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.

HIGHLAND HOSPITAL 300 56TH ST SE CHARLESTON, WV 25304 Nov. 18, 2020
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations, document review and interviews it was revealed two (2) pathways from the Admissions Department (AD) to the exterior of the building were unsecured on 11/3/20 at 9:45 p.m. when patient #1 eloped. It was revealed the facility failed to maintain the physical plant to keep patients from exiting the facility unescorted. This failure places all patients at risk for harm, injury or death as a result of exiting into an unsafe, unsecured environment.

Findings include:

A. Observation and interviews conducted during a tour of the AD on 11/16/20 at 9:10 a.m. revealed two (2) unsecured pathways to the exterior of the building were available to patients in the AD on 11/3/20 at 9:45 p.m. Patient #1 eloped using one (1) of those pathways on 11/3/20 at 9:45 p.m.

1. The first pathway was through a door that was key card protected that staff had propped open. That door led into a vestibule with a fire door leading to the exterior of the building. The fire door released when patient #1 pulled the fire alarm. The fire alarm was not key protected.

2. During the tour the State surveyor noted a second available pathway for elopement. A door leading into a waiting room from the AD had no lock. The door leading from the waiting room into the lobby had been removed. This door had been pass key protected in the past. Therefore, patients had unrestricted access from the AD to the lobby which has unlocked doors leading to the exterior of the building.

B. A review of a document titled "Summit BHC -- Highland Hospital Incident Investigation Report Format...Name of Patient: {patient #1}" listed investigation started/completed dates of 11/4/2020 -- 11/12/2020. The document contains no reference to the unlocked, unsecured pathway in the AD that led through the removed door. There is no reference to securing that pathway.

C. An interview was conducted with the Chief Executive Officer, the Director of Risk and Quality and the AD Manager on 11/16/20 at 9:50 a.m. They stated they did not know why the waiting room door was removed. They agreed the second pathway had not been identified or secured. The CEO acknowledged patients could elope using that pathway and stated the door would be rehung. In addition, the CEO stated the fire alarm located in the second pathway should be key protected.
VIOLATION: INFECTION CONTROL LOG Tag No: A0750
Based on interviews it was revealed the facility failed to provide infection control guidance and education to staff to prevent the spread of Corona Virus Disease-19 (COVID-19). This disease has been declared a pandemic and has been designated a public health emergency since 3/2020. The spread statewide and nationwide is on the rise. This failure has the potential to place patients and staff at risk for serious illness or death from the spread of the disease.

Findings include:

1. An interview was conducted on 11/16/20 at 2:38 p.m. with the Infection Prevention Controller (IPC). She stated she had only been in this position since August 2020. The IPC stated prior to taking the position, she had been doing some infection control activities on and off since June. She revealed the facility uses Centers for Disease Control (CDC) guidance as a basis for their infection control program. She stated staff have been educated on COVID-19, sporadically. She stated staff were educated on donning/doffing personal protective equipment (PPE) in May or June but there are no records of the education. She reviewed the only policy she has relating to COVID-19 with the surveyor. She acknowledged the policy had not been updated to include all symptoms which the CDC recommends to use for screening.

2. A telephone interview was conducted with the Nurse Supervisor on 11/17/20 at 11:50 a.m. She revealed she has had no training on donning/doffing PPE. She stated she thinks COVID instructions are sent to staff by email and memos.

3. A telephone interview was conducted with the security guard, who is supposed to be under contract. He stated he had been given no updated training since the beginning of the COVID-19 pandemic.

4. A telephone interview was conducted with Registered Nurse (RN) #1 on 11/17/20 at 12:45 p.m. She revealed she wasn't sure if there was a COVID-19 policy. During the interview she searched for a policy and found one (1) she stated had an effective date of 3/20/20. She stated the facility has not provided her with training on donning/doffing PPE. RN #1 stated the only information the facility gave her after the initial policy came out in March was a reminder that it was important to get a flu shot, especially because of the COVID-19 pandemic.

5. A telephone interview was conducted with RN #2 on 11/18/20 at 11:00 a.m. When asked if she had received training on care of a patient who was under suspicion for COVID-19 or who had COVID-19, she said no. When questioned if she knew what signs to look for, she stated she was given a list of symptoms to look for but couldn't recall them all. She stated she had the list of symptoms in part, "..in the bottom of my locker or at home." RN #2 further stated she did not know if equipment would be dedicated for a patient under suspicion for COVID-19 or who had COVID-19.

