Kingsboro Psychiatric Hospital

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 39392 . Based on document review and interview, the facility became aware of a patient elopement and implemented corrective actions to be completed by 09/18/2024; however, as at 06/12/2026, the facility had not fully implemented the corrective actions. Findings include: Review of the facility’s corrective actions to a patient elopement dated 08/30/2024 revealed the facility would strengthen its patient privileges and passes process by requiring the attending psychiatrist, in consultation with the treatment team, to determine and review privilege levels at least every 30 days or more frequently as clinically indicated. Physician orders must include the privilege parameters, clinical rationale, and therapeutic purpose, with all decisions documented in the medical record. Medical record review for four of fourteen sampled patients revealed the facility failed to complete required elopement risk assessments prior to granting out-of-building privileges for scheduled clinical appointments. Patient #1 had physician orders for out-of-building privileges dated 5/4/2026 and 5/6/2026; however, no documented elopement risk assessments were completed prior to these activities. Patient #2 had physician orders for out-of-building privileges dated 5/20/2026, 5/26/2026, and 5/27/2026; however, no documented elopement risk assessments were completed for these dates. Patient #3 had a physician order for out-of-building privileges dated 5/26/2026; however, no documented elopement risk assessment was completed prior to the activity. Patient #13 had physician orders authorizing out-of-facility clinic privileges dated 4/9/2026 and 4/17/2026; however, no documented elopement risk assessments were associated with either order. During the interview conducted on 6/11/2026 at 12:35 PM, Staff G acknowledged attending physicians’ noncompliance with completing required elopement risk assessments. During the interview conducted on 6/11/2026 at 9:45 AM, Staff H acknowledged the same noncompliance and confirmed that the facility has not achieved its established compliance threshold of 90%.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 10686 Based on medical record review, document review, staff interview, and video surveillance record review, the facility failed to ensure psychiatric inpatients were effectively monitored, and protective measures were implemented during on-grounds and off-grounds therapeutic activities to prevent elopement. (Patient #1, Patient #2, and Patient #3) Findings include: (1) Review of the facility Incident report dated 1/4/24 documented: patient (identified as Patient #1) eloped while on an off-grounds activity in the community. The patient was escorted by a Mental Health Therapy Aide (MHTA) as per the policy. While at the clubhouse, after 15-to-30-minute rounds by the MHTA the patient could not be located, and no one saw the patient leave the clubhouse. The building was searched, and the patient was not found. A neighborhood search was started. The KPC (Kingsboro Psychiatric Center) Safety Department was notified, and they participated in the community search. The police department was also notified of the missing patient. It was also noted that the patient was not at risk for harm. The Justice Department was notified of the missing patient and the NIMRS (New York State Incident Management and Reporting System) report was completed on 1/4/24. Due diligence searches were made by telephone to various community settings and there was no information about the patient’s whereabouts. The incident report documentation identified that the patient was admitted to an acute facility with CPEP (Comprehensive Psychiatric Emergency Program), and he returned to Kingsboro Psychiatric Center on 2/21/24. Review of Patient # 1 Medical Record (MR) identified: On 7/10/23, the patient was admitted to the facility for mental health management. The Individual Service Plan (ISP)was developed on admission. It identified patient goals, objectives and methods that would guide the multidisciplinary treatment process. The ISP was reviewed and updated monthly and documented patient progress and treatment goals. The ISP review period 11/28/23 to 1/26/24 documented that the patient was progressing well with his treatment and preparation for discharge was in effect. There was a signed physician order for patient to attend psychosocial services at a community clubhouse with a facility escort. The patient eloped form the clubhouse on the first day he attended 1/3/24. Nursing Note: 1/3/24, documented, patient left the unit at 8:58 AM accompanied by MHTA (Mental Health Therapy Aide) for a scheduled appointment outside to the clubhouse facility...At about 1:10PM a call was received from nursing administration office stating that patient # 1 had eloped from the clubhouse and Safety Officers were notified, a search was in progress to locate the patient. The physicians were notified, and the patient was placed on absent status at 3:50 PM as per physician order. On 2/21/24, a psychiatrist documented mental status review when the patient returned to the facility. The documentation stated, on 2/19/24 the patient was admitted to a facility CPEP because he was experiencing auditory hallucinations, he felt anxious and went to the emergency department for help. When it was identified the patient was missing from KPC (Kingsboro Psychiatric Center) he was receptive to returning to KPC. He was medically cleared for transfer back to KPC. Upon his return on 2/21/24 he was calm, cooperative, maintained good eye contact and related well with others. No delusions were observed, he denied hallucinations as well as suicidal and homicidal ideations. His impulse control was good, his insight and