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.

STRATEGIC BEHAVIORAL CENTER-CHARLOTTE 1715 SHARON ROAD WEST CHARLOTTE, NC Feb. 8, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy review, medical record review, incident report review, facility written summary review, police report review, video review, observation and staff interview, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the protection of patients' rights and safe delivery of care to adolescent behavioral health patients.

The findings included:

1. The facility failed to protect and promote patients' rights by neglecting to ensure a safe environment for the delivery of care to adolescent behavioral health patients with a known history of elopement risk. The facility's Governing Body with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements. Patient #1 eloped from the facility on February 6, 2018 at 1620, which required police intervention.

~cross refer to 482.13 Patient Rights' Condition: Tag 0115

2. The hospital staff failed to have an effective Quality Assessment and Performance Improvement program by failing to develop systems to ensure safety and prevent elopement of an adolescent behavioral health patient. The facility's Governing Body with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements.

~cross refer to 482.21 QAPI Condition: Tag A0263

3. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and monitored adolescent behavioral health patients according to policy to ensure a safe environment and prevent elopement. The facility's Governing Body and Nursing Leadership with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements.

~cross refer to 482.23 Nursing Services Condition: Tag 0385.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on policy review, medical record review, incident report review, facility written summary review, police report review, video review, observation and staff interview, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and monitored adolescent behavioral health patients according to policy to ensure a safe environment and prevent elopement.

The findings included:

Facility nursing staff failed to ensure the safety of adolescent patients by failing to communicate history of elopement risk, implement policies, procedures, elopement precautions and supervise patients with a known history of eloping and running away for 4 of 4 sampled patients (#1, #4, #2 and #3). Patient #1 eloped from the facility on February 6, 2018 at 1620, which required police intervention. The facility's Governing Body and Nursing Leadership with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with and without documented history of elopements.

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, incident report review, facility written summary review, police report review, video review, observation and staff interview, facility nursing staff failed to ensure the safety of adolescent patients by failing to communicate history of elopement risk, implement policies, procedures, elopement precautions and supervise patients with a known history of eloping and running away for 4 of 4 sampled patients (#1, #4, #2 and #3). Patient #1 eloped from the facility on February 6, 2018 at 1620, which required police intervention.

The findings included:

Review on 02/08/2018 of the facility policy titled "Assessment of Risk" reviewed/revised 12/2016 revealed "... (Name of facility) evaluates residents for risk upon admission and at any significant change in functioning. ... The assessment shall be conducted by a clinician/RN. A safety plan is developed at this time based on the results of the assessment to address areas of safety concerns. ... The RN/Clinician shall communicate with all appropriate staff on the needs of the resident and document accordingly in all the identified locations, e.g., elopement risk ..."

Review on 02/08/2018 of the facility policy titled "Elopement Precautions" reviewed/revised 12/2016 revealed "... Residents who talk of running away, participate with or know of a planned runaway or actually run away will be placed on elopement precautions ...Procedure ...2. The adolescent who returns from an elopement must write a detailed narrative describing the events prior to the run, the run itself, and what transpired while the resident was away. This narrative must complete prior to the client being removed from elopement precautions. The narrative should include an effort to discover an alternative manner of coping, other than running away. 3. Adolescents on elopement precautions will have a bedtime of 8:30 pm every night. 4. Adolescents will be provided foam slippers to use as footwear. No shoes will be permitted. 5. Residents will not be allowed to leave the unit. 6. The individual's treatment plan will be modified to reflect the interventions necessary to maintain safety, i.e. room search daily, limited phone calls. 7. A physician's order will be required to remove the resident from elopement precautions. 8. Criteria for advancement from elopement precautions include: no dangerous behavior to self or others, no sneaky or suspicious behavior, compliance with rules/medications, the willingness to talk with staff regularly about concerns/feelings."

1. Open medical record review of Patient #1 revealed a [AGE] year-old male admitted on [DATE] for homicidal and suicidal ideations, depression, anxiety and post traumatic stress disorder (PTSD). Review of the "Comprehensive/Psychosocial Assessment Tool" dated 01/07/2018 stated Patient #1 had a "Running Away risk" with a note that recorded the patient had run away "a few times to commit suicide, runs from different places." Record review revealed the patient left against medical advice on 01/20/2018.

