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 interview and document review, the hospital failed to protect the right of three patients to receive care in a safe setting for 3 of 13 patients reviewed, P1, P2, and P3. The hospital did not ensure that the three patients were supervised and kept safe prior to the three patients' elopements from three different units within the hospital. The hospital was found not in substantial compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

Findings include:

The hospital failed to protect and promote the right to receive care in a safe setting for 3 of 13 patients reviewed. Staff failed to implement adequate monitoring and safety/security measures for P1, P2 and P3, who were on hold orders, and according to the facility policy, were to be on independent observation status (IOS), meaning 1:1 staff monitoring. P1's 1:1 monitoring was not being completed by staff as ordered when P1 eloped from a behavioral health unit by following an employee out of the locked door; P2 was being monitored by a video camera located in his room and in the hallway of the medical-surgical unit. However, the person monitoring the camera was at an off-site location and failed to promptly notify hospital staff when P2 eloped from the unit via the elevator; P3 was in the emergency department (ED) without any security measures or 1:1 staff monitoring in place and eloped from the unit prior to receiving care. Refer to the deficiency issued at A144.
Based on interview and document review, the hospital failed to implement adequate safety and security precautions to prevent elopement for 3 of 13 patients (P1, P2, and, P3) reviewed for elopement.

Findings include:

P1's hospital record indicated the patient was admitted to the hospital's adult Behavioral Health Unit on 6/20/18, due to increased paranoid delusions and noncompliance with medications. A petition for civil commitment was filed when P1 was admitted , and a a physician's order indicated the patient was placed on Status Individual Observation (SIO), which included 1:1 staff observation within 5-10 feet of P1 during wake hours due to high elopement risk.

P1's hospital note indicated on 7/19/18, P1 eloped from the unit by following a staff member out of the double locked doors. The staff member who was assigned to P1's 1:1 observation was at the desk and not within an appropriate distance to effectively conduct a 1:1 observation of the patient. The patient was found three hours later and brought back unharmed to the hospital and returned to the Behavioral Health Unit.

P1's physician's progress note dated 7/19/18, indicated P1 was admitted to the unit on a 72 hour hold. P1 began lingering by the door, made comments about eloping, and attempted to elope from the unit on multiple occasions prior to eloping from the unit on 7/19/18. Due to those behaviors, P1 had been placed on 1:1 observation within 5-10 feet prior to P1's 7/19/18 elopement.

An event report, dated 7/19/18, indicated P1 eloped from the unit on 7/19/18. The report indicated P1 had been on elopement precautions and was to be on 1:1 observations at the time of the elopement. However, Psychiatric Associate (PA)-G, who was the staff responsible for P1's 1:1 observation on 7/19/18, had stepped behind the desk and failed to see P1 follow a staff person out the door.

P1's physician's progress note dated 7/20/18, indicated P1 was returned to the unit after eloping and being located at the airport. There was no indication of injury or change in physical or psychiatric status that warranted any medication intervention. P1 remained on close 1:1, but within a 5 feet distance, due to P1's heightened elopement risk.

When interviewed on 8/6/18, at 2:00 p.m. PA-G stated s/he was assigned to complete 1:1 observation on 7/19/18, however, that shift was very busy and s/he did not see P1 follow the staff member out the door. PA-G was aware of P1's 1:1 observation which indicated staff was to remain within 5-10 feet of the patient.

Two Patient Safety Advisory notifications, dated 6/7/18, and 7/20/18, were reviewed. The issue addressed in both documents is the following: Risk of Elopement when Entering or Exiting Secure Behavioral Health Units. The documents provided background, assessment information, and recommendations for entry/exit from secure behavioral health units.

P2's hospital record indicated the patient had a history of polysubstance abuse, IV drug use, and was treated for sepsis, right shoulder pain, and chest pain in the hospital's ED on 6/25/18. P2 was placed on a 72 hour hold order in the ED and was transferred and admitted to the hospital's medical-surgical unit on 1:1 observation. P2's sepsis was being treated with IV antibiotics during the in-patient admission on the medical-surgical unit. P2 was also placed on a court hold in connection with commitment petition proceedings. On 7/25/18, with the court hold still in place, P2 was changed from 1:1 monitoring to 1:1 monitoring during the day, and video patient monitoring (VPM) in the evening. Although staff had previously allowed P2 to go off the unit to smoke, hospital staff advised P2 not to leave the unit during the VPM monitoring. However, the video shows that on 7/25/18, P2 left his/her room and the person monitoring P2's video monitor at a remote site failed to promptly report this to staff on P2's unit. P2 walked by the nurse's desk and eloped from the unit via the elevator. P2's IV treatment had not been completed, and P2 had a connected IV channel in place when s/he eloped from the hospital. The police were notified about P2's elopement, however, P2 was not located.

