HospitalInspections.org

The hospital did not protect and promote each patient's rights as it failed to:

A. Ensure that each patient or his/her parents or guardians were allowed to actively participate in the patient's plan of care or treatment plan. Cross refer Patient Rights: Participation in Care Planning 482.13(b)(1).

B. Obtain a signed consent for psychoactive medication prior to the administration of such medication. Cross refer Patient Rights: Informed Consent 482.13(b)(2).

C. Ensure the right of each patient to be free from neglect as it failed to safeguard the safety of adolescent patients from elopement. Cross refer Patient Rights: Free from Abuse/harassment 482.13(c)(3).

D. Notify in a timely manner the parents of a 16-year-old female patient who had eloped. Cross refer Patient Rights: Free from Abuse/harassment 482.13(c)(3).

E. Place patients on the appropriate level of observation required after elopement according to hospital policy. Cross refer Patient Rights: Free from Abuse/harassment 482.13(c)(3).

Based on a review of facility documentation and staff interview, the facility failed to ensure that each patient or his/her parents or guardians were allowed to actively participate in the patient's plan of care or treatment plan for 1 of 4 patients (Patient #4).

Findings were:

Facility policy #PC-047 entitled Treatment Planning, last reviewed 8/2016, included the following:
"8.0 The patient (or guardian) shall be given the opportunity to have input in the development of the Treatment Plan. This shall be accomplished by the therapist meeting with the patient and/or family member to review the recommendations of the treatment team. The therapist shall be responsible for obtaining the signature of the patient or guardian to document acknowledgement of the Treatment Plan.
9.0 The overall responsibility for the Treatment Plan is assigned to the attending physician who must indicate approval by signature ..."

Review of the medical record of Patient #4, a 14-year-old male, revealed an Interdisciplinary Treatment Plan completed on 8/4/17. The plan included a section entitled "Patient/Family/Legal Representative Involvement." The section was blank. The patient was discharged in the care of his parents on 8/7/17.

These findings were confirmed in an interview with the hospital CEO and Director of Performance Improvement/Risk Management on the afternoon of 10/16/17 in the facility conference room.

Based on a review of facility documentation and staff interview, the facility failed to ensure informed patient consent as it failed to obtain a signed consent for psychoactive medication prior to the administration of such medication for 1 of 4 patients (Patient #1).

Findings were:

Facility policy #MM 002, entitled Informed Consent, Medication, last reviewed 8/16, included the following:
"PURPOSE
To establish a mechanism for obtaining and documenting education and informed consent for psychotropic medications ordered during hospitalization.
PROCEDURE
The requirement for informed consent applies to psychoactive medications, consent must be obtained for each individual medication, not by medication class.
Informed consent will be secured prior to the initial dose of medication except in an emergency situation.
It is the responsibility of the ordering practitioner to obtain the signed informed consent of the patient and/or legal representative ..."

A review of the medical record of Patient #1 revealed the 16-year-old patient was administered Abilify, an antipsychotic medication, on 8/12/17 at 9:00 p.m. The record included no consent for treatment with this psychoactive medication.

The above findings were confirmed in an interview with the CEO and Director of Performance Improvement/Risk Management on the afternoon of 10/16/17 in the facility conference room.

Based on a review of facility documentation, unit tour and staff interview, the facility failed to ensure the right of each patient to be free from neglect as it failed to safeguard 4 of 4 adolescent patients from elopement (Patients #1 and #3-5). In addition, the facility failed to notify in a timely manner the parents of a 16-year-old female patient who had eloped (Patient #1). Finally, two adolescent patients were not placed on the appropriate level of observation required after elopement (Patients #1 and #5) according to hospital policy.

Findings were:

Facility policy entitled Patient Rights, included the following:
"All patients have the following rights:
· You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity.
· You have the right to appropriate treatment in the least restrictive appropriate setting available. This is the setting that provides you with the highest likelihood for improvement and is not more restrictive of your physical or social liberties than is necessary for the most effective treatment and for protections against any dangers which you might pose to yourself or others.
· You have the right to be free from mistreatment, abuse, neglect, and exploitation."

