The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on medical record review, policy and procedure review, and staff interviews; the hospital administrative staff failed to implement systems to prevent patients from eloping from the locked Behavior Health Unit (Patients #1, 2, and 3) and to prevent patients from bringing contraband into the locked Behavioral Health Unit (Patient # 1).

Patient #1 eloped during his first admission to the Behavior Health Unit and was able to take matches into the unit despite a search for contraband at the time he was returned to the unit from the emergency department. The matches allowed the patient to set fire to his mattress at 1:30 AM on 10/3/14 in an attempt to divert the attention of staff, patients, and safety personnel in an unsuccessful attempt to elope from the unit a second time.

This failure by the hospital staff to make system changes to prevent elopements and to prevent contraband items in the Behavior health Unit endangered patients and staff on the unit and resulted in a finding of Immediate Jeopardy (IJ). The development of an appropriate corrective action plan and its implementation by the hospital resulted in the the IJ abatement on 10/24/14.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision or quality psychiatric care in a safe environment for the patients.

Refer to A 144.

I. Based on observation, review of hospital documents, and interviews with staff, the hospital failed to ensure patients in the locked Behavioral Health Unit were not able to elope from the locked unit and failed to ensure contraband items were not brought into the locked unit. The hospital identified 4 elopements by 3 patients from 4/14/14 through the time of the investigation (Patients #1, 2, and 3) including an unsuccessful elopement by 1 patient attempting elopement a 2nd time that involved diverting attention by setting his mattress on fire (Patient #1). The hospital's administrative staff reported a census of 30 patients at the time of the investigation.

Failure to ensure patients received care in a safe setting while receiving psychiatric care allowed patients to elope from the locked unit, bring contraband (matches) into the unit, and set a fire at 1:30 AM on 10/3/14. Elopements, the ability to bring contraband onto the unit, and setting a fire could have caused severe harm or death for patient, staff, visitors, and others in the unit.

Findings include:

A. General Behavioral Health Unit observations on 10/20/14 at 1:35 PM, and 10/21/14 at 12:45 PM, with Director of Behavioral Health revealed the following.

1. Large housekeeping carts were on the unit for trash/laundry pickup.

2. Large dietary carts were on the unit for patient meal trays.

3. Locked entrance/exit doors, 2 sets of locked entrance and exit doors that required a hospital identification badge or key for entry or exit.

4. Locked emergency exit doors at the end of each hall that exit to stairwells. Locked red panels on the adjacent walls labeled fire, containing fire hose and fire extinguisher. Metal plates, lock guards, approximately 12 inches long, on the stairwell side, covering the lock mechanism for protection from individuals trying to jimmy the lock for entrance.

5. Exit door alarms that only sounded in the nurses station, when the doors were opened.

6. Patients dressed in street clothes or scrubs with pockets.

7. Staff making rounds and assisting patients.

8. Camera monitoring of each hall appeared on screens located in the nurses station. Staff was not assigned to watch the cameras. The cameras lacked full and complete visualization of the exit doors.

B. Review of the medical records revealed the following information.

1. Patient #1's medical record included the following documents and information.

a. The 9/23/14 Psychiatry History and Physical revealed an admitted [DATE] with a diagnosis of court order for mental health evaluation. A [AGE] year old male was brought to the ED (Emergency Department) on court order filed by family members. The court papers alleged that he had been making threats to harm himself and his family, causing his family to be afraid. He had auditory hallucinations of voices that count like his mother and father cursing at him. He was born in another country and moved to the the United States while in the third grade. Treatment was admission to an acute psychiatric unit per court order.

b. The 9/22/14 ED nurses notes revealed the registered nurse (RN) in the ED, Staff A, gave the patient a gown and scrub pants after the doctor saw him.

c. The 9/22/14 Admission note by an RN in the Behavioral Health Unit revealed the patient was admitted to the unit, being transported with the assistance of public safety, very reluctant to come to the unit, refusing to change clothes or get out of the chair in the hallway; it took the patient more than 40 minutes to come into the unit. Patient #1 was crying, stating there was nothing wrong with him, and he wanted out of the nut house now. Staff were unable to redirect him and he refused medications.

d. The 9/26/14 Behavioral Health nurses notes by Staff C, RN in the Behavioral Health, revealed the E hallway door alarm sounded. Staff were informed by another patient that had witnessed the event that Patient #1 was let out of the E Hallway door by an unknown person after the person unlocked the door with an unknown object from the outside.

