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 document review, observation, and interview, it was determined that the Hospital failed to ensure that the patient's right to safe care was protected. This places all current and future suicidal/elopement patients at potential risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to secure all fire exit doors, to ensure that care was provided in a safe setting. See deficiency at A-144.

An Immediate Jeopardy (IJ) began on 3/06/2020 (date of patient's elopement), due to the Hospital's failure to ensure that the Adolescent Behavioral Health Unit fire doors were secured at all times, which allowed for a patient's elopement. This places all psychiatric patients, at potential risk for serious harm.

The IJ was identified and announced on 3/13/2020 at 12:45 PM, during a meeting with the Chief Medical Officer, Chief Nursing Officer, Accreditation Officer, Vice President Chief Quality Officer, and Executive Director of Behavioral Health Services. The IJ was removed by the survey exit date on 3/17/2020.

The IJ was removed on 3/17/2020, based on observation, interview, and document review as follows:

1. On 3/17/2020 between 1:00 PM and 1:30 PM, the BHU (3 North, 2 North, and 2 South) was toured. All fire doors were being monitored hourly by assigned staff and were locked. Staff had a key that opens the locked unit doors and fire doors.

The outpatient addiction unit (3 South) was also toured. The fire doors of this unit are also monitored hourly by assigned staff.

2. Random Interviews were conducted with MHAs E #7, E #8 and E #9. They were assigned to do the q (every) 15 minutes safety rounds on their assigned units. They stated as part of their responsibilities they are to monitor the fire doors hourly to ensure they remain secured.

3. Review of the Hospital's Behavioral Health sign in roster dated 3/2020, regarding new policies. All Behavioral Health staff, with the exception of one employee on a leave of absence, has completed the required in-services and testing for the new policies and procedures.

4. Review of the Hospital's Hourly Door Checks from all Behavioral Health Units for 3/12/2020, 3/13/2020, 3/14/2020, 3/15/2020, and 3/16/2020. The checks were completed every hour, as required.

5. Review of the Hospital's policy entitled, "Safety Precautions in Behavioral Health Services," (last Hospital review 3/13/2020) included, " ...9. Staff maintain a safe physical environment that included the following ...c. Hourly check that the hallway entrance door and fire doors are secure ..."

6. Review of the Hospital's policy entitled, "Mandatory Behavioral Health Training for NCH Support Services and Contracted Services,"(Effective 3/13/2020), that included, "Policy: To identify the process and mandatory training for NCH support and contracted staff prior to working in the behavioral health building."

Based on document review, observation, and interview, it was determined that for 1 of 1 patient (Pt #1) who eloped from the Hospital's locked Behavioral Health Unit, the Hospital failed to secure all fire exit doors, to ensure that care was provided in a safe setting.

Findings include:

1. On 3/12/20, the Hospital's policy titled, "Patients' Rights and Responsibility" (reviewed 9/17/2019) was reviewed and required "...Our Mission: We exist to improve health of the communities we serve and to meet individuals' healthcare needs ... Policy ... Patient care will be provided in response to the patient's ... need within our capacity, mission and philosophy, applicable laws and regulations..."

2. On 3/12/20, the Hospital's policy titled, "Safety Precautions in Behavioral Health Services" (revised 1/28/2020) was reviewed and required "...(The Hospital) provides a safe ... environment for hospitalized patients in the Behavioral Health Services Unit ... Staff maintain a safe physical environment that includes the following...observe patients for safety every 15 minutes...monitor hallways for patient safety..."

3. On 3/12/20, Pt #1's clinical record was reviewed. Pt #1 was a [AGE]-year-old who presented to the Emergency Department (ED) on 3/6/20 at 8:27 AM for mental health evaluation. Pt #1 had a history of ADHD (attention-deficit hyperactivity disorder) and anxiety. The clinical record included:

-The ED history & physical dated, 3/6/20 at 8:46 AM, noted, "Positive for behavioral problems ...negative for suicidal ideas. Pt #1 stated that he is not suicidal but wanted to run away. Petition completed by mother for Pt #1's admission to behavioral health..."

- The Behavioral Health Unit nurse's progress note, dated 3/6/2020 at 5:09 PM included, "Received (Pt #1) from (the Hospital's ED) ... (Pt #1) presents as anxious, irritable, oppositional, ambivalent ... (Pt. #1) states reason for admission is 'I smashed my mom's computer ... with a hammer' ... (Pt. #1) reports he then ran away and mom called police. (Pt. #1) claims he was only found because mom put a tracker on his phone ... (Pt #1) also claims that if he is not discharged in 2 days, he is going to 'break out of here'... (Pt #1) placed on suicide, elopement and assault precautions and will be monitored for safety..."

- The progress notes of E #3 (Registered Nurse), dated 3/6/2020 at 9:12 PM, included, "At 6:30 PM, received phone call from dad. (Pt. #1's father) was concerned about how angry his son (Pt #1) was about being in the hospital. (E #3) told (Pt. #1's father) she (E #3) would check on (Pt #1) and offer (Pt. #1) medication to help him calm. Went to check on (Pt #1) but (Pt. #1) was not in his room. Asked assistance from other staff to locate (Pt #1). Searched unit, unable to find (Pt #1). Security notified. Called 911 and supervisor informed."

- The progress notes of E #3 dated 3/6/2020 at 6:30 PM included, "At approximately 6:47 PM, called (Pt. #1's) parents to inform them of (Pt. #1) leaving the unit. As (E #3) was speaking to (Pt. #1's) dad, dad stated, 'He (Pt #1) just got here! How did that happen?' ..."

4. On 3/12/2020, the Hospital presented an occurrence report for Pt. #1 dated 3/6/2020. The report included, " "Following a phone call from (Pt. #1's) parents, (E #3) went to check on (Pt. #1's) in his room but was unable to locate ... (E #2 and E #3) unsuccessful. RNs noticed the door to stairwell 4 was ajar and able to be pushed open. (E #3) went down the stairwell to look for (Pt. #1) and noticed fire exit door on ground level was not locked and was able to be pushed open without setting off any alarm ...The door to stairwell 5...door ajar and able to be pushed open as well"

5. On 3/12/2020 at approximately 11:36 AM, an interview with E #5 (Executive Director of Behavioral Health Services) was conducted. E #5 stated that the review of the occurrence regarding (Pt. #1's) elopement identified that the fire doors were left unlocked after maintenance staff were checking smoke detectors earlier in the day. E #5 also stated that Pt. #1 was able to escape through the unattended and unlocked fire doors.