Fairmount Behavioral issued 3rd consecutive provisional license after unsupervised patient eloped

Fairmount Behavioral Health Inpatient Unit was cited during a licensure inspection conducted by the Pennsylvania Department of Human Services (DHS) for repeat violations of regulations for adequate treatment, contents of treatment plan, release of information, and patient rights. Previously in December 2013 and June 2014, Fairmount was issued provisional licenses that lasted until February 2015. Another inspection was completed in November 2014 to determine whether the facility had sufficiently corrected the deficiencies found in prior inspections. However, DHS found repeat deficiencies and issued a third provisional license for the 6-month period of February 24, 2015 to August 24, 2015.

DHS found:

“the facility admitted Patient #2, 12 years old, as a direct admit on October 8, 2014 at         12:31pm. Around 4:00pm, the facility noticed the patient had eloped. There is no                 documentation of any patient observations or treatment that was provided from                   patient’s arrival up to patient’s elopement.”

Upon further review, it was revealed that the “admission staff completed a High Risk Visual Cue sheet identifying Patient #2 as an elopement risk who required 15 minutes checks” but observation round sheets for the same patient “did not identify any level of precaution.” DHS found that the same patient “was left unsupervised in an interview room for at least 3 hours before eloping” despite previous assessment for 15-minute observations.

DHS also found a “nursing assessment for Patient #3 documented that the patient reported a possible sexual assault 10 days prior to admission. The chart did not show evidence of any follow up or documentation verifying a report to ChildLine was made.” Also, this information related to Patient #3 was “neither addressed on the treatment plan nor deferred.”

The inspection report also noted that Patient #4 was “removed from a prior placement due to inappropriate sexual activity occurring at that residence” but additional information was “never added to assessments, incorporated into treatment planning.” Patient #4 was subsequently “discharged although still exhibiting the same symptoms and behaviors that qualified for admission to the inpatient level of care.” Further review showed that “documentation in the chart does not reflect the accomplishment or even progress towards any goal prescribed in the treatment plan.”

DHS also cited the facility for not following their own Physical Hold/Restraint Policy that specifics “at least two staff must participate in the physical hold application and one staff member as observer.” DHS found that a hold occurring on 10/14/14 “only documents the RN as observing the hold” and another hold on 10/31/14 did “not document the participation of any staff member.”

DHS also cited Fairmount after “multiple patient records were found unsecured in a television cabinet on the children unit.”

Fairmount Behavioral submitted a plan of correction and was “partially accepted” by the DHS’ Office of Mental Health and Substance Abuse Services.