6. A follow-up telephone interview was conducted with the IPC on 11/18/20 at 12:30 p.m. When the surveyor told her Governing Body meeting minutes in June reflected she was appointed to the IPC position in June 2020 she said, "Okay." She stated she was not given an IPC job description nor was she given any IPC training. She stated the only information she got about the position was from post-it notes and a sheet of paper that she found in another office. She stated training for staff has, in part: "...been hit or miss." She stated she has been taking two (2) different classes on infection control since October 2020. She stated she is trying to get infection control certification.
VIOLATION: IC PROFESSIONAL TRAINING Tag No: A0775
Based on interviews it was revealed the facility failed to provide infection control education to staff to prevent the spread of Corona Virus Disease-19 (COVID-19). This disease has been declared a pandemic and has been designated a public health emergency since 3/2020. The spread statewide and nationwide is on the rise. This failure has the potential to place patients and staff at risk for serious illness or death from the spread of the disease.

Findings include:

1. An interview was conducted on 11/16/20 at 2:38 p.m. with the Infection Prevention Controller (IPC). She stated she had only been in this position since August 2020. The IPC stated prior to taking the position, she had been doing some infection control activities on and off since June. She revealed the facility uses Centers for Disease Control (CDC) guidance as a basis for their infection control program. She stated staff have been educated on COVID-19, sporadically. She stated staff were educated on donning/doffing personal protective equipment (PPE) in May or June but there are no records of the education. She reviewed the only policy she has relating to COVID-19 with the surveyor. She acknowledged the policy had not been updated to include all symptoms which the CDC recommends to use for screening.

2. A telephone interview was conducted with the Nurse Supervisor on 11/17/20 at 11:50 a.m. She revealed she has had no training on donning/doffing PPE. She stated she thinks COVID instructions are sent to staff by email and memos.

3. A telephone interview was conducted with the security guard, who is supposed to be under contract. He stated he had been given no updated training since the beginning of the COVID-19 pandemic.

4. A telephone interview was conducted with Registered Nurse (RN) #1 on 11/17/20 at 12:45 p.m. She revealed she wasn't sure if there was a COVID-19 policy. During the interview she searched for a policy and found one (1) she stated had an effective date of 3/20/20. She stated the facility has not provided her with training on donning/doffing PPE. RN #1 stated the only information the facility gave her after the initial policy came out in March was a reminder that it was important to get a flu shot, especially because of the COVID-19 pandemic.

5. A telephone interview was conducted with RN #2 on 11/18/20 at 11:00 a.m. When asked if she had received training on care of a patient who was under suspicion for COVID-19 or who had COVID-19, she said no. When questioned if she knew what signs to look for, she stated she was given a list of symptoms to look for but couldn't recall them all. She stated she had the list of symptoms in part, "..in the bottom of my locker or at home." RN #2 further stated she did not know if equipment would be dedicated for a patient under suspicion for COVID-19 or who had COVID-19.

6. A follow-up telephone interview was conducted with the IPC on 11/18/20 at 12:30 p.m. When the surveyor told her Governing Body meeting minutes in June reflected she was appointed to the IPC position in June 2020 she said, "Okay." She stated she was not given an IPC job description nor was she given any IPC training. She stated the only information she got about the position was from post-it notes and a sheet of paper that she found in another office. She stated training for staff has, in part: "...been hit or miss." She stated she has been taking two (2) different classes on infection control since October 2020. She stated she is trying to get infection control certification.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on review of thirty (30) clinical records and interviews it was revealed all thirty (30) patient's (patients #1-30) clinical records did not include every fifteen (Q 15) minute checks as ordered by their doctors. This failure has the potential to place all patients at risk for harm.

Findings include:

1. A review of thirty (30) clinical records revealed every patient (patient #1-30) on Q 15 minute checks had no documentation they were completed as ordered.

2. A telephone interview was conducted on 11/17/20 at 2:57 p.m. with the Medical Records Director. She revealed she has no access to the Q 15 minute check documentation. She stated the checks are documented in another system separate from the clinical record. She stated the clinical record is closed after discharge of the patient and does not include the Q 15 minute documentation.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on document review, staff interview and observation it was determined the governing body of the facility failed to carry out its responsibilities for the conduct of the hospital. This failure has the potential to place all patients at risk for harm, injury or death (See Tags A 068, A 144, A 392, A 467, A 701, A 750, A 775).

