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Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they did not provide an appropriate medical screening examination (MSE) to rule out an emergency medical condition (EMC) within its capabilities and capacity for one patient (#23) out of 31 Emergency Department (ED) sampled cases from 09/28/21 through 03/28/22. Patient #23 presented to the ED by Emergency Medical Services (EMS) and law enforcement after he had made suicidal (SI, thoughts of causing ones' own death) statements to family, EMS and law enforcement. A mental health assessment was not completed prior to the patient's elopement (when a patient makes an intentional, unauthorized departure from a medical facility) from the hospital. As a result law enforcement was called but the patient was not found and was not returned to the hospital.

Findings included:

1. Review of the hospital's policy titled, "Request for Medical Screening Examination and Treatment," dated 06/20/08, showed that in the event an individual presents to the hospital's dedicated ED or on hospital property and requests a medical screening examination and treatment for what may be an emergency medical condition, or has such a request made on his/her behalf, the individual will receive an appropriate medical screening examination and treatment. In the event the individual refuses to be transferred, examined, or treated by the emergency personnel, he/she will be asked to sign a refusal form, which includes the risks and benefits of the refusal. The individual's refusal must be documented in the Emergency Department's log book.

Review of the hospital's policy titled, "Against Medical Advice (AMA)," dated 04/10/15, showed the following:
- In case of elopement or left without being seen (LWBS) complete the electronic medical record with any information that was provided.
- Complete an AMA form to include the reason for leaving, appropriate risks and benefits, and a patient signature. Patients are not required to sign an AMA form and may refuse to sign. In this case the departure is still an AMA and you document refused to sign and why on the form with your initials, date and time.
- A reasonable effort should be made to give the patient discharge instructions.
- Leaving AMA is determined by the patient's decision to leave the facility having been informed of and appreciating the risks of leaving without completing treatment. Fully competent patients are legally able to discharge themselves without completing treatment.
- Elopement is defined as a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave. Elopement is legally defined as a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected.

Review of the hospital's policy titled, "Suicide Risk and Precautions," dated 05/28/19, showed the following:
- Suicide risk is defined as a process of estimating the likelihood for a person to attempt or successfully end their life by suicide.
- Suicide results from a complicated array of factors. There are no standards for the prediction of suicide. The more risk factors and or warning signs the patient exhibits, the greater the risk of suicide.
- Factors that increased the patient's risk of suicide include psychiatric disorders, lack of impulse control, unexplained changes in behavior and prior suicide attempts.

Review of the hospital's undated document titled, "Psychiatric Safe Room Checklist and Documentation Guide," showed the following:
- If the safety of anyone is threatened, notify the EMS or House Supervisor for additional assistance.
- Any patient that requires continuous observation is a high risk patient.
- Patient's under continuous observation shall not leave their room, unauthorized.
- Patient's suffering from SI/attempt who are voluntary or involuntary may not leave and may have affidavits (a written statement confirmed by oath, for use as evidence in court) signed and notarized, or a 96 hour hold may be placed by law enforcement or a judge.

Review of the ED record for Patient #23 dated 01/27/22, showed that he was a 27 year old male who presented by EMS and law enforcement to the ED at 6:39 AM, with complaints of an anxiety (a feeling of fear or worry experienced intermittently) attack and suicidal thoughts. Nursing triage and assessment were completed and the patient was placed on suicide percautions with a 1:1 sitter. Staff I, ED Physician evaulated the patient and documented that he alternated between gettng angry and crying and threatened to leave. A psychiatric consult was ordered and an affidavit was completed by law enforcement. At 7:10 AM Patient #23 put his coat on and walked out the door of the hospital ED and eloped. Staff failed to follow their policy to provide Patient #23 with an adequate and completed MSE to rule out and EMC and failed to prevent the patient from leaving the hospital. The patient was not found or returned to the hospital for completion of the MSE.



See A-2406 for additional information.


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Based on interview and record review, the hospital failed to maintain an accurate central log for patients presenting to the emergency department (ED) for care. The log failed to accurately document the disposition of four patients (#7, #9, #23 and #27) of 31 ED records reviewed from the ED logs from September 2021 through March 2022. The hospital's average monthly ED census over the past six months was 655.

Findings included:

1. Although requested, the hospital did not have a policy that addressed the ED log.

Review of the ED log dated 10/06/21, showed that Patient #27 presented to the ED on 10/06/21 at 7:56 AM, with shortness of air and his disposition was discharged to home or self-care on 10/06/21 at 4:00 PM.

