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.

TWO RIVERS BEHAVIORAL HEALTH SYSTEM 5121 RAYTOWN ROAD KANSAS CITY, MO 64133 July 7, 2017
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, record review, policy review, and video recording review the facility failed to ensure that staff:
- Followed their internal policy regarding elopement (patient leaving a facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) prevention and close observation (a level of supervision provided to patients with an increased risk for injury) to prevent one patient (#8) of one reviewed elopement from a locked facility.
- Followed their internal policy on elopement response for one patient (#8) of one patient reviewed.
- Conducted a comprehensive investigation regarding the elopement of one patient (#8) of one patient reviewed, which resulted in the failure to implement corrective action to prevent potential elopements.
Please refer to A-395.

These deficient practices resulted in the facility's non-compliance with specific requirements with nursing oversight found under the Condition of Participation: Nursing Services. The facility census was 30.

The severity and cumulative effect of these practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 07/06/17, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 07/07/17, at the time of the survey exit, the facility provided an immediate action plan sufficient to remove the IJ by implementing the following:
- The facility revised the elopement response policy to instruct staff to immediately announce "Security Alert + Missing Person + (Location)" via overhead paging and two way radio in the event of a missing patient.
- The facility revised the elopement prevention policy to require staff to do a daily reassessment of elopement risk on all patients. Patients assessed as an elopement risk will require additional evaluation by the physician. An elopement reassessment tool was developed that identified the patient at risk for elopement based on population specific risk factors.
- The facility revised the patient observation policy to instruct staff to maintain a line of sight (continuous visual contact with a patient) of all assigned patients while in the courtyard area and position themselves accordingly. Leadership will audit compliance by conducting random observations once per shift (two times daily) for 30 days. After 30 days, leadership will conduct one observation per day alternating shifts for 60 days. Audits will continue once per week alternating shifts for 90 days.
-The facility revised the escorting policy to instruct staff to conduct a head count of patients prior to leaving the unit, upon arrival to the off-unit location, at every additional stop while off the unit, and upon returning to the unit. Leadership will audit compliance by conducting random observations once per shift (two times daily) for 30 days. After 30 days, leadership will conduct one observation per day alternating shifts for 60 days. Audits will continue once per week alternating shifts for 90 days.
- Education began to all facility staff according to the newly revised policies. Education will commence for all staff currently in the facility, and will continue until completed for all staff at their next scheduled shift. Staff will not be allowed to begin shift until training was completed and documented.
- Unscheduled/unannounced observed mock scenario drills for elopement response began once per shift (two times daily) until compliance was attained. Drills will then be conducted once daily alternating shifts until the revisit occurs.
- An immediate environmental assessment was completed by leadership; the identified improvements will be completed as soon as possible based on the complexity. A report of this assessment and plans for addressing the findings will be submitted to the Bureau of Hospital Standards.
- Staff P, V, W Patient Safety Technician (PST), will receive a final written warning "because patient safety was not maintained". This counseling will occur prior to their next scheduled shift.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, policy review, and video recording review the facility failed to:
- Follow their internal policy regarding elopement (patient leaving a facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge) prevention and close observation (a level of supervision provided to patients with an increased risk for injury) to prevent one patient (#8) of one reviewed elopement from a locked Facility.
- Follow their internal policy on elopement response for one patient (#8) of one patient reviewed.
- Conduct a comprehensive investigation regarding the elopement of one patient (#8) of one patient reviewed, which resulted in the failure to implement corrective action to prevent potential future elopements.

These failures had the potential to affect all inpatients related to staff failure to appropriately supervise and/or identify all inpatients for the risk of elopement, as elopement allows patients at risk to harm themselves and/or others. The facility census was 30.

