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UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW 2450 RIVERSIDE AVENUE MINNEAPOLIS, MN 55454 June 1, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and document review, the hospital failed to ensure adequate supervision for all patients placed on 6A locked adelescent unit who was at risk for elopement.

Therefore the hospital was unable to meet the condition of Participation of Patient Rights at 42 CFR 482.13. This deficient practice had the potential to affect patients on unit 6A locked adelescent unit and two other similar units.

See A-0144 - Based on observation, interview, and document review, the hospital failed to ensure each patient received care in a safe setting for four of four patients reviewed, Patient (P1, P2, P3, and P4). P1 eloped form the locked adolescent unit, the hospital failed to fully evaluate the circumstances surrounding P1's ability to elope and failed to initiate sufficient actions to prevent a similar reoccurrence, which did occur four days later when three more child patients (P2, P3, and P4) eloped out the same door.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and document review, the hospital failed to ensure each patient received care in a safe setting for four of four patients reviewed, Patient (P1, P2, P3 and P4). P1 eloped form the locked adolescent unit, the hospital failed to fully evaluate the circumstances surrounding P1's ability to elope and failed to initiate sufficient actions to prevent a similar reoccurrence, which did occur four days later when three more child patients (P2, P3, and P4) eloped out the same door.

Findings include:

Observations on 05/17/2017, at 1:45 p.m. established that the hospital's adolescent duel diagnosis is a locked hospital unit requiring acute inpatient care. The secure unit's main door is double-locked and can be accessed only by those staff who possess the restricted key card. The unit has one long hallway with an exit door at each end. The exit door leads to a stairwell. At the bottom of each stairwell is an exit to the hospital grounds. The unit's exit door is accessed with a restricted key care and a personal code. The unit has the capacity to serve 20 patients, six of the rooms are private, the rest of the room are two patients in a room. Staff check, observe, and document the whereabouts of every patient every 15 minutes, which represents the minimum interval for safety checks of patients unless the patient is a one to one level monitoring. The nurse's station is located in the center of the unit. The Charge Nurse's written shift report is kept at the nurse's station. Program Director (PD)-I accompanied the investigator during the tour and explained that the shift report is a fluid document that is managed by the Charge Nurse. The Charge Nurse updates the document with changes in patient condition, status and new physician's orders regarding patient care as they occur throughout the shift. The shift report denotes each patient's goals for the day, the patient's treatment plan, the frequency of patient safety checks for each patient, the status of each patient's privileges, and any special alerts or precautions for patients at risk for elopement, suicidal ideation, self-injurious behavior, or assault behavior.

P1's hospital record indicated P1 who was a child patient admitted to the hospital's locked adolescent unit (6A) with a duel diagnosis on 04/25/2017. At the time of admission, emergency record dated 04/25/2017, at 7:18 a.m. nursing progress notes indicated the patient was acutely ill with thought of suicide ingesting 20 tablets of Sertraline 100 milligram (MG). P1 was also threatening to leave and did not want to be admitted . P1 attempted to leave while in the emergency room psych unit and a four point restraint was applied, P1 was given 10 mg Zyprexa injection. Later that day, P1 was taken out of restraints when agreeing to stay in the hospital and to go to unit 6A. A nursing progress noted dated 04/26/2017, indicated P1 was calm the next day but was "hanging around the main door of the unit saying he wanted to leave and get out". Nursing progress notes dated 04/26/2017, at 7:47 p.m. indicated when P1 continued to say he wanted to leave and attempted to grab the main door, a psych associate followed him down the hallway toward the end of the hallway while P1 was saying I need to get off the unit. The psych associate said he jiggled the door handle. P1 slammed his/her shoulder into the door and it opened. P1 ran down the stairwell before staff could react. Security was notified, who notified the police. Code pink (missing child) was not initiated as the hospital policy directs staff to do. During an interview on 05/19/17 RN-R stated P1's care plan did not indicate P1 was at risk for elopement.

