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Based on document review and interview, the facility failed to ensure nursing staff followed facility policy related to the patient's right to be protected by the hospital as evidenced by patient elopement for 6 of 10 patient medical records (MR) reviewed. (Patients #1, 3, 4, 5, 6, and 7)

Findings include:

1. Facility policy titled "PATIENT RIGHTS", policy number #RI-001, with a revision date of 4/2024 indicated the following: PROCEDURE: Patient Rights: 1.g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation.

2. Review of Patient #1's medical record indicated the following:
(a.) Patient #1 was voluntarily admitted to the Adult Unit on 9/11/24 at 1:15 a.m. and discharged on 10/8/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent severe without psychotic features.

(b.) A review of Patient #1's BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated on 9/21/24 indicated that Patient #1 was on assault precautions beginning on 9/19/24 at 1:43 a.m. and elopement precautions beginning on 9/20/24 at 1:06 p.m.

(c.) A review of nurse's note for Patient #1 dated 9/22/24 at 12:52 a.m. indicated the following: At approximately 9:00 (p.m.) the pt (patient) grabbed a bracelet from one of the techs (Behavioral Health Technicians) and ran out the fire exit door at the end of the unit. We called 911 to report that the pt had eloped from the facility. The provider reached out to the directors, and they had determined that (he/she) was not a threat to (himself/herself) or others at this time, but that (he/she) was hypomanic and that they were going to discharge (him/her) AMA (Against Medical Advice).

(d.) Review of an incident report for Patient #1 dated 9/21/24 reported by N20 (Registered Nurse) indicated the following: Incident Date: 9/21/24 and Incident Time: 9:00 p.m. Time of the incident is approximate. Shift: Night. Location of Incident: 400 Unit hallway/Adult Unit. Patient precautions at the time of the incident? Yes. If yes, elopement. sexually acting out. Witnesses: Staff: (N34, Behavioral Health Technician) and (N35, Behavioral Health Technician). Type of Incident: Elopement and returned greater than 30 minutes. Facts of Summary Event: (Patient #1) crowded BHT and grabbed wrist fob and opened the emergency exit door to outside the building.

3. Review of Patient #3's medical record indicated the following:
(a.) Patient #3 was voluntarily admitted to the Adult Unit on 10/4/24 at 11:45 p.m., then admitted under an EDO dated 10/7/24 and discharged on 10/12/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, single episode, severe without psychotic features and adverse effect of amphetamines.

(b.) A review of Patient #3's BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated on 10/11/24 indicated that Patient #3 was on low suicide risk precautions beginning on 10/4/24 at 11:59 p.m.

(c.) A review of nurse's note for Patient #3 dated 10/11/24 at 7:30 p.m. indicated the following: While in the courtyard, patient grabbed a bracelet from the BHT and used that to elope. Police and emergency contact notified.

(d.) A review of a nurse's note for Patient #3 dated 10/12/24 at 9:00 a.m. indicated the following: Police have been unable to locate the patient. They have checked the areas near the facility and have not located (him/her). Emergency contact has not had any contact with (him/her) at this time.

(e.) A review of an incident report for Patient #3 dated 10/11/24 reported by N25 indicated the following: Incident Date: 10/11/24 and Incident Time: 7:00 p.m. Time of the incident is approximate. Shift: Day. Location of Incident: Courtyard Adult Unit. Main Party Involved Type: Patient. Patient precautions at the time of the incident? Yes. suicide. Witnesses: Staff: (N26) BHT. Type of Incident: Elopement: Not Returned. Facts of Summary Event: All patients were outside. Patient #3 ducked and grabbed staff's arm. After ripping off the staff's beacon (fob), (Patient #3) ran. Staff attempted to do a hold. (Patient #3) ran through the bushes and across the highway.

4. Review of Patient #4's medical record indicated the following:
(a.) Patient #4 was voluntarily admitted to the Adult Unit on 10/30/24 at 1:52 p.m. and discharged on 11/9/24. The patient had diagnoses that included, but were not limited to, schizoaffective disorder, bipolar type.

(b.) A review of Patient #4's BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated on 10/11/24 indicated that Patient #4 was not on precautions at time of elopement.

(c.) A review of nurse's note for Patient #4 dated 10/31/24 at 8:01 a.m. indicated the following: Patient eloped during this shift at approximately (6:10 a.m.). Unsure if patient was injured in the process of elopement as patient did not return and kept running.