Finding included:

1. Record review of the facility's policy titled, "Patient Observation," revised 01/2017 showed directives that staff completing the observation rounds form (a form staff documented on showing visual contact of a patient every 15 minutes) were responsible for:
- Observing each patient during an interval no longer than 15 minutes and document the observations on the observation form.
- Handing off assigned patient observation rounds to another staff member before leaving the patient treatment area.
- Verifying the correct patient was being observed by referencing the patient photo on the form.

Record review of the facility's policy titled, "Escorting Patients," revised 09/2014 showed directives for staff escorting patients to the courtyard maintain a staff to patient ratio of one staff to six patients.

2. Record review of the psychiatric evaluation (assessment of an individual's behavior and mental health) for Patient #8's showed he was a [AGE] year old male transferred from another facility for verbalizing increased suicide ideation (thought of killing self) with a plan to overdose (ingestion of a drug in quantities greater than prescribed). He was admitted to the facility on [DATE] for unspecified psychotic disorder (abnormal thinking and perception), severe alcohol use disorder, severe cocaine use disorder, and medical diagnoses of Human Immunodeficiency Virus (HIV, virus that attacks the body's ability to fight infections). The recommendations for treatment were that the patient was admitted to the facility as inpatient, monitored for mood, behavior, sleep, and suicidal ideation. The patient was to be provided with safe and structured environment to maintain safety. He was started on medication for Psychosis (a disorder characterized by false ideas about what is taking place or who one is) and for Depression (a long period of feeling worried or empty with loss of interest in activities once enjoyed.)

3. Record review of Patient #8's observation rounds dated 06/25/17, showed Staff P, Patient Safety Technician (PST) documented the following:
- 1:00 PM Patient #8 was in the hallway;
- 1:15 PM Patient #8 was in the courtyard; and
- 1:27 PM Not recorded (Staff P determined that Patient #8 was missing.)

4. Observation on 07/05/17 at 2:10 PM showed module B (unit for adults ages 18 or older) day room and the courtyard were secured with a card proximity maglock door (door that opens with the use of a badge, instead of a key.)

5. Review of the facility's video recording of 06/25/17 showed at:
- 1:00 PM, three PSTs ( P,V, and W), gathered 16 patients, including Patient #8, in the day room next to the locked door.
- 1:01 PM, the three staff and the 16 patients, including Patient #8, were in the hallway, and entered the courtyard.
- 1:15 PM, Staff W and one patient returned to the day room.
- 1:18 PM, Remaining staff and patients returned to dayroom, (camera view confirmed) that Patient #8 never returned from the courtyard.

During an interview on 07/05/17 at 3:55 PM, Staff P, PST, stated that:
- On 06/25/17 at 1:00 PM, she and Staff V and Staff W gathered 16 patients to go to the courtyard.
- The patient to staff ratio were to be one staff member to six patients.
- She was only responsible for making rounds on one patient (#8).
- "At approximately 1:18 PM, we gathered the patients to go back to module B unit and Staff V told me to go ahead. That indicated all patients were accounted for, but a head count was not done."

During an interview on 07/06/17 at 3:15 PM, Staff W, PST, stated that:
- She remembered the event with Patient #8 and taking the patients out to the courtyard.
- She had returned to the dayroom with another patient before the break was over; that left Staff P and V with the remaining 15 patients in the court yard.
- She returned to the hallway, and the remainder of the patients walked in toward the module B dayroom.

During an interview on 07/06/17 at 1:30 PM, Staff V, PST, stated that:
- She had taken the patients to the courtyard; there were 14 to 16 patients, she couldn't remember because she did not do a head count.
- At approximately 1:17 PM she gave a two minute warning, which indicated that the break was almost over.
- She and Staff P gathered the patients at the courtyard door and she scanned the courtyard but did not see any patients. The two staff and patients returned to module B dayroom.

Even though the facility polices show that staff ratios were to be one staff to six patients, Staff W left the courtyard which left Staff P and V, with the remaining 15 patients, not performing a handoff to verify the correct patient to be rounded on and leaving a ratio of 7.5 patients per staff member. As a result of the deficient practice, Patient #8 was left unsupervised and allowed to elope.

