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Based on observation, interview, review of the facility investigation, and review of patient records, it was determined the facility failed to ensure there was sufficient staffing to provide adequate supervision and patient care as needed for three (3) of ten (1) sampled patients (Patient #1, #2, and #3).

Patients #1, #2 and #3 were being escorted by staff from the Recovery Mall (third floor) to their unit (56G) on the ground floor. When passing though Unit 602/612 (second floor), staff failed to ensure the patients were supervised while the staff assisted with a resident who had pulled his/her pants down. Patients #1, #2, and #3 entered the elevator and rode it down to the ground floor without staff's knowledge. The Patients asked another staff member to escort them to their ward.

The findings include:

Review of facility policy titled, "Patient Management on the Units", dated 05/04/1998 and last revised in August 2014, revealed it states "Escorting groups of patients - All groups of patients will be escorted by a minim of two (2) staff members to therapeutic activities. The number of staff members required to escort the group is determined by the group number: a. two - ten (2 -10) patients require two (2) staff members.

Review of the Facility Investigation, not dated, revealed Patient #1, #2 , and #3 were left unsupervised on a unit (602/612) on the second floor while being escorted to their unit (56G)on the ground floor. Patients #1, #2, and #3 left the unit on the second floor by entering an elevator without staff knowledge. The Patients were found on the basement level approximately five (5) to eight (8) minutes later. Further review of the investigation revealed the facility unsubstantiated the allegation.

1. Review of the medical record revealed the facility admitted Patient #1 on 08/31/16 with diagnoses which included Major Neurocognitive Disorder due to trauma. The patient has a history of being impulsive, confused, and disoriented in nature. Patient #1 was on every fifteen (Q15) minute checks (standard supervision) at the time of the incident and was present for all Q15 checks on 06/16/17.

Interview with Patient #1 on 06/30/17 at approximately 9:45 AM, revealed he/she stated nothing happened, and they walked off. He/she stated "I don't want to talk about it, this is stupid and shouldn't be investigated. Nothing happened".

2. Review of the medical record revealed the facility admitted Patient #2 on 02/18/17 with diagnoses which included Schizoaffective Disorder, Bipolar type, and Major Neurocognitive Disorder due to trauma. Patient #2 was on standard Q15 minute checks at the time of the incident and was present for all Q15 minute checks on 06/16/17.

Interview with Patient #2 on 06/30/17 at approximately 9:48 AM, revealed Patient Aide #1 went to help someone who flashed them. He/she stated the elevator doors opened so they got on and were going back to their unit. He/she revealed they didn't do anything bad, that it was a prank to leave Patient Aide #1, and they were just going back to their unit. He/she further stated PA #1 met them and took them back to their unit. He/She also stated they didn't have any keys so they were unable to go to the recovery mall.

3. Review of the medical record revealed the facility admitted Patient #3 on 05/03/17 with diagnoses to include Schizophrenia Spectrum and other psychotic disorder. Patient #3 was on standard Q15 minute checks and was present for all Q15 minute checks on 06/16/17.

Interview with Patient #3 on 06/30/17 at approximately 9:52 AM, revealed they got on the elevator by themselves. He/she stated the elevator just opened, they did not have any keys,

Observations of the elevator on Units 602/612 on 06/30/17 at approximately 8:40 AM, revealed the elevator opens directly on the unit and has to be called with a key. Once inside the elevator, the second floor, third floor and ground floor are accessible without a key but a key is needed to access the first floor. Further observation revealed no staff was posted to monitor the elevator.

Interview with the Risk/Safety Manager, on 06/30/17 at approximately 8:47 AM, revealed he confirmed once in the elevator a key is needed to access the first floor only.

Interview with PA #1 on 06/30/17 at approximately 10:10 AM, revealed he and PA #2 were transporting the patients from Recovery Mall (third floor) back to unit 56G (ground floor). He stated when they got to units 602/612 (second floor) which are adjoining units there was a patient being aggressive and he was asked to help. He revealed he asked PA #2 and PA #3 to keep an eye on the patients and they said yes so he went to help with the other patient and when he came back Patient #1, #2, and #3 were gone. He also reported the patients told him they saw the elevator door open and got on because they were tired of waiting on him.

Interview with PA #2 on 06/30/17 at approximately 10:25 AM, revealed she and PA #1 were both escorting patients from recovery mall that day when they came up on a patient on 612 with his/her pants down. She revealed she told the patients to wait on Unit 602. She stated she reported the patient with his/her pants down to Registered Nurse (RN) #2 and PA #1 escorted the patient back to his/her room. She stated it was her understanding PA #4 on the 602 side said she would watch the patients and that RN #1 was also on the unit; however, PA #4 did not specifically tell her she would watch the patients. PA #2 revealed RN #2 knew PA #1 was transporting patients and asked for his help and it was about ten (10) minutes before they noticed the patients were not where they left them. She further stated she remembered PA #1 telling either RN #1 or PA #4 to watch the patients and was not 100% sure RN #1 or PA #4 acknowledged this but was pretty sure RN #1 said okay.

Interview with PA #3 on 06/30/17 at approximately 12:35 PM, revealed she was not asked by PA #1 to keep an eye on his patients and did not see the three (3) patients get on the elevator. She stated she saw the three (3) patients on the unit before going to the restroom and when she returned the patients were gone.

Interview with PA #4 on 07/03/17 at approximately 8:36 AM, revealed she was not asked to watch the patients and there is no staff specifically monitoring the elevator. She stated people getting on and off the elevator do not typically wait for the elevator doors to close behind them.

Interview with RN #1 on 06/30/17 at approximately 10:47 AM, revealed she did not recall PA #1 asking her to watch his patients but she did remember someone asking her if she saw any patients coming back from recovery mall and she was not involved. She stated she was at the desk surrounded by patients from her unit, 602, and did not know how or who opened the elevator doors.

Interview with RN #2 on 06/30/17 at approximately 12:38 PM, revealed she did ask PA #1 to help with another patient and knew PA #1 was escorting patients from the recovery mall back to the unit. She sated she assumed 602 staff was watching the patients but did not ensure PA #1's patients were being supervised. Additionally, she revealed no one knows how the elevator doors opened and to her knowledge no staff saw the three (3) patients get on the elevator.

Interview with the Leisure Recreation Therapist on 06/30/17 at approximately 10:55 AM, revealed she was in her office on the ground level when the three (3) patients arrived and asked her to unlock the door so they could get back to their unit. She stated they said they didn't want to watch the patient with his/her pants down get a shot. She revealed she asked the patients to sit, and security staff was there and watched them. She stated she had PA #1 paged and he was there with in three (3) to five (5) minutes. She also reported the patients did not seem afraid or agitated and when PA #1 arrived he escorted them back to their unit.

Interview with Investigator #1, on 06/29/17 at approximately 2:30 PM, revealed he conducted the facility investigation. He stated PA #1 was escorting three (3) patients from the intensive unit (56G) from recovery mall back to their unit. He revealed when they got to unit 602/612, a patient was naked from the waste down and RN #2 asked PA #1 to stay and help. PA #1 told the patients to stay put and helped RN #2. He reported all three (3) patients were on standard Q 15 minute checks. He also stated the three (3) patients were apologetic and said they should have waited for PA #1. He further revealed PA #1 was pulled from direct patient care on 06/16/17 at approximately 10:20 AM and returned to direct patient care on 06/17/17 at approximately 3:50 PM as he had unsubstantiated the investigation. Additionally he stated no re-education has been done with the staff.