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Based on observation and interview, the hospital failed to meet the requirement for the Condition of Participation for Patient Rights. This deficient practice is evidenced by failing to ensure that patients received care in a safe setting. In the past month, three patients (Patients #4, #5, #6) have climbed the fence in the playground and eloped from the hospital. (See findings under A-0144)

Based on observation, record review and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by 3 patients climbing the fence on the playground and eloping from the hospital in the past month (Patients #4, #5, #6).
Findings:

Patient #4
Review of the medical record revealed this 15 year old male was admitted on 11/02/2024 with diagnosis of suicidal ideations.

Review of an LDH Abuse/Neglect Self-Report dated 11/03/2024 revealed the following:
8:49AM - Patient walked out of gym door leading to outside, followed by MHT. The patient ran to different areas of the fence attempting to climb.
8:49:45AM - The patient begins climbing where the two fences meet as MHT is walking toward the patient.
8:49:59AM - The patient crosses over the fence.

The report further revealed that the patient was located later that day at a family member's home.

Patient #5
Review of the medical record revealed this 16 year old male was admitted on 11/14/2024 with a diagnosis of schizophrenia.

Review of an LDH Abuse/Neglect Self-Report dated 11/22/2024 revealed the following:
8:40AM - 2North unit is leaving the gym and preparing to exit the playground area. The patient feels the fence as he stands adjacent to the gate door.
8:40:53AM - Patient walked over to gate door and began climbing. He loses grip and begins climbing fence again. The nurse is standing by.
08:41:17AM - Patient jumps fence and elopes.

The report further stated that Patient #5 was located the next day, 11/23/2024.

Patient #6
Review of the medical record revealed this 17 year old patient was admitted on 11/23/2024 with a diagnosis of major depressive disorder.

Review of an LDH Abuse/Neglect Self-Report dated 11/27/2024 revealed the patient's unit was in the gym and another patient kicked the gym entrance door and it opened. The MHT was a few feet away opening the bathroom door for another patient. The report further revealed:
8:30:09AM - A patient kicks the gym entrance door and it opens
8:30:24AM - Another patient walks out of the gym door
8:30:28AM - Patient #6 walks out the gym door, looks back and runs to the gate with the door and climbs the gated door.
8:30:54AM - Patient #6 is seen sliding through the top of the gated door and running toward the street
9:00AM - MHTs prepare to exit playground and is noted looking for Patient #5 (unaware that he had eloped).
9:12AM - Code Dove called (elopement)
9:50AM - Patient #6 arrives back to facility per police.

On 12/09/2024 at 12:00PM, observations of the outside playground revealed S3Maintenance was replacing old and broken zip ties around the exit door where Patient #6 had squeezed through the fencing above the exit door. Interview with S3Maintenance at that time revealed that this morning was the first time he had been notified of the fence issues. He further stated he had ran out of zip ties and metal clamps but they were on order.

On 12/10/2024 at 9:30AM, interview with S1Director of Plant Operations revealed that she was first notified about possible issues with the fence in the playground by S2CEO on the afternoon of 12/06/2024. She stated that S2CEO informed her that there were openings in the mesh of the fence that needed to be repaired. S1Director of Plant Operations stated that the fence was not repaired until yesterday morning, with the fence being reinforced with new zip ties and metal clamps at some of the openings where patients could possibly use to climb the fence.

On 12/10/2024 at 9:40AM, tour of the outside playground area with S1Director of Plant Operations revealed the area was surrounded by a 12 foot fence with two exit doors. One of the doors to exit the playground had hinges that had a protrusion on the inside of the playground that would allow foot or hand placement on the hinges that would make it easier to climb the fence. There was another exit door on the playground that had a box with key access located on the inside of the playground that would allow a patient easier access to climb the fence.
Observation of the entire fenced area revealed gaps between the fencing and the metal poles on 3 corners that could be used to facilitate climbing the fence. These areas also contained brackets/clamps that patients could use to climb the fence and elope.

On 12/10/2024 at 10:00AM, interview with S1Director of Plant Operations revealed that the fence was supposed to be a "no climb" fence, but the patients were still climbing over the fence. When asked if there had been interventions put into place regarding the exposed hinges/brackets on the inside of the playground or other areas on the fencing that could facilitate climbing, she stated no. She stated a fencing company had been called to look at the fence, but they had not been to the hospital yet.

On 12/10/2024 at 1:30PM, interview with S4Director of PI confirmed that the patients are continuing to utilize the playground, although there continues to be areas in the fencing that could allow patients to climb over and elope from the hospital.

Based on observation, record review and interview, the hospital's performance improvement activities program failed to implement actions to prevent recurrence of adverse patient events following 3 patient elopements from secured areas (Patient #4, #5, #6).
Findings:

Patient #4
Review of the medical record revealed this 15 year old male was admitted on 11/02/2024 with diagnosis of suicidal ideations.

Review of an LDH Abuse/Neglect Self-Report dated 11/03/2024 revealed the following:
8:49AM - Patient walked out of gym door leading to outside, followed by MHT. The patient ran to different areas of the fence attempting to climb.
8:49:45AM - The patient begins climbing where the two fences meet as MHT is walking toward the patient.
8:49:59AM - The patient crosses over the fence.

The report further revealed that the patient was located later that day at a family member's home.

The area on Self-Report titled "Investigation Results" revealed that the investigation found that the door leading from the gym to the playground was not latching properly and the door has been reset. The investigation did not indicate any issues with the fencing in the playground.

Patient #5
Review of the medical record revealed this 16 year old male was admitted on 11/14/2024 with a diagnosis of schizophrenia.