Review of Patient #27's ED medical record showed he was a 64 year old male that presented to the ED on 10/06/21 at 7:56 AM, with the complaint listed as shortness of air. Patient #27 was discharged from the ED and admitted to the hospital as an inpatient on 10/06/21 at 10:23 AM, for hypoxia (not enough oxygen reaching the cells and tissues in the body), and volume overload.

Review of the ED log dated 01/20/22, showed Patient #9 presented to the ED on 01/20/22 at 3:22 PM, with alcohol withdraw and his disposition was left against medical advice (AMA) or discontinued care on 01/21/22 at 5:45 PM.

Review of Patient #9's ED medical record showed he was a 33 year old male that presented to the ED on 01/20/22 at 3:22 PM, with the complaint listed as alcohol withdraw. Patient #9 was discharged from the ED and admitted to the hospital as an inpatient on 01/20/22 at 7:30 PM, for pneumonia (infection in the lungs), alcoholism and chronic pancreatitis (inflammation of the pancreas).

Review of the ED log dated 01/27/22, showed Patient #23 presented to the ED on 01/27/22 at 6:39 AM, with suicidal ideation (SI, thoughts of causing one's own death) and his disposition was left AMA on 01/27/22 at 8:18 AM.

Review of Patient #23's ED medical record showed he was a 27 year old male that presented to the ED on 01/27/22 at 6:39 AM, with the complaint listed as anxiety attack and SI. Patient #23 left the hospital while he was on a one to one (1:1, continuous visual contact with close physical proximity), in paper scrubs with no shoes on, without the permission of the physician, prior to having a physician ordered psychiatric evaluation. AMA paperwork was not in medical record.

Review of the ED log dated 02/08/22, showed that Patient #7 presented to the ED on 02/08/22 at 12:00 PM, with the complaint listed as leg swelling and fluid retention and her disposition was left blank. The discharge date and time on the ED log was 02/18/22 at 12:45 PM.

Review of Patient #7's ED medical record showed that she was a 64 year old female that presented to the ED on 02/08/22 at 12:00 PM, with the complaint listed as leg swelling and fluid retention. Patient #7 was admitted to the hospital as an inpatient on 02/08/22 at 3:47 PM for exacerbation (increase in symptoms) of congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues).

During interviews on 03/29/22 at 8:45 AM, and 03/30/22 at 1:40 PM, Staff D, ED Supervisor, stated that the ED log did not have separate options for patients who left AMA, eloped, left without being seen (LWBS), and did not show hospital admissions from the ED. The ED log reflected the final disposition for the patient from the hospital, so if the patient were admitted to the hospital from the ED the log would show the discharge from the hospital inpatient stay and not the ED. The ED log did not reflect the true disposition of the patients from the ED, and there was no way for the hospital to determine the true disposition of patients from the ED based off the ED log.

The overall failure of the hospital to have a process that accurately entered patient information, including an accurate date, time and disposition, made it difficult to identify whether or not patients received a Medical Screening Examination (MSE), stabilizing treatment, were discharged appropriately, eloped or left AMA. This failure has the potential to effect all patients that presented to the hospital ED.

Based on interview, record review, and policy review the hospital failed to provide a complete medical screening examination (MSE) within its capacity and capability, to determine if an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid serious harm or serious impairment) existed for one patient (#23) of 31 patients' records reviewed who presented to the Emergency Department (ED) for emergency care, out of a sample selected from 09/28/21 to 03/28/22. Patient #23 presented to the ED by Emergency Medical Services (EMS) and law enforcement for suicidal ideations (SI, thoughts of causing ones' own death) with an affidavit (a written statement confirmed by oath, for use as evidence in court) for an involuntary hold (96 Hour Hold, court-ordered evaluation by behavioral specialists to determine if a person is at risk of harm to self or others). The hospital's ED saw an average of 655 patients per month.

Findings included:

1. Review of the law enforcement document titled, "Incident Report," dated 01/27/22 showed that:
- On 01/27/22 at 6:10 AM Law Enforcement Officer Q was dispatched to the home of Patient #23 to assist EMS.
- Upon arrival Patient #23 admitted to suicidal thoughts.
- The scene was secured and Patient #23 was transported to the hospital by EMS.
- Law Enforcement Officer Q also responded to the hospital to complete an affidavit for a 96 hour mental evaluation.