(d.) A review of a nurse's note for Patient #4 dated 10/31/24 at 10:15 a.m. indicated the following: Pt was brought back to the facility by (police) without incidence. Pt. was unharmed and was returned to the unit without further attempts to elope.

(e.) A review of a psychiatric evaluation for Patient #1 dated 10/31/24 at 2:30 p.m. indicated the following: Soon after (he/she) was admitted (he/she) became verbally aggressive got into an altercation with another patient, managed to kick open the fire escape door and took off into the night. Patient #1 was eventually brought back to intake by the police after a few hours and admitted to the unit.

(f.) Review of an incident report for Patient #4 dated 10/31/24 reported by N28 indicated the following: Incident Date: 10/31/24 and Incident Time: 6:05 a.m. Time of the incident is approximate. Shift: Night. Location of Incident: 400 Hallway/Adult Unit. Main Party Involved Type: Patient. Patient precautions at the time of the incident? No. Suicide -low risk. Witnesses: Staff: (N30) RN and (N40) RN. Type of Incident: Elopement: Returned greater than 30 minutes. Facts of Summary Event: Patient #4 pushed the door at approximately 6:00 a.m. (N28) RN removed (Patient #4) from that area. Soon after, another patient came out of (his/her) room yelling due to being woke up. Both patients had to be separated to prevent physical altercation. While (N28) attempted to separate, (Patient #4) sprinted to the end of the hallway and out the exit door. Police located and returned (Patient #4) at 8:06 a.m.

5. Review of Patient #5's medical record indicated the following:
(a.) Patient #5 was voluntarily admitted to the facility on 10/22/24 at 5:39 p.m. and was a current patient. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent severe without psychotic features and generalized anxiety disorder.

(b.) A review of Patient #5's BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated on 11/2/24 indicated that Patient #5 was on elopement and high suicide risk precautions beginning on 10/23/24 at 3:39 a.m.

(c.) A review of nurse's note for Patient #5 dated 11/2/24 at 10:03 a.m. indicated the following: Patient and two others formulated and executed a plan to choke a staff member, take their wrist band and escape. The patient was gone from the building for approximately 10 minutes.

(d.) Review of incident report dated 11/2/24 at 8:40 a.m. indicated the following: Patients #5, 6 and 7 were ordered every 15 minute observations. Patients had come back from breakfast and were escorted into the noisy activity room. (N32, Behavioral Health Technician), was in the hallway talking with a patient, (N33, Behavioral Health Technician) was in the noisy activity room with the patients, and (N22, Registered Nurse) was in the medication room, getting ready for medication pass. (Patient #5) came out of the group room and into the hallway requesting to get something out of (his/her) room. (N32), the patient (he/she) was speaking with, and (Patient #5) walked down the hallway. At this time, (Patients #6 and 7) came out of the noisy activity room and down the hallway. After (Patients #5, 6 and 7) escaped through the hallway emergency exit door, the patient, (N32) was speaking with ran to get staff (N22) and (N33).

6. Review of Patient #6's medical record indicated the following:
(a.) Patient #6 was voluntarily admitted to the facility on 10/10/24 at 9:00 p.m. and discharged on 11/4/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent unspecified and generalized anxiety disorder.

(b.) A review of nurse's note for Patient #6 dated 11/2/24 at 11:53 a.m. indicated the following: Patient and two others formulated and executed a plan to choke a staff member, take their wrist band and escape. The patient was gone from the building for approximately 5 minutes.

(c.) Review of incident report dated 11/2/24 at 8:40 a.m. indicated the following: Patients #5, 6 and 7 were ordered every 15 minute observations. Patients had come back from breakfast and were escorted into the noisy activity room. (N32, Behavioral Health Technician), was in the hallway talking with a patient, (N33, Behavioral Health Technician) was in the noisy activity room with the patients, and (N22, Registered Nurse) was in the medication room, getting ready for medication pass. (Patient #5) came out of the group room and into the hallway requesting to get something out of (his/her) room. (N32), the patient (he/she) was speaking with, and (Patient #5) walked down the hallway. At this time, (Patients #6 and 7) came out of the noisy activity room and down the hallway. After (Patients #5, 6 and 7) escaped through the hallway emergency exit door, the patient (N32) was speaking with ran to get staff (N22) and (N33).

