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Based on a review of medical records, interviews with staff, a review of policy and procedures, Medical Staff Rules and Regulations and Medical Staff Bylaws review, a review of the facility's event logs, and employee personnel files, it was determined the facility failed to treat and stabilize patients as required, within the facility's capabilities for further examination and treatment. Specifically, the facility failed to maintain a safe environment for three out of (P#2, P#3, and P#20) of 20 1013' d patients.

Cross-reference to findings at - A-2407.

Based on a review of medical records, interviews with staff, a review of policy and procedures, Medical Staff Rules and Regulations and Medical Staff Bylaws review, a review of the facility's event logs, and employee personnel files, it was determined the facility failed to treat and stabilize patients as required, within the facility's capabilities for further examination and treatment. Specifically, the facility failed to maintain a safe environment for three out of (P#2, P#3, and P#20) of 20 1013'd patients (P) sampled when:

Findings:

P#2 was evaluated and determined to be a danger to himself and others. P#2 was not monitored as ordered for safety on 6/5/22.

P#3 was evaluated and determined to be a danger to himself and others. P#3 was not monitored as ordered for safety and was able to elope from the facility on 6/5/22 and again on 6/6/22.

P#20 was evaluated and determined to be a danger to himself and others. P#20 was not monitored as ordered for safety and was able to elope from the facility on 4/18/22.


1. A review of Patient (P) #2's medical record revealed that he arrived at the ED on 5/25/22 at 1:00 p.m., accompanied by law enforcement. A continued review of the record revealed that P#2 arrived at the ED with a signed Form 1013 (legal document for transportation to an emergency receiving hospital for involuntary mental health treatment). A review of the Patient Order Summary revealed that Behavioral Health Precautions, Line of Sight Observation, was ordered on 5/25/22 at 1:14 p.m.

A review of the provider's note, time unknown, revealed that P#2 had been transported by law enforcement from an outpatient clinic with a signed 1013. P#2 reported that his outpatient therapist was concerned that he was agitated and signed a 1013 for him to be transported to the hospital. P#2 denied suicidal or homicidal ideations and was calm, cooperative, and alert. P#2 did not meet the criteria for an involuntary hold. At 4:35 p.m., a physician's note revealed that the 1013 was rescinded, and P#2 was agreeable to being discharged. After four hours of observation, the patient could be discharged. P#2 left the ED with discharge instructions at 6:13 p.m.

A review of P#2's medical record failed to reveal a triage assessment, no, behavior assessment was completed. Additionally, the medical record failed to reveal documentation of observations and monitoring from when Behavioral Health Precautions were ordered on 5/25/22 at 1:14 p.m. until Form 1013 was rescinded on 5/25/22 at 4:35 p.m.

A review of P#3's medical record revealed that he arrived at the ED on 6/5/22 at 11:02 a.m. with a behavioral health complaint. A Form 1013 was signed on 6/5/22 at 11:00 a.m. Triage was started at 11:11 a.m., and an acuity level of 2 (Emergent)was assigned.

A review of the Patient Order summary included orders for:
Behavioral Health Precautions: Line of Sight Observation was ordered on 6/5/22 at 11:11 a.m.
Geodon (an antipsychotic medication) by mouth twice a day was ordered on 6/5/22 at 11:31 a.m.
Behavioral Health Consultation and Medical Clearance were ordered on 6/5/22 at 12:16 p.m.

A medical screening exam (MSE) was started at 12:17 p.m. During triage, family members explained that P#3 had not been taking his anxiety and depression medications and had been wandering the streets. A review of 'Notes' revealed a social worker note on 6/5/22 at 12:26 p.m. that a request for a behavioral health consult and 1013 request had been entered. A telehealth visit with a contracted behavioral health provider was initiated at 1:41 p.m. A note by the behavioral health assessor on 6/5/22 at 2:57 p.m. revealed that P#3 scored 'no risk' on the suicide risk assessment. P#3 denied suicidal or homicidal ideations. An inpatient psychiatric transfer was recommended. The behavioral health assessor interviewed P#3's mother and learned that P#3 had recently been released from an inpatient psychiatric facility and had expressed suicidal ideations during that hospitalization. Continued review of 'Notes' revealed on 6/5/22 at 2:57 p.m. that a Form 1013 had been signed and that P#3's mother requested inpatient treatment. A note dated 6/5/22 at 6:01 p.m. revealed that P#3 eloped. A nurse's note revealed that staff attempted to stop P#3 from leaving, and the patient refused verbal de-escalation. Security and the physician were notified that P#3 had eloped.

