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The Condition of Participation for Patient Rights has not been met.

Based on clinical record review, review of hospital policy and staff interview for 2 of 3 patients reviewed for discharge, the hospital failed to ensure the safe discharges of two patients (Patient #1 was an adolescent and Patient #2 was cognitively impaired) by leaving the patients unattended outside while awaiting a ride to a safe location, both patients eloped from hospital property resulting in a finding of Immediate Jeopardy. And based on clinical record review, hospital policy and staff interview for 1 of 4 sampled patients reviewed for restraints, (Patient #4) the hospital failed to monitor the patient's behaviors while in restraints and failed to document when the patient's restraints were discontinued.


Please refer to A144 and A187

1. Based on clinical record review, review of hospital policy and staff interview for 2 of 3 patients reviewed for discharge, the hospital failed to ensure the safe discharges of two patients (Patient #1 was an adolescent and Patient #2 was cognitively impaired) by leaving the patients unattended outside while awaiting a ride to a safe location, both patients eloped from hospital property resulting in a finding of Immediate Jeopardy. The findings include:

a. Patient #1 arrived at the emergency department (ED) on 7/11/23 for aggressive behaviors and not taking medications. The safety assessment dated 7/11/23 at 1:22 AM noted the patient was not an elopement risk and a sitter was initiated. The ED provider note dated 7/11/23 at 2:04 AM noted the patient was an adolescent, with a history of attention deficit hyperactive disorder, disruptive mood dysregulation disorder and post-traumatic stress disorder who presented to the ED with aggressive behaviors and refusing to take medications. The note identified the patient was medically cleared for a psychiatric evaluation.

Review of psychiatric evaluation dated 7/11/23 at 3:31 AM noted patient reports aggressive behaviors at home and refusing to take medications. The note identified the patient was calm and not interested in taking medications right now but inquired when he/she would be able to leave. The note further identified the patient would be observed and re-evaluated in the morning.

Review of the Master of Social work (MSW) note dated 7/12/23 at 10:32 AM noted patient calm, guarded, difficult to engage, dismissive and inquiring about discharge. The note further identified the MSW reached out to the patient's community team, and it was reported that the patient has been refusing most clinical services and engaging in aggressive behaviors in the community. The clinical team felt it best the patient remains overnight and would be picked up by the case worker tomorrow to engage in clinical services as they are scheduled to meet weekly.

The Licensed Clinical Social Worker (LCSW) note dated 7/13/23 at 11:17 AM noted patient's case worker was contacted and advised of discharge plans for the afternoon. Further review of the notes identified at 3:00 PM, Patient #1's case manager called the LCSW to report he's been waiting outside to pick up the patient, however, could no longer wait and would return at 3:30 PM. The note identified the LCSW asked the unit secretary to call the mental health worker (MHW) to inform her that the patient's ride would be there at 3:30 PM. Additionally the note identified the unit secretary notified the LCSW and reported that the patient was left outside unattended by the MHW and was no longer there. The note identified the LCSW called the patient's case manager to advise him that the patient was not picked up by staff, was left outside unattended and was no longer at the hospital.

The Nurse's note dated 7/13/23 at 5:30 PM noted the patient was discharged at approximately 3:30 PM, a call was received that the patients ride was outside, patient was given belongings, discharge paperwork was reviewed, and the patient was walked outside with the MHW. The note further identified the patient's ride was not there and the patient walked off. The note identified protective services and the police were notified.

Interview with the Assistant Nurse Manager on 7/27/23 at 10:30 AM stated that when Patient #1 was discharged, the MHW left the patient outside unattended and did not hand the patient off to the patient's case manager. The Assistant Nurse Manager stated the MHW anticipated the patients ride being there and left the patient by the driveway and walked back inside. The Assistant Nurse Manager stated that they found out the patient had left when the patient's case manager called asking for the patient initially at 3PM. The Assistant Nurse Manager stated that she spoke to the MHW who said that it was not unusual to leave patients there waiting for rides and she did not feel she did anything wrong. The Assistant Nurse Manager stated that for patients who are adolescents or have cognitive impairment staff are to remain with the patient until their ride arrives. The Assistant Nurse Manager further stated that this was the second safety incident in one week of patients being left unattended for rides and following the second incident, the Manager put an email out to the MHW's stating, "under no circumstances are you to ever leave a patient before connecting with their designated transportation."

Interview with MHW #2 on 7/28/23 at 12:15 PM stated that she walked the patient outside the door and left the patient near the curb of the driveway and returned to the unit. MHW #2 stated that she was not told to stay with the patient by the nurse and that they don't usually wait with the patients.