Review revealed Patient #1 was readmitted on [DATE] with major depressive disorder (MDD) and was placed on every 15 minute observation checks. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/01/2018 stated Patient #1 had a "Running Away risk" with a note that recorded the patient had "ran away to commit suicide a couple of times." Review of nursing notes dated 02/06/2018 at 1100 recorded "Pt (Patient) verbalized frequent SI (suicide ideations) after being asked by writer about marking 'yes' to questions on self inventory sheet. Patient states he feels suicidal a lot, but states he can contact for safety. ... Patient very impulsive and lashes out seemingly without warning. Patient rates depression at 8/10 (scale of 1-10 with 10 being the worst), anxiety 4/10 and agitation 7/10. Pt. antagonistic and lacks insight. ..." Review of physician's orders revealed a telephone order dated 02/06/2018 at 1647 for elopement precautions in paper scrubs times 24 hours, one to one observation and no outside times 24 hours. Review of nursing notes dated 02/06/2018 at 1705 recorded "(Patient #1) returned to (hospital name) via (local police). He was alert and oriented times 4. He was angry and hostile with threats toward police. (Patient #1) visibly calmed when (police) left. (MD name) was notified and ordered Zyprexa (behavior medication) 10 mg (milligrams) IM (intramuscular). ... (Resident was searched and there was redness and slight edema to left wrist area and small abrasion at right elbow. ..."

Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Review of a "Health Incident Review Report" dated 02/06/2018 at 1645 revealed Patient #1 had eloped from the acute courtyard. Review of the report revealed "Reported per resident that he scurried up the conduit next to window and jumped over the fence and ran away and he was brought back to (facility) via police escort."

Review of the facility's written summary of the incident revealed there was one staff member in the courtyard with four patients at 1620 when Resident #1 eloped by climbing onto a picnic table that was located by an outside wall. Review revealed the patient got onto a peer's shoulders and onto the roof of the building and proceeded to jump off the roof and ran away. Review revealed staff responded to an emergency elopement code, 911 was called and Patient #1 was returned by the police at 1645 (25 minutes after eloping). Review of the summary revealed none of the patients were on any special precautions at the time of the elopement.

Review of a local Police Department Event Report revealed the police were called on 02/06/2018 at 1624 to assist with a missing child report. Review of the report revealed a "patient has escaped from the acute unit, spotted running towards the apts. (apartments) next door." Review of the report revealed Patient #1 was located and transported back to the facility.

Review on 02/08/2018 of facility video recordings of the acute hospital courtyard area on 02/06/2018 between 1616 and 1620 revealed Patient #1, fully dressed in street clothes in the courtyard. Review revealed five male patients in the courtyard with one female staff member at 1616. Review revealed a male patient climbed on top of a picnic table that was located next to the outside of the facility wall. Review revealed the male resident getting on and off the top of the picnic table. Patient #1 sat on the top of the picnic table at 1618. At 1619 Patient #1 remained seated on the top of the table and was looking in the direction of the wall and roof of the building. Resident #1 stood up on the table at 1620 and climbs up the wall . Review of the video recording revealed one staff member was in the courtyard at 1620 when Resident #1 eloped.

Interview on 02/18/2018 at 1235 with AS #1 revealed Patient #1 had eloped from the acute hospital on [DATE] at 1620 and was returned by the police at 1645. Interview confirmed Patient #1 had a known history of elopement risk and was on no elopement precautions when he eloped.

Observation on 02/08/2018 at 1135 revealed an "Elopement Precautions" policy reviewed/revised 12/2016 hanging on the wall in the nursing station on the 500 hall. The registered nurse (RN #2) was asked about the elopement precaution policy and stated that the new CEO had posted the "elopement policy in the acute nursing station today." The nurse stated it was not a new policy, but that it was new to some nurses. RN #2 stated "I have never seen this policy before. It has never been followed."

2. Open medical record review of Patient #4 revealed a [AGE] year-old female admitted on [DATE] with aggression, anxiety, homicidal and suicidal ideations. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/03/2018 stated Patient #4 had a "Running Away risk" with a note that recorded the patient had run away "one time for 20 minutes." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #4 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

3. Open medical record review of Patient #2 revealed a [AGE] year-old female admitted on [DATE] with major depressive disorder. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/07/2018 stated Patient #2 had a "Running Away risk" with a note that recorded the patient "runs out of house naked." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #2 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

4. Open medical record review of Patient #3 revealed a [AGE] year-old female admitted on [DATE] with major depressive disorder and substance abuse. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/03/2018 stated Patient #3 had a "history of "sneaking away." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #3 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

In summary, the facility's Governing Body and Nursing Leadership with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements.

