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Based on review of hospital policies/procedures, review of medical records, review of security video, and interview with staff, there was not a system in place to prevent a breakdown in communication to ensure patients received care in a safe environment on 9/21/14. The breakdown in communication occurred allowing Patient #11 to elope from the group including an occupational therapist and patients returning from an occupational therapy session outside of the locked psychiatric unit. The patient left the group as they waited for meal carts and dietary staff to exit the psychiatric unit prior to entering the locked unit. Patient #11 ran through the hospital, exited the hospital, went to the top of a parking ramp, and jumped off the ramp. The patient suffered significant life altering injuries as a result of the fall.


On 9/24/14, the patient was upset after learning about a pending discharge due to a lack of progress. The patient's occupational therapy was discontinued and a meal tray was ordered for the noon meal. A psychiatric nurse assistant took the patient out of the locked psychiatric unit to the occupational therapy kitchen area. The psychiatric nurse assistant was aware the patient was upset at the time but did not check with the patient's primary nurse or any other staff before leaving the locked psychiatric unit with the patient. The psychiatric nurse assistant was not assigned to Patient #11 on 9/24/14 and earlier in the shift she had worked in another unit at the hospital. The occupational therapist was aware that the patient had been discharged from the occupational therapy but allowed the patient to stay. When the occupational therapist escorted the patients back to the locked unit, Patient #11 eloped from the group. Refer to A 144.

Based on review of hospital policies/procedures, job descriptions, medical records, personnel records, video footage, and staff interview, the psychiatric and occupational therapy staff failed to communicate changes in nutritional therapy services and symptoms of emotional distress for 1 (of 1) eating disorder patient in the locked psychiatric unit (Patient #11). The failure of staff to communicate with each other allowed the patient to leave the unit with a psychiatric nurse assistant to attend a meal preparation therapy session outside the unit after the therapy had been discontinued. When returning to the group, the patient eloped and attempted suicide by jumping from the fifth floor of a hospital parking ramp. The Director of Psychiatric Services identified an average daily census of approximately 5 eating disorder patients on 1 Papa-John West (1-JPW), the psychiatric unit. On 9/24/14, there were 22 inpatients in the psychiatric unit.

Failure of staff working with psychiatric patients in the psychiatric unit and ancillary service areas to communicate changes in Patient #11's level of emotional distress and changes in nutritional occupational therapy (OT) orders resulted in Patient #11's elopement and attempted suicide by jumping from the 5th floor of a hospital parking ramp to the ground below. The patient fell 50 feet and sustained multiple, significant, life-altering injuries.

Findings include:

1. Review of the the following hospital documents revealed the following information applicable to the complaint investigation.

a. The hospital policy titled "Patients' Rights and Responsibilities" last revised 4/12, revealed the following in part, ..."Regarding their personal needs, patients have the right to...receive care in a safe and secure environment."

b. Review of "Suicide Risk Screening" reviewed 6/12, revealed the following in part, ..."To provide evidence-based suicide risk screening for those patients admitted for the treatment of emotional or behavioral disorders, whether they report suicidal ideation or not...each patient...admitted for treatment of emotional or behavioral disorders will be screened for suicide at admission and at least daily throughout hospitalization using the suicide risk scale."


c. Review of "Patient Care Standards of Practice" revised 8/13, revealed the following in part, ..."Ongoing assessment of patient's nursing care needs will be documented on appropriate forms...patients having provider appointments that include a nursing component will have the following completed and documented by a staff member: ...suicide risk screening for patients being evaluated primarily for emotional or behavioral disorders."

d. Review of "Eating Disorder Protocol" dated 1/14, revealed the following in part, ..."Nutritional Rehabilitation...planning, purchasing, preparing meals in occupational therapy meal preparation group." This is a very important important part of the therapy for the patients with eating disorders.

e. Review of job description titled "Psychiatric Nursing Assistant" (PNA) revised 7/09, revealed the following in part, ..."Under close supervision, performs specific nursing tasks to assist and provide for the comfort, welfare, and monitoring of psychiatric hospital patients...Reports potential crisis situations to team members, monitors and reports the behavior patterns of individual patients...Knowledge, skills/abilities: ...ability to communicate effectively with others...ability to provide care with regard to patient condition."

f. Review of job description titled "Occupational Therapist" revised 11/12, revealed the following in part, ..."Evaluates, and treats patients with...behavioral dysfunctions, disorders...provides...patient care...and treatment appropriate for patients with complex needs...maintains effective working relationships with...staff members."