Findings include:

1. Review of a document titled "Highland Hospital Highland Can Help" dated 10/19/2020 revealed it stated in part: "Effective today...Highland Hospital Governing Board has appointed {employee #1} as CEO of Highland Hospital."

Review of a document titled "Bylaws Of The Governing Board" (undated but provided to the surveyor 11/18/20 on request of current bylaws) stated in part: "The Governing Body appoints the Chief Executive Officer (CEO). ...As the CEO he/she shall be responsible for the overall operation of the Hospital..." The document further states in part: "The CEO has actual authority of administration of the Hospital..." It further states in part: "The CEO shall assure the Hospital is in compliance with all legal and moral responsibilities as described in appropriate statutes, ordinances, laws or governmental rules and regulations pertaining to the Hospital. Responsibilities: The CEO shall serve as the on-site Governing Board representative and shall manage the Hospital effectively and efficiently."

2. Document review, clinical record reviews and interviews revealed the facility failed to ensure one (1) out of thirty (30) patients (patient #1) was monitored by a Doctor of Medicine or Osteopathy after she was admitted .

A. Review of patient #1's clinical record revealed a document titled, "Master Client Inquiry". The document contained a heading titled, "Admission Data". The admitted listed was 11/3/20 with an admission time of 09:00 p.m. The setting was listed as inpatient/residential. Physician #1 was the listed admitting practitioner.

B. An interview was conducted on 11/17/20 at 2:45 p.m. with the Director of Risk and Quality. He stated patient #1 was not under a physician's care at the time she eloped. The surveyor informed him the clinical record shows an admission time of 9:00 p.m. on 11/3/20 and she eloped at 9:45 p.m. on 11/3/20. He then acknowledged a physician should have been notified when patient #1 eloped and when she returned.

C. A phone interview was conducted on 11/18/20 at 11:30 a.m. with the Medical Director. He recalled patient #1 and that she eloped from the AD. He revealed his expectation was that the on-call physician would be notified when a patient eloped and when the patient returned to ensure patient safety. He stated his expectation was that the physician would order a drug toxicity screening when the patient returned. He stated in part: "Especially in this situation."

3. Review of documents revealed that on 11/3/2020 patient #1 was in the AD after she was admitted due to being involuntarily committed. She began to escalate and act out. She went through a key card access door that had been propped open. She then pulled the fire alarm in the anteroom which released the fire door leading outside and exited the building.

A. A tour was conducted of the admissions unit on 11/16/20 at 9:50 a.m. The CEO and the Director of Risk Quality accompanied the State surveyor on the tour. Observations revealed two (2) doors located immediately in front of the admissions intake desk. One (1) door is pass key protected and leads into an anteroom which leads to the outside. There is a fire pull station beside the door in the anteroom. The second door leads from the admissions room into a small waiting room. That door is not pass key protected and is not locked. The waiting room doorway leads into the lobby. There is no door between the waiting room and the lobby. The lobby has doors leading to the exterior of the building. These doors are unlocked from the inside.

B. An interview was conducted in the AD with the Admissions Manager (AM) on 11/16/20 at 10:00 a.m. The CEO and the Director of Risk Quality were present at the interview. The AM revealed he had not viewed the footage of the elopement and had no knowledge of the facts found during the investigation. He revealed he has educated admissions unit staff on not propping the door but security staff were not educated. The AM concurred patient #1 had two (2) pathways for unsecured escape the night she eloped. One (1) leading to the vestibule which leads to the outside. The second one leading to the lobby which leads to the outside.

C. An interview was conducted with the CEO on 11/16/20 at 1050 a.m. He concurred with the above.

4. Document review and interviews revealed the facility failed to staff the AD with Registered Nurses (RNs).

A. Review of patient #1's clinical record revealed a document titled "Master Client Inquiry." The document contained a heading titled "Admission Data." The admitted listed was 11/3/20 with an admission time of 09:00 p.m. The setting was listed as inpatient/residential. Physician #1 was the listed admitting practitioner.

B. An interview was conducted on 11/16/20 at 9:50 a.m. with the Admissions Manager. He revealed the Admissions Department is staffed primarily by Bachelors prepared social workers. He stated the only other staff used to work the unit would be a therapist occasionally. He revealed the department is not staffed with a RN.

C. An interview was conducted on 11/16/20 at 1:55 p.m. with the Director of Risk and Quality. He revealed nurses are not staffed in the AD but doing this has been discussed in the past.

