State inspectors visited the hospital shortly after the death of 15-year-old Kayla Neal. They learned that Kayla and two other patients attempted to flee from Shodair Children’s the day before she died. Four other escape attempts also occurred at the facility this summer, several of which involved children pulling fire alarms to unlock the building’s doors, which is the same way Kayla exited the hospital.
Montana’s Department of Public Health and Human Services determined that Shodair Children’s failed to conduct root-cause analyses after patient escape attempts to prevent future events. The facility also did not give staff members clear instructions on how to respond to patient escapes, regulators said.
As part of its correction plan, Shodair Children’s now requires staff members to perform a risk assessment within one day of an escape attempt. The facility also updated and trained staff members on new policies involving patient escapes.
Health officials revisited Shodair Children’s in September and deemed it in compliance with all regulations.
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