2. Review of video footage captured on the hospital's security cameras throughout the hospital shows the elopement of Patient #11 from the area just outside the door of the locked psychiatric unit, 1 JPW, and her travel through the hospital to the parking ramp. The patient was with two other patients and the occupational therapist returning to the unit after the occupational therapy session.

a. At 1:11 PM, Patient #11 exited the elevator with Staff A, the occupational therapist, Patient #12 and two other patients. The group traveled down the hallway approximately 30 feet to the door of the 1 JPW unit. Staff A opened the door to the unit to allow a dietary cart and 2 dietary staff to exit through the door to the hallway, Patient #12 and another patient were standing next to Staff A. When Staff A turned around, Patient #11 was no longer standing with the group.

b. The cameras captured Patient #11 running down the hallway in the opposite direction of the 1 JPW unit towards the doorway to exit the hospital. At 1:13 PM, Patient #11 exited the hospital and ran across an intersection, towards parking ramp 4. At 1:14 PM, Staff A exited the hospital through the same doors the patient used earlier while looking for the patient.

c. At 1:15 PM, Patient #11 jumped from the 5th floor of parking ramp 4. The total time from the time the patient eloped from the hallway to the time she ran approximately 125 yards and jumped from the parking ramp was only 4 minutes and 12 seconds.

d. Two hospital nurses were outside and saw the patient on the ground. They started resuscitation and notified the Emergency Department. An ambulance arrived at site and the patient was moved to the hospital's emergency room within 8 minutes of the fall.

3. Review of Patient #11's medical record entries for 9/24/14 revealed the following information.

a. The patient transferred from a medical admission for gastrointestinal complaints to 1 JPW for psychiatric treatment for an eating disorder on 8/13/14. The patient was admitted to the unit voluntarily. The patient's health history included diagnoses of depression, delusional disorder, failure to thrive, mood disorder, obsessive compulsive disorder, and a somatic disorder. There were 2 previous suicide attempts by overdose. The last suicide attempt occurred approximately 3 years ago. The patient was evaluated as low risk for suicide attempt during the hospital stay.

b. Review of Patient#11's "Discharge Summary" dated 9/24/14 at 10:44 AM completed by Practitioner A, the psychiatrist, for Patient #11 revealed the following in part, ..."Patient was admitted on eating disorder protocol. We started her diet lower than usual...diet was gradually advanced...patient remained extremely fixated on gastrointestinal complaints...admit weight 105.4 pounds...discharge weight 116.6 pounds...her beliefs and preoccupations with underlying gastrointestinal issues, possibly secondary to history of laxative abuse...beliefs were borderline delusional at times and she remained extremely anxious."

c. Review of documentation by Practitioner A, "Attending Staff Comments", dated 9/24/14, for Patient #11 revealed the following in part, ..."On the morning of 9/24/14, I spoke with the patient over the course of three separate occasions...I explained that if she was not willing to follow recommendations regarding management of constipation we could not justify keeping her in our eating disorder program...we would discharge her tomorrow evening...I also explained that if she needed an additional day to work out discharge plans, we could keep her until 9/26/14...about 45 minutes after this conversation, she requested to talk with the treatment team a second time. We basically went through the same issues. She then said, "so what you are saying is that you are kicking me out not matter what." I explained that we would only discharge her if she was not able to cooperate with recommendations. The patient approached me a third time during the late morning while carrying a cordless phone with her husband on the line...she told him that we were kicking her out of the program...her husband encouraged her to cooperate and her husband said he would not come until the scheduled family meeting next week. He added that if she left the hospital sooner than that, she would be on her own...The patient participated in three group therapy sessions per day." Patient #11 attended occupational therapy meal preparation sessions three times a day. This was an integral part of the eating disorder protocol.

d. Review of the occupational therapy treatment plan notes written by the Staff A, an Occupational Therapist, dated 9/24/14, revealed the following in part, ...patient was initially not brought to the group session with peers but was brought up later by unit staff...patient was quietly social during meal...on the return trip to the unit, the patient eloped from the group."

e. Review of the "Ineffective coping" care plan by documentation by Staff B, Registered Nurse (RN), on 9/24/14, revealed the following in part, ..."Patient...informed this nurse she was no longer on eating disorder protocol...she spent most of the morning on the phone...she demanded to see the doctors at 10:30 because they needed to figure out if she was discharging today or tomorrow...This nurse told the occupational therapist that the patient did not have to go to the cooking activity. Dietary was paged and then called to get a tray. After the tray arrived this nurse was informed the patient was taken to cooking activity. Around 1315 (1:15 PM) the call about the elopement was received."

4. During general interviews on the behavior health nursing units nursing staff reported the following information.

a. On 10/1/14 at 9:50 AM, Staff I, a PNA (Psychiatric Nurse Assistant) said the hospital educated nursing staff to monitor patients on the behavioral health units and report any changes in mood or behaviors to the RN. Staff I said this was imperative so the nurse can assess the patient to determine if the patient's needs were being met.

b. On 10/7/14 at 7:45 AM, Staff K, a PNA, reported among the roles and responsibilities PNAs have is serving as advocates for the patients. It is essential that PNAs work closely with their peers and the nurses. Staff K said the PNAs received education at orientation and annually (Crisis Prevention Intervention training) for monitoring for changes in behavior. If the patient was upset, frustrated, or angry, then the PNA observes the patient, insures they are safe, and notifies the RN so the nurse can assess the patient.

