this unit, but that only the staff on the APA unit received the education. S2 confirmed that staff members can float and work on other units, including patient observers.

4. On 12/28/23, upon review of safety risk assessments documented for Patient 2 (P2), P3, P4, P5, P6, P7, and P10, the following was revealed:

-P2, admitting diagnosis paranoid schizophrenia, was assessed on 12/21/23 at 2:41 PM and documented as a "moderate risk level." Provider order written on 12/21/23 at 2:47 PM indicated the patient was placed on every (q) 5-minute safety checks.

-P3, admitting diagnosis manic depression and schizoaffective disorder, was assessed on 12/17/23 at 3:38 PM and a complete safety risk assessment was not conducted. Provider order written on 12/17/23 at 3:45 PM indicated the patient was placed on q15-minute safety checks.

-P4, admitting diagnosis schizophrenia, was assessed on 12/20/23 at 4:00 AM and documented as "unable to complete." Upon request, S2 was unable to provide a safety risk assessment that was done at admission. Provider order written on 12/19/23 at 8:53 PM indicated the patient was placed on q5-minute safety checks.

-P5, admitting diagnosis schizophrenia with passive suicidal thoughts, was assessed on 12/24/23 at 7:33 PM and documented as a "moderate risk level." Upon request, S2 was unable to provide a safety risk assessment that was done at admission. Provider order written 12/23/23 at 9:56 PM indicates the patient was placed on q5-minute safety checks. On 12/23/23 at 9:51 PM, P5 had a "positive screen" for his/her suicide screening status. A secondary screening titled "ED-Safe Secondary Screener (ESS-6)" was not conducted. S10, AVP of Nursing, confirmed that a secondary suicide screening was not conducted on 01/02/24 at 3:40 PM. A progress note was written by a registered nurse on 12/24/23 at 12:16 PM that stated the patient " ...contracts for safety."

-P6, admitting diagnosis bipolar disorder with depression, was assessed on 12/16/23 at 4:35 AM and documented as "moderate risk level". Provider order written 12/16/23 at 5:12 AM indicates the patient was placed on q15-minute safety checks.

-P7, admitting diagnosis major depressive disorder with psychotic features, was assessed on 12/20/23 at 4:20 PM and had a "positive screen" for his/her suicide screening status. The secondary screening, ESS-6, recommended the level of intervention as "current level". The chart failed to reveal what the "current level" was. A provider order written on 12/20/23 at 4:07 PM indicates the patient was placed on q15-minute safety checks. An interview was conducted with S14 that indicated he/she would have placed the patient on q5-minute checks given the positive screen and the patient's past history.

-P8, admitting diagnosis bipolar disorder, was assessed 12/24/23 at 12:53 PM and documented as "moderate risk level". Provider order written 12/24/23 at 12:58 PM indicates the patient was placed on q15-minute safety checks.

-P10, admitting diagnosis schizoaffective disorder depressive type, had an initial psychiatric assessment conducted on 12/18/23 at 9:33 AM. The physician wrote, "Patient agreed to stay safe ..."

An interview was conducted with S14, the Psychiatric Nurse Practitioner, on 01/02/24 at 11:35 AM concerning the "Safety Risk Assessment," S14 stated that, "low risk indicates a q15 minute check, moderate risk indicates a q5 minute check, and high risk indicates a 1:1." S14 confirmed that safety risk assessments are conducted on every patient at admission and throughout his/her inpatient stay and this helps to guide the level of observation needed for the patient. Upon request, S2 provided the facility policy titled, "Observation Status and Special Precautions" for review. Upon review of the policy, the policy lacked definition of the frequency of observation in relation to the safety risk assessment risk levels. Upon request, S2 was unable to provide a policy regarding the safety risk assessment.

During an interview with S14 on 01/02/24 at 11:30 AM, the process of admitting a patient with suicidal thoughts was reviewed. S14 stated the patient has multiple safety screenings, including the " ...PHQ9 [which is] done first and then safety risk assessment, and suicide assessment". S14 explained these safety assessments in conjunction with an initial full patient assessment help to determine the level of patient observation. Per S14, an additional factor is whether the patient is able to "contract for safety" which, "is not signed but is documented in the note." During an interview with S1, the Vice President of Patient Care Services, he/she stated, "we do not use contracts for safety."

