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.

SOUTH FLORIDA STATE HOSPITAL 800 E CYPRESS DR PEMBROKE PINES, FL 33025 May 17, 2019
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to provide a safe environment with adequate supervision and interventions to prevent patient elopement for 1 of 1 patients (Patient #1) and to prevent patient to patient physical altercations involving 85 of approximately 340 patients within one month, April 2019. This affects the safety and security of all patients.

The findings included:

1) South Florida State Hospital is a locked facility. The facility's Policy and Procedure titled Eloped/Escaped/Missing Person Served (patient) documents the Policy "The following procedure will be followed when it has been reported that a person served may have eloped/escaped from the grounds of SFSH or when person served are discovered missing or reported missing" and under Procedure "Prevention of elopements/escapes is held in high priority and prevention is the responsibility of every employee. When prevention fails and an elopement/escape occurs, every effort will be made to recapture the person(s) served and return them to SFSH (South Florida State Hospital), in as short a time as possible. The safety of the person(s) served and the public will be of the utmost concern until such time the person(s) served is back in SFSH custody" and "When a person served is discovered missing from a residential unit or program area, the unit nurse or other designated unit staff will immediately contact the Security Control Room Officer (Sec/Control Rm Officer) to inform the S/O that a person served is unaccounted for. Or, when it is determined by an employee that a person served has affected an elopement elopement/escape, the employee shall immediately notify the Sec/Control Rm Officer of the elopement/escape." This Procedure also documents "Upon discovering that a person served is missing, Nursing/Programs staff will make inquiries about the persons served whereabouts on the unit or program area from which the persons served is missing. Nursing/Programs staff will conduct a thorough search, which will include the entire persons served residence/program area (every room, closet, conference/consult rooms, rest rooms, lounge, day rooms and patios). Nursing/Programs staff will notify the Sec/Control Rm Officer to gain access to any locked room for the search. The search will be completed within five (5) minutes. If the person(s) served is not located during this search, an immediate call will be made to inform the Sec/Control Rm Officer of the missing person(s) served."

Review of the record revealed Patient #1 was admitted on [DATE] with a diagnosis of paranoid schizophrenia. Patient #1's Person Served Off Campus Data Sheet documents he was a high risk transport alert and supervision intervals of 30 minutes for reasons (risks) of "assault, elopement, fall." An Elopement Reporting Card dated 05/13/19 at 01:09 AM documents Patient #1 was last seen at 6:18 PM and security was notified by Officer, Staff "C," that Patient #1 was missing at 00:25 AM.

On 05/16/19 at 5:35 PM Nursing Supervisor, Staff "A" stated Patient #1 had eloped from the facility at about 6:45 PM and was discovered missing after midnight.

On 05/16/19 at 5:51 PM Nursing Supervisor, Staff "B" stated that she was on duty while Patient #1's elopement "supposedly happened" on Sunday, 05/12/19 but that she left the office on 05/12/19 at 11:55 PM without being notified that a person was missing. Staff "B" stated upon review of the incident report that the time of discovery was documented as 11:05 PM but that could not be correct since the supervisor's office was not notified before leaving and, if she had been notified, she would have stayed to help look for Patient #1.

On 05/17/19 at 1:08 PM Security Officer, Staff "C" reported he worked the overnight shift beginning Sunday 05/12/19, that when he walked on the Las Olas unit at 00:20 on 05/13/19 staff looked nervous and he asked a nurse what was wrong, at which point he was informed there was a person they couldn't find, that they were trying to search the unit. Staff "C" said he had staff do a head count, notified the Captain by 00:25, and called a "Code Orange" to initiate procedures for a missing person served (patient). Staff "C" stated he is very familiar with the process for Code Orange and they can usually get a person back if they are notified quickly, before they get too far, but this patient was gone 6 hours before security was made aware.

Review of video footage time-stamped 05/12/19, for 6:18 PM to 6:20 PM, with a Risk Manager, Staff "D" revealed several persons with a staff member near the front of the first group exiting one building (satellite kitchen) with no apparent efforts to count or watch patients or keep the group together, followed out by small groups and individuals at irregular intervals for a total of 23 to 25 patients (as identified by Staff "D"), who generally proceeded along the sidewalk towards a second building. The video showed them followed out by 2 more staff members, one of whom did not stay with the group but went around the corner of the first building. Since patients sprawled the distance between buildings with no apparent organization, the front of the line entering the second building (Las Olas) as the following staff left the first building, all persons being moved were not within sight of the single following staff member. A person matching the appearance of Patient #1 who had started out towards the front of the group was seen by video on the other side of the fence and a row of bushes, moments after the rest of this group passed the area, having already exited the enclosure. Despite the benefit of video footage, Patient #1's escape from the group/facility could not be seen due to the fluid disorganized movements of multiple persons in the area he was last seen. The staff member who followed the group, from a similar angle to the camera footage, would also have had difficulty to visualize all patients in the group to ensure they were escorted safely back to their unit. Video footage of the parking lot on 05/12/19 at 6:42 PM showed the similar figure cautiously hustling across the parking lot towards the road.