c. On 10/7/14 at 7:55 AM, Staff J, PNA reported that during orientation, PNAs are educated to report any changes in patients' mood or behaviors to the primary care nurse. Staff J said this was important because the nurse could assess the patient to determine if the patient may need medication to calm down.

d. During an interview on 10/1/14 at 12:20 PM, Staff C, RN and Nurse Manager of 1 JPW, said patients with mood disorders generally suffer from increased mood changes, predominately sleep less, and make decisions impulsively without thinking of the consequences.
Staff C said patients suffering from obsessive compulsive personality traits prefer routine patient-oriented care. Staff on 1 JPW would be trained to recognize patients with this type of disorder prefer certain routines and they would try to accommodate this. Staff C said patients with somatic disorders are obsessed that they have physical disorders or suffer from a significant illness despite medical evidence that nothing is wrong. Patients with a delusional disorder have a fixed, false belief in spite of strong evidence to the contrary.

Staff C said the only thing out of the ordinary for Patient #11 on 9/24/14 was that the patient's psychiatrist, Practitioner A, spoke with Patient #11 that morning regarding discharge related to the patient's lack of progress with the eating disorder program and non-compliance with physician orders to treat gastrointestinal symptoms. Staff C said Patient #11 was frustrated and upset with the staff, with the physician, and with her husband.

During a follow up interview on 10/7/14 at 10:40 AM, Staff C acknowledged that Staff F, a PNA, failed to communicate the change in Patient #11's mood and behavior to Staff E, the RN assigned to Patient #11 on 9/24/14, prior to taking the patient off the unit to occupational therapy. Staff C said the fact the patient was upset after the phone conversations earlier that day would have indicated there may have been a change in the Patient #11's mood and behavior. This information warranted notification to the primary nurse to ascertain if an assessment was necessary. Staff C said that they started to educate all staff to communicate with the primary nursing staff regarding the status of patients prior to leaving the behavioral health units for off-unit activities.

e. During an interview on 10/2/14 at 9:35 AM, Staff E, RN, verified she was Patient #11's primary nurse on 9/24/14. Staff E said the patient approached her at approximately 10:30 AM that day and told her that Practitioner A, the psychiatrist, had discharged her from the occupational therapy program. Staff E informed Staff A, the occupational therapist, when she arrived to the unit at approximately 11:30 AM that the patient did not need to go to occupational therapy. A lunch tray had been ordered and the patient should not be taken off the unit.
Staff E, reported she assessed Patient #11 on 9/24/14 at between 9:00 - 9:30 AM for suicide risk and the score was 4 (low risk). Staff E said the protocol for documenting assessments in the patients medical record on their unit was generally before 11:00 AM. Staff E said it was important to document the assessment findings in a timely manner so doctors, nurses, and other professional staff may access and review all information to accommodate patient needs and implement precautions if necessary. Staff E acknowledged she failed to document the suicide risk score on 9/24/14 until 3:53 PM.

Staff E said Staff F, a PNA who was not assigned to care for Patient #11 on 9/24/14, took Patient #11 to occupational therapy at approximately 11:45 AM. Staff F did not check with her prior to leaving the unit with the patient. Staff E said standard procedure on 1 JPW was the PNA staff communicated with nursing staff about a patient's status if they are going to leave the unit with the patient. Staff E said the lunch tray for Patient #11 arrived at the unit but by that time the patient had been taken off the unit by Staff F. Shortly thereafter she heard Patient #11 had eloped from the hospital and jumped from the fifth level of the parking ramp.

f. During an interview on 10/2/14 at 10:10 AM, Staff F acknowledged she was scheduled to work on 1 JPW on 9/24/14 but shortly after clocking in at approximately 6:30 AM, she was paged to go work in another unit. Staff F confirmed she was not assigned to care for Patient #11 on that day and was not aware of changes in the patient's occupational therapy or impending discharge orders. Staff F said she came back to 1 JPW at approximately 11:30 AM. She immediately started completing 15 minute checks on all patients. Staff F said Patient #11 was in her room talking on the cordless phone and was visibly upset, tearful, angry, the patient's tone of voice vacillated, and the patient appeared frustrated. At the end of the call, Patient #11 requested that Staff F take her to occupational therapy. Staff F agreed because this was the normal routine for Patient #11. Patient #11 had been on the unit for 42 days and had gone to occupational therapy sessions. Staff F said she escorted the patient to the occupational therapy unit. Staff F was not assigned to care for Patient #11 on 9/24/14 and was unaware of the events earlier that morning.

Staff F confirmed she did not communicate the patient's symptoms of emotional distress she described to the patient's primary nurse, she did not ask the nurse if there were any changes in occupational therapy, she did not review the patient's medical record to see if there were any changes in the patient's status or treatments, and she was unaware of the patient's proposed discharge.