A physician's progress note, dated 7/21/18, indicated P2 is on a 72 hour hold and has MRSA bacteremia with septic pulmonary emboli, mitral and tricuspid endocarditis and is receiving Vancomycin (antibiotic) per IV and continues to have problematic behaviors.

A nursing progress note, dated 7/21/18, indicated P2 continued to be on a 72 hour hold and 1:1 observation due to a high risk that (P2) may attempt to leave the unit.

A physician's order, dated 7/25/18, indicated video patient monitoring would be initiated for P2.

An event report, dated 7/25/18, was reviewed. The report provided a narrative account of P2's 7/25/18 elopement. The report indicated P2 was on a hold order and 1:1 staff observation, but during the afternoon of 7/25/18, P2 was changed from 1:1 staff observation to video patient monitoring. The report stated that at approximately 5:00 p.m. on 7/25/18, P2 left his/her room and and got on the elevator and eloped from the hospital. The police were notified about P2's elopement but they were unable to locate P2.

When interviewed on 8/6/18, at 3:00 p.m. Registered Nurse (RN)-I stated s/he was P2's primary nurse when P2 eloped from the unit. P2 was placed on a hold order due to his/her prior drug use and risk of elopement from the unit, and P2 should have been on continuous 1:1 monitoring in response to being placed on a hold order. RN-I stated when P2 eloped the patient still had the IV in place.

A Patient Safety Advisory notification, dated 9/18/17, was reviewed. The issue addressed in the document included: Patients at risk of elopement or receiving care on an involuntary basis must stay on the unit. The only exceptions would be to ensure that patients receive clinical care not available on the unit; emergency medical situation regarding care/treatment if not available on the unit, and emergency evacuation (e.g. fire, flood).

P3's hospital record indicated the patient arrived at the hospital via ambulance at 12:34 a.m. on 7/23/18. P3 was admitted to the hospital's ED (East Campus) on 7/23/18, with diagnoses of anxiety disorder, brief psychotic disorder and delusional disorders. P3 was placed on a 72 hour hold at 2:33 a.m. per a physician's order, however, there was no indication the patient was placed on 1:1 observation or a security watch in connection with the 72 hour hold according to the hospital's policy. P3 eloped from the ED following his/her admission to the ED.

P3's physician's progress note dated 7/23/18, at 12:07 p.m., indicated P3 was seen in the ED pending psychiatric admission for paranoia and delusions. The note indicates P3 was placed on a 72 hour hold for paranoia and delusions two and 1/2 hours after s/he arrived in the ED but was not placed on a security watch. The note further indicated the physician did not find P3 in the treatment room when s/he went to provide care to P3. The physican note indicated attempts were made to contact P3 by cell phone and overhead page, and the police were notified about P3's elopement from the ED.

An event report dated 7/23/18, indicated on 7/23/18, P3 was placed on a 72 hour hold while in the ED, but was not placed on 1:1 observations in the ED because P3 was "just sleeping." According to the report P3 eloped from the ED and was not located on the campus.

During interview on 8/7/18, at 9:15 a.m. RN-K stated s/he was working in the ED (7:00 p.m. to 7:00 a.m.) when P3 arrived in the ED at 12:30 a.m. on 7/23/18. RN-K stated P3 had called the ambulance and was a voluntary admission to the ED. P3 was very delusional and anxious when s/he arrived at the ED and the patient would be admitted for inpatient care when a bed became available. RN-K stated she asked the ED physician if P3's room in the ED should be moved closer to the desk, be on 1:1 observation, or have a security watch (guard outside P3's door), and the physician responded that it was not necessary. The physician placed P3 on a 72 hold order at 3:00 a.m. on 7/23/18, but did not order 1:1 observation or any security measures for P3 per the hospital's hold order policy.

During interview on 8/7/18, at 10:45 a.m. RN-L stated s/he reviewed the incident and was aware P3 was placed on a hold order at 3:00 am. but no security measures, such as staff 1:1 observation, were ordered by the physician. The hospital's hold policy was not followed related to P3's elopement. The police found P3 at his/her home following the elopement and P3 sustained no injury.

The hospital policy titled Increasing Level of Patient Supervision, including 1:1 Attendant, dated July 2016, indicated an Emergency hospitalization (72-hour) Hold is a patient situation that requires a 1:1 attendant. A Hold (emergency hospitalization , 72-hr, court-ordered and commitment) requires appropriate physician documentation. The RN or MD is responsible to document the decision for continuing, decreasing, or discontinuing the increased level or 1:1 supervision of the patient.