7. Review of Patient #7's medical record indicated the following:
(a.) Patient #7 was voluntarily admitted to the facility on 10/22/24 at 11:08 p.m. and discharged on 11/14/24. The patient had diagnoses that included, but were not limited to, major depressive disorder, recurrent, severe with psychotic symptoms and generalized anxiety disorder.

(b.) A review of nurse's note for Patient #7 dated 11/2/24 at 11:59 a.m. indicated the following: Patient and two others formulated and executed a plan to choke a staff member, take their wrist band and escape. The patient was gone from the building for approximately 5 minutes.

(c.) A review of Patient #7's BEHAVIORAL HEALTH - PATIENT OBSERVATION SHEET dated 11/3/24 indicated that Patient #7 also continued to be on fall precaution and high suicide risk precautions. The observation check sheet did not indicate that Patient #7 was on elopement precautions on 11/3/24. A review of Patient #7's BEHAVIORAL HEALTH -PATIENT OBSERVATION SHEETS indicated that elopement precautions were added on 11/7/24 at 4:07 a.m. and discontinued on 11/7/24 at 10:26 a.m. and then added on 11/11/24 at 6:32 p.m. and were on the observation sheets for the patient until discharge on 11/14/24.

(d.) Review of incident report dated 11/2/24 at 8:40 a.m. indicated the following: Patients #5, 6 and 7 were ordered every 15 minute observations. Patients had come back from breakfast and were escorted into the noisy activity room. (N32, Behavioral Health Technician), was in the hallway talking with a patient, (N33, Behavioral Health Technician) was in the noisy activity room with the patients, and (N22, Registered Nurse) was in the medication room, getting ready for medication pass. (Patient #5) came out of the group room and into the hallway requesting to get something out of (his/her) room. (N32), the patient (he/she) was speaking with, and (Patient #5) walked down the hallway. At this time, (Patients #6 and 7) came out of the noisy activity room and down the hallway. After (Patients #5, 6 and 7) escaped through the hallway emergency exit door, the patient (N32) was speaking with ran to get staff (N22) and (N33).

8. During an interview with A1 on 11/15/24 at approximately 2:00 p.m., A1 verified the medical record information for Patients #1, 3, 4, 5, 6 and 7.

Based on document review and interview, the facility failed to ensure adequate licensed nursing staff and other personnel to provide nursing care to all patients as needed. (Adult Inpatient Units and Adolescent Inpatient Unit)

Findings include:

1. Facility policy titled "STAFFING PLAN FOR NURSING SERVICES", last revised on 5/2024 indicated the following: "POLICY: The Staffing Plan for Nursing Services reflects specific service needs to meet patient care and organizational needs. GENERAL STAFFING GUIDELINES: The Staffing Plan has been developed to identify staffing needs based on the following criteria: * Acadia Safe Staffing Guidelines. * Patient population. * Average daily census. * Length of stay. * Speciality needs of patient population served/acuity. * Physical environment and available technology. * Type of patient care delivered system utilized. * Skill mix. * Competencies required. * Measurable outcomes of clinical care. Core Coverage: A. The minimum staffing needed for each skill level (RNs [Registered Nurses], LPNs [Licensed Practical Nurses], Behavioral Health Associates, others) is determined by the nurse-patient ratio guidelines and patient care needs of the population. Core coverage staffing plans should be considered guidelines. (See attached staffing grids by unit.).

2. A review of the staffing grid matrix for the Adult Inpatient Unit indicated the following:
(a.) Day Shift: Census of 1 to 12 patients would require 1 RN (Registered Nurse). Census of 13 to 20 patients would require 2 RNs. Census of 1 to 10 and 13, 14, 15, 16 patients would require 1 BHT (Behavioral Health Technician). Census of 11, 12 and 17 to 20 patients would require 2 BHTs.
(b.) Night Shift: Census of 1 to 20 patients would require 1 RN. Census of 1 to 14 patients would require 1 BHT. Census of 15 to 20 patients would require 2 BHTs.

3. A review of nurse staffing worksheets provided and signed by N31 on 11/14/24 for the time period of 9/21/24 through 9/22/24, 10/11/24 through 10/13/24, 10/30/24 through 11/14/24 for the Adult Inpatient Units indicated unit was short staffed for the 300 hall/Adult Unit for the following dates:
(a.) On 11/2/24 for day shift, the census was 17 patients with 2 RNs and 1 BHT indicating the unit was short staffed by 1 BHT, based on the facility staffing grid/matrix.
(b.) On 11/6/24 for day shift, the census was 19 patients with 1 RN and 2 BHT's indicating the unit was short staffed by 1 RN, based on the facility staffing matrix.
(c.) On 11/9/24 for day shift, the census was 17 patients with 2 RN's and 1 BHT indicating the unit was short staffed by 1 BHT, based on the facility staffing matrix.
(d.) On 11/14/24 for day shift, the census was 15 patients with 1 RN and 2 BHT's indicating the unit was short staffed by 1 RN. based on the facility staffing matrix.