During a follow up interview on 10/7/14 at 8:05 AM, Staff F admitted if she had been aware of these changes she would not have taken Patient #11 off the unit. Staff F said she needed to make certain she received a thorough report from the patient's nurse before providing care and services especially if she was not familiar with changes that had occurred during the time she was working in another unit.

g. During an interview on 10/2/14 at 10:55 AM, Staff G, a Licensed Master Social Worker, said on 9/24/14 in the AM, the interdisciplinary team spoke with Patient #11 about discharge and the patient expressed concerns that her husband would not take her back yet. Staff G said the patient had been in the hospital approximately 42 days at that point and the team determined that the patient was not progressing in therapies and treatment and was non-compliant with the treatment modalities.

h. During an interview on 10/2/14 at 12:55 PM, Practitioner A, Psychiatrist, explained he treated Patient #11 for the following conditions including but not limited to a dysphoric mood. Practitioner A defined dysphoric mood as negative emotions that may include anxiety and depression. The patient had an atypical eating disorder and Practitioner defined as refusal to ingest normal food resulting in weight loss. The patient had made progress towards resolution of this eating disorder. The patient also had a somatic disorder and had problems with dealing with stress. Practitioner A said Patient #11 was obsessed with different bodily processes such as her bowels and kidneys despite the fact that both medical and psychiatric physicians had provided her with critical information and reassurance that there were no clinical reasons or problems detected on a multitude of laboratory and radiological tests.

Practitioner A said on 9/24/14 after discussing possible discharge from the hospital and discharge from occupational therapy, [Patient #11] disagreed with him about the impending discharge. The patient appeared anxious and depressed but he did not feel this attributed to the patient's elopement. He did not feel that there was anything they could have done to predict the event.

i. During an interview on 10/2/14 at 2:00 PM, Staff A, an occupational therapist said she had been working with Patient #11 since admission to 1 JPW. Staff A said she did not take Patient #11 off the unit for occupational therapy on 9/24/14 . Staff A said the patient arrived to the occupational therapy kitchen around 12:10 PM accompanied by Staff F, a PNA. They cooked a meal, ate the meal, and left the kitchen shortly after 1:00 PM. Staff A said when they left the elevator on 1 JPW they headed towards the unit. Staff A said she did not recall where Patient #11 was while they headed to the unit, she just recalled that as they approached the door to the unit she could see the dietary cart and 2 dietary aides leaving the unit. She opened the door allowing them to pass and by the time she turned around Patient #11 was gone. Staff A escorted the remaining patients to their appropriate areas on the unit and then went to go to look for the patient. Staff A acknowledged there was "miscommunication" on the nursing unit that day and Staff F should not have brought Patient #11 to occupational therapy.

j. During an interview on 10/2/14 at 3:00 PM, Patient #12 confirmed bring present during the occupational therapist session on 9/24/14. Patient #12 said that after lunch, they got on the elevator with Staff A and when they arrived at the unit they turned around and Patient #11 was gone. When asked if the patient behaved any differently that day, Patient #12 said she was quieter than usual and it was the first time in weeks she wasn't obsessing about her bowels.

k. During an interview on 10/3/13 at 10:25 AM, Staff H, Director of Rehab Therapies acknowledged Staff A, the occupational therapist, failed to communicate changes with Patient #11 with Staff F at the time Staff F brought the patient to the occupational therapy meal preparation on that day. Staff A was aware that Patient #11 was not coming to occupational therapy that day and a meal had been ordered for the patient on the unit. Staff A did not question Staff F when the patient was brought to occupational therapy because she did not want to make the patient uncomfortable.

l. During a follow up interview on 10/7/14 at 8:35 AM, Staff C acknowledged Staff F failed to communicate changes in Patient #11's behavior to nursing staff on 9/24/14. Staff C said Staff F should have communicated the changes in behavior to Patient #11's nurse or should not have taken Patient #11 off the unit without authorization from the patient's primary nurse. Staff C said if Staff F had communicated with Patient #11's nurse, she would have been aware the patient was receiving a tray in the unit.

m. During a follow up interview on 10/7/14 at 10:00 AM, Staff D acknowledged Staff F failed to follow the hospital's standard of care by not communicating with Patient #11's primary care nurse on 9/24/14. Staff D said when Staff F arrived back to 1 JPW that day, she should have had a "hand off" of verbal communication on the status of all patients on the unit including Patient #11.
Staff D acknowledged Staff A failed to communicate changes in Patient #11's status when Staff F brought the patient to occupational therapy that day, essentially the breakdowns that occurred that day were Staff F failing to communicate with Staff B and Staff A failing to communicate with Staff F. Staff D said although the hospital lacked a policy specific to communicating changes in a patient's status, it would be a "best practice" for all nursing staff to communicate any and all changes not just verbally but documenting the information in the patient's medical record as well.

5. Review of "New Requirement involving taking Patients Off unit for activities or outings" dated 9/25/14 confirmed the hospital implemented education regarding screening patients for suicide and documenting the results in the patients medical record prior to patients leaving the unit.

