HospitalInspections.org

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Based on document review, video surveillance review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services.

Findings include:

1. The hospital failed to ensure that appropriate number of staff was available to respond to a Cod Grey (emergency code for management of aggressive patients' behavior). Subsequently, 4 patients (Pt. #1, Pt. #2, Pt. #3 and Pt. #4) were able to elope from the hospital. See deficiency cited at A-392.

Based on document review, video review, and interviews, it was determined that for 1 of 2 emergency codes (events) reviewed, the hospital failed to ensure that appropriate number of staff was available to respond to a Cod Gray (emergency code for management of aggressive patients' behavior). Subsequently, 4 patients (Pt. #1, Pt. #2, Pt. #3 and Pt. #4) were able to elope from the hospital.

Findings include:

1. The hospital's policy titled, "Staffing Plan for Nursing Services" (dated 6/2022) was reviewed and required, " ...One staff person cannot be left alone on an inpatient, Adolescent Unit ...Code response: For acute care facilities, three staff members should always be available to respond; cross-trained staff can be utilized ..."

2. The hospital's policy titled, "Emergency Codes" (dated 1/2022) was reviewed and required, " ...2. It is the responsibility of all staff members to know all emergency codes and to respond when indicated ..."

3. The incident report log for 7/2024 to 10/2024 was reviewed and indicated an entry for 9/30/2024 which includes, "[Pt.#1]...elope-not returned - Patients (Pt. #1, Pt. #2, Pt. #3 and Pt. #4) became agitated and repeatedly attempted to break down dayroom door to attack select peers. Staff had to relocate peers through nursing station and into the hallway behind the breakroom due to fear of patients breaking dayroom door. Patients became aggressive towards staff by threatening and endorsing intent to attack staff and take their badge. When unable to attack hallway staff, patients relocated near stairwell doors and began exit door until it broke, resulting in patients successfully eloping from unit down the stairwell and outdoors approximately [11:13 PM]."

4. The Patient Care Assignment Sheets for Unit 3 (Pediatric), 4 (Adolescent Girls), and 5 (Adolescent Boys) for 9/30/2024 were reviewed. The patient care assignment sheets indicated that Unit 3 was staffed with 2 RNs (Registered Nurses) and 1 BHA (Behavioral Health Associate). Unit 4 was staffed with 1 RN and 1 BHA. Unit 5 was staffed with 2 RNs. 1 BHA was scheduled to work at Unit 5 at 11:15 PM. Each assignment sheet designated one staff member to respond to Code Grey.

5. On 10/16/2024 at approximately 2:00 PM, a video surveillance for the 5th floor adolescent boys behavioral unit was reviewed for an incident that occurred on 9/30/2024 between approximately 10:30 PM and 11:30 PM. The video surveillance showed that there were 2 RNs (E#3 and E#4) staffed on the unit and that patients (Pts.# 1, 2, 3, and 4) began displaying aggressive behavior towards 3 other patients. At approximately 10:40 PM, E #5 (RN) from another unit came to respond/assist. The video surveillance showed that the behavior of Pts#1, 2, 3, and 4 continued to escalate at which point E#3 enters the nurses' station for his safety. The video surveillance showed that Pts#1, 2, 3, and 4 then go to the stairwell door and start to kick and hit the door. The patients (Pt. #1, #2, #3 and #4) succeed in opening and they eloped from the hospital.

6. An interview was conducted with the Registered Nurse (E#3) on 10/17/2024 at approximately 9:30 AM. E#3 stated that on 9/30/2024 at approximately 10:30 PM, E#3 noted aggressive behavior displayed by 3 patients (identified as Pts #2, 3, and 4) towards 3 other patients. Later on, Pt.#1 joined. E#3 stated that E#3 attempted to de-escalate the situation. When E#3 noted the escalation of aggressive behavior of Pts. #1, 2, 3, and 4, E#3 called a Code Grey (Emergency Management of Aggressive Behavior) and placed the 3 patients in the dayroom and locked the door. E#3 stated that only RN/E#5 responded. E#3 stated that there was no night supervisor on duty that evening. E#3 stated that E#4 was in the nurses' station making phone calls to doctors and supervisors and AOC (administrator on call). E#3 stated that when the situation could no longer be de-escalated and fearing for their own safety, E#3 went inside the nurses' station to join E#4 and E#5. E#3 stated that Pts.#1, 2, 3, and 4, then directed their attention towards breaking down the stairwell door and open it and eloped the unit and eventually the hospital. E#3 stated that their normal protocol is for a staff from each unit to respond to the Code Grey. E#3 stated that there should always be 1 RN and 1 BHA on the unit. E#3 stated that if the unit is staffed bare minimum (1 RN and 1 BHA), no other staff can respond when a code is called. E#3 stated that if they were staffed better, more staff could have responded.

7. An interview was conducted with Registered Nurse (E#5) on 10/17/2024 at approximately 10:30 AM. E#5 stated that on 9/30/2024, E#5 responded to a Code Grey called by E#3 at approximately 10:30 PM. E#5 stated that E#5 attempted to de-escalate the situation and later went in the nurses' station to assist E#4 in making phone calls to the supervisor and the AOC. E#5 stated that the patients being targeted by Pts.#1, Pt. #2, Pt. #3, and Pt. #4 were moved from the dayroom to the hallway behind the nurses' station through an adjoining door since they noted that the dayroom door was about to break open. E#5 stated that Pts.#1 and 2 had previous history of eloping from other facilities and were considered the worst wards in DCFS (Department of Child and Family Services). E#5 stated that when a Code Grey is called, their usual protocol is for at least 1 staff member from each unit to respond. E#5 stated that if the intake staff is not busy, the intake staff also responds to the Code Grey. E#5 stated that if a supervisor is present, the supervisor also responds to the Code Grey. E#5 stated that there was no one else available that evening to respond except E#5.