P2's hospital record indicted P2 who was a child admitted to the hospital's locked adolescent unit 6A with a diagnosis of suicide ideation on 04/23/2017. On 04/26/2017, at 9:49 p.m. nursing staff overheard P2 asking other patients if they wanted to start a riot. On 04/26/2017, at 11:19 p.m. P2 was yelling he wanted to start a riot, and was bragging and laughing about a patient whom had eloped off the unit earlier. A note on 04/28/2017, at 12:58 p.m. indicated P2 and two other male patients were told to not have contact with each other. On the same day at 2:07 p.m. the therapist had a discussion with P2 because P2 continued to say he would not abide by the no contact rule. P2 told them he did not care if they took away privileges, P2 said he was not going to follow the rules. On 04/30/2017, at 10:23 p.m. at the 7:00 p.m. safety checks P2 was found missing. During an interview on 05/19/17 at 8:00 a.m. RN-R stated there was no mention of elopement risk was on the care plan.

P3 who was a child patient admitted to the hospital's locked adolescent unit 6A with a diagnosis of suicide ideation with multiple plans including jumping out a window on 04/25/2017. The emergency room noted dated 04/25/2017, at 1:02 a.m. indicated P3 was treated the day before at another hospital for taking 2-10 tablets of Zanax ingestion, P3 was treated and was discharged to the bridge (living facility) but after getting there attempted to jump out a window. Nursing and physician progress notes 04/25/2017 to 04/29/2017 revealed P3 was cooperative and denied planning to commit suicide or elope. On 04/29/2017, at 10:12 p.m. P3 stated wanting to leave. P3 had a history of running away. On 04/30/2017, at 10:23 p.m. at the 7:00 p.m. safety checks P3 was found missing. During an interview on 05/19/17 at 8:00 a.m. RN-R stated there was a physician order for elopement precautions but no mention of elopement risk was on the care plan.

P4 who was a child patient admitted to the hospital's locked adolescent unit 6A with a diagnosis of suicide ideation on 04/20/2017. An emergency room physician note indicated P4 stated was planning of shooting himself at the end of the week. On 04/24/2017, at 1:02 p.m. the physician noted indicated P4 expressed difficulty following rules and demonstrated behaviors such as throwing water in the air, punching a wall, and throwing an ice pack against the window. P4 admitted having difficulties reigning his anger in. Nursing progress notes dated 04/27/2017, at 10:30 p.m. indicated P4 head banging at times but otherwise uneventful. On 04/30/2017, at 10:23 p.m. at the 7:00 p.m. safety checks P4 was found missing. During an interview on 05/19/17 at 8:00 a.m. RN-R stated there was a physician order for elopement precautions but no mention of elopement risk was on the care plan.

Departmental policy indicated all patients are monitored every 15 minute during safety checks on the unit unless they are monitored one-to-one by staff. The physician can order a one-to-one and the nurses can initiate as well.

Staffing for 04/26/2017, was reviewed finding staffing met the requirement for the 18 patients on the unit. Staffing for 04/30/2017, was reviewed finding 18 patients and the staffing was one person over the guideline requirements.

Preventative maintenance records for the exit door on unit 6A was reviewed and found the elements inspected appropriate and timely.

The video was viewed with the facilities staff. The elopement on 04/26/2017, P1 pushed on the secured magnetic door four times and the door opened allowing P1 to exit. The event on 05/30/2017, P3 pushed on the same door two times which allowed P3, P2, and P4 to exit the same secured unit. P3 was never found after the event.

During an interview on 05/17/2017, at 1:45 p.m. Regulatory Compliance (RC)-A stated P1 eloped from a locked emergency exit on unit 6A on 04/26/2017. P1 went out the exit door. Facilities checked the door on the unit finding nothing wrong with them. The door had a 1400 pound magnet that secured the door from opening the door. On 05/01/2017, the magnet was changed to a 1800 pound magnet and on 05/04/2017 the door magnet was changed to 4000 pound.

During an interview on 05/17/2017, at 2:00 p.m. with facilities management (FM)-E and FM-M stated said they think if you hold the handle down and lean into it, it opens. The door requires a badge and a personal code to open the door so staff do not use the door very often. FM-E said they door had a 1200 pound magnet, they put on a 1800 pound magnet and than went on to put on a 4000 pound magnet on the door. The 4000 pound magnet includes prongs which fit into the door jam so it has a duel action.. FM-E thinks that will stop further elopements. The 4000 pound magnet was installed 05/04/2017.

