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Based on review of documents, review of the medical record for patient #7 and staff interviews it was revealed the facility failed to ensure care was rendered in a safe setting (see tag 144).

Based on document review, staff interview and review of video surveillance it was determined care was not provided in a safe setting due to an inpatient door that is to remain locked for patient safety was unlocked and patient #7 was able to get out of the door and into a hallway. The lock on the door remained unattended and was not fixed for twenty-nine (29) hours in one (1) of one (1) doors used for elopement. This failure has the potential for all patients to elope and cause harm to themselves or others.

Findings include:

1. A review of the policy titled "Work Order Policy, effective date: July 2009, stated in part: "I. Maintenance Priorities 1. Priority 1: Objective - Make safe and minimize damage, Serious safety hazard/incident, ... Priority 1 Response Time: Within 1 hour (during normal working hours), Within 2 hours (after hours)."

2. A telephone interview was conducted with the Information Systems Specialist 1 on 1/27/21 at 11:06 a.m. regarding video of patient #7's elopement off unit N2. He stated maintenance first assessed the door on 12/29/20 at 10:47 a.m. When asked if any staff stayed at the door until maintenance checked the door, he stated the video does not show any staff at the door after the patient elopement. He stated the video showed a staff member entering the unit on 12/28/20 and patient #7 was about twenty (20) feet in front of her. The staff member had her left hand on the unit door, being extra careful not to slam shut the door and awake patients at 5:20 a.m. He stated the doors have an auto close and auto lock mechanism, and if you don't allow it to shut properly it will not always lock. He stated the doors will make a clicking sound but will not latch. He stated the video shows patient #7 going over to the door after the staff left, puts his hand on the door latch and the door opens. He stated the video shows the patient pushing on N1 door, but he could not get in once he had exited N2. He stated the video shows maintenance fixing the door on 12/29/20 about one (1) to one and a half hours (1-1/2) after they initially assessed the door. He stated the video showed the nursing staff checking the door as part of their ten (10) minute hall walks safety checks. They grabbed the handle and pushed on it and the door did not open.

3. A telephone interview was conducted with the head of maintenance on 1/27/21 at 11:43 a.m. When asked when maintenance was notified patient #7 was able to elope from N2, he stated they were notified on 12/29/20. He stated they went immediately to assess the door. He stated the latch wasn't going into the strike blade, causing the latch to intermittently not work properly. He stated they had to adjust the latch.

4. A telephone interview was conducted with the Chief Nursing Officer on 1/27/21 at 1:40 p.m. When asked what her expectations are for the nursing staff when they potentially have a problem with maintenance issues, she stated it is the responsibility for the nursing staff to contact the house supervisor and they are to contact maintenance. She stated she reviewed the video and the staff checked the door every ten (10) minutes on hall walks and they could not recreate the door opening, She stated the patient tried to open the door again and could not get it to open. When informed, maintenance stated the latch was not going into the strike blade intermittently and had to be adjusted. She stated it is her interpretation the door was not locked because the staff did not shut it properly when they came on the unit. She stated maintenance was notified as a precaution and did not feel it was a problem with the lock.

Based on review of documents, review of the medical record for patient #7 and staff interviews it was revealed the facility failed to ensure nursing care services was provided as per hospital policy and procedures (see Tag 398).

Based on document review, staff interview and review of video surveillance it was determined care was not provided in a safe setting due to an inpatient door that is to remain locked for patient safety was unlocked and patient #7 was able to get out of the door and into a hallway. The lock on the door remained unattended and was not fixed for twenty-nine (29) hours in one (1) of one (1) doors used for elopement. This failure has the potential for all patients to elope and cause harm to themselves or others.

Findings include:

1. A review of the policy titled "Work Order Policy, effective date: July 2009, stated in part: "I. Maintenance Priorities 1. Priority 1: Objective - Make safe and minimize damage, Serious safety hazard/incident, ... Priority 1 Response Time: Within 1 hour (during normal working hours), Within 2 hours (after hours)."

2. A telephone interview was conducted with the Information Systems Specialist 1 on 1/27/21 at 11:06 a.m. regarding video of patient #7's elopement off unit N2. He stated maintenance first assessed the door on 12/29/20 at 10:47 a.m. When asked if any staff stayed at the door until maintenance checked the door, he stated the video does not show any staff at the door after the patient elopement. He stated the video showed a staff member entering the unit on 12/28/20 and patient #7 was about twenty (20) feet in front of her. The staff member had her left hand on the unit door, being extra careful not to slam shut the door and awake patients at 5:20 a.m. He stated the doors have an auto close and auto lock mechanism, and if you don't allow it to shut properly it will not always lock. He stated the doors will make a clicking sound but will not latch. He stated the video shows patient #7 going over to the door after the staff left, puts his hand on the door latch and the door opens. He stated the video shows the patient pushing on N1 door, but he could not get in once he had exited N2. He stated the video shows maintenance fixing the door on 12/29/20 about one (1) to one and a half hours (1-1/2) after they initially assessed the door. He stated the video showed the nursing staff checking the door as part of their ten (10) minute hall walks safety checks. They grabbed the handle and pushed on it and the door did not open.

