HospitalInspections.org

Based on interview and document review, the hospital failed to protect patient rights when a patient was not adequately supervised and the hospital was found not in substantial compliance with the Condition of Patient Rights at 42 CFR 482.13.

The hospital failed to protect and promote each patient's right to care in a safe setting for 1 of 10 patients (P1) when staff failed to adequately supervise P1 in the courtyard. P1 climbed the coutyard fence, eloped from the hospital and took an overdose of Benadryl.

This deficient practice had the potential to impact all patients receiving services at the hospital.

Based on interview and document review the hospital failed to protect and promote each patient's right to care in a safe setting for 1 of 10 patients reviewed (P1) when staff failed to adequately supervise P1 in the courtyard. P1 climbed the courtyard fence, eloped from the hospital and took an overdose of Benadryl.

Findings include:

Medical record review revealed that P1 was admitted to the hospital under court ordered mental health commitment.

P1's psychiatric assessment dated 9/13/2017 revealed P1's diagnoses included Bipolar Disorder and Substance Use Disorder. P1 had a history of suicide attempts and elopement from hospitals.

The document titled Progress notes, dated 9/13/2017 revealed P1 was placed on frequent observations (every 15 minute checks by staff) due to her history of self injurious behaviors and high risk behavior.

The document titled Progress notes, dated 9/13/2017 at 4:49 p.m. and titled Risk of Elopement revealed P1 was observed by staff to be in the courtyard, standing on a chair with books piled on it in an attempt to elope by climbing over the fence. Staff intervened and brought P1 back into the building.

The document titled Progress notes, dated 9/13/2017 at 5:25 p.m. and titled Attempt Elopement revealed P1 was observed by staff to go into the courtyard with 2 chairs, stacked on top of one another, stand on the chairs and reach up to the top of the fence. Staff intervened and brought P1 back into the building.

The document titled Progress notes, dated 9/17/2017 at 5:57 a.m. and titled Frequent Observations revealed P1 was noted by staff to be closely watching the doors as staff entered and exited the unit, and then went into the courtyard and attempted to look around the side of the building to see the road.

The document titled progress notes, dated 9/18/2017 at 4:16 p.m. and titled Therapeutic Precautions revealed P1 attempted to bring a chair and boxes out to the courtyard.

The document titled Progress Note, dated 9/21/2017 and written by P1's physician, MD-D indicated despite P1 being on frequent observations for elopement risk, on 9/19/2017 P1 was able to climb the fence in the courtyard with the help of another patient at about 7:30 p.m. and elope form the building unobserved. P1 acquired 100 Benadryl 25 mg. pills at a local store and she took 64 of the 100 pills in the bottle in an effort to get high. P1 was returned to the hospital when local law enforcement picked her up and brought her back. When staff assessed P1 she was found to be tachycardic with a pulse of 160. Hospital staff transferred P1 to a local acute care hospital where P1 was treated for the overdose.

During an interview on 9/25/2017 at 10:50 a.m., Human Services Technician (HST)-H stated on 9/19/2017 she was assigned to do rounds on all patients according to their care plans. P1's care plan included every 15 minute checks during rounds (frequent observations.) At 7:40 p.m. she observed P1 on the unit. At about 7:50 p.m. the nurse passing medications asked HST-H where P1 was. HST-H was unable to find P1 anywhere on the unit. At about 7:53 p.m. she reported to Registered Nurse (RN)-B that she could not locate P1 on the unit. The hospital had no policy related to patient supervision when patients were in the courtyard. The courtyard was unlocked at all times and patients could come and go outside into the fenced courtyard at will.

During an interview on 9/22/2017 at 12:10 p.m. Registered Nurse (RN)-B stated on 9/19/2017 at 7:53 p.m. he received a call from P1's family member stating P1 was not at the hospital, but was at a local gas station. When he asked HST-H where P1 was, HST-H told him she was looking for P1 right now. P1 was on frequent observations and her next check-in was due at 7:55 p.m. RN-B stated staff looked throughout the hospital and called 911 when P1 could not be located. Between 8:30 and 8:45 p.m. an officer from the local police department brought P1 back to the hospital. When P1 came back, law enforcement gave staff a bottle of Benadryl that P1 had when law enforcement found her. The bottle originally had 100 pills in it. Staff counted the pills and 64 of the pills were missing. Staff asked P1 if she took the pills and she admitted to taking 7 of them. Staff members checked P1's vital signs and her pulse was elevated. Staff members called P1's physician and P1 was sent to the local acute care hospital for a possible overdose. P1 was hospitalized in the local acute care for 2 days and was then readmitted back the facility.

During an interview on 9/22/2017 at 1:45 p.m. P1's physician (MD)-D stated P1 had a history of elopement and smuggling drugs through visitors before coming to this hospital. On 9/19/2017 P1 received assistance from a male peer to lift her onto his shoulders and scale the fence in the courtyard. No staff members were in the courtyard at the time. Due to P1's history of elopement, she was on frequent observations and should not have been in the courtyard without staff in the courtyard with her. The number of Benadryl P1 took could have been toxic without medical intervention. P1's hospital course included tachycardia and confusion. She was in ICU for one day, and then on the mental health unit at the acute care hospital for one day before she was transferred back the the facility. Since this incident P1 is on 1:1 staffing and no patient is allowed in the courtyard unless staff are present in the courtyard. P1 did not take the Benadryl as a suicide attempt, but took them for recreational purposes.

During an interview on 9/25/2017 at 11:15 a.m., P1 stated she climbed on someone's shoulders to climb the fence in the courtyard and eloped from the hospital. P1 stated she wanted to get Benadryl to get high. P1 stated she took about 70 of the Benadryl pills.

During an interview on 9/22/2017 at 11:00 a.m., RN-A stated the policy/practice prior to this incident was to leave the courtyard door unlocked and patients could go into and out of the courtyard at will. There was no policy that staff had to be present in the courtyard when patient's were there. Since this incident the hospital has initiated a new guideline that staff are to be present in the courtyard whenever patients are out there. The charge nurse will assign staff to that task. If no staff member is available, the door to the courtyard will be locked.

The policy titled Unauthorized Absences/Elopement: Prevention and Response, dated January 3, 2017 revealed under Procedures: 2. Plan: a. When the treatment team identifies an increased likelihood of elopement, the level of supervision will be immediately adjusted as necessary.