During an interview on 05/17/2017, at 3:30 p.m. psych associate (PA)-J stated was working on 04/30/2017, when the three patients eloped, the patients were congregating and they knew they are not suppose to congregate. There was an admit being done by the nurse and PA-J was watching the child patients in the hallway but a couple of parents needed to be let out of the unit, when PA-J got done, the charge nurse was at the desk. PA-J did the 7:00 p.m. safety checks and found three patients missing. PA-J was asked to search the rooms and when done searching, heard code pink called overhead announcement.

During an interview on 05/17/2017, at 4:00 p.m. registered nurse (RN)-K was working on 04/26/2017 when P1 eloped. RN-K said P1 had received a phone call and seemed upset. RN-K asked PA-G to go with P1 and calm him down. PA-G was following P1 down the hallway, P1 pushed on the door, it opened and P1 ran away down the stairs. RN-K called security and told them. RN-K said the unit is staffed with one psych associate assigned to monitor the hallway 24-hours a day 7-days a week. Fifteen minute safety checks are done every 15 minutes. The staff assigned to the patient is who makes assessments. When they are making assessment they look at history of eloping and behavior on the unit. There is not specific document to ensure elopement risks are done the same by everyone. RN-K said the staff use nurse clinical judgement when doing an assessment. RN-K was not aware of any policies about elopement of adolescent patients.

During an interview on 05/18/2017, at 4:30 p.m. program director (PD)-I stated the nursing supervisor contacted security and asked them to monitor the door for the rest of the night and until facilities checked the security of the door. Facilities said the door was safe. After the first elopement, one additional staff person was added to monitor the hallways and the exit doors. The adolescent unit was staffed per the staffing guidelines and they added one more staff person after the first elopement. PD-I stated the patients must have talked before at the time of the second elopement. no one knows how the patients got the door open.

During an interview on 05/18/2017, at 9:30 a.m. patient safety director (PS)-N said after the first elopement the door was checked by facilities management, and they initiated the following action plan:
- If a patient under the age of 18 is missing, call a code pink prior to searching entire unit.
- Increase a psych associate by one staff per shift.
- A security staff to monitor the door until facilities deems the door safe (was done that one night only)
- Facilities checked the door and unable to determine the cause.
- Increase security rounding (no definition of where and frequency).
The root cause analysis was not completed until after the second event. The following was initiated:
-Security again posted at door until a larger magnet could be increase to 1800 pounds (magnet was installed the exit door on 05/01/2017 for the one night).
- Continue an extra psych associate until 4000 pound magnet was installed on on the exit door on 05/04/2017.
- Monitor for potential hiding places for patients.
- Keep lighting in hallways so there is good visibility.
- A patient safety advisory dated 05/01/2017, advising staff of event and recommendations.
During the same interview PS-N stated the facility had not identified the root cause of the first or second elopements.

During an interview and document review with RN-R on 05/19/2017 at 8:00 a.m. it was found in the medical records there was no elopement assessment on P1, P2, P3, and P4. RN-R confirmed P1, P2, P3, and P4 did not have an entry on the care plan regarding elopements.

During an interview on 05/19/2017, at 4:00 p.m. security (S)-aa said the cameras on the exit doors were not monitored by security. No one monitors the number of failed attempts on each door. There was no increase security officers monitoring the exit door from 04/26/2017 to 05/01/2017. Security did monitor the door after the 04/30/2017 through the night until the 1800 pound magnet was installed the morning of 05/01/2017.

The hospital's policy entitled elopement revised 12/2016, indicated If the patient is under 18, the staff must call a code pink, and notify security who also notify's the police. This policy goes into effect when a patient is absent from the patent care unit.

The hospital's policy entitled code pink revised 01/2017, the policy defined a child as anyone under [AGE] years old and instructs staff to call the emergency number with a description of the missing child and what they were wearing.

The hospital failed to protect patient safety by thoroughly evaluating the circumstances of P1's elopement and the potential for harm that existed when any patient elopes from staff supervision and is able to flee the hospital's property unsupervised. P2 has not been found.