Patient #1 escaped through the E Hallway door. Staff did not see which way the patient was headed. Public safety, the house charge nurse, the MD on call, the police department, the Behavioral Health Director, the Magistrate Judge on call, the sheriff's department, and the patient's sister were notified. The patient's shoes were found outside of the hospital's laboratory door. Maintenance was notified and came to inspect the door, and a staff person was assigned to sit at the door until the problem was fixed.

e. The 9/28/14 Psychiatry Progress Note revealed Patient #1 was brought back to the hospital yesterday evening by the police. The police were contacted by the patient's family. The patient was quite agitated and confrontational in the ED, got physically aggressive with the security staff. IM (intramuscularly) medications were administered for aggression and the medications were effective. He declined to comment about what he did after eloping from the hospital. He had written a 5 page letter stating that he was normal and does not need to be treated for any reason, and he feels he does not need medications.

f. The 9/27/14 ED nurses note revealed Staff D, an RN in the ED, documented the patient was returned to the hospital after elopement on 9/26/14. Patient was cuffed and ambulatory. Patient was wanded and placed in the behavioral health room. The patient pulled fire alarm several times.

g. The 9/27/14 Behavioral Health nurses notes by Staff B showed the patient returned to the unit from ED and was transported to the unit with assistance due to the court order patient in bed on seclusion hall, B Hall.

2. Patient # 2 medical record revealed the following.

a. The 9/26/14 Psychiatry History and Physical revealed an admitted [DATE] with a diagnosis of homicidal ideation. A [AGE] year old male who has been living in assisted living facilities most of his life due to traumatic brain injuries. He was brought into the ED last night by staff members under a court order filed by staff at the assisted living facility because of increasingly violent behaviors. Reportedly he has been pushing, shoving, physically aggressive toward staff and other residents, calling 911, breaking things, has threatened to hurt himself and to "destroy the house".

b. The 10/15/14 Focus (Brief) Note revealed patient eloped from the Behavioral Health unit late yesterday morning and was brought back by the staff after he was found near the receptionist's check-in desk for the Behavioral Health Unit. Patient feels bored on the unit and wants to be discharged as soon as possible.

c. The 10/14/14 Behavioral Health nurses notes revealed Staff F, RN Behavioral Health, patient eloped today. Outpatient therapy called and said they had this patient sitting in the lobby. Patient told them he was discharged and wanted to talk to his doctor. The patient was sitting calmly in lobby. The patient was easily verbally redirected back to the unit. Patient still continues to say he wants to leave.

3. Patient #3's medical record included the following information.

a. The 4/22/14 Psychiatry History and Physical revealed an admitted [DATE] with a diagnosis of psychosis and schizophrenia. The patient was a voluntary admission. A [AGE] year old male who doesn't really know how he ended up in the Behavioral Health Unit. According to the Crisis Team Assessment he was brought in by the local police for medical clearance and he was experiencing hallucinations and delusions. He complains of depression going on for "a while" He states he has auditory hallucinations that are "talk talk" all the time. He acknowledges suicidal ideation and says he had planned to jump off a bridge yesterday.

b. The 4/23/14 Behavioral Health nurses notes by Staff G, RN Behavioral Health, revealed Patient #3 escaped from the unit, while two other patients were being discharged . Both the inner locked unit door and outer entrance door were simultaneously opened allowing the patient to exit. The provider was present at time of elopement, he ran after the patient to no avail. Patient #3 bed was put on a 24 hour hold, the patient did not return during this time and was discharged AMA (Against Medical Advice).

C. Review of the following policies revealed the following information.

1. Unauthorized Departures (Elopements), dated 5/12, stated in part..."A. When a patient leaves the unit or medical center grounds without appropriate provider orders the following action will be taken: 1. Nursing staff will pursue only within the medical center building, and then only in an attempt to convince the patient to return to the unit. 2. Unit staff and Public Safety Officers are not to physically detain any patient attempting to leave the hospital grounds unless the patient is deemed an immediate danger to self and others".

At section C it stated the following. "When an involuntary patient elopes, follow these guidelines: 1. Notify the physician, social worker, magistrate, and Nursing Director. 2. Notify the Polk County Sheriff's Department...3. Notify the patient's family or significant other. Instruct the family to seek assistance from the Sheriff's Department if the patient appears at home and is exhibiting problem behavior....5. When a patient returns from unauthorized departure, a body search will be conducted before the patient will return to the previously assigned unit for a condition assessment....9. An incident report should be completed whenever an unauthorized departure occurs."

