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 observation, record review, video review and staff interview it was determined an Immediate Jeopardy was identified in that the hospital failed to maintain a safe setting in the play area where a section of the fence allowed a patient to elope (see Tag A 144).

Upon entrance to the hospital on [DATE] at 11:30 a.m., Administration was informed the elopement was a matter of Immediate Jeopardy (IJ) under Patient Rights and that they must provide the State Agency with a written plan to create a safe setting and abate the IJ before the surveyors exited the building that day.

An acceptable written plan to abate the IJ was provided at 2:55 p.m. on 6/6/17. Extra staff was assigned to the play area, which included a security person to ensure against an elopement. This short term fix will be in place until a contractor makes the necessary changes to the play area fence; the adjustments to the fence will be completed within the next few days.
Based on observation, record review, video review and staff interview it was determined the hospital failed to provide care in a safe setting, including keeping patients free from eloping the grounds, for all patients in the Unit 2 West outdoor play area. This failure impacted one (1) of three (3) patients who eloped from the outdoor play area (patient #1). This failure has the potential for all patients to elope and be harmed following elopement from the facility.

Findings include:

1. A tour of the outdoor play area for patients on Unit 2 West revealed a 9' x 5" fenced in area with inward awning on most of the fence except over the emergency exit area of the fence. The fence was extended above the door but no inward awning to prevent elopement was noted.

2. Review of the medical record for patient #1 revealed the patient went to do the outdoor play area on 06/04/17 at 3:40 p.m. with patients #2 and 3. Behavior Health Worker (BHW) #1 was present for supervision of care. Further review of the medical record revealed at 4:05 p.m. patient #1 jumped the fence and BHW #1 yelled for him but he never stopped; she then notified her Charge Nurse and called a code MIA at 4:05 p.m.

3. On 06/07/17 at 8:20 a.m. a review of the video of the outdoor play area, beginning at 4:00 p.m. on 06/04/17, with the Director of Nursing revealed patients #1 and 2 were playing basketball at 4:00 p.m. approximately four (4) feet from the emergency exit door. At 4:01:59 the patient made a dunk shot and immediately ran for the fence, grabbed the top of the door, lifted himself up, grabbed the fence post on the top of the fence and jumped over the fence; by 4:02:03 the patient was no longer in view of the camera on the opposite side of the fence. At 4:02 p.m. the video showed that BHW #1 began to run, gathered patients #2 and 3 and opened a door into the hospital.

4. An interview was conducted on 06/07/17 at 8:30 a.m. with patient #1, with telephone consent from his guardian. When asked how long he had been planning to elope and if he had notified anyone that he was thinking of leaving the hospital, he stated, in part: "I knew I was leaving as soon as I got outside but I never made a plan; the second I decided, I just jumped over the fence because I knew I could. I've jumped higher fences." When asked if BHW #1 had tried to stop him, he stated, "She yelled for me as soon as I hit the top of the fence and I felt bad for her but what was I gonna do, I was already over. I'm pretty fast, she couldn't have stopped me." When asked why he decided to leave, he stated, "I missed my mom and wanted to go home and I went straight to the grocery store and called her to come and pick me up. She told me she was calling the hospital and I had to go with them, and I did."

5. An interview was conducted on 06/07/17 at 1:00 p.m. with BHW #1. When asked to explain the activity that occurred on the outdoor play yard the day patient #1 eloped, she stated, in part: "Him and another patient were playing basketball and having fun and he made a basket and took off running. I started to run after him and he was already over; I yelled for the other patients to come in and they ran with me. I went into the IDD department and called my Charge Nurse and she called an MIA." When asked if he had any abnormal behavior that would suggest something was wrong, she stated, "No, he was quiet to begin with and then he started playing basketball and never caused any problems until he jumped the fence."

6. An interview was conducted on 06/07/17 at 2:00 p.m. with the Director of Nursing and she concurred with the above findings.