During interview on 05/17/19 at 3:31 PM, Assistant Director of Nursing, Staff "E" stated the staff escorting the group from which Patient #1 escaped the facility had not followed policy; that the escort at the front of the group was supposed to do a head count in the dining room before leaving the first building and radio ahead with that count before starting out, and the escorts should radio with a second head count on arrival to the second building to ensure all persons were accounted for and security aware of persons being moved. On 05/17/19 at 5:05 PM Staff "E" stated that the staff member behind the group did not follow policy since they obviously must have passed Patient #1 since he wasn't with the group and by policy was supposed to stay behind the last person in the group. Staff "E" also said 3 persons had falsified face checks, that one of these persons said they saw a bunched blanket but did not enter the room or watch for Patient #1's breathing, and therefore did not follow policy.

During telephone interview on 05/20/19 at 10:51 AM, Staff "F" confirmed they worked the evening shift on 05/12/19 and described staffing on Las Olas unit that day. Staff "F" stated there were 4 Mental Health Techs (MHTs) that evening, instead of full staffing with 5 or 6; that at all times one of the male MHTs must stay with a patient who needed direct 1:1 staff supervision; that 2 other MHTs had to stay on the "A-wing" at all times; and this left 1 tech for the other 2 wings. Staff "F" reported they were short-staffed due to call offs because of Mother's Day. Staff "F" denied ever seeing nurse management help out on the units in times of staffing shortages.

2) The facility's Policy and Procedure titled Management of Minimum Staffing documents "The purpose of this policy is to provide guidelines in maintaining staffing coverage that ensures adequate staffing exists at all times, and provides a safe environment in which persons served can live and staff can work" and under Procedure "5.1 The following minimum staffing guidelines are established and will be followed. 5.1.1 Staffing for each unit and shift will be established based on the acuity of the unit and the intensity of care required. 5.1.2 The minimum number of staff required to maintain a safe and therapeutic environment will be assessed at least daily. 5.1.3 The staffing will be reviewed daily by the CNO (Chief Nursing Officer)/ADON (Assistant Director of Nursing)/Nursing Supervisor. 5.1.4 The number of required staff can be temporarily changed depending on the number and requirements of persons served needing services at any given time, and the existence of any specialized therapeutic observations" and, under Definitions "6.1 Minimum Staffing. The number of staff required to operate a unit to support a safe and therapeutic environment that meets the needs of the persons served. Minimum staffing does not include assigned specialized therapeutic observations such as 1:1 ( 1 staff to observe 1 patient) or 2:1. Specialized therapeutic observations will require additional staff."

Review of the facility's incident log from April 2019 revealed 85 patients were involved in physical altercations between patients, resulting in 20 injuries requiring at least first aid treatment and at least one transfer to the emergency room for evaluation and CT scan for head injury. Out of the 85 patients involved in physical altercations, 39 patients had no record of initiating aggressive actions towards others that month and 12 of these 39 incurred injuries. For reference, the facility has capacity for 350 patients and on 05/17/19 there were 340 patients. Fluctuations in census are minimal since patients are involuntarily committed to the facility, typically by 6-month intervals. The April 2019 incident log also documents 14 patient to staff physical altercations, an increase from an average monthly number of patient to staff physical altercations of 8.25 in 2018, and that 5 of these staff had injuries requiring Worker's Compensation, an increase from the average monthly number of patient altercations resulting in staff injuries requiring Worker's Compensation of 1.83 in 2018.

During interview on 05/16/19 at 6:09 PM Nurse, Staff "G" reported when people call off, staffing tries to replace them but can't get people to come in and when they're short, they're short. Staff "G" denied the unit staffing levels increasing in the last 10 years although they keep getting more forensic patients and there is increasingly more violence on the units; but that staffing numbers have gotten worse.

During interview on 05/16/19 at 6:41 PM, Nurse, Staff "H" reported the unit is supposed to have 5 MHTs but that when there are call outs they can't replace them all and may be short. Staff "H" reported the unit is much calmer this week with security presence on the unit but the facility can't staff that regularly. Staff "H" stated that since the patient requiring 1:1 supervision has to have male MHTs, there are usually 3 female MHTs with the all-male population of that unit. Staff "H" stated she is afraid for her life of 2 patients in the facility, both of whom have assaulted and injured staff in the past, and one of whom is on the same unit she works.

During interview on 05/17/19 at 1:08 PM Officer, Staff "I" stated they have recently added a security rotation to one unit at a time which has definitely calmed whichever unit they are on, and that they try to have that rotation on whichever unit is "hot" at the time. Staff "I" agreed that more than one unit can be "hot" at a time but they can only staff one unit.