Facility policy # PC-025, entitled Elopement, last reviewed 8/2016, included the following:
"PROCEDURE ...
5. Staff will notify the following of the patient's elopement
· Attending physician
· CEO/AOC (administrator on call)
· Director of Nursing/designee
· Police
· Family/Legal Representative ...
7. If patient is located and returned, staff shall: ...
· Place the patient on Line of Sight observation status and Elopement Precautions ..."

In an interview with Staff #4, Director of Performance Improvement/Risk Management, on the morning of 10/16/17 in the facility conference room, she was asked to supply a list of patients who had eloped from beginning August, 2017 through end September, 2017. She supplied a list of 4 patients - all patients on the Child & Adolescent Unit of the hospital. Two boys ages 14 and 15 eloped on 8/7/17 at approximately 8:53 p.m. (Patients #3-4). Two adolescent females eloped on 8/14/17 at approximately 9:55 p.m. (Patients #1 & #5). Staff #4 was asked about how the facility had addressed the problem to ensure other adolescents would have more difficulty eloping. She stated, "We've been researching the codes for the outside doors and looking at keying the outside doors ... We're also looking at separate badges for the entry that staff wouldn't wear on their bodies ... What happened here with the girls is that several patients created a diversion. They pulled the nurse's lanyard and got her badge and eloped ..." When asked when the facility would actually be deciding what to do, she stated, "The final decision will be this week at the Safety Committee meeting ... All the elopements were in August."

In an interview with Staff #2, hospital CEO, on the afternoon of 10/16/17 in the facility conference room, she was asked what the final decision had been regarding the best manner to address the elopements of 4 adolescents in August. She stated, "We're looking at the doors. We have one door that you can badge out of it. We want to be able to open it if there's a fire. There's also the possibility that we could have an actual key. Our corporate EoC (environment of care) Plant Ops Director was looking into that. We've been doing education - just saying to make sure to watch patients who are at risk of elopement. When they're around, a staff person's badge shouldn't be easily accessible ... We've spoken with the nurse who was working both those nights to ask her to safeguard her badge."

In a telephone interview with Staff #7, RN, Child & Adolescent Unit, at 11:23 a.m. on the morning of 11/17/17, she stated, "I was the nurse working on the nights when both those elopements occurred ...Patients were going off all over the place that night ..." When asked if she believed future elopements of adolescent patients could occur, Staff #7 stated, "Honestly, yes, I feel that it could happen again. There are two doors that have no keyed lock - doors on the children's hall and on the teenage girls' hall. They're telling me that they don't have doors that lock with keys because of something to do with fire codes. Other places I've worked have locking keys to any exterior doors that patients have access to ... If there are real keys, the patients have to fumble with the keys and there's usually time to get them back before they get out ..."

A tour of the Children & Adolescent Unit on the morning of 10/17/17 with Staff #4, Director of Performance Improvement/Risk Management, revealed two exterior doors on the unit. She identified the doors as opening with a staff badge.

Patient #1 was a 16-year-old female patient who eloped at approximately 9:55 p.m. on the evening of 8/13/17 with another adolescent female. A Nursing Progress Note on 8/13/17 at 3:00 a.m. included the following: "At 2155, pt & peers were standing in pt hall. This nurse went to ask pts to go to bed. Pt and younger peer (who was not supposed to be on teen hall) grabbed this nurse, held her and pulled off badge and eloped through rear hall exit door. All admin notified along [with] on-call physician. The police were called immediately [after] elopement. Pt & peer were returned by police to unit at 0010. Parents were notified. This pt's parents called the unit at 2320 to report pt had called them from a McDonald's. The police were immediately called back and girls were picked up and brought back ..."

The parents of Patient #1 were notified of the elopement of their 16-year-old daughter by their daughter calling them approximately one and one-half hours after her elopement. The hospital only notified the parents when their daughter was returned to the facility approximately 3 hours after the elopement.

Patient #1 eloped with another adolescent female, Patient #5, on the evening of 8/13/17. Patient #1 was discharged on 8/24/17. Patient #5 was discharged on 9/30/17. Neither patient was placed on Line of Sight monitoring after the elopement according to hospital policy.

The above findings were all confirmed in an interview with the CEO and Director of Performance Improvement/Risk Management in an interview on the afternoon of 10/16/17 in the facility conference room.