A continued review of P#3's medical record revealed that he presented back to the ED on 6/6/22 at 9:17 a.m., accompanied by the police department, due to an elopement on 6/5/22. P#3 was calm and cooperative and denied suicidal or homicidal ideations. An MSE was initiated at 9:20 a.m. Triage was started at 9:22 a.m., and an acuity level of 2 was assigned. A Form 1013 was signed at 9:30 a.m. A nurse's note by LPN GG revealed that P#3 eloped at 9:45 a.m., and security was notified.

P#3 was returned to the ED by the police department on 6/6/22 at 11:25 a.m. At 9:06 p.m., ARC notified staff that P#3 had been accepted by another facility. P#3's mother was notified of the pending transfer, and she arrived at the ED to sign documentation. P#3 left the ED at 10:40 p.m. en route to an inpatient psychiatric hospital. A review of a Transfer Form revealed that a physician signed it on 6/6/22, time illegible. Continued review of the Transfer Form revealed that a physician accepted P#3 at the receiving facility, and the nurse-to-nurse report was given on 6/6/22, time illegible. The time of transfer on the Transfer Form was 11:05 p.m.

A review of the medical record for P#3 failed to reveal documentation of monitoring and observations during the ED visit on 6/5/22 and 6/6/22.


A review of P#20's medical record revealed that he presented to the ED on 4/18/22 at 3:25 p.m. with complaints of suicidal ideations. Triage was started at 3:38 p.m., and P#20 was assigned a level 2 acuity. A review of the triage notes revealed that P#20's father brought him to the ED and reported that P#20 was talking to people that were not there and had suicidal ideations. An MSE was done at 3:41 p.m.

A review of the Patient Order Summary included a Behavioral Health Precautions: Line of Sight Observation, a Behavioral Health Consult, and Medical Clearance on 4/18/22 at 3:43 p.m.
Form 1013 was signed at 3:45 p.m.

A nurse's note by RN JJ revealed that at 4:30 p.m., the staff went into P#20's room to move him to one of the behavioral health rooms and found the P#20's father standing at the door. P#20's father informed the staff member that P#20 had left about 10 minutes earlier. Security and county law enforcement were notified.

A review of P#20's medical record failed to reveal documentation of monitoring and observations.


An interview with a Laboratory staff member (Lab) EE was conducted during the ED tour on 6/6/22 at 1:30 p.m. in the main ED hallway. Lab EE explained that she was assigned to 'sit' with P#3. She explained that this was the first time she had been asked to sit with a behavioral health patient. She had never had de-escalation training and stated that she would notify another staff member or security if she needed assistance. She further explained that if a behavioral health patient attempted to leave, she would verbally attempt to get them to stay and notify the physician.

An interview with Patient Care Technician (PCT) FF was conducted during the tour of the ED on 6/6/22 at 1:45 p.m. in the hallway. PCT FF explained that she had worked at the facility for seven years and was in the float pool. She explained that she was currently responsible for seven behavioral health patients, four in private rooms and three on stretchers in the hallways. She stated that P#3 had 'ran away' earlier this morning and was brought back to the facility by the police. Lab EE was now sitting with P#3. She stated that she did not even know that P#3 was assigned to her until after he eloped (to leave intentionally and unauthorized). PCT FF explained that the four rooms were monitored via video. PCT FF stated that she had not been offered de-escalation training.

An interview with Chief Nursing Officer (CNO) DD was conducted on 6/6/22 at 2:00 p.m. in the
conference room. CNO DD explained that the facility had a pool of Patient Safety Attendants (PSA) that were used to 'sit' with behavioral health patients. She stated that if a staff member was pulled to sit with a patient that had never been assigned to this task before, they received 'just in time' training and sitting with patients. She explained that the facility had a behavioral health unit but was limited to geriatrics. The hospital contracted with a behavioral health provider to do tele-psych services. The contracted behavioral health provider staff assisted with transferring patients that needed admission.

An interview was conducted with the ED Manager (MGR) CC on 6/6/22 at 2:40 p.m. in the conference room. MGR CC explained that after a behavioral health patient received a medical clearance, the contracted behavioral health provider was consulted to do an assessment and make recommendations. Behavioral health patients were monitored depending on the physician's order. MGR CC was not aware of de-escalation training for PSAs. She stated that the ambulance entrance could not be exited without a badge or code. She said that the ED did not utilize restraints a lot.

