Insufficient Staffing on Evening Shift; Patient Elopes and then Threatens Staff With Rusty Fork

Inspectors from the Centers for Medicare and Medicaid Services (CMS) determined that the facility failed to “maintain an adequate number of registered nurses, licensed practical nurses and mental health workers to provide the nursing care necessary under each patient’s active treatment program.” CMS found that one evening shift had only one registered nurse, one LVN and one mental health technician to supervise 14 child and adolescent patients, four of whom were on line of sight monitoring precautions. Based on the facility’s staffing grid, there should have been one more mental health technician on this shift.

In the middle of this understaffed shift, a patient eloped from the facility by jumping over the fence. When he was returned by law enforcement, facility staff apparently failed to search him for contraband. Five minutes after returning, the patient placed a staff member “in a choke hold and held a rusty fork to her neck.” Examination of the facility’s policies revealed “no instructions regarding safety searches of patients for contraband or weapons following their return to the facility after an elopement.”