D. A phone interview was conducted on 11/17/20 at 11:50 p.m. with the Nursing Supervisor. She revealed RNs do not staff the AD. She stated Nurse Supervisors are available if needed. RN #1 stated that she was on another unit with an agitated patient at the time patient #1 eloped from the AD. RN #1 stated she did not know if a barrier existed between the AD and the vestibule where patient #1 eloped. She stated she was unaware the door to the vestibule had been propped..

5. A review of thirty (30) clinical record reviews and an interview revealed all patient's (patients #1-30) clinical records did not include every fifteen (Q 15) minute checks as ordered by their doctors.

A telephone interview was conducted on 11/17/20 at 2:57 p.m. with the Medical Records Director. She revealed she has no access to the Q 15 minute check documentation. She stated the checks are documented in another system separate from the clinical record. She stated the clinical record is closed after discharge of the patient and does not include the Q 15 minute documentation.

6. Observations, document review and interviews revealed the facility failed to maintain the physical plant to keep patients safe and secure. One (1) patient (patient #1) eloped from the AD 11/3/20 at 9:45 p.m. through an unsecured exit.

A. A tour of the AD was conducted 11/16/20 at 9:10 a.m. Observations revealed one (1) unsecured pathway was through a door, that was key card protected, that staff had propped open. That door led into a vestibule with a fire door leading to the exterior of the building. The fire door released when patient #1 pulled the fire alarm. The fire alarm was not key protected.

Observation revealed a second unsecured pathway existed in the AD when the patient #1 eloped. That pathway still existed at the time of the tour. The pathway was through a door leading into a waiting room from the AD which had no lock. The door leading from the waiting room into the lobby had been removed. This door had been pass key protected in the past. Therefore, patients had unrestricted access from the AD to the lobby which has unlocked doors leading to the exterior of the building.

B. A review of a document titled "Summit BHC -- Highland Hospital Incident Investigation Report Format...Name of Patient: {patient #1)}" listed investigation started/completed dates of 11/4/2020 -- 11/12/2020. The document contains no reference to the unlocked, unsecured pathway in the AD which leads through the removed door. There is no reference to securing that pathway.

C. An interview was conducted with the CEO, the Director of Risk and Quality and the AD Manager on 11/16/20 at 9:50 a.m. They stated they did not know why the waiting room door was removed. They agreed the second pathway had not been identified or secured. The CEO acknowledged patients could elope using that pathway and stated the door would be rehung. In addition, the CEO stated the fire alarm located in the second pathway should be key protected.

7. Interviews revealed the facility failed to provide infection control guidance and education to staff to prevent the spread of Corona Virus Disease-19 (COVID-19). This disease was declared a pandemic and designated a public health emergency 3/2020. The spread of COVID 19 statewide and nationwide is on the rise. This failure has the potential to place patients and staff at risk for serious illness or death from the spread of the disease.

A. An interview was conducted on 11/16/20 at 2:38 p.m. with the Infection Prevention Controller (IPC). She stated she had only been in this position since August 2020. The IPC stated prior to taking the position, she had been doing some infection control activities on and off since June. She revealed the facility uses Centers for Disease Control (CDC) guidance as a basis for their infection control program. She stated staff have been educated on COVID-19, sporadically. She stated staff were educated on donning/doffing personal protective equipment (PPE) in May or June but there are no records of the education. She reviewed the only policy she has relating to COVID-19 with the surveyor. She acknowledged the policy had not been updated to include all symptoms which the CDC recommends to use for screening.

B. A telephone interview was conducted with the Nurse Supervisor on 11/17/20 at 11:50 a.m. She revealed she has had no training on donning/doffing PPE. She stated she thinks COVID instructions are sent to staff by email and memos.

C. A telephone interview was conducted with the security guard, who is supposed to be under contract. He stated he had been given no updated training since the beginning of the COVID-19 pandemic.

D. A telephone interview was conducted with Registered Nurse (RN) #1 on 11/17/20 at 12:45 p.m. She revealed she wasn't sure if there was a COVID-19 policy. During the interview she searched for a policy and found one (1) she stated had an effective date of 3/20/20. She stated the facility has not provided her with training on donning/doffing PPE. RN #1 stated the only information the facility gave her after the initial policy came out in March
was a reminder that it was important to get a flu shot, especially because of the COVID-19 pandemic.
VIOLATION: CARE OF PATIENTS - RESPONSIBILITY FOR CARE Tag No: A0068
Based on document review, clinical record review and interviews it was revealed the facility failed to ensure one (1) out of thirty (30) patients (patient #1) was monitored by a Doctor of Medicine or Osteopathy after she was admitted . This failure places all patients at risk for harm, injury or death from unsupervised care.