D. The 9/26/14 Incident Report completed by Staff C, for Patient #1 stated in part... "Comments: Patient eloped from E Hallway door after an unknown person on the outside used an unknown object to break open the door. Event location adult psych. Hospital supervisors, physicians, police, and court notified of Patient #1 elopement."

The 10/14/14 Incident Report completed by Staff F, for Patient #2 stated in part..."Patient was found in the lobby area of the outpatient therapy. Patient eloped with a visitor unfamiliar with protocols and vigilance. the patient was easily directed back to the unit. Staff member at outpatient therapy called inpatient unit reporting the patient was sitting in the lobby of outpatient therapy. The patient reported he had been discharged and was waiting to talk to his doctor. Staff F and another staff RN ran to the outpatient therapy. The patient was observed calmly sitting in lobby chair. The patient was easily directed back to inpatient unit. When the patient was asked what he was wanting he stated "I want a future. I'm tired of being here. I want to see them doctors." The patient verbalized frustration with remaining an inpatient and has difficulty understanding why he is waiting for placement and can't go back to his previous facility. The patient was easily directed back to the unit. Director of Behavioral Health notified of elopement."

The 4/23/14 Incident Report completed by Staff G, for Patient #3, stated in part... "Patient did elope from the Behavioral Health Unit while unit doors were open simultaneously. Public safety, the patient's physician, and nursing staff were present and unable to stop or catch the patient. The patient escaped to outside of the building, police department notified. Director of Behavioral Health notified of elopement.

E. The following interviews and observations revealed additional information.

1. On 10/20/14 at 1:35 PM, the Director of Behavioral Health revealed she had conducted meetings with hospital managerial staff and Behavioral Health physicians to discuss various options to detour elopements from the unit. New policies have been drafted but had not been implemented.

On 10/20/14 at 3:30 PM, observation of the exit doors found at the end of each hallway, verified a new lock guard in place to prohibit jimmying of the lock and subsequent elopement of Behavioral Health patients.

2. On 10/21/14 at 3:25 PM, Staff J, Behavioral Health Care Technician, revealed she had noticed Patient #1 hanging out at the end of E Hallway on 9/26/14. She was rounding at the time she was notified that Patient #1 was missing. Room searches were conducted in an attempt to locate Patient #1. All doors were checked to make sure they were locked. No door alarm was heard on the unit, to alert staff of a alarmed door opening. Staff were notified by Patient #1's roommate that a big guy on the outside of E hallway exit door, opened the door to let Patient #1 elope.

3. On 10/22/14 at 7:35 AM, Staff I, Behavioral Health Care Technician, revealed she saw Patient #1 climb over the Dutch door (a door that allows the top part to remain open when the lower part is closed) of the nurses station, in an attempt to elope during the fire alarm in the early AM of 10/3/14.

Additional interviews with other Behavioral Health Staff were consistent and described the same elopement attempt by Patient #1. These were consistent with the hospital's Department of Public Safety's report of the mattress fire.

4. On 10/22/14 at 7:50 AM, Staff M, Behavioral Health Care Technician, revealed being aware elopements were occurring on the Behavioral Health Unit and attributed it to staff not being alert to their surroundings.

5. On 10/22/14 at 8:45 AM, Staff MN, Behavioral Health Care Technician, revealed he was aware elopements were occurring on the Behavioral Health Unit and attributed it to people were not diligent or alert to the patients.

6. On 10/22/14 at 10:00 AM, Staff O, Behavioral Health Care Technician, revealed she was aware elopements were occurring on the Behavioral Health Unit and attributed it to staff not paying attention to who they let in and out. When staff follow the protocols there should not be people getting out of the unit.

7. On 10/23/14 at 8:00 AM, Staff C revealed she was assigned to Patient #1 at the time of his elopement on 9/26/14. Staff C was in the nurses station when the door alarm sounded, and did not see Patient #1 elope. After the elopement was confirmed Staff C notified the physician, social worker, and Nursing Director, Sheriff's Department, patient's family and the magistrate.

8. On 10/23/14 at 12:05 AM, Staff N, Behavioral Health RN, revealed she was aware elopements were occurring on the Behavioral Health Unit and attributed it to leaving the entry/exit doors open too long or both sets of doors being open at the same time. Other hospital employees enter the unlit hallway (housekeeping and dietary) with big carts and were not aware of the type of patients we have or who are patients and potentially enable elopement.