Based on review of hospital policies/procedures, review of medical records, review of security video, and interview with staff, there was not a system in place to prevent a breakdown in communication to ensure patients received care in a safe environment on 9/21/14. The breakdown in communication occurred allowing Patient #11 to elope from the group including an occupational therapist and patients returning from an occupational therapy session outside of the locked psychiatric unit. The patient left the group as they waited for meal carts and dietary staff to exit the psychiatric unit prior to entering the locked unit. Patient #11 ran through the hospital, exited the hospital, went to the top of a parking ramp, and jumped off the ramp. The patient suffered significant life altering injuries as a result of the fall.


On 9/24/14, the patient was upset after learning about a pending discharge due to a lack of progress. The patient's occupational therapy was discontinued and a meal tray was ordered for the noon meal. A psychiatric nurse assistant took the patient out of the locked psychiatric unit to the occupational therapy kitchen area. The psychiatric nurse assistant was aware the patient was upset at the time but did not check with the patient's primary nurse or any other staff before leaving the locked psychiatric unit with the patient. The psychiatric nurse assistant was not assigned to Patient #11 on 9/24/14 and earlier in the shift she had worked in another unit at the hospital. The occupational therapist was aware that the patient had been discharged from the occupational therapy but allowed the patient to stay. When the occupational therapist escorted the patients back to the locked unit, Patient #11 eloped from the group. Refer to A 144.

Based on review of hospital policies/procedures, job descriptions, medical records, personnel records, video footage, and staff interview, the psychiatric and occupational therapy staff failed to communicate changes in nutritional therapy services and symptoms of emotional distress for 1 (of 1) eating disorder patient in the locked psychiatric unit (Patient #11). The failure of staff to communicate with each other allowed the patient to leave the unit with a psychiatric nurse assistant to attend a meal preparation therapy session outside the unit after the therapy had been discontinued. When returning to the group, the patient eloped and attempted suicide by jumping from the fifth floor of a hospital parking ramp. The Director of Psychiatric Services identified an average daily census of approximately 5 eating disorder patients on 1 Papa-John West (1-JPW), the psychiatric unit. On 9/24/14, there were 22 inpatients in the psychiatric unit.

Failure of staff working with psychiatric patients in the psychiatric unit and ancillary service areas to communicate changes in Patient #11's level of emotional distress and changes in nutritional occupational therapy (OT) orders resulted in Patient #11's elopement and attempted suicide by jumping from the 5th floor of a hospital parking ramp to the ground below. The patient fell 50 feet and sustained multiple, significant, life-altering injuries.

Findings include:

1. Review of the the following hospital documents revealed the following information applicable to the complaint investigation.

a. The hospital policy titled "Patients' Rights and Responsibilities" last revised 4/12, revealed the following in part, ..."Regarding their personal needs, patients have the right to...receive care in a safe and secure environment."

b. Review of "Suicide Risk Screening" reviewed 6/12, revealed the following in part, ..."To provide evidence-based suicide risk screening for those patients admitted for the treatment of emotional or behavioral disorders, whether they report suicidal ideation or not...each patient...admitted for treatment of emotional or behavioral disorders will be screened for suicide at admission and at least daily throughout hospitalization using the suicide risk scale."


c. Review of "Patient Care Standards of Practice" revised 8/13, revealed the following in part, ..."Ongoing assessment of patient's nursing care needs will be documented on appropriate forms...patients having provider appointments that include a nursing component will have the following completed and documented by a staff member: ...suicide risk screening for patients being evaluated primarily for emotional or behavioral disorders."

d. Review of "Eating Disorder Protocol" dated 1/14, revealed the following in part, ..."Nutritional Rehabilitation...planning, purchasing, preparing meals in occupational therapy meal preparation group." This is a very important important part of the therapy for the patients with eating disorders.

e. Review of job description titled "Psychiatric Nursing Assistant" (PNA) revised 7/09, revealed the following in part, ..."Under close supervision, performs specific nursing tasks to assist and provide for the comfort, welfare, and monitoring of psychiatric hospital patients...Reports potential crisis situations to team members, monitors and reports the behavior patterns of individual patients...Knowledge, skills/abilities: ...ability to communicate effectively with others...ability to provide care with regard to patient condition."

f. Review of job description titled "Occupational Therapist" revised 11/12, revealed the following in part, ..."Evaluates, and treats patients with...behavioral dysfunctions, disorders...provides...patient care...and treatment appropriate for patients with complex needs...maintains effective working relationships with...staff members."