3. A telephone interview was conducted with the head of maintenance on 1/27/21 at 11:43 a.m. When asked when maintenance was notified patient #7 was able to elope from N2, he stated they were notified on 12/29/20. He stated they went immediately to assess the door. He stated the latch wasn't going into the strike blade, causing the latch to intermittently not work properly. He stated they had to adjust the latch.

4. A telephone interview was conducted with the Chief Nursing Officer on 1/27/21 at 1:40 p.m. When asked what her expectations are for the nursing staff when they potentially have a problem with maintenance issues, she stated it is the responsibility for the nursing staff to contact the house supervisor and they are to contact maintenance. She stated she reviewed the video and the staff checked the door every ten (10) minutes on hall walks and they could not recreate the door opening, She stated the patient tried to open the door again and could not get it to open. When informed, maintenance stated the latch was not going into the strike blade intermittently and had to be adjusted. She stated it is her interpretation the door was not locked because the staff did not shut it properly when they came on the unit. She stated maintenance was notified as a precaution and did not feel it was a problem with the lock.

Based on document review and staff interview it was revealed the facility failed to ensure the safety of the patients. (see Tag 701).

Based on document review, staff interview and review of video surveillance it was determined an inpatient door that is to remain locked for patient safety was unlocked and patient #7 was able to get out of the door and into a hallway. The lock on the door remained unattended and was not fixed for twenty-nine (29) hours in one (1) of one (1) doors used for elopement. This failure has the potential for all patients to elope and cause harm to themselves or others.

Findings include:

1. A review of the policy titled "Work Order Policy, effective date: July 2009, stated in part: "I. Maintenance Priorities 1. Priority 1: Objective - Make safe and minimize damage, Serious safety hazard/incident, ... Priority 1 Response Time: Within 1 hour (during normal working hours), Within 2 hours (after hours)."

2. A telephone interview was conducted with the Information Systems Specialist 1 on 1/27/21 at 11:06 a.m. regarding video of patient #7's elopement off unit N2. He stated maintenance first assessed the door on 12/29/20 at 10:47 a.m. When asked if any staff stayed at the door until maintenance checked the door, he stated the video does not show any staff at the door after the patient elopement. He stated the video showed a staff member entering the unit on 12/28/20 and patient #7 was about twenty (20) feet in front of her. The staff member had her left hand on the unit door, being extra careful not to slam shut the door and awake patients at 5:20 a.m. He stated the doors have an auto close and auto lock mechanism, and if you don't allow it to shut properly it will not always lock. He stated the doors will make a clicking sound but will not latch. He stated the video shows patient #7 going over to the door after the staff left, puts his hand on the door latch and the door opens. He stated the video shows the patient pushing on N1 door, but he could not get in once he had exited N2. He stated the video shows maintenance fixing the door on 12/29/20 about one (1) to one and a half hours (1-1/2) after they initially assessed the door. He stated the video showed the nursing staff checking the door as part of their ten (10) minute hall walks safety checks. They grabbed the handle and pushed on it and the door did not open.

3. A telephone interview was conducted with the head of maintenance on 1/27/21 at 11:43 a.m. When asked when maintenance was notified patient #7 was able to elope from N2, he stated they were notified on 12/29/20. He stated they went immediately to assess the door. He stated the latch wasn't going into the strike blade, causing the latch to intermittently not work properly. He stated they had to adjust the latch.

4. A telephone interview was conducted with the Chief Nursing Officer on 1/27/21 at 1:40 p.m. When asked what her expectations are for the nursing staff when they potentially have a problem with maintenance issues, she stated it is the responsibility for the nursing staff to contact the house supervisor and they are to contact maintenance. She stated she reviewed the video and the staff checked the door every ten (10) minutes on hall walks and they could not recreate the door opening, She stated the patient tried to open the door again and could not get it to open. When informed, maintenance stated the latch was not going into the strike blade intermittently and had to be adjusted. She stated it is her interpretation the door was not locked because the staff did not shut it properly when they came on the unit. She stated maintenance was notified as a precaution and did not feel it was a problem with the lock.