judgement were improved. The patient was monitored for elopement precautions and for signs of unpredictable behavior every 15 minutes for 24 hours as per the physician order. Mental health treatment was continuing. (2) Review of the facility’s Incident Reporting Form, dated 2/5/24, at 10:30AM, identified Patient #2 and Patient #3. Staff B, Psychiatrist involved, reported Patient #2 and Patient #3 were taken out for a walk on-grounds (scheduled group activity) when Patient #2 started running towards the open gates and Patient #3 followed. Staff B immediately notified security. Staff B followed Patient #3 with another safety officer. Staff B and a safety officer caught Patient #3 when he stopped running. At 11:18 AM, Patient #3 was returned to the unit. Another safety officer followed Patient #2. Staff B reported she scoured the neighborhood but could not find Patient #2. Review of the medical record for Patient #2 identified the following: He was admitted on 8/31/2023, untimed, the Psychiatrist Comprehensive Evaluation documented History of Present Illness as, a 25-year-old male, admitted to Kingsboro Psychiatric Hospital from an acute care hospital. Risk Identification/Assessment Form dated 8/31/2023 by Psychiatrist documented, including, but not limited to Assessment of Risk/Dangerousness: Quickly Decompensate without medications. Elopement box was unchecked. Patient was not identified at risk for elopement. Review of the Individual Service Plan by multidisciplinary team dated 12/5/2023 revealed the patient making moderate progress. Psychiatrist Note documented patient informed treatment team that he continued to take his medications. Psychiatrist noted to meet patient weekly to provide psycho education regarding benefits and risk of psychotropic medications; assess and monitor progress in psychiatric stabilization to assess discharge readiness. Plan of care revealed patient can participate in various group activities including with Psychiatrist, Social Worker, Peer Specialist, Recreational Therapist, and others. Review of the Individual Service Plan by multidisciplinary team dated 2/2/2024 documented anticipated discharge of 3/25/2024. The patient wanted to be discharged to his family, and family stated that they would locate a private mental health treatment when he was ready for discharge. Plan of care was continued. The patient was not identified at elopement risk. On 2/5/2024 at 2:34 PM, Nursing Note, the patient was received alert and oriented x3. Internally preoccupied. No aggressive behavior. The patient was compliant with medications. Staff B, Psychiatrist notified staff that during group activity by walking on the grounds, patient eloped through the open gate at Clarkson Avenue. Team notified. Family notified by Social Worker. Search done by KPC safety officers. On 2/10/2024 at 3:35 PM, Nursing Note documented the patient arrived at Unit 10 at 2:50 PM, alert and oriented x3, accompanied by facility’s staff. Patient was seen at an acute care hospital for medical clearance. Blood work, chest x-ray and EKG done as per documentation. No recommendations or follow-up appointment noted. The patient was calm, cooperative; Denied any pain or discomfort. He also denied any suicidal or homicidal ideations. No cuts or bruises noted. Patient was placed on elopement precautions. Close monitoring for safety and behavioral changes ongoing by staff. (3) A review of the medical record of Patient #3 revealed a 47-year-old male was admitted to the Kingsboro Psychiatric Hospital on 3/30/23 for further stabilization. The hospital’s risk identification form, dated 3/30/23, noted that the patient had no history of elopement. The patient had been granted escorted ground privileges. The facility’s video recording for the event of 2/5/2024 at 10:30 AM was reviewed with Staff C, Director of Risk Management, and surveyors. Staff C identified the people in the video recording. -At 10:30 AM, observed three (3) people were leaving the lobby of Patient Building 2: on the leftmost was Staff B, Psychiatrist, in the middle was Patient #2, and to the right was Patient #3. -At 10:38:19 AM, observed Staff B exited from Patient Building #2 with Patient #2 and Patient #3, down to the stairs, and then to open grounds. -At 10:39:25 AM, observed Patient #2 started running towards the open gate (adjacent to Patient Building #2, identified as the Clarkson gate). Patient #3 followed Patient #2. Staff B was seen running following Patient #3. Review of the facility’s email dated 2/2/2024 at 2:40 PM, addressed for all email users and safety, documented that the Troy gate will be closed Monday, Feb 5 - Feb 8, due to construction, to conduct repair of water main break. The Troy Ave gate will be closed from 9AM - 3PM, Monday, Tuesday, and Wednesday of next week. During this time employees can use the 45th Street gate to enter and exit the campus. Please post for those who do not have access to email. During interview on 2/22/24 at about 3:00 PM, Staff D, Director of Admissions and Support Services stated that the gate which is located at E 45th Street and Clarkson was opened, this gate is usually closed. The main gate located at Clarkson and Troy Avenue was closed due to a scheduled repair of the roadway on the grounds, related to a previous water main break. The notification email concerning the scheduled repair was sent to the staff on 2/2/24 informing them that the main gate on Clarkson and Troy Avenue would be closed, due to repair work on the grounds starting 2/5/24 to 2/8/24. There was a Safety Officer posted at both gates the E 45 Street and the Troy Avenue entrance/ exit. During interview on 2/23/24 at about 11:52 AM, Staff B Psychiatrist 2, stated that all patients are permitted escorted ground privileges unless there is an identified behavior problem. The