9. On 10/23/14 at 1:55 PM, Staff D, RN, revealed she was aware elopements were occurring on the Behavioral Health Unit and attributed it to a lot of new Behavioral Health staff and visitors not securing their personal items prior to entering the Unit.

10. On 10/21/14 at 1:15 PM, Patient #1 revealed he felt the Behavioral Health staff were rude, but he would like to work at the hospital. He did admit to starting the fire to create a diversion to allow him to elope because he knew all doors unlock during a fire alarm.

II. Based on review of hospital documents and staff interviews the hospital failed to remove all patient's contraband prior to entering the locked Behavioral Health Unit for 1 (of 1) patients.

Failure to find and secure Patient #1's contraband (matches) when he was readmitted to the psychiatric unit after his first elopement resulted in a fire when he used the matches to start his mattress on fire around 1:30 AM on 10/3/14 placing all patients and staff in the unit at risk for harm.

Findings include:

A. Review of Patient #1 medical record revealed the following information.

1. The patient's Psychiatry History and Physical, dated 9/23/14, revealed an admitted [DATE] for court ordered mental health care. He was brought to the ED (Emergency Department) on a mental health court order filed by his mother and sister. The court papers alleged that he had been making threats to harm himself and his family, causing his family to be afraid. He has auditory hallucinations of voices that count like his mother and father cursing at him. He was born in another country and moved to the US in the third grade. The treatment was to admit to acute psychiatry per court order.

2. The patient's Psychiatry Progress Note, dated 10/3/14, revealed the patient had set a fire in his room last night causing significant damage to the room, but no injuries. The patient was agitated following this and received IM medication with seclusion. The patient stated that he set the fire last night because he wanted "attention from someone that would listen to me and believe me that I am telling the truth." He insisted that he had no intention to harm anyone when he set the fire.

3. The Behavioral Health nurses notes, dated 10/3/14, revealed Staff E, RN Behavioral Health, document that Patient #1 was in seclusion at the time. Assessed to be an immediate harm to self and a threat to others after admitting to setting a fire in his bedroom. Patient had body search completed and paper gown on at this time. Patient noted to be agitated: pacing, cursing, posturing. Patient was receiving one to one observations.

B. Review of the policies revealed the following information.

1. The policy titled Behavioral Health Security in the ED (Emergency Department), dated 6/13, stated in part..."A. Security will be called by the Triage RN to wand any patient triaged as high risk for suicide or homicide, The Triage Nurse will document that Security was called and the patient was wanded for weapons (wanding only detects metal objects)....4. Any high risk patient for homicide or suicide or Court Order will be escorted to the bathroom and put in a patient gown. If the patient is not appropriate to leave the exam room; the patient may be placed in a gown in the room as long as patient privacy is maintained. 5. Patient belongings will be placed in a patient belonging bag and locked in a locker in the Crisis Team/Security office unit the patient is either admitted or discharged ."

The policy titled Admission to the Psychiatric Unit, dated 5/11, stated in part..."I. Nursing Responsibilities 1. Upon arrival to the unit a picture of the patient will be taken and printed for identification purposes. All patients will undergo a visual body search before the admission process is begun. Two staff will assist with the body search. One staff member should be an RN, if possible. The RN that assisted with the body search will document any identifying marks, medical conditions visualized, and evidence of violence or self inflicted wounds on inpatient psych body search assessment. In addition all clothing is to be search for contraband. Medications, sharps, or other contraband found will be confiscated and stored according to policy..."

C. The Incident Report, dated 10/3/14, completed by Staff H, RN House Supervisor, for Patient #1 states in part... Patient set fire to his mattress. Staff responded to the fire alarm. As they went towards D hallway, they observed the patient in the activity room. Staff opened the door and entered room D-5 with Security. The room was filled with smoke and they saw that Patient #1's bed was full of flames. Staff E, called out "Is anybody in here?" and the patient in the other bed woke up and ran from the room. Staff woke up all the patients in D and E Hallways and escorted them to the common area on the other side of the unit. Patient #1 jumped over the half door (47 inch high lower part of a Dutch door) into the nurse's station and attempted to elope. Patient #1 was unable to gain access to the outside Hallway, and was escorted to B Hallway (locked hallway) and placed into a paper gown. Hospital managers, and appropriate physicians were notified.