Findings include:

1. Review of patient #1's clinical record revealed a document titled "Master Client Inquiry." The document contained a heading titled "Admission Data." The admitted listed was 11/3/20 with an admission time of 09:00 p.m. The setting was listed as inpatient/residential. The admitting practitioner was listed as EL-KHATIB MD, HUSSEIN.

2. An interview was conducted on 11/17/20 at 2:45 p.m. with the Director of Risk and Quality. He stated patient #1 was not under a physician's care at the time she eloped. The surveyor informed him the clinical record shows an admission time of 9:00 p.m. on 11/3/20 and she eloped at 9:45 p.m. on 11/3/20. He then acknowledged a physician was not notified when patient #1 eloped nor when she returned.

3. A phone interview was conducted on 11/18/20 at 11:30 a.m. with the Medical Director. He recalled patient #1 and that she eloped from the Admitting Department. He revealed his expectation was that the on-call physician would be notified when a patient eloped and when the patient returned to ensure patient safety. He stated his expectation was that the physician would order a drug toxicity screening when the patient returned. He stated in part, "Especially in this situation."
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review it was determined the facility failed to ensure a secure environment in the Admissions Department (AD). This failure resulted in an admitted , committed patient (patient #1) eloping from the AD into the community. This failure has the potential to place all patients at risk for harm, injury or death as a result of being in an unsecured environment unaccompanied by staff (See Tag A 144).

An immediate jeopardy (IJ) was called on 11/16/20 at 11:90 a.m. The facility abated the IJ on 11/16/20 at 4:14 p.m.

A. Noncompliance--
The facility to ensure patient's rights to care in a safe setting. The facility failed to provide a secure unit for all patients being admitted through the AD. This failure lead to one (1) patient (patient #1) eloping from the admissions unit into the community. This could have resulted in serious harm, injury or death. Failure to secure the unit places all patients being treated in the admissions unit from serious harm, injury or death due to eloping through an unsecured door.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome--
Patient #1 was in the AD. She was escalating and acting out. Patient #1 eloped into the community. The potential existed for her to experience serious harm, injury or death.

C. Need for Immediate Action--
Patients continue to be admitted through the AD. Some may not be stable and attempt to elope. There were two (2) pathways available to patient #1 to elope. One (1) pathway is still unsecured.

Findings include:

1. On 11/3/2020 patient #1 was in the admissions unit after being involuntarily committed. She began to escalate and act out. She went through a pass key access door that had been propped open. She then pulled the fire alarm in the anteroom which released the fire door leading outside and exited the building.

2. A tour was conducted of the admissions unit on 11/16/20 at 9:50 a.m. The Chief Executive Officer CEO) and the Director of Risk Quality accompanied the State surveyor on the tour. Observations revealed two (2) doors located immediately in front of the admissions intake desk. One (1) door is pass key protected and leads into an anteroom which leads to the outside. There is a fire pull station beside the door in the anteroom. The second door leads from the admissions room into a small waiting room. That door is not pass key protected and is not locked. The waiting room doorway leads into the lobby. There is no door between the waiting room and the lobby.

3. An interview was conducted with the Admissions Manager (AM) on 11/16/20 at 10:00 a.m. The CEO and the Director of Risk Quality were present at the interview, which took place on the admissions unit. The AM revealed he had not viewed the footage of the elopement and had no knowledge of the facts found during the investigation. He revealed he has educated admissions unit staff on not propping the door but security staff were not educated. The AM concurred patient #1 had two (2) avenues of unsecured escape the night she eloped. One (1) led to the vestibule which led to the outside. The second one led to the lobby which led to the outside. The AM stated he was waiting for the investigation into the elopement to be completed before taking any formal actions as a response to the elopement.

4. An interview was conducted with the CEO on 11/16/20 at 1050 a.m. He concurred with the above.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of documents, observations and interviews it was revealed the facility failed to ensure a secure environment in the Admissions Department (AD). This failure resulted in an admitted , committed patient (patient #1) eloping from the AD into the community. This failure has the potential to place all patients at risk for harm, injury or death as a result of being in an unsecured environment unaccompanied by staff. (Cross-reference tag A 145).