An interview was conducted with Licensed Practical Nurse (LPN) GG on 6/6/22 at 3:05 p.m. in the conference room. RN GG explained that he had worked in the ED for 19 years. She recalled that at the beginning of the morning shift (6/6/22) there were three RNs for the entire ED. The charge nurse did triage from 7:00 a.m. to 11:00 a.m. The 'low acuity' area had two medics today. When the ED needed 'sitters,' the house supervisor was responsible for providing a staff member; if one was unavailable, the ED had to pull from their own staff. LPN GG explained that at the time of this interview, seven behavioral health patients were in the ED with a 1013 that was supposed to have close monitoring. She explained that if a patient arrived with a behavioral health complaint, a 1013 was initiated by the ED provider or the behavioral health assessor if necessary. All behavioral health patients received an MSE by the ED provider and were medically cleared prior to transfer to a behavioral health facility. A contracted company provided the behavioral health consults, which were exclusively teleservices. She explained that the local police department would bring patients in and leave them while the county sheriff's department was better at remaining with the patients and trying to ensure safety. LPN GG explained that the most recent ED Director had worked hard to hire and retain staff and had begun making progress until COVID, when it went to 'crap.'

LPN GG explained that yesterday, P#3 had eloped and was brought back to the ED by the police department. He again eloped this morning and was brought back by the police. At this point, a laboratory staff member was assigned to be the 'sitter.' If a 1013 patient eloped, staff called security, and the police were called. She stated that she did not advocate the staff putting themselves in harm's way to detain a patient. She further explained that the current scenario was not unusual for the ED. She stated that the ED staff had de-escalation training but was unsure about the staff that floated or who were assigned to be 'sitters.' She did not recall any specific violent incidents during the past few weeks that involved behavioral health patients. LPN GG stated that ED staff did not usually enter a patient's incident for elopements. She assumed that the house supervisor did that. The personnel file for LPN GG was reviewed. The personnel file for LPN GG failed to include evidence of current emergency de-escalation training.


An interview with RN JJ was conducted on 6/7/22 at 11:40 a.m. via telephone. RN JJ had been employed by the facility for ten years. RN JJ explained that she was a Clinical Nurse Consultant or charge nurse. She recalled that the volume of behavioral health patients had increased over the past few years. She stated that there were not enough sitters to monitor 1013 patients. She stated that on the last shift that she worked, there were six or seven 1013 patients. She explained that 1013 patients were moved to best accommodate monitoring, especially when there were no sitters. A sitter could observe the door of rooms 1, 2, 3, 4, and 7. A recent event occurred when one sitter was sitting outside of the 'pod,' and the patient in room 7 ran. By the time the sitter was able to get to room 7, the patient was gone. She further explained that most sitters were young female sitters and couldn't physically keep a person from leaving. Sometimes if the police brought in a patient, an officer would stay with the patient. She explained that the house supervisor attempted to float nurses, but most of the time, a float nurse could not function to the capacity of an ED nurse. RN JJ explained that staffing in the ED continued to be very bad. The personnel file for RN JJ was reviewed. The personnel files for RN JJ failed to include evidence of current emergency de-escalation training.


An interview was conducted with Unit Secretary (US) HH via telephone on 6/7/22 at 12:00 p.m. US HH had been employed at the facility for 11 years. She recalled that a patient had already eloped on 5/31/22 when she arrived for her shift (7:00 p.m.). It had happened prior to her arrival. She recalled that she put a note in the medical record because someone had entered AMA (left against medical advice) into the record instead of ELOPED. She stated that the house supervisor attempted to assign sitters to the ED, but often there were none available. She said she had heard of two incidents one year ago in which a behavioral health patient eloped and stole an ambulance. She stated that elopements happen 'a lot', and if the patient was a 1013, the police department was notified. She explained that most of the sitters were young females that were afraid to attempt to physically keep someone from leaving. She said it was unsafe conditions for the staff. US HH stated that staffing was increased on the days that 'the State' was in the facility. She acknowledged that the facility used an over code to alert staff that investigators were in the building. She recalled that one night, there was a violent behavioral health patient in the ED and the three nurses were busy with a cardiac arrest patient. During this time, the behavioral health patient eloped.