Review of an LDH Abuse/Neglect Self-Report dated 11/22/2024 revealed the following:
8:40AM - 2North unit is leaving the gym and preparing to exit the playground area. The patient feels the fence as he stands adjacent to the gate door.
8:40:53AM - Patient walked over to gate door and began climbing. He loses grip and begins climbing fence again. The nurse is standing by.
08:41:17AM - Patient jumps fence and elopes.

The report further stated that Patient #5 was located the next day, 11/23/2024.

The area on the Self-Report titled "Investigation Results" revealed that the nurse verbally attempted to get the patient to come down from the fence but feared that a physical attempt would cause harm to her or the patient. The patient was noted to be on elopement precautions, however elopement precautions indicate the patient shall remain on the unit. The staff member has received 1:1 education by the nurse manager and will sign off on elopement policy.
The investigation did not indicate any issues with the fencing in the playground.

Patient #6
Review of the medical record revealed this 17 year old patient was admitted on 11/23/2024 with a diagnosis of major depressive disorder.

Review of an LDH Abuse/Neglect Self-Report dated 11/27/2024 revealed the patient's unit was in the gym and another patient kicked the gym entrance door and it opened. The MHT was a few feet away opening the bathroom door for another patient. The report further revealed:
8:30:09AM - A patient kicks the gym entrance door and it opens
8:30:24AM - Another patient walks out of the gym door
8:30:28AM - Patient #6 walks out the gym door, looks back and runs to the gate with the door and climbs the gated door.
8:30:54AM - Patient #6 is seen sliding through the top of the gated door and running toward the street
9:00AM - MHTs prepare to exit playground and is noted looking for Patient #5 (unaware that he had eloped).
9:12AM - Code Dove called (elopement)
9:50AM - Patient #6 arrives back to facility per police.

On 12/09/2024 at 12:00PM, observations of the outside playground revealed S3Maintenance was replacing old and broken zip ties around the exit door where Patient #6 had squeezed through the fencing above the exit door. Interview with S3Maintenance at that time revealed that this morning was the first time he had been notified of the fence issues. He further stated he had ran out of zip ties and metal clamps but they were on order.

On 12/10/2024 at 9:30AM, interview with S1Director of Plant Operations revealed that she was first notified about possible issues with the fence in the playground by S2CEO on the afternoon of 12/06/2024. She stated that S2CEO informed her that there were openings in the mesh of the fence that needed to be repaired. S1Director of Plant Operations stated that the fence was not repaired until yesterday morning (12/09/2024), with the fence being reinforced with new zip ties and metal clamps at some of the openings where patients could possibly use to climb the fence.

On 12/10/2024 at 9:40AM, tour of the outside playground area with S1Director of Plant Operations revealed the area was surrounded by a 12 foot fence with two exit doors. One of the doors to exit the playground had hinges that had a protrusion on the inside of the playground that would allow foot or hand placement on the hinges that would make it easier to climb the fence. There was another exit door on the playground that had a box with key access located on the inside of the playground that would allow a patient easier access to climb the fence.
Observation of the entire fenced area revealed gaps between the fencing and the metal poles on 3 corners that could be used to facilitate climbing the fence. These areas also contained brackets/clamps that patients could use to climb the fence and elope.

On 12/10/2024 at 10:00AM, interview with S1Director of Plant Operations revealed that the fence was supposed to be a "no climb" fence, but the patients were still climbing over the fence. When asked if there had been interventions put into place regarding the exposed hinges/brackets on the inside of the playground or other areas on the fencing that could facilitate climbing, she stated no. She stated a fencing company had been called to look at the fence, but they had not been to the hospital yet.

On 12/10/2024 at 1:30PM, interview with S4Director of PI confirmed that the patients are continuing to utilize the playground, although there continues to be areas in the fencing that could allow patients to climb over and elope from the hospital.

Based on record review and interview, the hospital failed to ensure that all medical records were accurately written for 2 (Patient #4, #5) of 4 (Patient #3, #4, #5, #6) records reviewed for accuracy.
Findings:


Patient #4
Review of an LDH Abuse/Neglect Self-Report dated 11/03/2024 at 8:49AM revealed the patient climbed the fence on the playground and eloped from the hospital.

Review of Patient #4's nurses notes dated 11/03/2024 at 10:09AM revealed the nurse notified the patient's mother that he had eloped.

Review of Patient #4's observation sheet dated 11/03/2024 revealed the tech documented that the patient was in the gym and cooperative at 8:57AM and was in the dining room and cooperative at 10:57AM.

On 12/10/2024 at 2:20PM, S4Director of PI reviewed the patients record with the surveyor and confirmed the inaccurate documentation on the observation sheet dated 11/03/2024. She confirmed the patient had not been located at those times and was not in the hospital.


Patient #5
Review of an LDH Abuse/Neglect Self-Report dated 11/22/2024 at 8:40AM revealed the patient climbed the fence on the playground and eloped from the hospital. Further review of the report revealed the patient was located the next day, 11/23/2024.

Review of Patient #5's nurses notes dated 11/22/2024 at 8:40AM stated the patient was traveling from the gym to the main building and the patient climbed over the gate. Writer shouted for the patient to get down off the gate, but the patient continued climbing and escaped.

Review of nurses notes dated 11/22/2024 at 10:00AM revealed patient appears isolative, minimal talking. Nods his head and gives thumbs up or down to writer. Climbed over gate and escaped.

On 12/10/2024 at 2:10PM, S4Director of PI reviewed the patient's record with the surveyor and confirmed that the nurses note dated 11/22/2024 at 10:00AM was inaccurate because the patient had eloped and was not at the hospital at that time.