HospitalInspections.org

Based on observations, records reviewed and interviews the Psychiatric Hospital failed to ensure implementation of an interim environmental safety corrective action after two adolescent psychiatric patients eloped (escaped, left without authorization) from a locked unit. The Hospital failed to ensure one window in a patient room, that could be opened, was secured with a window-sensor alarm device twelve days after the Hospital identified the additional corrective action.

Findings included:

DAP Note regarding Patient #1, dated at 10:30 A.M. on 4/4/19, and DAP Note regarding Patient #2, dated 7:44 on 4/3/19, indicated Patients #1 & #2 eloped together on the evening of 4/3/19.

The Surveyor interviewed the Chief Quality Officer, at 11:30 A.M. on 4/12/19. The Chief Quality Officer said two adolescent patients eloped from the Hospital on 4/3/19. The Chief Quality Officer said a video surveillance camera recording showed Patient #1 obtained a window key within six seconds. Patient #1 unlatched the nurses station dutch-door handle where the medication cart was located that contained the window key in an unlocked drawer and unknown to the nurse administering medications. The medication cart was unlocked, and with the nurse's back to the medication cart, Patient #1 obtained the window key.

The Surveyor interviewed the Chief Psychiatrist at 12:00 P.M. and the Hospital Administrator at 12:30 P.M. on 4/12/19. The Chief Psychiatrist, Hospital Administrator and Chief Quality Officer said the key Patient #1 used to elope was "gone" (the key was lost).

The Hospital provided no interim corrective action regarding the lost key in the event a patient used the lost key to elope in the future, 12 days after the elopements.

The Surveyor interviewed the Hospital Administrator at 2:30 P.M. on 4/12/19. The Hospital Administrator said the Hospital would install window-sensor alarm devices on the adolescent unit on 4/12/19 and that the Hospital would install the window-sensor alarm devices on the other two patient care units over the weekend (as an additional corrective action regarding the lost window key).

The Surveyor interviewed the Chief Psychiatrist, at 7:30 A.M. on 4/24/19. The Chief Psychiatrist said the installation of the window-sensor alarm devices was completed.

The Surveyor observed, at 8:45 A.M. on 4/24/19 with the Maintenance Supervisor, that a patient room did not alarm when the Maintenance Supervisor unlocked the window. The Maintenance Supervisor said that the window did not have a widow-sensor alarm device.