HospitalInspections.org

Based on review of an item covered by local media, review of facility policies, and staff interview, the facility staff failed to implement approved policies to prevent unauthorized leave by a civilly committed patient for 1 of 1 patients reviewed (Patient #1).

Staff failure to follow facility policy and procedures for patient escort activities and timely notification of facility and community authorities risked harm to the patient and community.

Findings included:

Review of a news release revealed that a patient at the mental health facility had "escaped" from the facility on 06/08/17. The article went on to disclose that the patient had a history of assault and an unspecified psychotic disorder; that he had been seen about 8 PM, and reported missing about 2 hours later at 10 PM.

Record review of the facility's policy titled, "Escorting Civilly Committed Patients," Policy No.: 1.87 dated 08/15 showed that staff who were assigned to escort patients were to remain in close proximity in order to adequately observe, supervise, and assist patients they were escorting by maintaining visual and communication contact at all times. In addition, staff escorting patients to outside yard areas were to do a roll call and patient count prior to entering and leaving the yard to ensure all patients who entered the yard were accounted for when the group left the yard. Also, staff were to check the grounds before and after the group entered the yard to ensure that fencing and locked gates were intact; and that the smoke shack was clear of patients or contraband. Staff were to notify security and the RN 3 if a safety hazard was discovered (for example, a missing patient).

A second facility policy titled, "Unauthorized Leave," Policy No.: 1.28 dated 05/16 showed that the first person to become aware of the unauthorized leave was to contact 911 immediately to inform law enforcement of the patient's history and current condition.

A third facility policy titled, "Patient Observations," Policy No.: 1.56 dated 05/17 showed that staff assigned to monitor patients were to give the "Patient Observation Record" of the specific patient to the next assigned staff person at the end of the assigned time period and assure the oncoming staff knew they were responsible for monitoring the patient. The RN was to review the "Patient Observation Record" at the end of the shift and evaluate the patient's behavior based on the documentation by assigned staff.

During an interview on 06/20/17 at 9:45 AM, Staff A, Quality Assurance Director, stated that facility review of the incident revealed that staff failed to follow facility procedure to sweep the yard after the group left, and failed to account for each patient in the group. She stated 15 patients went out with 6 staff members, but only 14 patients returned. Review of a facility security camera tape revealed Patient #1 had hidden in the yard's Smoke Shack when the group left the yard at approximately 7:48 PM. Observation of the fence and gate showed he had kicked a hinge off the locked gate of the first fence, then scaled an 8 foot fence in order to leave the facility grounds.

Review of Patient #1's record showed that, following the group's return from the yard, Staff B and Staff C documented they made 15 minute location observations of Patient #1 as required by Patient #1's treatment plan: Staff B documented observations at 8 PM, 8:15 PM, 8:30 PM and 8:45 PM. Staff B gave report to Staff C who documented the patient was observed in bed at 9 PM.

At 9:15 PM, supervising staff identified that Patient #1 was actually missing. Security was notified and searched the grounds for 1.5 hours. At 10 PM, staff notified 911 and Law Enforcement of the patient's unauthorized leave.

Failure of staff to sweep the yard following the group's exit, failure to survey the perimeter for condition of the fence and gates, and failure to perform a roll call and patient count could have prevented, and would have identified that Patient #1 was missing at about 8 PM.

Supervising staff failed to monitor the accuracy of staff actions related to facility procedures, and failed to monitor the accuracy of staff documentation related to Patient #1's Treatment Plan.