An interview was conducted with Physician Assistant (PA) KK on 6/7/22 at 12:30 p.m. in the nursing office. PA KK had been on staff since January 2021 and was not on staff at any other facilities. She typically worked in the low acuity area, which consisted of 13 beds. She recalled that, at times, there was one nurse for low acuity and triage. Sometimes medics were assigned to the low acuity area. PA KK could not recall a specific incident that involved P#20. She stated that she had called security a couple of times for violent, non-behavioral health patients, and they responded quickly. She had never seen staff physically restrain a patient. She affirmed that the contracted behavioral health provider did behavioral health consults and assisted with placement if needed. She further explained that the nursing staffing was 'horrible,' and most of the time, there were only three RNs for the main portion of the ED.

An interview was conducted with Interim Director of Security (IDS) AA on 6/7/22 at 2:00 p.m. in the conference room. IDS AA explained that he had been the Interim Security Director for a few months and employed at the facility in various roles for about 15 years. He explained that the nursing staff notified the security department of a 1013 was signed on a patient. A security officer assisted with ensuring the patient was changed into an appropriate gown and their valuables were secured. IDS AA further explained that if a 1013 patient attempted to elope, the staff tried to verbally de-escalate the situation and persuade them to stay. In the past, security officers did physically hold patients if needed. The nursing staff was responsible for applying restraints and medicating patients if needed.

IDS AA explained that all security staff was required to complete Crisis Prevention Intervention (CPI) training. The training included an online module and a 'live' training session. During the 'live' portion, staff did not demonstrate any 'hands-on' training. CPI was now mandatory every two years. Prior to COVID, training was annual. He stated that all security staff, ED staff, and Behavioral Health Unit staff were required to take CPI. IDS AA explained that rooms 4 and 7 in the ED could be locked. There was typically one sitter for 4 to 5 patients. He stated that there was not enough security staff to exclusively assign a security officer to the ED. If there were several 1013 patients in the ED, security tended to 'be around' the ED. If a 1013 patient eloped, the staff were to call a 'Code Silver' overhead, notify security, notify the house supervisor, and notify the police department. Calling a 'Code Silver' was a newer process, and staff did not remember to do this each time. Once security was notified of an eloped patient, they made a sweep. If the patient was observed on hospital property, security staff attempted to physically bring the patient back into the ED. If the patient was observed off-site, such as across the street, the police department was notified. He recalled at least two incidents where an eloped patient got into an ambulance and drove off. One incident was many years ago, and one was more recent. The most recent was intercepted by security staff and safely returned to the ED. IDS AA explained that the video was retained for 30 days. There were various video cameras throughout the facility.

An interview was conducted with House Supervisor (HS) LL on 6/7/22 at 3:30 p.m. in the conference room. HS LL explained that when a 1013 patient or other patients with one-to-one orders arrived, the staff notified the house supervisor. The house supervisor's office usually had two sitters per shift and two PCTs per shift that could be used as sitters. If sitter resources were low, a staff member could be assigned to 'sitter' duties. If possible, the unit provided the sitter relief for breaks and meals. If the unit was unable to provide relief, the house supervisor's office could assist in ensuring that the staff received their break. HS LL explained that when a 1013 patient eloped, the staff was supposed to call a 'Code Silver.' The house supervisor, security, and local police department were also notified in no particular order. In addition, a 'button' in the ED could be pushed to activate a 'Code Silver.'

An interview was conducted with the Vice President of Human Resources (VP) OO in the conference room on 6/8/22 at 11:30 a.m. VP OO explained that Crisis Prevention training had been online for a couple of years. He stated that per the educator, security, ED, and behavioral health unit staff were required to take CPI. VP OO acknowledged that LPN GG and RN JJ's personnel file did not contain evidence of current CPI.

A phone interview with Physician (MD) II was conducted via telephone at 12:00 p.m. MD II stated that he had been on staff at this facility for three years. MD II recalled that a sitter was available to observe 1013 patients most of the time. He further explained that staff notified security when an elopement occurred for a behavior health patient. MD II stated that security refused to call the police department in the past, but that had improved. He said that if security responded to an aggressive patient in the ED, they 'just stood around.' He continued stating that security did not attempt to stop a 1013 patient from eloping. MD II recalled having several 1013 patients was a normal occurrence in the ED. Staff was not expected to physically detain patients as they were not trained. MD II stated that staffing was a problem, and there were usually only three nurses at night.

An interview was conducted with QA BB on 6/8/22 at 1:00 p.m. in the conference room. QA BB acknowledged that no additional medical record documentation was located for the medical records requested for review.

During a follow-up phone interview with IDS AA on 6/8/22 at 1:15 p.m., he explained that a review of the video recordings in the ED waiting area on 5/25/22 failed to show any disruptive behavior.

