HospitalInspections.org

Based upon record review, interview and review of facility policies and reports, the facility failed to provide a safe environment by not establishing appropriate policies and procedures for admission; and failed to assess, monitor and provide needed oversight for one (Patient #35) of one patients with mental retardation and illness in the Outpatient Behavior Health Program who eloped. The facility inpatient census was 324 and the Outpatient Behavior Health Program census was 80.
Findings included:
1. Record review of Patient #35 showed he/she lived in a nursing facility and was admitted to the Outpatient Behavior Health Program (day program), with a diagnosis of mild Mental Retardation and Schizoid-Effective Disorder, which included intermittent times when he/she would hear voices guiding him/her to self harm.
Record review showed Patient #35 had a legal guardian and responsibility included the need for the provision of 24 hour oversight.
Record review of the nursing facility documentation (no date) of Initial Psychosocial Assessment and Social History, showed that Patient #35 completed the 3rd Grade level of education and currently had the mental capacity of a ten to twelve year old.
Record review revealed the following information:
- Patient #35 left the Outpatient Behavior Health Program (a day program from 9:00 AM - 2:30 PM),on 01/17/11 at approximately 12:40 PM, during the lunch break, unattended and unescorted, without permission, and without notifying the staff of a planned departure.
- The police found Patient #35 on a nearby street within a short time and notified the hospital's inpatient unit. However, the Director of the Inpatient Unit was not aware a patient was missing from the Outpatient Behavior Health Program. The police were told there was no party of interest missing from the hospital.
- Review of Police reports dated 01/17/11 showed the patient was transported via police car at about 1:00 PM to MetroLink (an intra-city rail transport system); and from there to the downtown area of St. Louis city, a distance of about 40 miles. The patient told the police that he/she wanted to go to the homeless shelter and knew the address.
- Patient #35 was found by the inner city plice about 10:00 P.M. sitting on a park bench looking disheveled and cold. Note: the patient had been exposed to cold weather conditions with temperatures between 20 - 40 degrees Fahrenheit, from 1:00 PM, until 10:00 PM (approximately nine hours). The police requested identification but the patient had no form of identity and told the police an inaccurate name and address. The patient told police that he/she had taken a bus trip from California to St. Louis and had decided it was a mistake. He/she wanted to go back home to California but did not have money.
- The police transported the patient to another local hospital for evaluation. Review of a Physical exam for Patient #35, at the Emergency Department on 01/17/11 at 10:00 PM, showed reports of laboratory blood values which included a blood glucose reading of 331 milligram/deciliter (mg/dl). The normal range for blood glucose level is approximately 65-199).
Note: the risk of excess glucose in the blood includes long term damage to the eyes, kidneys, nerves, small blood vessels and, eventually, larger blood vessels. This damage to the blood vessels increases the risk of cardio-vascular disease and the possibility of stroke.
During the time of the Emergency Department evaluation, Patient #35 was assessed by the facility Social Worker. The Social Worker then researched the appropriate name for Patient #35, and managed to locate the nursing facility where he/she resides and was able to arrange for transportation for Patient #35 back to the nursing facility.
During an interview on 01/24/11 at 1:30 PM, the Director of the Outpatient Program, Staff A stated that the intention of the Outpatient Program was that of a voluntary the program did not provide continual oversight of clients during the lunch break.
Review of facility policy titled, "Attendance/Leaving Program without Permission /Observation" showed the following: "Clients are responsible for notifying the group leader if they must be absent during part of a group. Otherwise, clients are expected to attend the full group session."