Review of the law enforcement document titled, "Affidavit In Support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours," dated 01/27/22 showed that:
- On 01/27/22 Law Enforcement Officer Q was dispatched to a residence in reference to Patient #23 for an anxiety attack.
- Upon arrival Patient #23's mother advised Law Enforcement Officer Q that the patient was suicidal.
- Law Enforcement Officer Q asked Patient #23 if he was having suicidal thoughts and the patient replied that he was.
- The affidavit was signed and notarized by Staff D, RN, ED Supervisor.

During a telephone interview on 04/01/22 at 11:19 AM, Law Enforcement Officer Q confirmed that he had completed an affidavit for Patient #23 on 01/27/22 after Patient #23 had made suicidal statements. Law Enforcement Officer Q stated that he had either given the completed affidavit to the patient's nurse or the physician because that was the normal process and he never gave affidavits to registration clerks.

Review of the ED record for Patient #23 dated 01/27/22, showed that he was a 27 year old male who presented by EMS and law enforcement to the ED at 6:39 AM, with complaints of an anxiety (a feeling of fear or worry experienced intermittently) attack and suicidal thoughts. Nursing triage and assessment performed by Staff N, Registered Nurse, (RN), showed that the patient was at risk for self/harm and elopement and had experienced SI and anxiety every other day for the past year. Staff N, RN documented that the patient was having chest pain/tightness, shortness of breath, increased breathing, repetitive statements, had a disheveled appearance and was crying. The patient informed Staff N that he had taken a shot of alcohol that morning and had last used methamphetamine (a drug with more rapid and lasting effects than amphetamine, used illegally as a stimulant) three days prior. Staff I, ED Physician, documented at 6:40 AM that the patient was brought in by EMS accompanied by law enforcement for anxiety attack and SI, that he had SI and anxiety every other day for the last year and did not have a plan for suicide. Staff I also documented that the patient was well known to the EMS with a history of methamphetamine use, last used three days prior and EMS and law enforcement were completing affidavits. The patient had presented to the ED multiple times over the past eight months for anxiety, depression, panic disorder and substance abuse. Staff I, ED Physician, documented that the patient reported he was on mental health medications but had not taken them for over a year. Staff I documented that the patient's affect (observable facial, vocal or gestural behaviors that are an expression of feelings) was inappropriate, he was agitated, paced in the room, alternated between getting angry and crying and threatened to leave. Staff D, RN, ED Supervisor, documented at 6:56 AM that Staff L, Certified Nursing Assistant (CNA), was there to do 1:1 direct continuous observation and documented that the patient got up out of bed and stated that he was leaving and that they had no reason to keep him there. Staff D documented that he tried to talk to the patient and convince him to stay but the patient told him to get out of his way, the police were called and the patient left the building. Staff I, ED Physician, documented that at 7:10 AM the patient put his coat on and walked out the door and stated that he was leaving while only wearing hospital issued paper scrub pants, with no shirt and no shoes on. The patient walked out into the parking lot while ED staff attempted to convince him to stay but he pushed his way out the door and into the parking lot. Local law enforcement was called to find the patient and return him to the ED so he could go through a mental health evaluation. At 8:00 AM, Staff I documented that the patient had not yet returned to the ED so he closed the chart and dismissed the patient. The discharge summary documented by Staff I, ED Physician, showed a discharge diagnosis of suicidal thoughts and the disposition of the patient was documented as left AMA or elopement. Lab results showed a blood alcohol level (BAL, the amount of alcohol in the blood) of 80 (considered legally intoxicated as normal range 0-10) collected at 6:58 AM with a result time of 7:30 AM and his urine drug screen was positive for amphetamines, methamphetamines, and Tetrahydrocannabinol (synthetic marijuana, more harmful than plant-based marijuana) with a collection time of 6:51 AM and a result time of 7:15 AM. Patient #23 had his blood drawn for testing beginning at 6:51 AM with results received after the patients' elopement at 7:10 AM. A psychiatry consult for a mental health evaluation was ordered by Staff I, ED Physician at 6:47 AM. There were no AMA forms or affidavits in the medical record.

During an interview on 03/31/22 at 9:45 AM, Staff N, RN, stated that he had worked the night shift and was the primary care nurse for Patient #23 on his arrival to the ED until his shift ended at 7:00 AM. He stated that if a patient with SI precautions left the hospital without permission that law enforcement would be called and it would be considered to be an elopement.

During an interview on 03/30/22 at 3:52 PM, Staff J, EMT, stated that she was the sitter for Patient #23 until the end of her shift at 7:00 AM. She stated that the patient had not mentioned SI to her but that he had very high anxiety. She stated that elopement was when a patient left and was not in their right mental capacity to do so.

