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Based on chart review, interviews, and policy and procedure reviews the facility failed to follow its own policy and procedures. The facility failed to ensure the safety of the patient and assess the patient for changes in condition after an elopement from the facility.
Review of patient #1's chart revealed patient #1 and her mother presented at the Emergency Department (ED) on 9/15/14 at 5:37PM.The nurse's notes revealed patient #1 had a previous diagnosis of Bipolar Disorder and Borderline Personality Disorder. The nurses note revealed patient #1 had slammed her head into a door multiple times and received a laceration to the forehead. The mother of patient #1 had reported to the nurse that patient #1 had tried to harm herself in the past. The diagnosis read, "Suicidal Ideation." Under screening for suicidal risk assessment the nurse documented, "Suicidal Thinking Present-No." There was no documentation of homicidal ideation.
Review of the physician notes on 9/15/14 at 6:42PM stated, "This 17 years old Other Female presents to ED via Walk-in with complaints of Psych Problem. The patient presents to the emergency department with harming herself. The patient has no associated signs or symptoms."
Review of policy and procedure "Management of Patient's with Psychiatric Disorders" stated, "Patients presenting with a psychiatric complaint or for medical clearance for admission to a psychiatric facility should be placed in a room with direct observation."
During a tour of the ER on 11/19/14 Staff #1 reported patient #1 was put in the Minor ER room to address the laceration to the head. The minor ER rooms are behind closed doors in a hallway that is not visual from the nurse's station or physician area. There was no staff stationed in this hallway to monitor the patients.
Review of the nurse's notes on 9/15/14 at 8:35PM revealed the mental health authority arrived to talk to patient #1. There was no physician order or documentation found for a psychiatric evaluation from the mental health authority. There was no physician order to hold the patient in the ER for a psychiatric evaluation.
Review of the nurse's notes on 9/15/14 at 8:47PM stated, "Pt left the ED w/o parental consent. Texarkana, Tx PD notified." There was no documentation that the Physician or Nurse Practitioner (NP) was notified or aware of patient #1's elopement. Review of the physician notes for 9/15/14 revealed no documentation found of patient #1's elopement.
Review of policy and procedure "Assessment and Reassessment" stated, "Patients are reassessed as indicated by the patient's condition. Reassessment should be performed if there is a change in the patient's condition. Reassessments should be performed and documented after interventions. The condition of the patient should be documented upon discharge."
Review of the nurse's notes on 9/15/14 at 9:00 PM stated, "Brought back to the ER by TPD." There was no documentation of a re-assessment. The patient was gone from the ER for 13 minutes. There was no documentation of where the patient was found, the condition of the patient, or if the patient was placed in a safe environment.
Review of the physician's chart 9/15/14 at 10:24 PM stated, "Pt is in the hall yelling aloud. She has to be moved from M7 to T7 for closer observation. "After patient #1 eloped from the ER and was brought back to the ER, patient #1 was placed back in the same room. Patient #1 was not placed in a room visual to the ER staff and physicians for safety.
An interview with staff #1 on 11/19/14 stated, "I'm not sure why she was not put back in the minor other than there might have not been an available room."
Review of the nurse's notes on 9/15/14 at 10:39 PM revealed patient #1 was administered Ativan (anti-anxiety) 2mg IM right arm and Benadryl (antihistamine) 50mg IM to the left arm. There was no physician/nurse practitioner documentation found for "indication for use" or if the nurse practitioner had re-evaluated the patient.
An interview with staff #7 on 11/19/15 at 1:17 PM reported that he was not patient #1's nurse but had assisted with giving her meds and checking on her. Staff #7 stated, "Patient #1 was yelling and screaming out causing problems in the ER. Dr. Fry went to talk to her and told her she had to calm down because she was disturbing the whole ER. Dr. Fry never touched her. One of the nurses came to get the patient and took her to another room. I went in to talk to patient #1 and assist staff #6 to administer medication to calm her down. She had actually calmed down at that time and accepted the medication without a hold."
Review of the nurse's notes on 9/16/14 at 12:37 AM reported that the patient #1 was transferred to a psychiatric facility by ambulance.