Interview with the Patient Service Manager (PSM) of psych ER on 8/2/23 at 9:50 AM stated that in certain circumstances such as an adolescent or a patient with dementia, staff are to remain with the patient until their ride arrives. The PSM stated that an email went out to MHW's identifying that no patients are to be left unattended until they connect with their designated transportation. And that further education would be coming. Patient #1 was found approximately an hour and one half later at a store near the family's home.



b. Patient #2 arrived at the ED on 7/3/23 with paranoia and confusion. The ED provider note dated 7/3/23 at 7:51 PM noted paranoia and confusion, patient called police on caregivers and most likely paranoia in the setting of dementia. The note identified the patient was disoriented with rapid tangential speech, verbose with some pressured speech and will require a psychiatry evaluation for potential manic episode with paranoid delusion.

Review of the ED psych evaluation dated 7/3/23 at 10:22 PM noted anxiety and paranoid thoughts, will hold over night in the behavioral unit to monitor mood and safety while the family arranges for increased help at home. The note further identified the patient was conserved with a history of dementia, anxiety and depression. The note identified to continue home medications, will trial Seroquel and if tolerated consider continuation to help address paranoia, will discharge home after home services are set up.

Psychiatric observation progress note dated 7/5/23 at 11:35 AM noted patient placed on observation status in order to provide ongoing care in a safe environment and allow for further evaluation to determine the appropriate disposition. The note further identified the patient has dementia, paranoid thoughts and will hold overnight to monitor mood, safety while family arranges increased help at home and likely discharge on 7/6/23.

The MSW note dated 7/6/23 at 12:20 PM noted the patient can be discharged to home via medical cab at 2:00 PM. Nurse's notes dated 7/6/23 at 4:22 PM noted at 3:15 PM discharge paperwork reviewed with patient, belongings returned, and unit secretary called for medical cab and patient was escorted outside by a MHW. The note identified at 3:45 PM per the MHW when the patient was escorted outside the patient continuously walked away from staff and the waiting area while waiting for the medical cab. The note identified the police, protective services, MD, family, and nursing manager were notified the patient was unable to be located.

The nurse's note at 4:20 PM noted patient's family called as to why patient was not supervised while waiting for ride. The nurse's notes at 4:50 PM noted the patient was not located at their residence and at 6:22 PM the patient was located and returned to the ED at 6:43 PM (a total of 3 hours and 28 minutes the patient was unable to be located).

Review of the ED provider note dated 7/6/23 at 6:43 PM noted the patient escaped from the behavioral unit and was found by EMS. The note identified the patient was diaphoretic, but the weather was extremely hot and humid. The note identified the patient has dementia with wandering behavior, no evidence of trauma, likely slightly dehydrated in the setting of being outside, tolerating fluids, will likely return to behavioral unit for observation.

Interview with MHW #1 on 7/27/23 at 12:50 PM stated that she was asked to bring the patient upstairs and outside to the medical cab that was waiting to take the patient home. MHW #1 stated that she brought patient #2 outside, but the patient kept walking away from her towards the benches that are outside. MHW #1 stated that she waited awhile with the patient but was thinking she needed to get back to the unit, so she left the patient outside alone. MHW #1 stated that she remembered thinking she was told once the patient is outside, they are no longer her responsibility, so she returned to the unit. MHW #1 stated that when the nurse asked her to take the patient outside, she did not tell her she had to stay with the patient. MHW #1 further stated that although she is aware an email came out to the MHW's she could not recall what it said.

Interview with MSW #1 on 8/1/23 at 12:35 PM stated that she coordinated Patient #2's discharge, set up for a ride with a medical taxi and handed it over to nursing.

Interview with Psych Service Administrator on 8/1/23 at 12:50 PM stated that she was at the nursing station when the call came in that the cab was there, but the patient was missing. The Administrator stated she reported to nursing and she contacted the family regarding what happened, and that the patient was left unattended.

Interview with RN #1 on 8/2/23 at 9:30 AM stated that she was covering the nurse on the behavioral unit when the patient was discharged. RN #1 stated she gave the paperwork to the patient and the MHW escorted the patient outside. RN #1 stated that sometime later the medical cab called and said the patient never got into the cab. RN #1 stated that the police and protective services were notified, and staff went and looked outside for the patient. RN #1 stated that she could not recall if she directed the MHW to remain with the patient until the ride picked up the patient, but she should not have left the patient due to the patient's dementia. RN #1 stated that MHW's carry a phone on them and if the MHW was having a problem with the patient remaining with her she should have called or let security know.