NC 563 and NC 640
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy review, medical record review, incident report review, facility written summary review, police report review, video review, observation and staff interview, the facility failed to protect and promote patients' rights by neglecting to ensure a safe environment for the delivery of care to adolescent behavioral health patients with a known history of elopement risk. Patient #1 eloped from the facility on February 6, 2018 at 1620, which required police intervention.

The findings included:

1. Facility staff neglected to supervise and provide a safe environment for the delivery of care to adolescent behavioral health patients for 4 of 4 sampled patients that had a known history of elopement risk (#1, #4, #2 and #3). The facility's Governing Body with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements.

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144

2. The facility neglected to ensure the safety of adolescent patients by failing to communicate history of elopement risk, implement policies, procedures, elopement precautions and supervise patients with a known history of eloping and running away for 4 of 4 sampled patients (#1, #4, #2 and #3). The facility's Governing Body with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements.

~cross refer to 482.13(c)(3) Patient Rights' Standard: Tag A0145
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, incident report review, facility written summary review, police report review, video review, observation and staff interview, facility staff neglected to supervise and provide a safe environment for the delivery of care to adolescent behavioral health patients for 4 of 4 sampled patients that had a known history of elopement risk (#1, #4, #2 and #3). Patient #1 eloped from the facility on February 6, 2018 at 1620, which required police intervention.

The findings included:

Review on 02/08/2018 of the facility policy titled "Assessment of Risk" reviewed/revised 12/2016 revealed "... (Name of facility) evaluates residents for risk upon admission and at any significant change in functioning. ... The assessment shall be conducted by a clinician/RN. A safety plan is developed at this time based on the results of the assessment to address areas of safety concerns. ... The RN/Clinician shall communicate with all appropriate staff on the needs of the resident and document accordingly in all the identified locations, e.g., elopement risk ..."

Review on 02/08/2018 of the facility policy titled "Elopement Precautions" reviewed/revised 12/2016 revealed "... Residents who talk of running away, participate with or know of a planned runaway or actually run away will be placed on elopement precautions ...Procedure ...2. The adolescent who returns from an elopement must write a detailed narrative describing the events prior to the run, the run itself, and what transpired while the resident was away. This narrative must complete prior to the client being removed from elopement precautions. The narrative should include an effort to discover an alternative manner of coping, other than running away. 3. Adolescents on elopement precautions will have a bedtime of 8:30 pm every night. 4. Adolescents will be provided foam slippers to use as footwear. No shoes will be permitted. 5. Residents will not be allowed to leave the unit. 6. The individual's treatment plan will be modified to reflect the interventions necessary to maintain safety, i.e. room search daily, limited phone calls. 7. A physician's order will be required to remove the resident from elopement precautions. 8. Criteria for advancement from elopement precautions include: no dangerous behavior to self or others, no sneaky or suspicious behavior, compliance with rules/medications, the willingness to talk with staff regularly about concerns/feelings."

1. Open medical record review of Patient #1 revealed a [AGE] year-old male admitted on [DATE] for homicidal and suicidal ideations, depression, anxiety and post traumatic stress disorder (PTSD). Review of the "Comprehensive/Psychosocial Assessment Tool" dated 01/07/2018 stated Patient #1 had a "Running Away risk" with a note that recorded the patient had run away "a few times to commit suicide, runs from different places." Record review revealed the patient left against medical advice on 01/20/2018.

Review revealed Patient #1 was readmitted on [DATE] with major depressive disorder (MDD) and was placed on every 15 minute observation checks. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/01/2018 stated Patient #1 had a "Running Away risk" with a note that recorded the patient had "ran away to commit suicide a couple of times." Review of nursing notes dated 02/06/2018 at 1100 recorded "Pt (Patient) verbalized frequent SI (suicide ideations) after being asked by writer about marking 'yes' to questions on self inventory sheet. Patient states he feels suicidal a lot, but states he can contact for safety. ... Patient very impulsive and lashes out seemingly without warning. Patient rates depression at 8/10 (scale of 1-10 with 10 being the worst), anxiety 4/10 and agitation 7/10. Pt. antagonistic and lacks insight. ..." Review of physician's orders revealed a telephone order dated 02/06/2018 at 1647 for elopement precautions in paper scrubs times 24 hours, one to one observation and no outside times 24 hours. Review of nursing notes dated 02/06/2018 at 1705 recorded "(Patient #1) returned to (hospital name) via (local police). He was alert and oriented times 4. He was angry and hostile with threats toward police. (Patient #1) visibly calmed when (police) left. (MD name) was notified and ordered Zyprexa (behavior medication) 10 mg (milligrams) IM (intramuscular). ... (Resident was searched and there was redness and slight edema to left wrist area and small abrasion at right elbow. ..."

Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Review of a "Health Incident Review Report" dated 02/06/2018 at 1645 revealed Patient #1 had eloped from the acute courtyard. Review of the report revealed "Reported per resident that he scurried up the conduit next to window and jumped over the fence and ran away and he was brought back to (facility) via police escort."

Review of the facility's written summary of the incident revealed there was one staff member in the courtyard with four patients at 1620 when Resident #1 eloped by climbing onto a picnic table that was located by an outside wall. Review revealed the patient got onto a peer's shoulders and onto the roof of the building and proceeded to jump off the roof and ran away. Review revealed staff responded to an emergency elopement code, 911 was called and Patient #1 was returned by the police at 1645 (25 minutes after eloping). Review of the summary revealed none of the patients were on any special precautions at the time of the elopement.

Review of a local Police Department Event Report revealed the police were called on 02/06/2018 at 1624 to assist with a missing child report. Review of the report revealed a "patient has escaped from the acute unit, spotted running towards the apts. (apartments) next door." Review of the report revealed Patient #1 was located and transported back to the facility.

Review on 02/08/2018 of facility video recordings of the acute hospital courtyard area on 02/06/2018 between 1616 and 1620 revealed Patient #1, fully dressed in street clothes in the courtyard. Review revealed five male patients in the courtyard with one female staff member at 1616. Review revealed a male patient climbed on top of a picnic table that was located next to the outside of the facility wall. Review revealed the male resident getting on and off the top of the picnic table. Patient #1 sat on the top of the picnic table at 1618. At 1619 Patient #1 remained seated on the top of the table and was looking in the direction of the wall and roof of the building. Resident #1 stood up on the table at 1620 and climbs up the wall . Review of the video recording revealed one staff member was in the courtyard at 1620 when Resident #1 eloped.

Interview on 02/18/2018 at 1235 with AS #1 revealed Patient #1 had eloped from the acute hospital on [DATE] at 1620 and was returned by the police at 1645. Interview confirmed Patient #1 had a known history of elopement risk and was on no elopement precautions when he eloped.

Observation on 02/08/2018 at 1135 revealed an "Elopement Precautions" policy reviewed/revised 12/2016 hanging on the wall in the nursing station on the 500 hall. The registered nurse (RN #2) was asked about the elopement precaution policy and stated that the new CEO had posted the "elopement policy in the acute nursing station today." The nurse stated it was not a new policy, but that it was new to some nurses. RN #2 stated "I have never seen this policy before. It has never been followed."

2. Open medical record review of Patient #4 revealed a [AGE] year-old female admitted on [DATE] with aggression, anxiety, homicidal and suicidal ideations. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/03/2018 stated Patient #4 had a "Running Away risk" with a note that recorded the patient had run away "one time for 20 minutes." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #4 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

3. Open medical record review of Patient #2 revealed a [AGE] year-old female admitted on [DATE] with major depressive disorder. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/07/2018 stated Patient #2 had a "Running Away risk" with a note that recorded the patient "runs out of house naked." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #2 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

4. Open medical record review of Patient #3 revealed a [AGE] year-old female admitted on [DATE] with major depressive disorder and substance abuse. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/03/2018 stated Patient #3 had a "history of "sneaking away." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #3 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

In summary, the facility's Governing Body with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, incident report review, facility written summary review, police report review, video review, observation and staff interview, the facility neglected to ensure the safety of adolescent patients by failing to communicate history of elopement risk, implement policies, procedures, elopement precautions and supervise patients with a known history of eloping and running away for 4 of 4 sampled patients (#1, #4, #2 and #3). Patient #1 eloped from the facility on February 6, 2018 at 1620, which required police intervention.

The findings included:

Review on 02/08/2018 of the facility policy titled "Assessment of Risk" reviewed/revised 12/2016 revealed "... (Name of facility) evaluates residents for risk upon admission and at any significant change in functioning. ... The assessment shall be conducted by a clinician/RN. A safety plan is developed at this time based on the results of the assessment to address areas of safety concerns. ... The RN/Clinician shall communicate with all appropriate staff on the needs of the resident and document accordingly in all the identified locations, e.g., elopement risk ..."