During an interview on 03/30/22 at 4:42 PM, Staff L, CNA, stated that she worked day shift and usually worked on the inpatient units but sometimes filled in the ED as a patient sitter. She stated that she had received online training for performing 1:1 observation, but had not received training in de-escalation (reduction of the intensity of a conflict or potentially violent situation) and she confirmed that she was the sitter for Patient #23 on the day shift of 01/27/22. She stated that when she arrived to the ED, to take over the role of patient sitter, law enforcement was inside the patients room with the door closed. She stated that after law enforcement left lab personnel entered the room to draw blood and when they were finished she took the patient to the bathroom for him to change into paper scrubs. Staff L stated that when they returned to the room the patient ripped off the paper scrub shirt, grabbed his coat and walked towards the doorway. She stated she stood up with her arms straight out to her sides in an attempt to prevent him from exiting the room when Staff D, RN, ED Supervisor told her not to fight the patient and the patient walked out of the room and exited the building. She stated that Staff D tried to talk to the patient to get him to come back. She stated that during his stay Patient #23 "yelled a lot" and she recalled that the patient stated he only came to the hospital for drugs. Staff L stated that she remembered it was cold outside with snow on the ground and that the patient had no shoes on.

During interviews on 03/28/22 at 2:10 PM and 03/30/22 at 1:38 PM, Staff D, RN, ED Supervisor, stated that he was aware that Patient #23 had presented to the ED with EMS and law enforcement for SI. He stated that as the patient was exiting the building Staff D spoke with Staff I, ED Physician, and Staff I told him that Patient #23 was of sound mind, alert, oriented and was not suicidal. Staff D stated that he followed the patient out the exit door and tried to talk to him. He stated that the patient did not come back inside so law enforcement was called due to "obligation" to get him back and get him the help he needed as it was the "right thing to do." Staff D stated that Patient #23's departure was considered to be an AMA and not an elopement because it was a witnessed event and an elopement was an unwitnessed event. He stated that they generally wouldn't call law enforcement with an AMA patient but Patient #23's case was different because of the statements the patient made to EMS and law enforcement and he needed to come back to get a mental health evaluation. Staff D stated that the hospital had a contract with another hospital to provide tele-psych services 24 hours a day, seven days a week to patients who needed a mental health evaluation. He stated that Patient #23 did not have an incident report completed for the AMA per hospital policy. Staff D confirmed that Patient #23 had not yet received a mental health evaluation prior to his departure from the hospital. Staff D also stated he had no knowledge of an affidavit with this patient. (Staff D signed and notarized the affidavit that was completed by Law Enforcement Officer Q)

During an interview on 03/30/22 at 2:59 PM, Staff I, ED Physician, stated that when Patient #23 walked out of the ED he was adamant that he wasn't suicidal. He stated he was concerned that Patient #23 would get physical when he attempted to leave and that the patient was just high on meth and was saying stupid things but he "could make sound decisions." He stated that after the patient left the building they called law enforcement so that he wouldn't be walking around in the cold with no shoes on. Staff I stated that it was the end of his shift so he completed the discharge summary so Patient #23 would not be left on the ED patient listing as an active patient. He stated that he completed the discharge summary and confirmed that he entered the discharge diagnosis as suicidal thoughts with a disposition of AMA or elopement.

Review of the hospital's document titled, "Telemedicine Agreement," dated 02/2019, showed that Hospital D agreed to provide telemedicine services and call coverage for emergency behavioral health patients including call coverage from 02/2019 through 02/2022, 24 hours a day, seven days a week and 365 days a year. Physicians and other qualified medical personnel, including licensed clinical social workers and mental health professionals were available to provide screening and assessment of emergency behavioral health conditions. Telemedicine for behavioral health patients was available on 01/27/22.

The hospital failed to ensure that Patient #23 received a mental health evaluation as part of his MSE to determine if he was suffering from an EMC. The patient presented by EMS and law enforcement with an affidavit for a 96 hour hold, after he had made suicidal statements to family, EMS and law enforcement. While the patient was in the ED he displayed lack of impulse control, changes in behavior that were all warning signs of SI (per hospital policy). The hospital had the capability to contact on-call mental health assessment staff, who were available by phone for evaluation of the patient's mental health, and referral for inpatient placement, if necessary. The patient's behavior escalated and he eloped, the hospital staff made no attempts to prevent him from leaving. The patient did not return to the hospital for further evaluation as he was not found by law enforcement.




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