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AUSTIN OAKS HOSPITAL 1407 WEST STASSNEY LANE AUSTIN, TX 78745 Dec. 10, 2018
VIOLATION: CONTENT OF RECORD: COMPLICATIONS Tag No: A0465
Based on facility policy review, clinical record review and staff interview, the facility failed to ensure all records had documentation of complications.

Findings included:

Facility Adolescent PHP [partial hospitalization program] Orientation Packet stated in part, "Please read the following program rules and expectations carefully:
...7. AOH Outpatient Clinic is an open campus this means that if the child leaves the premises of the building without permission the Austin Police Department has jurisdiction and will be notified immediately."

Facility policy titled "Elopement" stated in part, "Policy: In the event of an elopement, staff will take every measure necessary to ensure the eloped patients safety, including search of grounds, and notification of all necessary parties as clinically indicated.
Procedures:
...12. Documentation will be entered in patient's record describing the elopement, attempts to intervene and outcome ..."

Review of patient #1's chart revealed no documentation describing the patient leaving or attempts to intervene. Without documentation, it is unknown what the staff discussed with the patient or if they attempted to keep him from leaving the facility.

The above was confirmed in an interview with staff #1 and #3.