Review on 02/08/2018 of the facility policy titled "Elopement Precautions" reviewed/revised 12/2016 revealed "... Residents who talk of running away, participate with or know of a planned runaway or actually run away will be placed on elopement precautions ...Procedure ...2. The adolescent who returns from an elopement must write a detailed narrative describing the events prior to the run, the run itself, and what transpired while the resident was away. This narrative must complete prior to the client being removed from elopement precautions. The narrative should include an effort to discover an alternative manner of coping, other than running away. 3. Adolescents on elopement precautions will have a bedtime of 8:30 pm every night. 4. Adolescents will be provided foam slippers to use as footwear. No shoes will be permitted. 5. Residents will not be allowed to leave the unit. 6. The individual's treatment plan will be modified to reflect the interventions necessary to maintain safety, i.e. room search daily, limited phone calls. 7. A physician's order will be required to remove the resident from elopement precautions. 8. Criteria for advancement from elopement precautions include: no dangerous behavior to self or others, no sneaky or suspicious behavior, compliance with rules/medications, the willingness to talk with staff regularly about concerns/feelings."

1. Open medical record review of Patient #1 revealed a [AGE] year-old male admitted on [DATE] for homicidal and suicidal ideations, depression, anxiety and post traumatic stress disorder (PTSD). Review of the "Comprehensive/Psychosocial Assessment Tool" dated 01/07/2018 stated Patient #1 had a "Running Away risk" with a note that recorded the patient had run away "a few times to commit suicide, runs from different places." Record review revealed the patient left against medical advice on 01/20/2018.

Review revealed Patient #1 was readmitted on [DATE] with major depressive disorder (MDD) and was placed on every 15 minute observation checks. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/01/2018 stated Patient #1 had a "Running Away risk" with a note that recorded the patient had "ran away to commit suicide a couple of times." Review of nursing notes dated 02/06/2018 at 1100 recorded "Pt (Patient) verbalized frequent SI (suicide ideations) after being asked by writer about marking 'yes' to questions on self inventory sheet. Patient states he feels suicidal a lot, but states he can contact for safety. ... Patient very impulsive and lashes out seemingly without warning. Patient rates depression at 8/10 (scale of 1-10 with 10 being the worst), anxiety 4/10 and agitation 7/10. Pt. antagonistic and lacks insight. ..." Review of physician's orders revealed a telephone order dated 02/06/2018 at 1647 for elopement precautions in paper scrubs times 24 hours, one to one observation and no outside times 24 hours. Review of nursing notes dated 02/06/2018 at 1705 recorded "(Patient #1) returned to (hospital name) via (local police). He was alert and oriented times 4. He was angry and hostile with threats toward police. (Patient #1) visibly calmed when (police) left. (MD name) was notified and ordered Zyprexa (behavior medication) 10 mg (milligrams) IM (intramuscular). ... (Resident was searched and there was redness and slight edema to left wrist area and small abrasion at right elbow. ..."

Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Review of a "Health Incident Review Report" dated 02/06/2018 at 1645 revealed Patient #1 had eloped from the acute courtyard. Review of the report revealed "Reported per resident that he scurried up the conduit next to window and jumped over the fence and ran away and he was brought back to (facility) via police escort."

Review of the facility's written summary of the incident revealed there was one staff member in the courtyard with four patients at 1620 when Resident #1 eloped by climbing onto a picnic table that was located by an outside wall. Review revealed the patient got onto a peer's shoulders and onto the roof of the building and proceeded to jump off the roof and ran away. Review revealed staff responded to an emergency elopement code, 911 was called and Patient #1 was returned by the police at 1645 (25 minutes after eloping). Review of the summary revealed none of the patients were on any special precautions at the time of the elopement.

Review of a local Police Department Event Report revealed the police were called on 02/06/2018 at 1624 to assist with a missing child report. Review of the report revealed a "patient has escaped from the acute unit, spotted running towards the apts. (apartments) next door." Review of the report revealed Patient #1 was located and transported back to the facility.

