HospitalInspections.org

Based on medical record review, documentation review, observation, video review and staff interviews, the facility failed to ensure that guardians were notified in a timely manner that patients had eloped. The failure to follow facility policy affected two (2) out of ten (10) patients (patients 1 and 2) reviewed and has the potential to affect all patients receiving services.

Findings:


A medical record review was conducted on patient 1. Patient 1 was a voluntary admission to the facility on 7/15/25, for depression and substance abuse. The patient has an extensive history of substance abuse and impulsive behaviors. This is the patient's second admission for substance abuse, depression and self-harm. The last hospitalization was March 2025. Patient 1 has current pending legal issues and is on probation. Patient 1 was admitted to the two (2) west unit. While there the patient received daily group therapy, individual therapy, milieu therapy and medication management.

On 7/18/25, around 3:30 p.m., the patient, along with peers from the unit, left the gym to return to the unit. As staff was unlocking the gate coming from the courtyard, a peer fell to the ground and appeared to be suffering a seizure. While the staff were attending to the medical emergency, patient 1 and another peer (patient 2) ran to the side gate and climbed over the fence and eloped down the street.

A document titled "HEALTHCARE SAFETY ZONE, Live Event, Event Number: 78257", completed on 7/18/25, was reviewed. The report stated in part, " ...Brief Summary of Incident: Patient on their way back from the gym with staff. When staff opened gate to the yard, peer fell to the ground with what appeared to be a seizure. While staff was distracted, with the medical emergency, patient climbed the fence and eloped. Staff and CPD [Charleston Police Department] looking for patient" ...

A review of a document titled "Narrative Note", dated 7/18/25 at 3:30 p.m., completed by staff 5 states, "Patients on their way back from the gym with staff. When staff opened gate to the yard peer fell to the ground with what appeared to be a seizure. While staff was distracted, with the medical emergency, patient climbed the fence and eloped. Staff and CPD [Charleston Police Department] looking for patient".

A review of a document titled "Narrative Note", dated 7/18/25 at 3:30 p.m., completed by staff 5 states, "Father called an notified of patients elopement. Father requested to speak with nurse supervisor, call transferred to supervisor".

A review of a document titled "Narrative Note", dated 7/18/25 at 5:00 p.m., completed by staff 3 states, "This writer was notified by the Youth Services Nurse Manager that [patient 1] had eloped from the courtyard, and requested that this writer contact 911. This writer contacted 911 at 1545 [3:45 p.m.] and provided demographics and description of patient. Demographics and patient picture provided to the receptionist to provide to the police upon arrival".

A review of a document titled "Narrative Note", dated 7/18/25 at 8:33 p.m., completed by staff 4 states, "Spoke with [patient's] [guardian], [patient's family member], at length beginning at 7:32 PM regarding elopement. Answered all of [guardian's] questions, including police involvement and multiple staff searching for [patient]. Informed [him/her] of precipitating events. [Guardian] asked if the law enforcement can take [patient] directly to detention once located instead of returning to [facility]. Stated [patient] is on house arrest and elopement is a violation of his/her probation. Informed [him/her] that the police will need to make that decision and recommended that [he/she] speak with police directly with this request. Informed [guardian] that [he/she] will be contacted with any new updates. Informed [staff 3], [staff 13], [staff 14], [staff 7] and [staff 2]".

A review of a document titled "Narrative Note", dated 7/18/25 at 8:40 p.m., completed by staff 4 states, "Addendum: [Guardian] stated that [patient] may be headed toward [his/her] mother's home ... [Guardian] provided consent for staff to contact [mother] should it be necessary".

Review of a document titled "City of Charleston, West Virginia Police Department", was reviewed. The police report states, "Reported at 07/18/25 1645 [4:45 p.m.] ...Incident Code 7903: Juvenile Runaway ...Victim [Patient 1]".

A review of video from the exterrior entrance gate was completed on 8/4/25 at 1:15 p.m. The video shows that at 3:39:46 p.m., patient 1's knee is seen at the fence and patient 2 is in the middle section of the fence, starting to climb. Patient 1 comes into view at 3:39:52 p.m. and is still on the fence on the outside at 3:39:53 p.m. and on the ground by 3:39:56 p.m. Patient 1 takes off running down Noyes Avenue. Patient 2 is struggling at the top of the fence at 3:39:56 p.m. At 3:40:00 p.m., patient 2 is on the ground outside the fence and heads down Noyes Avenue.

A review of a document titled "Employee Corrective Action", dated 8/6/25, states, "It was determined during an elopement event that [staff 5] did not notify the guardian as per policy. During documentation review it was noted the time of the note did not match the time of the event. Response: [Staff 5] will be provided with policy of Elopement Protocol. [Staff 5] will receive training upon [his/her] return from the Nurse Educator"...

A tour and observation of the courtyard was completed on 8/4/25 at 1:30 p.m. Once you come out of the locked facility, you enter a locked fenced in area. There is a walkway that extends to the left and right of the building. This area is fenced in on both the left and right with an eight (8) foot fence and locked gates on each end. The one area to the right above the fence where the gate is located has been altered to make climbing over seemingly impossible. The gate to the left and on the side of Noyes Avenue on the southeast side of the hospital has not been altered. There is a chain link fence that has three (3) sections. There is the middle section with the gate and two (2) side panels. The fence goes up and tilts backward. There are ten clamps that are attached to the metal poles on each section which makes a small protruding offset to the fence line. The clamps protruding position could allow for someone to place a foot on it and secure their footing. The left side above the fence has an open space between the building and the fence. It was noted that there was a camera on the Noyes Avenue side of the hospital that does face the side gate where the patient could be seen climbing the fence.

An interview was conducted on 8/5/25 at 8:47 a.m. with staff 2. Staff 2 stated, "it is the expectation that the [guardian or legal representative] would be contacted immediately after you tend to the patients. I agree that three (3) hours later is concerning. We will be doing additional training on these matters. The fence is being addressed as well. We will be using a poly carbon plastic to cover the sections of the fence. It is durable and it has no sharp edges and would be impossible to climb. This will be completed in the near future, we have already contacted the company, and they will be coming out to measure in the next few days".

An interview was conducted on 8/5/25 at 10:30 a.m. with staff 4. Staff 4 stated, "A notification of elopement should be done immediately"...

An interview was conducted with staff 5 on 8/5/25 at 9:45 a.m. Staff 5 stated, "I was the charge nurse that day. The therapist had completed group therapy and was taking the kids to the gym around 2:30 p.m. I was at my desk with staff 14, when staff 14 said the kids were going over the fence. I got on the walkie talkie and announced that there was an issue. I told [staff 12]. [Staff 12] said [he/she] was going to call it in, but [he/she] didn't. I couldn't tell who the patients were that went over the fence until someone came up and told me. I didn't find out right away. I called the [guardian] at 6:30 p.m., yes, it was three (3) hours later. The [guardian] was returning a call about medications. I didn't think [he/she] knew but I wasn't sure. I wanted to verify it first, then I called back and told [him/her]. I don't remember the protocol elopement. I do know we do incident reports and notifications for every incident. I was not present at the incident; I only saw it on camera".

An interview was conducted with staff 13 on 8/6/25 at 10:45p.m. Staff 13 stated, "...Usually the charge nurse handles that. If it is a medical emergency, they deal with that first. But I would expect that [he/she] would call once all the details are gathered, usually within an hour"...