HospitalInspections.org

Based on policy review, record review, and staff interview, it has been determined that the hospital failed to follow their policy relative to staff to patient ratios, and assessment of patients prior to the patients participation in outdoor activities for 1 of 3 patients reviewed for elopement, Patient ID #1.

Findings are as follows:

The hospital's policy for, "Patient Supervision Levels Policy and Procedure" states in part,

...V. Procedures:

Courtyard supervision - The treatment team will evaluate the appropriateness of patients to attend any activity planned...

i. The SRN/Charge RN - will determine the need for extra staff with special attention to any activities being conducted.

ii. The staff member on duty will be provided a portable phone/2-way radio to contact staff in the event of an emergency...

iv. ...The RN/LIP will determine the staff to patient ratio prior to any outside activity and will communicate this to the SRN and Standing Office..."

According to the hospital's report submitted to the Rhode Island Department of Health on 6/14/2022, Patient ID #1 "...scaled the top of the fence and ran through the campus..." at approximately 11:57 AM on 6/13/2022 after she/he and five other patients "...entered the outdoor courtyard for fresh air..."

Record review for Patient ID #1 revealed that she/he was admitted in December of 2021 for competency restoration and has a diagnosis of schizophrenia.

Review of the "PATIENT PEN SIGN-OUT SHEET" for the Adolf Myer building unit 9, revealed that on 6/13/2022 at 11:53 AM, Employee-A, a Psychiatric Technician, signed 6 patients, including Patient ID #1, out of the unit to attend the outdoor activity in the courtyard.

During a surveyor interview on 6/21/2022 at 1:40 PM with Employee A, she indicated that after lunch on 6/13/2022, the patients requested to go outside, and she decided to take 6 patients out into the courtyard. She revealed that when she decided to take the patients outdoors, the nurse was not available, and she did not have the nurse assess the patients prior to leaving the unit. She revealed that she was in a rush and grabbed a radio without ensuring it was working. She then revealed that while outside, one of the patients told her that Patient ID #1 had climbed the fence. She indicated that she tried to use her radio at this time but found it was not working. She revealed that she then began to gather the other patients and returned to the unit to alert another staff member, Employee B, who then notified the Charge Nurse, Employee C.

During a surveyor interview on 6/21/2022 at 11:18 AM and on 6/22/2022 at 8:17 AM with the Charge Nurse, Employee C, revealed that around 12:05 PM on 6/13/2022, Employee B told her that Patient ID #1 eloped by climbing over the fence in the courtyard. She revealed that she was not aware that Employee A brought 6 patients out into the courtyard. She indicated that it is her practice to assess patients who want to go outside, prior to the activity to ensure that the patients are fit to attend it. She stated that she would have expected Employee A to ask her before taking the patients outside. She revealed that if she would have known that the 6 patients were going outside with Employee A as the only supervising staff, she would not have allowed Employee A to conduct the courtyard activity as it is her practice to always send two staff members to supervise patients while in the courtyard.

During a surveyor interview on 6/21/2022 at approximately 2:00 PM with the Risk Manager, he revealed that the police notified the hospital at 1:30 PM that Patient ID #1 was in their custody. He revealed that Patient ID #1 returned to the hospital by 3:00 PM.

During a surveyor interview on 6/21/2022 at 2:15 PM and on 6/22/2022 at 8:26 AM with the Interim Chief Nursing Officer, she acknowledged that Employee A, did not ensure her radio was working prior to going outside, and did not wait for the nurse to determine the staff to patient ratio prior to taking the patients outside per the hospital's policy. Additionally, she indicated that for safety reasons, staff have been told to have 2 staff members present when outdoors in the courtyard with patients and acknowledged that Employee A did not ensure this happened.