Review on 02/08/2018 of facility video recordings of the acute hospital courtyard area on 02/06/2018 between 1616 and 1620 revealed Patient #1, fully dressed in street clothes in the courtyard. Review revealed five male patients in the courtyard with one female staff member at 1616. Review revealed a male patient climbed on top of a picnic table that was located next to the outside of the facility wall. Review revealed the male resident getting on and off the top of the picnic table. Patient #1 sat on the top of the picnic table at 1618. At 1619 Patient #1 remained seated on the top of the table and was looking in the direction of the wall and roof of the building. Resident #1 stood up on the table at 1620 and climbs up the wall . Review of the video recording revealed one staff member was in the courtyard at 1620 when Resident #1 eloped.

Interview on 02/18/2018 at 1235 with AS #1 revealed Patient #1 had eloped from the acute hospital on [DATE] at 1620 and was returned by the police at 1645. Interview confirmed Patient #1 had a known history of elopement risk and was on no elopement precautions when he eloped.

Observation on 02/08/2018 at 1135 revealed an "Elopement Precautions" policy reviewed/revised 12/2016 hanging on the wall in the nursing station on the 500 hall. The registered nurse (RN #2) was asked about the elopement precaution policy and stated that the new CEO had posted the "elopement policy in the acute nursing station today." The nurse stated it was not a new policy, but that it was new to some nurses. RN #2 stated "I have never seen this policy before. It has never been followed."

2. Open medical record review of Patient #4 revealed a [AGE] year-old female admitted on [DATE] with aggression, anxiety, homicidal and suicidal ideations. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/03/2018 stated Patient #4 had a "Running Away risk" with a note that recorded the patient had run away "one time for 20 minutes." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #4 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

3. Open medical record review of Patient #2 revealed a [AGE] year-old female admitted on [DATE] with major depressive disorder. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/07/2018 stated Patient #2 had a "Running Away risk" with a note that recorded the patient "runs out of house naked." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #2 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

4. Open medical record review of Patient #3 revealed a [AGE] year-old female admitted on [DATE] with major depressive disorder and substance abuse. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/03/2018 stated Patient #3 had a "history of "sneaking away." Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Interview on 02/18/2018 at 1345 with AS #1 revealed Patient #3 had a history of elopement risk identified on admission. Interview confirmed no interventions were in place to address the history of elopement.

In summary, the facility's Governing Body with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements.
VIOLATION: QAPI Tag No: A0263
Based on policy review, medical record review, incident report review, facility written summary review, police report review, video review, observation and staff interview, the hospital staff failed to have an effective Quality Assessment and Performance Improvement program by failing to develop systems to ensure safety and prevent elopement of an adolescent behavioral health patient.

The findings included:

The hospital failed to ensure elopement risks and precautions were evaluated and communicated to care staff to prevent elopement for 1 of 1 sampled patient that eloped (Patient #1). The facility's Governing Body with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with and without documented history of elopements.

~ cross refer to 482. 21 Quality Assessment and Performance Improvement - Standard A0286.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, incident report review, facility written summary review, police report review, video review, observation and staff interview, the hospital failed to ensure elopement risks and precautions were evaluated and communicated to care staff to prevent elopement for 1 of 1 sampled patient that eloped (Patient #1).

The findings included:

Review on 02/08/2018 of the facility policy titled "Assessment of Risk" reviewed/revised 12/2016 revealed "... (Name of facility) evaluates residents for risk upon admission and at any significant change in functioning. ... The assessment shall be conducted by a clinician/RN. A safety plan is developed at this time based on the results of the assessment to address areas of safety concerns. ... The RN/Clinician shall communicate with all appropriate staff on the needs of the resident and document accordingly in all the identified locations, e.g., elopement risk ..."

Review on 02/08/2018 of the facility policy titled "Elopement Precautions" reviewed/revised 12/2016 revealed "... Residents who talk of running away, participate with or know of a planned runaway or actually run away will be placed on elopement precautions ...Procedure ...2. The adolescent who returns from an elopement must write a detailed narrative describing the events prior to the run, the run itself, and what transpired while the resident was away. This narrative must complete prior to the client being removed from elopement precautions. The narrative should include an effort to discover an alternative manner of coping, other than running away. 3. Adolescents on elopement precautions will have a bedtime of 8:30 pm every night. 4. Adolescents will be provided foam slippers to use as footwear. No shoes will be permitted. 5. Residents will not be allowed to leave the unit. 6. The individual's treatment plan will be modified to reflect the interventions necessary to maintain safety, i.e. room search daily, limited phone calls. 7. A physician's order will be required to remove the resident from elopement precautions. 8. Criteria for advancement from elopement precautions include: no dangerous behavior to self or others, no sneaky or suspicious behavior, compliance with rules/medications, the willingness to talk with staff regularly about concerns/feelings."