4. A review of nurse staffing worksheets provided and signed by N31 on 11/14/24 for the time period of 9/21/24 through 9/22/24, 10/11/24 through 10/13/24, 10/30/24 through 11/14/24 for the Adult Inpatient Units indicated unit was short staffed for the 400 hall/Adult Unit for the following dates:
(a.) On 11/5/24 for day shift, the census was 15 patients with 1 RN and 2 BHT's indicating the unit was short staffed by 1 RN, based on the facility staffing matrix.
(b.) On 11/6/24 for day shift, the census was 17 patients with 1 RN and 2 BHT's indicating the unit was short staffed by 1 RN, based on the facility staffing matrix.

5. A review of the staffing grid matrix for the Adolescent Inpatient Unit indicated the following:
(a.) Day Shift: Census of 1 to 12 patients would require 1 RN. Census of 13 to 20 patients would require 2 RNs. Census of 1 to 9 patients would require 1 BHT. Census of 10 to 17 patients would require 2 BHTs. Census of 18 to 20 patients would require 3 BHTs.
(b.) Night Shift: Census of 1 to 19 patients would require 1 RN. Census of 20 patients would require 2 RNs. Census of 1 to 11 patients would require 1 BHT. Census of 12 to 20 patients would require 2 BHTs.

6. A review of nurse staffing worksheets/assignment logs for the time period of 11/1/24 through 11/14/24 for the Adolescent Inpatient Unit indicated unit was short staffed for the 600 hall/Adult Unit for the following dates:
(a.) On 11/3/24 for night shift, the census was 11 patients with 1 RN and 1 BHT indicating the unit was staffed at minimum and lacked an additional staff member to monitor the emergency exit door on the hall.
(b.) On 11/5/24 for day shift, the census was 11 patients with 1 RN and 2 BHT's indicating the unit was staffed at a minimum and lacked an additional staff member to monitor the emergency exit door on the hall.
(c.) On 11/6/24 for day shift, the census was 14 patients with 1 RN and 3 BHT's indicating the unit was short staffed by 1 RN, based on the facility staffing matrix.
(d.) On 11/7/24 for day shift, the census was 13 patients with 1 RN and 3 BHT's indicating the unit was short staffed by 1 RN, based on the facility staffing matrix.

7. During an interview with N31 (Registered Nurse/Chief Nursing Officer) on 11/14/24 beginning at 3:00 p.m., N31 verified the nurse staffing for the Adolescent Unit and Adult Units.

Based on document review and interview, the facility failed to ensure contracted nursing staff failed to obtain de-escalation and restraint certification for 2 of 16 personnel files reviewed. (N29, Registered Nurse/Agency and N34, Behavioral Health Technician/Agency)

Findings include:

1. Facility policy titled "RN [Registered Nurse] Job Description" last revised on 1/1/2020 indicated the following: PURPOSE STATEMENT: "Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority. LICENSES/DESIGNATIONS/CERTIFICATIONS: CPR [cardiopulmonary resuscitation] and de-escalation and restraint certification required (training available upon hire and offered by facility.)"

2. Facility policy titled "Behavioral Health Technician Associate III Job Description" last revised on 1/1/2020 indicated the following: PURPOSE STATEMENT: "Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership. ESSENTIAL FUNCTIONS: Applies de-escalation techniques to help manage patient's emotions, behavior and participate in treatment and assist with seclusion and restraint when necessary. LICENSES/DESIGNATIONS/CERTIFICATIONS: CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.)"

3. A review of personnel file for N29 (Registered Nurse/Agency)'s personnel file lacked documentation of general/department specific orientation, patient rights, Handle with Care, seclusion/restraint and elopement education/training.

4. A review of personnel file for N34 (Behavioral Health Technician/Agency)'s personnel file lacked documentation of patient rights, Handle with Care, seclusion/restraint and elopement education/training.

5. During an interview with A3 (Human Resources Director) on 11/14/24 beginning at 1:00 p.m., A3 verifed the personnel file information for N29 and N34.