A review of the facility's policy titled, "Observation Status and Special Precautions" stated patients are placed on 1:1 observance if the patient, " ...is unable or unwilling to verbalize that they will NOT attempt to harm themselves" or observed every 5 minutes if the patient "may verbalize uncertainty in ability to maintain personal safety but is agreeable with utilizing coping skills or reaching out to staff if additional support is needed."

The facility failed to ensure implementation of their suicide screenings in conjunction with contracting for safety in their policies and procedures to provide a safe environment for the patient.


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Based on medical record review and staff interviews, it was determined that the facility failed to ensure an accurate written discharge disposition in the medical record for one of 10 medical records reviewed (#1).

Findings include:

On 12/28/23, review of Patient 1's (P1) medical record revealed his/her discharge disposition as "home" despite P1 having eloped on 12/25/23. Upon review with Staff 10 (S10), AVP of Nursing, concerning the documented discharge disposition, S10 stated, "I don't know why it says that. [He/she] eloped."

Based on medical record review and staff interviews, it was determined the facility failed to provide the patient with a full psychiatric evaluation within 60 hours of admission, in one of ten medical records reviewed (#9).

Findings include:

On 12/28/23, review of P9's medical record revealed the following:

On 12/15/23 at 6:31 PM, P9 was admitted to the facility. An "Attending Assessment Note" was documented by psychiatry on 12/18/2023 at 7:28 PM, approximately 73 hours after admission.

Upon interview, on 1/2/24 at 11:30 AM, Staff 14 (S14), the Psychiatric Nurse Practitioner, stated, "a patient should be evaluated by an APN [Advanced Nurse Practitioner] or MD [Medical Doctor] upon admission for stabilization and getting [the patient] to the unit. This evaluation is called an 'Access Assessment' and must be completed within 24 hours. The full assessment is done by the patient's primary psychiatrist and that note is called the 'Attending Assessment Note'." S2, the Assistant VP of Risk, confirmed this information on 1/2/24 at 10:50 AM, and stated, "there are two psychiatric assessments. The first one is the initial psych and that is done on admission and the [second assessment is the] full medical assessment [which] has to be done within 60 hours." When the Attending Assessment Note was presented to S10, the AVP of Nursing, he/she confirmed that the evaluation was done late, and stated, "that's what I have." The facility was unable to provide documentated evidence that a full psychiatric examination was completed within 60 hours of admission.

Based on medical record review, staff interview, and review of facility policies and procedures, it was determined that the facility failed to provide an individualized, comprehensive treatment plan, in accordance with facility policy, in three of 10 medical records reviewed (#1, #9, and #10).

Findings include:

On 12/28/23, a review of Patient 1 (P1), P9, and P10's medical records revealed the following:

On 12/20/23 at 8:00 PM, P1 was admitted with a diagnosis of manic-depressive disorder. The medical record lacked a treatment of care plan for the patient. On 1/2/24 at 1:47 PM, a request was made to Staff 10 (S10), the AVP of Nursing, for P1's treatment of care plan. S10 was unable to provide the treatment of care plan and stated, "we don't have one for [him/her]."

On 12/15/23 at 6:31 PM, P9 was admitted with a diagnosis of bipolar disorder manic with psychotic features. P9's treatment of care plan was never finalized and was left in "draft" format. On 01/02/24 at 3:15 PM, S10 confirmed that the treatment of care plan was still in "draft" format.

On 12/15/23 at 11:39 PM, P10 was admitted with a diagnosis of schizoaffective disorder, depressive type. P10's treatment of care plan was finalized on 12/22/23. On 01/02/24 at 03:25 PM, S10 confirmed there was a delay in finalizing the treatment of care plan.

Facility policy titled, "Medical Staff Documentation" last approved 03/21, was reviewed and stated, "...a master treatment plan is done within 72 hours of admission by the multidisciplinary team involved in the assessment and treatment of the patient."

The facility was unable to provide evidence that P1, P9 and P10's treatment of care plan was completed and finalized within 72 hours post admission, in accordance with facility policy.