1. Open medical record review of Patient #1 revealed a [AGE] year-old male admitted on [DATE] for homicidal and suicidal ideations, depression, anxiety and post traumatic stress disorder (PTSD). Review of the "Comprehensive/Psychosocial Assessment Tool" dated 01/07/2018 stated Patient #1 had a "Running Away risk" with a note that recorded the patient had run away "a few times to commit suicide, runs from different places." Record review revealed the patient left against medical advice on 01/20/2018.

Review revealed Patient #1 was readmitted on [DATE] with major depressive disorder (MDD) and was placed on every 15 minute observation checks. Review of the "Comprehensive/Psychosocial Assessment Tool" dated 02/01/2018 stated Patient #1 had a "Running Away risk" with a note that recorded the patient had "ran away to commit suicide a couple of times." Review of physician's orders revealed a telephone order dated 02/06/2018 at 1647 for elopement precautions in paper scrubs times 24 hours, one to one observation and no outside times 24 hours. Review of nursing notes dated 02/06/2018 at 1705 recorded "(Patient #1) returned to (hospital name) via (local police). He was alert and oriented times 4. He was angry and hostile with threats toward police. (Patient #1) visibly calmed when (police) left. (MD name) was notified and ordered Zyprexa (behavior medication) 10 mg (milligrams) IM (intramuscular). ... (Resident was searched and there was redness and slight edema to left wrist area and small abrasion at right elbow. ..."

Based on the medical record review there was no evidence available to determine facility staff implemented a treatment plan to address the history of elopement.

Review of a "Health Incident Review Report" dated 02/06/2018 at 1645 revealed Patient #1 had eloped from the acute courtyard. Review of the report revealed "Reported per resident that he scurried up the conduit next to window and jumped over the fence and ran away and he was brought back to (facility) via police escort."

Review of the facility's written summary of the incident revealed there was one staff member in the courtyard with four patients at 1620 when Resident #1 eloped by climbing onto a picnic table that was located by an outside wall. Review revealed the patient got onto a peer's shoulders and onto the roof of the building and proceeded to jump off the roof and ran away. Review revealed staff responded to an emergency elopement code, 911 was called and Patient #1 was returned by the police at 1645 (25 minutes after eloping). Review of the summary revealed none of the patients were on any special precautions at the time of the elopement.

Review of a local Police Department Event Report revealed the police were called on 02/06/2018 at 1624 to assist with a missing child report. Review of the report revealed a "patient has escaped from the acute unit, spotted running towards the apts. (apartments) next door." Review of the report revealed Patient #1 was located and transported back to the facility.

Review on 02/08/2018 of facility video recordings of the acute hospital courtyard area on 02/06/2018 between 1616 and 1620 revealed Patient #1, fully dressed in street clothes in the courtyard. Review revealed five male patients in the courtyard with one female staff member at 1616. Review revealed a male patient climbed on top of a picnic table that was located next to the outside of the facility wall. Review revealed the male resident getting on and off the top of the picnic table. Patient #1 sat on the top of the picnic table at 1618. At 1619 Patient #1 remained seated on the top of the table and was looking in the direction of the wall and roof of the building. Resident #1 stood up on the table at 1620 and climbs up the wall . Review of the video recording revealed one staff member was in the courtyard at 1620 when Resident #1 eloped.

Interview on 02/18/2018 at 1235 with AS #1 revealed Patient #1 had eloped from the acute hospital on [DATE] at 1620 and was returned by the police at 1645. Interview confirmed Patient #1 had a known history of elopement risk and was on no elopement precautions when he eloped.

Observation on 02/08/2018 at 1135 revealed an "Elopement Precautions" policy reviewed/revised 12/2016 hanging on the wall in the nursing station on the 500 hall. The registered nurse (RN #2) was asked about the elopement precaution policy and stated that the new CEO had posted the "elopement policy in the acute nursing station today." The nurse stated it was not a new policy, but that it was new to some nurses. RN #2 stated "I have never seen this policy before. It has never been followed."

In summary, the facility's Governing Body with a known history of ten residents eloping from the residential unit on January 1, 2018 which required police intervention, failed to implement systemic processes to address elopements of patients with or without documented history of elopements.