During interview on 05/17/19 at 2:06 PM MHT, Staff "K" stated for day shifts the unit is supposed to have 4 to 5 MHTs and 2 to 3 nurses, which includes 1:1 supervision coverage for one patient, but on weekends they only have 3 to 4 MHTs during the day. Although it's an all-male unit, Staff "K" also reported the 1:1 case needs male coverage because "females are not safe" with him, so it is mostly female MHTs with the rest of the patients.

During interview on 05/17/19 at 2:33 PM MHT, Staff "J" stated there are usually 5 techs on day shift but 1 person has to be with the 1:1 case and patients have to be accompanied by an MHT to go to the clinic so they are often left with 3 MHTs on the unit.

During interview on 05/17/19 at 5:05 PM, Assistant Director of Nursing, Staff "E" reported full staffing levels as 5 MHTs and 3 nurses per unit during the day and evening shifts. Staff "E" was asked if staffing was considered as a factor in the number of assaults by patients towards other patients and staff. Staff "E" denied staffing was an issue because the DCF (Department of Children and Families) contract mandates the staffing they can have and they are already above the 3 minimum MHTs per unit they are recommended. Staff "E" stated as far as she is concerned they have plenty of staff because they are way over and, although staff may be busy, there are times that she sees them "sitting around with nothing to do." Staff "E" denied using the unit's staffing coverage for the person requiring 1:1 supervision on Las Olas because she said the male MHTs rotate with that patient for a couple hours at a time but are still on the unit. With further inquiry Staff "E" reported the rotation for 1:1 coverage did come from the unit's staff rather than adding an MHT to the schedule. Staff "E" stated they only add an MHT to the unit staffing level if 2 people require 1:1 coverage. Staff "E" verified the MHT on 1:1 coverage can not leave that patient no matter what, and that 2 MHTs also had to stay on the A-wing at all times because it contained the most aggressive patients, leaving no more than two MHTs to care for approximately 2/3rds of the unit's 48 patients. Furthermore, Staff "E" verified that patients who leave the unit for the clinic, outside appointments, or to go to the hospital must each be accompanied by an MHT, who is sent with them from the unit's staffing. When asked about call-outs, Staff "E" stated they have about 24 per diem staff they can call (for 7 units) and the facility gives a lot of overtime. Staff "E" said it is hard to get people to come in on short notice for call-offs, and it is hard to keep staff because they "just quit." Staff "E" said she didn't understand why they leave because they only hire people who have experience with the psychiatric population. When asked about DCF's contracted staffing levels, Staff "E" reported they had been the same for 10 years. Staff "E" agreed that the forensic population had increased and said it was "nothing like this back then." The Risk Manager, Staff "D" who joined this interview, stated there was more violence on the units as the number of forensic cases has increased; that they have no control over who is sent to the facility and it has gotten a lot worse but staffing has not increased with the increase in forensic cases and violent incidents and assaults on staff.

Contract No. LI809 between Florida Department of Children and Families and Correct Care, LLC for the operation and maintenance of the hospital was reviewed and documents in Exhibit A2 "The Provider shall be knowledgeable of and fully comply with all applicable state and federal laws, rules and regulations, and Department operating procedures as amended from time to time, that affect the subject areas of the Contract. Authorities include but are not limited to the following: ...CFOP 155-29 Management of Minimum Coverage in State Mental Health Treatment Facilities."

CFOP 155-29 documents the definition of Minimum Staffing as "The number of staff required to operate a ward, dorm or unit to support a safe and therapeutic environment that meets the needs of the residents. Minimum staffing does not include assigned specialized therapeutic observations such as 1:1 or 2:1. Specialized therapeutic observations will require additional staff."

CFOP 155-29 documents under Procedure "The facility operating procedure/protocol will address the management of minimum staffing in accordance with the minimum staffing definition using the following guidelines:
(1) Staffing for each unit and shift will be established based on the acuity of the unit and the intensity of care required.
(2) The minimum number of staff required to maintain a safe and therapeutic environment will be assessed at least daily.
(3) The Unit Supervisor and/or Charge Nurse will ensure staffing on the unit complies with the minimum staffing for that unit indicated in the facility policy.
c. The number of required staff can be temporarily changed depending on the number and requirements of residents needing services at any given time, and the existence of any specialized therapeutic observations.

Contract No. LI809 between Florida Department of Children and Families and Correct Care, LLC for the operation and maintenance of the hospital also documents within Exhibit C "The Provider shall deliver services informed by the principles of Trauma Informed Care, which is a service system that uses an understanding of the role and effect of trauma to accommodate the vulnerabilities of trauma survivors and allows services to be delivered in a way that will avoid inadvertent re-traumatization and will facilitate individual participation in treatment."