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Based on review of medical records (MR), staff interviews, and review of facility documents, it was determined that the facility failed to protect and prevent a developmentally delayed patient from eloping from the facility as evidenced by: 1). the monitoring of patients during outdoor therapy group is implemented, in accordance with facility policy (A0144); 2). notification to law enforcement upon confirmation of the elopement of a patient, in accordance with facility policy (A0144); and 3). risk assessments of all grounds, buildings, and outdoor activity areas that include the perimeter fence and greenhouse are conducted (A0144).

This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patients.

On December 31, 2024 at 12:00 PM, an IJ was identified for the facility's failure to ensure that staff monitor all patients within their line-of-sight during outdoor therapy group sessions; and report the elopement of an "at risk" patient to law enforcement.

On December 31, 2024, at 12:54 PM, the IJ Template was presented to the administration and a removal plan was requested. On January 2, 2025, at 1:57 PM, and acceptable removal plan was received. The facility implemented the following to address the IJ: the elopement policy was revised to ensure that physicians and other staff notify law enforcement for all elopements, regardless of the patient's legal status. Physicians received education regarding the revised policy and process changes. Rehabilitation Services Staff, Psychologists, and Social Work Services Staff (all who are responsible for monitoring outdoor activities) received education for patient observation and increased monitoring during outdoor groups.

The IJ was removed on January 2, 2025 at 2:10 PM, after the State Survey Agency verified the full implementation of the removal plan, and Condition Level non-compliance remains.

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1). the monitoring of patients during outdoor therapy group is implemented, in accordance with facility policy in one of 15 medical records reviewed (Patient (P) 1); 2). notification to law enforcement upon confirmation of the elopement of a patient, in accordance with facility policy in one of 15 medical records reviewed (P1); and 3). risk assessments of all grounds, buildings, and outdoor activity areas that include the perimeter fence and greenhouse are conducted.

Findings include:

1. Facility policy titled, "Elopement" (Revised 11/2023) states, " ... IV. Procedure: ... Remain with and observe patients escorted to/from social and/or recreational activities. ..."

Upon interview on 12/30/24 at 10:20 AM, Staff (S)2 (Administrator) stated that on 12/17/24 at approximately 1:30 PM, P1 eloped from the facility by scaling a chain-link fence that enclosed the backyard of the facility during an outdoor therapy group. S2 confirmed that the patient has not yet been found.

During an interview on 12/31/24 at 10:20 AM, S9 (Art Therapist) confirmed [he/she] was the group therapist that conducted the 1:00 PM outdoor walking group on 12/17/24 when P1 eloped. According to S9, P1 has attended outdoor therapy groups in the past and has been known to walk away from the group but always comes back. S9 further stated, "This time, (P1) walked to a corner of the fenced yard to a blind spot. I could not see [him/her.] When we walked to that area, the patient was gone. I think [name of patient] climbed the fence and eloped." When questioned what immediate measures were taken upon discovering that P1 eloped, S9 stated, "I notified my supervisor, and completed the incident report. The psychiatrist was notified right away." When questioned whether law enforcement was contacted at that time, S9 stated, "I don't know."

A review of P1's medical record revealed that the patient was involuntarily admitted to the facility on 4/23/24. P1 was diagnosed with schizophrenia, schizoaffective disorder, and developmental delay. The patient's legal status was changed from involuntary to CEPP (Conditional Extension Pending Placement) on 5/21/24. The patient was on "Level 3" status, which permits the patient to attend outdoor therapy group.

A progress note written by S22 (Registered Nurse [RN]) on 12/17/24 at 1:20 PM stated, "Pt (patient) eloped from outdoor group with rehab. [Name] Psychiatrist, [Name] Assistant Director of Nursing, and Security were notified." The progress note written by S9 on 12/17/24 at 1:56 PM stated, "Pt (patient) was in 'walk and Talk' group in outside recreation area. Pt was walking away from group, despite therapist's prompts. Pt disappeared-possibly climbing the fence or rolling under. Reported to Security and supervisor."

On 12/31/24, upon interview, S2 stated, "I don't know how the patient walked to a blind spot in the yard. The therapists have to keep an eye on the patients during groups."

2. Facility policy titled, "Elopement" (Revised 11/2023) states, " ... B. Elopement: ... The physician completes the "Patient Elopement Report" and determines if the patient is at risk or dangerous. If the patient is on a committed status or determined to be at risk or dangerous, the patient will be placed on Teletype (Teletype is the notification system used by law enforcement to share missing persons information from national and state precincts quickly) following approval by the Medical Director or designee; If Teletype is warranted, the physician notifies Security who will then notify the Sheriff's Department by faxing the Patient Elopement Report..."