A review of the facility's "Rules and Regulations," last revised on 11/11/21, revealed:
Transfers and EMTALA Compliance: to comply with Medical Staff Bylaws, which required adherence to state and federal regulations, as well as to comply with applicable EMTALA regulations and to ensure that patients were appropriately treated, the following was enforced:

Substance Abuse/Psychiatric Patients
Any patient known to be suicidal in intent with a primary diagnosis of substance abuse or psychiatric disorder was assessed, stabilized, and transferred to another institution where suitable facilities were available. All patients admitted while awaiting transfer were medically assessed and stabilized prior to transfer. The care of such patients remained with the attending physician until transfer or discharge. If a patient with a primary behavioral health diagnosis had a non-psychiatric condition that required treatment, the patient could be admitted. Explicit orders regarding precautionary measures were required as well as a consultation with a psychiatrist.

Emergency Medical Screening
Any individual that presented to the hospital either alone or accompanied and requested an examination for treatment of an emergency medical condition must be screened by an appropriate practitioner. The practitioner determined whether an emergency medical condition existed.

A review of the facility's policy titled 'EMTALA-Medical Screening Examination and Stabilization, policy #8539251, last approved 2/1/22, revealed that an EMTALA obligation was triggered when an individual came to a dedicated emergency department and:
1. The individual or representative acting on the individual's behalf requested an examination or treatment for a medical condition; or
2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needed an examination or treatment of a medical condition.
3. An appropriate MSE within the capabilities of the hospital's dedicated emergency department (DED) (included ancillary services routinely available) was performed. The MSE must be completed by an individual (i) qualified to perform such an examination to determine whether an EMC exists or (ii) in the case of a pregnant woman. If an EMC was determined to exist, the individual was provided necessary stabilizing treatment within the capacity and capability of the facility, or an appropriate transfer was defined by and required by EMTALA.

A continued review of the policy revealed that if a law enforcement official requested hospital emergency personnel to provide medical clearance for incarceration, the hospital had an EMTALA obligation to provide an MSE to determine if an EMC existed. If an EMC was found and was stabilized, the hospital had met its EMTALA obligations, and additional requests for assessments or testing were not required.

If a law enforcement official brought a person exhibiting behavior suggestive of intoxication to the DED to draw blood alcohol levels and requested an MSE for treatment of a possible EMC, an MSE must be performed.

The extent of the MSE:

a. The hospital must perform an MSE to determine if an EMC existed. It was not appropriate to merely 'log in' or triage an individual with a medical condition and not provide an MSE. Triage was not equivalent to an MSE. Triage entailed the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual would be screened by physician or other qualified medical person (QMP).
b. An MSE was the process required to reach, with reasonable clinical confidence, the point at which it was determined if an EMC existed. It was not an isolated event. The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
c. The individual was continuously monitored according to the individual's needs until it was determined whether or not an EMC existed, and if it did, until he or she was stabilized or appropriately admitted or transferred. The record should reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer.
d. The extent of the necessary examination to determine whether an EMC existed was generally within the judgment and discretion of the physician or other QMP performing the examination function according to algorithms or protocols established and approved by the medical staff and governing board.
e. Extent of MSE varied by presenting symptoms.

ii. Individuals with psychiatric or behavioral symptoms: the medical record indicated both medical and psychiatric or behavioral components of the MSE. The MSE for psychiatric purposes was to determine if the psychiatric symptoms had a physiological etiology. The psychiatric MSE included an assessment of suicidal or homicidal thoughts or gestures that indicated danger to self or others.


Stabilizing Treatment Within Hospital Capacity:
The determination of whether an individual was stable was not based on the clinical outcome of the medical condition. Sufficient stabilizing treatment was when the physician treating the individual in the DED had determined, within reasonable clinical confidence, that no material deterioration of the condition was likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility. In the case of an individual with a psychiatric or behavioral health condition, the individual was protected and prevented from injuring himself or others. For those who were administered chemical or physical restraints for purposes of transfer from one facility to another, stabilization may occur for a period and remove the immediate EMC, but the underlying medical condition may persist and, if not treated for longevity, the individual may experience an exacerbation of the EMC. Therefore, the treating physician should use great care when determining the EMC was, in fact, stable after administering chemical or physical restraints.
a. Stable-
The physician or QMP providing the MSE and treating the emergency determined within reasonable clinical confidence that the EMC that caused the individual to seek care had been resolved, although the underlying medical condition may exist. Once stable, EMTALA no longer applied.
b. Stabilizing Treatment within the Hospital Capacity and Transfer-
Once an MSE and stabilizing treatment had been provided, an appropriate transfer may be affected with appropriate transfer provisions.
c. Stabilizing Treatment and EMCs that was resolved-
An individual was considered stable and ready for discharge when within reasonable clinical confidence, it was determined that continued care could reasonably be performed as an outpatient or later as an inpatient, provided that a follow-up plan and discharge instructions were provided. Hospitals were expected, within reason, to assist/provide discharge the necessary information to secure follow-up.