identification of patients who are allowed escorted ground privileges on any particular day is determined by information received upon morning rounds. The two patients who eloped were not on elopement precautions. She arrived outside between after 10:00 AM with the two patients who eloped. They were standing in front of the building near the sitting area, as she was speaking to one patient, she observed the other “trotting” away, she called out to him (Patient #2), and he did not respond. Then the second patient (Patient #3) started to run in the direction of the first patient, she immediately called the Safety department from her phone. She ran after both patients who ran through the opened gate on E 45th Street and Clarkson Avenue. A Safety Officer was running after the patients and caught up with one of the patients a few blocks away and this patient was escorted back to the unit (Patient #3). Other Safety Officers and herself continued to search for the second patient, there were officers in the patrol car driving around, she also was involved in the search on foot, but the patient was not located on that day. She was not aware that the gate on E 45th Street and Clarkson Avenue was opened. The Safety Officer who was present at the entrance of the unit # 2 building, was informed by her that she was going outside with the patient as per the policy. The following morning after unit rounds the team was informed by her superiors that escorted ground rounds was cancelled until further notice. During interview on 2/23/24 at about 2:03 PM, Staff A, Safety Officer stated that he was working on 2/5/24 the day of the elopement of two patients. He was assigned as the safety officer for the gate located at E 45th Street and Clarkson Avenue. He arrived at the designated station about 8:00 AM and monitored transportation and walk-ins in and out of the gate, he particularly stressed that he remained outside near the booth to ensure that there were no problems. It was cold outside and about after 10:00 AM he entered the booth to warm up. He observed two heads with hats moving quickly, he looked outside and saw the two patients running through the gate and the doctor was running after them. He realized that was a problem he immediately called the safety department since he could not leave his post. He also heard the announcement of the elopement on his radio. As soon as he got out of the booth, he saw another safety officer running to catch up with the patients and the doctor. He also observed when an officer walked back with one of the patients who did not appear to be hurt. Since the incident date he has not observed any escorted walks on the facility grounds. On 2/26/2024 at 1:58 PM, Staff K, RN Charge Nurse working on 2/5/2024 Day shift was interviewed, and the following information were gathered. Staff K stated after the staff morning rounds of 2/5/2024, Staff B, Psychiatrist spoke with her in the chart room, to take Patient #2 and Patient #3 for an outside walk. Staff K stated Patient #2 was not identified an elopement risk. Elopement risk patient is when patient is observed frequently seeking towards the door and verbalizes desire to leave and/or go home. If patient has elopement risk, the Safety staff is notified. Staff K stated by mid-morning, she was notified by Safety Officer that Patient #2 and Patient #3 ran through the Clarkson gate. On 2/27/2024 at 11:16 AM, a follow-up interview with Staff B, Psychiatrist was conducted. As per Staff B, she had taken out Patient #2 and Patient #3 before, but was unable to remember the exact dates as part of their group activity. Staff B stated she had done therapeutic walks before with no events, and no elopement for 4 years as far as she could remember. Staff B stated the facility has multi group activities and includes the therapeutic walk outside. Staff B stated, the team documents group activities but not specifically about therapeutic walk. An Immediate Jeopardy situation (IJ) was identified on 2/28/2024 at 1:19 PM due to the facility’s failure to implement protective measures to prevent elopement for patients who have been committed for psychiatric treatment in a locked behavioral unit. The facility provided an IJ removal plan to survey staff on 2/28/2024 at 8:29 PM, which included: 1) CL-034 Level of Patient Supervision policy has been revised to include additional information related to patient privileges and passes, procedure and expectations by discipline, introduction of a Risk Designation List to be maintained by each unit, and revised timeframes for patient assessment. 2) All staff impacted by the policy change will be expeditiously trained on the updated policy. Staff will be trained prior to the start of their shift. Those staff on pass days or extended leave will be trained upon return to the facility. 3) The gate at Kingsboro is not intended to keep patients from leaving the grounds. A majority of OMH (Office of Mental Health) Psychiatric Centers do not have gates and also conduct escorted on-ground and off-ground passes. The purpose of a supervised system for on and off-ground patient passes is to help individuals build and test skills and confidence to achieve a safe and successful return to the community. The IJ was removed on 3/5/2024 at 4:17 PM based on onsite verification of the facility’s implementation of the IJ Removal Plan, which included a revised policy and procedure on Level of Patient Supervision. All staff who reported to work on 3/2, 3/3, 3/4, and 3/5/2024, completed education and training regarding the revised policy and procedure on Level of Patient Supervision, as validated by staff interview and review of staff education sign-in sheets. Remaining staff members who were out on leave and have not been trained will receive training upon return to work.”