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 and interview the facility failed to prevent the elopement of 1 (Patient 1) of 76 patients in facility.


Record review of facility incident reports dated 12/19/19 reads, Patient # 1 was in the admission area. The Admission Nurse had come from taking another patient through door. The key dropped off the key ring, patient grabbed it and ran out of door.

A review of the Supervisor (Staff B) statement reads, a staff member told me she lost her key. Went out to hall to look. Patient moved out of way so I could look around him. Patient 1 moved out of way from chair, when I didn't see any key, I moved over to look elsewhere. I had my back turned and Patient # 1, ran out the door.

During an interview on 12/23/19 at 10:40 AM, with Staff B, Supervisor. I was the manager in charge that day. Patient #1 was sitting outside admissions office with another patient. When the nurse turned around the key (1 key) was not on her ring. I was heading out to the unit when I heard the door slam and Patient #1 was gone.

During an interview on 12/23/19 at 11:30 AM, with Patient # 1, stated to the surveyor that he wanted a beer badly. I saw nurse put her keys down in her purse and I took it. They had me in this hospital gown and just ran to the homeless camp next door and got clothes from them. I got my beers and cigarettes and I was coming back.

Review of the facility's policy tilted" Patient Observation Policy and Procedure" reads:
to assess the condition of the patient in regard to their safety needs, implement an observation level to meet the patient's safety needs, and continue to observe the patient routinely for safety in compliance with physicians' order and prescribed protocols.

Review of the facility's policy titled " Safety and Health Assessment Policy and Procedure"
The purpose of this policy is to ensure each inpatient is evaluated by nursing staff upon admission for health and safety reasons.

Review of the facility's policy tilted " Elopement of Patients Policy and Procedure"
Purpose: the purpose of this policy is to establish guidelines for the staff in the handling of patients who have eloped or are deemed to be missing from the program, to ensure patients are provided with follow up care, they are not in imminent danger to themselves or others, to ensure all safety measures are taken and to provide adequate documentation in the patient's medical record.

Review of the facility's policy titled " Patient Rights While in Treatment Policy and Procedure" reads: The right to humane care and protection from harm.