D. The following interviews were conducted during the investigation with staff and Patient #1.

1. On 10/20/14 at 3:20 PM and on 10/23/14 at 1:30 PM, the Director of Emergency Services revealed he had conducted meetings on 10/6/14 at approximately 7:30 AM with employees, following the fire on 10/3/14, to re-educate staff on the search procedure (for contraband) at admission to the ED for Behavioral Health patients. The Director lacked written documentation to confirm the meeting, and stated approximately 7 RN's and 1 Nursing Technician attended. The Director of the Emergency Services verified the ED employs 25 RN's and 6 Nursing Technicians. The Director stated that a monthly newsletter was distributed that included the information reviewed at the meeting (all staff received the newsletter via e-mail). A review of newsletter dated 9/12/14, stated in part... "Gowning Patients - There have been a few close calls over the past few months and weeks with patients that we have not placed in gowns prior to placing them in the Behavioral Health Hallway. There is a team evaluating this process and trying to improve it for everyone including the patient and there is more to come on that. We will begin auditing the compliance with it in order to ensure patient safety but until then we still need to be closely evaluating every patient and getting them in a gown as appropriate and please seek the advice of the crisis team as well. Nobody wants to be the one that had the patient that got through with something in their pocket because the wand missed it." The newsletter dated on 9/12/14 was approximately 3 weeks prior to the fire set on 10/3/14. The newsletter lacked confirmation that all staff acknowledge receiving and reading it.

2. On 10/20/14 at 1:35 PM, the Director of Behavioral Health revealed she had conducted meetings with hospital managerial staff and Behavioral Health physicians to discuss various options to detour contraband from entering the unit. New policies have been drafted, that lack implementation.

3. On 10/22/14 at 8:15 AM, Staff E revealed he was the Charge Nurse on 10/3/14 when Patient #1 set fire to his mattress. The fire occurred in the early morning of 10/3/14, Patient #1 was in the activity room at the time the alarm sounded. When the door to Patient #1's room was opened, smoke poured out of the room into the hallway, flames were high and coming from Patient #1 mattress. Patient's #1 roommate was asleep in the room and immediately awakened and evacuated along with other patients on D hallway.

Patient #1 announced he started the fire and was placed in seclusion (B hallway). A search of Patient #1, patient rooms, and common areas (for contraband) was conducted, an empty book of matches were found in the activity area, where Patient #1 was sitting at the time of the fire. All patients were assessed for smoke inhalation. Additional Behavioral Health Staff RN interviews revealed the same fire and evacuation process. All staff acknowledged that staff and patients acted appropriately and kept calm during the fire.

4. On 10/23/14 at 7:00 AM, Staff A revealed that Public Safety wands all Behavioral Health patients, the patients then are given a gown and scrub pants and asked to change in the bathroom. All belongings are taken and placed in the Crisis team office until the patient is admitted or discharged . Body searches are done by the Behavioral Health Unit staff. Additional interviews of ED RN's revealed the same process for wanding and gowning of Behavioral Health patients.

5. On 10/23/14 at 9:10 AM, Staff F revealed body searches are completed by the RN's and Health Care Techs of the same sex. At the initial assessment the patient's scrubs are not removed, but the patient is given a new set of scrubs and asked to change into them. If the patient is wearing a bra we ask her to shake it out, socks are removed and checked for contraband. Underwear is not checked. Staff look into pockets of scrubs to check for contraband.

6. On 10/23/14 at 9:25 AM, Staff K, Behavioral Health Care Technician, revealed body searches are completed by staff of the same sex. Staff K was instructed how complete body searches during the orientation process. At the time of admission patient is wearing a gown and scrubs from the ED. The gown is lifted up to view the chest, back, and waistline. Legs of the scrub pants are lifted up to the thigh, socks are not removed but visualized for contraband, the bottom of foot is not checked.

7. On 10/23/14 at 9:50 AM, Staff L, Behavioral Health Care Technician, revealed he was instructed how to complete a body search during the orientation process. Body searches are completed as part of the admission, completed by same sex staff and patients. The patient's gown is removed and front and back of the patient is visually checked for contraband, socks are removed. Scrub pants pockets and legs are checked by patting them down, scrub pants are not removed. He reported he stays with the patient and having them change scrub pants, patient's underwear is not removed and not patted down.

8. On 10/21/14 at 1:15 PM, Patient #1 revealed he felt the Behavioral Health staff were rude, but he would like to work at the hospital. He brought the matches in with him after the elopement and he would not answer any questions regarding where he hid the matches during the admission search or how he kept them hid until he started the fire. He did admit to starting the fire to create a diversion to allow him to elope, as all doors unlock during the fire alarm activation.