Findings include:

1. A review of a document titled "Master Client Inquiry...Client Name (patient #1)" revealed patient #1 was admitted on [DATE] at 9:00 p.m.

A review of a document titled "Highland Hospital Incident Report" revealed patient #1 eloped from the facility from the AD on 11/3/20 at 9:45 p.m. The document revealed the Nursing Supervisor was told the patient pulled the fire alarm and eloped from the facility.

A review of a document titled "Summit BHC -- Highland Hospital Incident Investigation Report Format" revealed an investigation into patient #1's elopement was conducted from 11/4/20 to 11/12/20. The document stated in part: "Upon admission to Highland Hospital on a civil commitment, while in the admissions department (patient #1) pulled the fire alarm that in turn released a locked door and eloped."

A review of patient #1's clinical record document titled "Client Profile -- Order Details" printed for the surveyor 11/17/20 at 11:40 a.m. included thirteen (13) sequential pages (Pages 1-13). Physician's orders were documented from 11/4/20 at 02:45 a.m. through 11/10/20 at 05:28 p.m. There were no orders to admit. There was an order for discharge.

2. A tour was conducted of the admissions unit on 11/16/20 at 9:50 a.m. The Chief Executive Officer (CEO) and the Director of Risk Quality accompanied the State surveyor on the tour. Observations revealed two (2) doors located immediately in front of the admissions intake desk. One (1) door is pass key protected and leads into an anteroom which leads to the outside. There is a fire pull station beside the door in the anteroom. The second door leads from the admissions room into a small waiting room. That door is not pass key protected and is not locked. The waiting room doorway leads into the lobby. There is no door between the waiting room and the lobby.

3. An interview was conducted with the Admissions Manager (AM) on 11/16/20 at 10:00 a.m. The CEO and the Director of Risk Quality were present at the interview, which took place on the admissions unit. The AM revealed he has not viewed the footage of the elopement and has no knowledge of the facts found during the investigation. He revealed he has educated admissions unit staff on not propping the door but security staff were not educated. The AM concurred patient #1 had two (2) pathways of unsecured escape the night she eloped. One (1) pathway led to the vestibule which led to the outside and the second pathway led to the lobby which led to the outside. The AM stated he was waiting for the investigation into the elopement to be completed before taking any formal actions as a response to the elopement.

4. An interview was conducted with the CEO on 11/16/20 at 10:50 a.m. He concurred with the above.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interviews it was revealed the facility failed to staff the Admissions Department (AD) with Registered Nurses (RNs). This failure to ensure the immediate availability of a RN, when needed, places all patients at risk for harm, injury or death.

Findings include:

1. Review of patient #1's clinical record revealed a document titled "Master Client Inquiry." The document contained a heading titled "Admission Data." The admitted listed was 11/3/20 with an admission time of 09:00 p.m. The setting was listed as inpatient/residential. The admitting practitioner was listed as EL-KHATIB MD, HUSSEIN.

2. An interview was conducted on 11/16/20 at 9:50 a.m. with the Admissions Manager. He revealed the AD is staffed primarily by Bachelors prepared social workers. He stated the only other staff used to work the unit would be a therapist, occasionally. He revealed the department is not staffed with a RN.

3. An interview was conducted on 11/16/20 at 1:55 p.m. with the Director of Risk and Quality. He revealed no nurses staff the AD but staffing the department with RNs has been discussed in the past.

4. A telephone interview was conducted on 11/17/20 at 11:50 p.m. with the Nursing Supervisor. She revealed RNs do not staff the AD. She stated Nurse Supervisors are available if needed. RN #1 stated that she was on another unit with an agitated patient at the time patient #1 eloped from the AD. RN #1 stated she did not know if a barrier existed between the AD and the vestibule where patient #1 eloped. She stated she was unaware the door to the vestibule had been propped.

5. An interview was conducted on 11/17/20 at 2:45 p.m. with the Director of Risk and Quality. He acknowledged the client inquiry form documented patient #1 was admitted [DATE] at 9:00 p.m. He acknowledged a physician was not notified when patient #1 eloped on 11/3/20 at 9:45 p.m. nor when she returned around 12:00 a.m. on 11/4/20.

6. A telephone interview was conducted on 11/18/20 at 11:30 a.m. with the Medical Director. He revealed his expectation was the on-call physician would be notified when a patient eloped and when the patient returned to ensure patient safety.