Review of the hospitals policy for discharge planning with the Assistant Nurse Manager on 7/28/23 at 12:10 PM identified although the policy identified the patient receives the after-visit summary which the nurse reviews with the patient, family, care partner, care giver or patient representative, the policy lacked documentation regarding patients who are adolescents or have cognitive impairment to ensure a safe discharge.

Immediate Jeopardy was identified on 7/27/23 for failure to ensure Patient #1 and Patient #2 were provided adequate supervision during discharge resulting in Immediate Jeopardy.

The Hospital provided the Department with an action plan that included in part: Education of all ED behavioral health staff regarding remaining with patients who are minors, conserved or have a cognitive impairment until the designated transportation arrives and the staff hand off the patient, and the CBO (competency Based Orientation) was updated to include remaining with adolescent patients and patients with cognitive impairment until transportation arrives, and auditing of the discharge process.


2. Based on clinical record review, observation of photographs and staff interview for 1 of 3 sampled patients (Patient #3) reviewed for supervision and assistive devices while eating, the hospital failed to supervise the patient and failed to ensure the patient had the appropriate eating utensils during a meal. The finding includes:

Patient #3 was admitted to the hospital on 6/30/23 with urinary retention. Nurse's notes dated 7/1/23 at 1:30AM noted patient arrived at unit. The note identified instructions were provided by group home that the patient is on a puree diet, can feed self but requires a metal spoon and supervision. Interview with Person # 1 on 7/28/23 at 1:00PM stated that she visited patient #3 on 7/14/23 at lunch time and when she entered the room the patient was eating with plastic utensils and no staff was present. Person #1 stated she took pictures of the patient's daily board that identified the patient was a puree diet, required to be fed, and required a metal spoon only.

Observations of Patient # 3 on 7/14/23 while eating noted the patient was alone in the room and eating with plastic spoon.

Interview with RN # 2 on 8/1/23 at 1:50PM stated that dietary staff deliver trays to the patients. RN #2 stated that he recalls being told that the patient had a plastic utensil, so he went into the patient's room and removed the tray and called down to the dietary department to report the patient was given a plastic spoon.

Interview with RN #3 on 8/2/23 at 9AM stated that he could not recall speaking to anyone regarding the patient receiving plastic silverware on their meal tray. RN #3 stated that the patient does require supervision while eating but could not recall if on that day the patient was eating alone. RN #3 further stated that metal utensils were not kept on the unit until 2 weeks ago.

Interview with the Assistant Nurse Manger # 2 on 8/1/23 at 9:05AM stated that Patient #3 required supervision with meals and metal utensils because the patient has a history of ingestion. The Assistant Manager further stated that signs were posted at the patient's bed about having no plastic utensils. The Assistant Nure Manager stated that since the day the patient was served plastic utensils for eating, they have posted signs at the doorway noting "no plastic utensils", and the patients' tray is brought to the desk to be checked prior to bringing the tray in.

Based on clinical record review, hospital policy and staff interview for 1 of 4 sampled patients reviewed for restraints, (Patient #4) the hospital failed to monitor the patient's behaviors while in restraints and failed to document when the patient's restraints were discontinued. The finding includes:


Patient #4 was admitted to the behavioral health unit on 7/19/23. A nurse's note dated 7/23/23 at 7:20AM noted at approximately 4:30AM patient #4 snatched the RN's keys from around her neck and was able to make it past the units' doors before being stopped by security. The note identified the patient was placed in 4-point restraints at 5:15AM, Haldol and Ativan were administered, and the patient was transferred to the ED for evaluation.

Review of the ED Nurse's notes dated 7/23/23 at 6:20AM noted patient experienced a fall down the stairs, striking head while attempting to elope, patient arrives in 4-point restraints. Review of the ED provider note dated 7/23/23 at 6:25AM noted patient brought to ED after experiencing a fall on stairs and striking head while attempting to elope. Patient arrived in 4-point restraints.

Review of the clinical record and interview on 7/28/23 at 11:25AM with Director of Regulatory identified the patient was placed in 4-point restraints while on the behavioral unit and was transferred to the ED, but the clinical record lacked documentation that the patient's behaviors were monitored every 15 minutes and the record lacked documentation as to when the restraints were discontinued.

Review of the hospital policy for restraints and seclusion identified continuous observation of the patient and the behaviors exhibited are documented in the clinical record and the restraint is to be discontinued at the earliest time after the behaviors have stopped.