2. Review of video footage captured on the hospital's security cameras throughout the hospital shows the elopement of Patient #11 from the area just outside the door of the locked psychiatric unit, 1 JPW, and her travel through the hospital to the parking ramp. The patient was with two other patients and the occupational therapist returning to the unit after the occupational therapy session.

a. At 1:11 PM, Patient #11 exited the elevator with Staff A, the occupational therapist, Patient #12 and two other patients. The group traveled down the hallway approximately 30 feet to the door of the 1 JPW unit. Staff A opened the door to the unit to allow a dietary cart and 2 dietary staff to exit through the door to the hallway, Patient #12 and another patient were standing next to Staff A. When Staff A turned around, Patient #11 was no longer standing with the group.

b. The cameras captured Patient #11 running down the hallway in the opposite direction of the 1 JPW unit towards the doorway to exit the hospital. At 1:13 PM, Patient #11 exited the hospital and ran across an intersection, towards parking ramp 4. At 1:14 PM, Staff A exited the hospital through the same doors the patient used earlier while looking for the patient.

c. At 1:15 PM, Patient #11 jumped from the 5th floor of parking ramp 4. The total time from the time the patient eloped from the hallway to the time she ran approximately 125 yards and jumped from the parking ramp was only 4 minutes and 12 seconds.

d. Two hospital nurses were outside and saw the patient on the ground. They started resuscitation and notified the Emergency Department. An ambulance arrived at site and the patient was moved to the hospital's emergency room within 8 minutes of the fall.

3. Review of Patient #11's medical record entries for 9/24/14 revealed the following information.

a. The patient transferred from a medical admission for gastrointestinal complaints to 1 JPW for psychiatric treatment for an eating disorder on 8/13/14. The patient was admitted to the unit voluntarily. The patient's health history included diagnoses of depression, delusional disorder, failure to thrive, mood disorder, obsessive compulsive disorder, and a somatic disorder. There were 2 previous suicide attempts by overdose. The last suicide attempt occurred approximately 3 years ago. The patient was evaluated as low risk for suicide attempt during the hospital stay.

b. Review of Patient#11's "Discharge Summary" dated 9/24/14 at 10:44 AM completed by Practitioner A, the psychiatrist, for Patient #11 revealed the following in part, ..."Patient was admitted on eating disorder protocol. We started her diet lower than usual...diet was gradually advanced...patient remained extremely fixated on gastrointestinal complaints...admit weight 105.4 pounds...discharge weight 116.6 pounds...her beliefs and preoccupations with underlying gastrointestinal issues, possibly secondary to history of laxative abuse...beliefs were borderline delusional at times and she remained extremely anxious."

c. Review of documentation by Practitioner A, "Attending Staff Comments", dated 9/24/14, for Patient #11 revealed the following in part, ..."On the morning of 9/24/14, I spoke with the patient over the course of three separate occasions...I explained that if she was not willing to follow recommendations regarding management of constipation we could not justify keeping her in our eating disorder program...we would discharge her tomorrow evening...I also explained that if she needed an additional day to work out discharge plans, we could keep her until 9/26/14...about 45 minutes after this conversation, she requested to talk with the treatment team a second time. We basically went through the same issues. She then said, "so what you are saying is that you are kicking me out not matter what." I explained that we would only discharge her if she was not able to cooperate with recommendations. The patient approached me a third time during the late morning while carrying a cordless phone with her husband on the line...she told him that we were kicking her out of the program...her husband encouraged her to cooperate and her husband said he would not come until the scheduled family meeting next week. He added that if she left the hospital sooner than that, she would be on her own...The patient participated in three group therapy sessions per day." Patient #11 attended occupational therapy meal preparation sessions three times a day. This was an integral part of the eating disorder protocol.

d. Review of the occupational therapy treatment plan notes written by the Staff A, an Occupational Therapist, dated 9/24/14, revealed the following in part, ...patient was initially not brought to the group session with peers but was brought up later by unit staff...patient was quietly social during meal...on the return trip to the unit, the patient eloped from the group."

e. Review of the "Ineffective coping" care plan by documentation by Staff B, Registered Nurse (RN), on 9/24/14, revealed the following in part, ..."Patient...informed this nurse she was no longer on eating disorder protocol...she spent most of the morning on the phone...she demanded to see the doctors at 10:30 because they needed to figure out if she was discharging today or tomorrow...This nurse told the occupational therapist that the patient did not have to go to the cooking activity. Dietary was paged and then called to get a tray. After the tray arrived this nurse was informed the patient was taken to cooking activity. Around 1315 (1:15 PM) the call about the elopement was received."

4. During general interviews on the behavior health nursing units nursing staff reported the following information.

a. On 10/1/14 at 9:50 AM, Staff I, a PNA (Psychiatric Nurse Assistant) said the hospital educated nursing staff to monitor patients on the behavioral health units and report any changes in mood or behaviors to the RN. Staff I said this was imperative so the nurse can assess the patient to determine if the patient's needs were being met.

b. On 10/7/14 at 7:45 AM, Staff K, a PNA, reported among the roles and responsibilities PNAs have is serving as advocates for the patients. It is essential that PNAs work closely with their peers and the nurses. Staff K said the PNAs received education at orientation and annually (Crisis Prevention Intervention training) for monitoring for changes in behavior. If the patient was upset, frustrated, or angry, then the PNA observes the patient, insures they are safe, and notifies the RN so the nurse can assess the patient.