6. Record review of the facility's policy titled, "Elopement Response," revised 03/2015 showed directives for staff in the event a patient cannot be located:
- Alert the charge nurse, nurse manger, and/or the house supervisor.
- All available unit staff will conduct a search of all areas of the unit to locate the patient.
- Move all other patients into a group room or ensure that they were accounted for in their own rooms.
- Immediately call the receptionist to announce "security alert" via overhead page.
- Staff will respond to the area paged and attempt to locate the patient.

7. Review of the facility's video recorded on 06/25/17 showed at:
- 1:27 PM, Staff P was going from room to room and appeared to be looking for someone.
- 1:30 PM, Staff P was talking to Staff W.
- 1:31 PM, Patients were in various areas throughout the dayroom, not gathered (together in a group).
- 1:33 PM, Staff P talked to Staff N, Charge Nurse.
- 1:38 PM, Staff P continued to look for someone. A staff member unlocked the door in the day room, entered the day room, and started to restock the refrigerator.
- 1:48 PM, Patient #8 was seen walking across the facility parking lot.

During an interview on 07/05/17 at 3:55 PM, Staff P, PST, stated that:
- She went to round on Patient #8, and could not find him.
- She searched the rooms and dayroom, could not find him, and went and told Staff W.
- She called Staff O, Registration but did not tell her to call a code. She wanted to keep it discrete.
- She then told Staff N, Charge Nurse.
- She did not hear a security alert for a missing person called.
- She was not instructed to gather or account for the rest of the patients.

During an interview on 07/05/17 at 3:10 PM, Staff N, Charge Nurse, stated that:
- She was charge nurse on module B on 06/25/17, and remembered the event with Patient #8.
- Staff P told her that she could not find Patient #8.
- She notified Staff Q, House Supervisor, and told him to lock the front door.
- "We did not call a security alert, but after this event was reviewed, we should have call a security alert."

During an interview on 07/05/17 at 2:20 PM, Staff O, Registration, stated that:
- She was working at the registration desk on 06/25/17 and remembered the event with Patient #8.
- Staff P did call and told her that Patient #8 was missing.
- Staff P, N, or Q, never told her to call a security alert for missing person.

During an interview on 07/06/17 at 1:30 PM, Staff V, PST, stated that she did not hear a security alert for a missing person paged overhead. She was not instructed to gather or account for the rest of the patients.

During an interview on 07/06/17 at 3:15 PM, Staff W, PST, stated that she did not hear a security alert for a missing person paged overhead. She was not instructed to gather or account for the rest of the patients.

During an interview on 07/06/17 at 2:50 PM, Staff Q, House Supervisor, stated, "We should have called a security alert for a missing person as soon as it was identified that Patient #8 was missing."

The facility failure to follow policies on elopement response placed all inpatients at risk for injury or harm by allowing an eloped patient to be in areas of a locked facility, unsupervised, or to physically leave the building.

8. Record review of the summary of self-report, submitted to the State Agency office on 06/26/17 showed that the facility had completed their investigation of the patient's elopement which occurred on 06/25/17. It was the facility's conclusion that the facility's policies were followed.

During an interview on 07/06/17 at 9:35 AM, Staff K, Interim CEO, stated that after reviewing the video recording, it was clear that the staff failed to follow policy.

During an interview on 07/06/17 at 1:30 PM, Staff V, PST, stated that since the event with Patient #8, she had not received any training on elopement response.

During an interview on 07/06/17 at 2:55 PM, Staff R, Registration, stated that she had not received any training on elopement response.

During an interview on 07/06/17 at 9:50 AM, Staff J, Interim Risk Manager, stated that the facility had not performed any training on elopement response because the investigation was just done one week ago.

During an interview on 07/07/17 at 8:20 AM, Staff L, Chief Nursing Officer, stated that the staff did not follow the policy on patient elopement and how to proceed after that.