Review of P1's medical record revealed that the patient was involuntarily admitted to the facility on 4/23/24. P1 was diagnosed with schizophrenia, schizoaffective disorder, and developmental delay. The patient's legal status was changed from "involuntary" to CEPP (Conditional Extension Pending Placement) on 5/21/24. The patient was on Level 3 status, which permits the patient to attend outdoor therapy group.

A Treatment Plan Update written on 12/4/24 at 9:45 AM, signed by S15 (Social Worker), stated, "... Problem 2: Discharge; Progress: Pt (patient) will need DDD (Division of Developmental Disabilities) group home; Team Recommendations: SW (social worker) to contact DDD. ... Active Problem: Discharge issues; Pt may ['may' was crossed off and 'will' was written in] will need DDD group home." P1 was awaiting DDD (Division of Development Disabilities) placement into a group home at the time [he/she] successfully eloped from the facility on 12/17/24.

Review of P1's medical record revealed that on 12/17/24 at approximately 1:20 PM, during an outdoor group therapy, P1 eloped from the facility by scaling a chain-link fence that encloses the back yard of the facility. There was no documentation in the medical record entered by the psychiatrist of the patient's elopement. A review of the incident report filed on 12/17/24 revealed, " ...Physician's Initial Assessment: Patient eloped. MD informed 1:34 PM." This entry was signed by S17 (Psychiatrist) on 12/17/24 at 1:52 PM.

During an interview conducted on 12/31/24 at 11:50 AM, with S18 (Sheriff Officer, Supervisor), [he/she] confirmed that the Sheriff's Office was notified of P1's elopement on 12/18/24 at 9:30 AM, 20 hours after the patient eloped from the facility. S18 confirmed that the "Patient Elopement Report" was not received from the facility until 12/18/24 at 9:30 AM. S18 stated that after the Sheriff's Office was notified, law enforcement was dispatched, and officers initiated a missing person search of the area and its surroundings immediately. S18 confirmed that a state-wide and nation-wide Teletype (notification used to share missing persons information from national and state law enforcement precincts quickly) was generated on 12/18/24 upon notification to law enforcement of the patient's elopement.

S18 confirmed that P1 was considered an "at risk" person due to developmental delay and cognitive restrictions. When questioned if the facility's delay in reporting impacted law enforcement's chance of locating the patient, S18 stated, "I don't want to say that, but everyone knows the sooner, the better. We would have flooded the area immediately as soon as we got the notification."

A review of the facility's security log, maintained by security officers, lacked documented evidence concerning P1's elopement on 12/17/24. Upon request, S18 was unable to provide the completed "Patient Elopement Report" for P1 from 12/17/24 after multiple requests on 12/30/24 (at 10:45 AM and 2:00 PM), and 12/31/24 (at 9:45 AM and 11:55 AM). An interview with S18 on 12/31/24 confirmed the document was not submitted to the Sheriff's Office.

3. Facility document titled, "Safety Management Plan" (no date) stated, "... Vision Statement: ... Maintaining and supervising all grounds and equipment, including special activity areas used by patients; ... an effective risk assessment program must take into account the facility location, clientele, and services offered, and include Security, Buildings, Grounds, Equipment, Occupants, and Internal Physical Systems ..."

Interviews conducted with S2 on 12/30/24 at 1:00 PM, and with S9 on 12/30/24 at 11:25 AM, confirmed that patients on Level 3 and 4 are eligible to attend outdoor recreational groups. A review of the facility's Environment of Care Annual Evaluation (2023), lacked evidence that the facility identified the perimeter fence as an environmental risk. S2 confirmed that the perimeter fence was not included in the facility's risk assessment in accordance with the facility's Safety Management Plan.

Upon interview with S2 on 12/30/24 at 2:00 PM, he/she explained that the facility has "gone to court with the local residents" about the perimeter fence. S2 explained that the facility wanted to install a different type of fence, but "lost the case in litigation." S2 did not identify what year this occurred. S2 further stated, "this is not jail and we cannot keep everyone here like criminals, our patients have the right to leave. If a patient wants to leave, they will. If a patient tried to climb a 'slanted' or different type of fence, we would run the risk of them falling back into the yard and injuring themselves, and we [the facility] would be liable. We have not had an elopement via the fence in a long time [last elopement via the fence was not identified]."

Upon request, the S2 was unable to provide an Environmental Risk Assessment for 2024. Review of the 2023 Environmental Risk Assessment lacked evidence that the facility identified the fence and "blind spot" in the yard as a potential risk for patients.