c. On 10/7/14 at 7:55 AM, Staff J, PNA reported that during orientation, PNAs are educated to report any changes in patients' mood or behaviors to the primary care nurse. Staff J said this was important because the nurse could assess the patient to determine if the patient may need medication to calm down.

d. During an interview on 10/1/14 at 12:20 PM, Staff C, RN and Nurse Manager of 1 JPW, said patients with mood disorders generally suffer from increased mood changes, predominately sleep less, and make decisions impulsively without thinking of the consequences.
Staff C said patients suffering from obsessive compulsive personality traits prefer routine patient-oriented care. Staff on 1 JPW would be trained to recognize patients with this type of disorder prefer certain routines and they would try to accommodate this. Staff C said patients with somatic disorders are obsessed that they have physical disorders or suffer from a significant illness despite medical evidence that nothing is wrong. Patients with a delusional disorder have a fixed, false belief in spite of strong evidence to the contrary.

Staff C said the only thing out of the ordinary for Patient #11 on 9/24/14 was that the patient's psychiatrist, Practitioner A, spoke with Patient #11 that morning regarding discharge related to the patient's lack of progress with the eating disorder program and non-compliance with physician orders to treat gastrointestinal symptoms. Staff C said Patient #11 was frustrated and upset with the staff, with the physician, and with her husband.

During a follow up interview on 10/7/14 at 10:40 AM, Staff C acknowledged that Staff F, a PNA, failed to communicate the change in Patient #11's mood and behavior to Staff E, the RN assigned to Patient #11 on 9/24/14, prior to taking the patient off the unit to occupational therapy. Staff C said the fact the patient was upset after the phone conversations earlier that day would have indicated there may have been a change in the Patient #11's mood and behavior. This information warranted notification to the primary nurse to ascertain if an assessment was necessary. Staff C said that they started to educate all staff to communicate with the primary nursing staff regarding the status of patients prior to leaving the behavioral health units for off-unit activities.

e. During an interview on 10/2/14 at 9:35 AM, Staff E, RN, verified she was Patient #11's primary nurse on 9/24/14. Staff E said the patient approached her at approximately 10:30 AM that day and told her that Practitioner A, the psychiatrist, had discharged her from the occupational therapy program. Staff E informed Staff A, the occupational therapist, when she arrived to the unit at approximately 11:30 AM that the patient did not need to go to occupational therapy. A lunch tray had been ordered and the patient should not be taken off the unit.
Staff E, reported she assessed Patient #11 on 9/24/14 at between 9:00 - 9:30 AM for suicide risk and the score was 4 (low risk). Staff E said the protocol for documenting assessments in the patients medical record on their unit was generally before 11:00 AM. Staff E said it was important to document the assessment findings in a timely manner so doctors, nurses, and other professional staff may access and review all information to accommodate patient needs and implement precautions if necessary. Staff E acknowledged she failed to document the suicide risk score on 9/24/14 until 3:53 PM.

Staff E said Staff F, a PNA who was not assigned to care for Patient #11 on 9/24/14, took Patient #11 to occupational therapy at approximately 11:45 AM. Staff F did not check with her prior to leaving the unit with the patient. Staff E said standard procedure on 1 JPW was the PNA staff communicated with nursing staff about a patient's status if they are going to leave the unit with the patient. Staff E said the lunch tray for Patient #11 arrived at the unit but by that time the patient had been taken off the unit by Staff F. Shortly thereafter she heard Patient #11 had eloped from the hospital and jumped from the fifth level of the parking ramp.

f. During an interview on 10/2/14 at 10:10 AM, Staff F acknowledged she was scheduled to work on 1 JPW on 9/24/14 but shortly after clocking in at approximately 6:30 AM, she was paged to go work in another unit. Staff F confirmed she was not assigned to care for Patient #11 on that day and was not aware of changes in the patient's occupational therapy or impending discharge orders. Staff F said she came back to 1 JPW at approximately 11:30 AM. She immediately started completing 15 minute checks on all patients. Staff F said Patient #11 was in her room talking on the cordless phone and was visibly upset, tearful, angry, the patient's tone of voice vacillated, and the patient appeared frustrated. At the end of the call, Patient #11 requested that Staff F take her to occupational therapy. Staff F agreed because this was the normal routine for Patient #11. Patient #11 had been on the unit for 42 days and had gone to occupational therapy sessions. Staff F said she escorted the patient to the occupational therapy unit. Staff F was not assigned to care for Patient #11 on 9/24/14 and was unaware of the events earlier that morning.

Staff F confirmed she did not communicate the patient's symptoms of emotional distress she described to the patient's primary nurse, she did not ask the nurse if there were any changes in occupational therapy, she did not review the patient's medical record to see if there were any changes in the patient's status or treatments, and she was unaware of the patient's proposed discharge.