A review of the facility's titled 'Sitter Utilization,' policy #9497360, last approved 2/1/22, revealed that the facility utilized a sitter when one of the following criteria had been met:
1. The patient had an order for involuntary treatment in effect for mental health or substance abuse (i.e., 1013, 2013) or,
2. The patient had been deemed a suicide risk or,
3. Medical necessity, as assessed by the clinical team caring for the patient, could include confusion, agitation, and fall risk, based on the IHI by using the mnemonic (ABCs)

When determined necessary per criteria, the need for a sitter was communicated to the House Supervisor via telephone; upon approval by the Chief Nursing Officer (CNO) or designee, the Nursing Supervisor coordinated staffing of employed personnel to perform as a sitter. A sitter was used only after safety measures had been exhausted for the patient that required a sitter due to medical necessity. When a 1013 or suicide precautions were in place, family, friends, or healthcare proxy could not substitute for a facility-provided sitter.

Procedure:
1. The primary nurse identified the need for a sitter based on criteria.
2. The CNO approval was not necessary for patients with orders for involuntary treatment in effect for mental health or substance abuse and one-to-one behavioral health patients.
3. The House Supervisor coordinated the staffing of a sitter.
4. The bedside sitter reported to the charge nurse on the nursing unit assigned when reporting to duty and prior to leaving for break or end of shift.
5. The house supervisor followed up with each sitter every 8 hours to determine ongoing needs.

A review of the facility titled 'Care of the At-Risk or Suicide Patient,' policy #10096688, last approved 7/16/21, revealed that the purpose was to ensure a safe environment that provided an appropriate level of observation to ensure successful management of patients that were at an increased risk of suicide and/or self-destructive behaviors.

Definitions included:

Elopement: When a patient, prior to discharge, made an intentional, unauthorized departure from the hospital unit, area, or department where he/she was expected to be. Depending on the legal status of the patient or assessed risk, elopement was considered to occur
1. As soon as the patient was seen leaving the department/area
2. As soon as the patient was discovered missing and not found after an immediate quick search of the department/area
3. If more than 30 minutes had lapsed since the patient was last seen.

Safety Attendant: An employee that had responsibility and demonstrated competence in the care of patients that required continuous supervision with focus on patient safety.

Suicide Risk Assessment: The assessment followed the SAFE-T model for suicide assessment. Evidenced-based tool utilized for Suicide Assessment was the Columbia Suicide Severity Rating Scale.

Policy:
A. In the ED, an RN screened every patient that was evaluated or treated for behavioral health conditions as their primary reason for care. The RN screened every patient upon inpatient admission for suicide risk, and anytime a patient verbalized a risk.
B. Any patient that made suicidal statements was considered at risk and was immediately placed on suicide precautions.
C. Suicide risk screening of patients under the influence of drugs and/or alcohol was revalidated when the patient demonstrated no further signs of impairment.
D. Physicians were notified if a patient was assessed 'at risk'- all levels (low, moderate, high)
E. An environment of care was created that fostered the accurate identification and successful management of patients that were at risk for suicide or self-harm.
F. Patients at risk had support, close observation, and frequent reassessment for their emotional and physical well-being.
G. The identification of risk began prior to admission and continued until discharge.
H. When a staff member recognized that an individual was losing rational control of their behavior, they should use the following techniques to regain control:
1. Respect the individual's personal space by maintaining a safe distance. If it became necessary to touch the patient, make sure to explain what you are doing prior to touching the patient.
2. Stand at an angle to the individual.
3. Keep non-verbal cues nonthreatening by maintaining a calm and respectful attitude.
4. Set and enforce reasonable limits by offering clear choices and consequences to the negative behavior.
5. Permit verbal venting when possible.
6. Stay composed and professional.
7. Maintain clear access to exit for continued escalation of disruptive behavior.
I. When staff recognized that de-escalation techniques were ineffective and potentially aggressive or aggravated physical resistance situations, they immediately disengaged and called a Code BERT.
J. Employees were not expected to put themselves in harm's way.
K. If a patient was successful in leaving the premises, securit