During a follow up interview on 10/7/14 at 8:05 AM, Staff F admitted if she had been aware of these changes she would not have taken Patient #11 off the unit. Staff F said she needed to make certain she received a thorough report from the patient's nurse before providing care and services especially if she was not familiar with changes that had occurred during the time she was working in another unit.

g. During an interview on 10/2/14 at 10:55 AM, Staff G, a Licensed Master Social Worker, said on 9/24/14 in the AM, the interdisciplinary team spoke with Patient #11 about discharge and the patient expressed concerns that her husband would not take her back yet. Staff G said the patient had been in the hospital approximately 42 days at that point and the team determined that the patient was not progressing in therapies and treatment and was non-compliant with the treatment modalities.

h. During an interview on 10/2/14 at 12:55 PM, Practitioner A, Psychiatrist, explained he treated Patient #11 for the following conditions including but not limited to a dysphoric mood. Practitioner A defined dysphoric mood as negative emotions that may include anxiety and depression. The patient had an atypical eating disorder and Practitioner defined as refusal to ingest normal food resulting in weight loss. The patient had made progress towards resolution of this eating disorder. The patient also had a somatic disorder and had problems with dealing with stress. Practitioner A said Patient #11 was obsessed with different bodily processes such as her bowels and kidneys despite the fact that both medical and psychiatric physicians had provided her with critical information and reassurance that there were no clinical reasons or problems detected on a multitude of laboratory and radiological tests.

Practitioner A said on 9/24/14 after discussing possible discharge from the hospital and discharge from occupational therapy, [Patient #11] disagreed with him about the impending discharge. The patient appeared anxious and depressed but he did not feel this attributed to the patient's elopement. He did not feel that there was anything they could have done to predict the event.

i. During an interview on 10/2/14 at 2:00 PM, Staff A, an occupational therapist said she had been working with Patient #11 since admission to 1 JPW. Staff A said she did not take Patient #11 off the unit for occupational therapy on 9/24/14 . Staff A said the patient arrived to the occupational therapy kitchen around 12:10 PM accompanied by Staff F, a PNA. They cooked a meal, ate the meal, and left the kitchen shortly after 1:00 PM. Staff A said when they left the elevator on 1 JPW they headed towards the unit. Staff A said she did not recall where Patient #11 was while they headed to the unit, she just recalled that as they approached the door to the unit she could see the dietary cart and 2 dietary aides leaving the unit. She opened the door allowing them to pass and by the time she turned around Patient #11 was gone. Staff A escorted the remaining patients to their appropriate areas on the unit and then went to go to look for the patient. Staff A acknowledged there was "miscommunication" on the nursing unit that day and Staff F should not have brought Patient #11 to occupational therapy.

j. During an interview on 10/2/14 at 3:00 PM, Patient #12 confirmed bring present during the occupational therapist session on 9/24/14. Patient #12 said that after lunch, they got on the elevator with Staff A and when they arrived at the unit they turned around and Patient #11 was gone. When asked if the patient behaved any differently that day, Patient #12 said she was quieter than usual and it was the first time in weeks she wasn't obsessing about her bowels.

k. During an interview on 10/3/13 at 10:25 AM, Staff H, Director of Rehab Therapies acknowledged Staff A, the occupational therapist, failed to communicate changes with Patient #11 with Staff F at the time Staff F brought the patient to the occupational therapy meal preparation on that day. Staff A was aware that Patient #11 was not coming to occupational therapy that day and a meal had been ordered for the patient on the unit. Staff A did not question Staff F when the patient was brought to occupational therapy because she did not want to make the patient uncomfortable.

l. During a follow up interview on 10/7/14 at 8:35 AM, Staff C acknowledged Staff F failed to communicate changes in Patient #11's behavior to nursing staff on 9/24/14. Staff C said Staff F should have communicated the changes in behavior to Patient #11's nurse or should not have taken Patient #11 off the unit without authorization from the patient's primary nurse. Staff C said if Staff F had communicated with Patient #11's nurse, she would have been aware the patient was receiving a tray in the unit.

m. During a follow up interview on 10/7/14 at 10:00 AM, Staff D acknowledged Staff F failed to follow the hospital's standard of care by not communicating with Patient #11's primary care nurse on 9/24/14. Staff D said when Staff F arrived back to 1 JPW that day, she should have had a "hand off" of verbal communication on the status of all patients on the unit including Patient #11.
Staff D acknowledged Staff A failed to communicate changes in Patient #11's status when Staff F brought the patient to occupational therapy that day, essentially the breakdowns that occurred that day were Staff F failing to communicate with Staff B and Staff A failing to communicate with Staff F. Staff D said although the hospital lacked a policy specific to communicating changes in a patient's status, it would be a "best practice" for all nursing staff to communicate any and all changes not just verbally but documenting the information in the patient's medical record as well.

5. Review of "New Requirement involving taking Patients Off unit for activities or outings" dated 9/25/14 confirmed the hospital implemented education regarding screening patients for suicide and documenting the results in the patients medical record prior to patients leaving the unit.