HospitalInspections.org

Based on record reviews, observation of a hospital-provided recorded tape of an elopement event in the Emergency Department (ED) on 02/23/14, and interviews, the hospital failed to ensure health care services were provided in the ED in accordance with the hospital's written policies as evidenced by:

1) Failure to provide continuous direct visual observation of a patient in the ED with an executed Physician Emergency Certificate (PEC) as required by hospital policy, conduct a search of a patient who presented to the ED for psychiatric evaluation to retain any objects that could be used by the patient to harm himself or others as required by hospital policy, ensure that visitors of a PEC'd patient did not bring any belongings in the patient's room as required by hospital policy, activate the hospital's Code White (used to obtain a team of employees to respond to a crisis situation in which there is a potential for a patient, visitor, or employee to become disruptive or assaultive) when a PEC'd patient was attempting to leave the ED as required by hospital policy, and document the police record number in the patient's medical record for 1 of 1 patient's record reviewed who eloped from the hospital from a total sample of 11 patients (#3);

2) Failure to ensure that continuous direct visual observation was conducted and documented every 15 minutes as required by hospital policy for patients with an executed PEC in the ED as evidenced by failure to have documented evidence that continuous visual observation was maintained and documented every 15 minutes for 9 of 10 ED patients' records reviewed who were PEC'd and had orders for direct psychiatric observation from a total sample of 11 patients (#1, #2, #3, #5, #7, #8, #9, #10, #11); and

3) Failure to ensure the ED physician ordered a patient with an executed PEC to be on direct visual observation as required by hospital policy as evidenced by S12ED Physician ordering Patient #5, who had an executed PEC due to being suicidal and a danger to self, to be on routine psychiatric observation rather than direct psychiatric observation for 1 of 10 patients' records reviewed who were PEC'd and ordered routine psychiatric observation from a total of 11 sampled patients (#5).
Findings:

1) Failure to provide continuous direct visual observation of a patient in the ED with an executed PEC as required by hospital policy, conduct a search of a patient who presented to the ED for psychiatric evaluation to retain any objects that could be used by the patient to harm himself or others as required by hospital policy, ensure that visitors of a PEC'd patient did not bring any belongings in the patient's room as required by hospital policy, and activate the hospital's Code White when a PEC'd patient was attempting to leave the ED as required by hospital policy:
Review of the hospital policy titled "Care of the Psychiatric Patient in the Emergency Department", revised March 2013 and presented as the current policy by S1Chief Operations Officer (COO), revealed that all patients presenting to the ED for psychiatric evaluation will be escorted to a treatment room for physician evaluation as soon as possible. Security and/or an ED nurse will perform a personal search and retain any objects that can be used by the patient to harm him/her or others. All patients will be placed in paper scrubs/gowns. All patients will be placed under a direct psychiatric observation status (a staff member will maintain direct visual contact with the patient at all times; movement from the designated room will require staff escort at all times) unless ordered otherwise by the physician. Documentation of observation will be completed at a minimum of every 15 minutes on the precautionary measures flow sheet and be retained as part of the medical record. Review revealed that all patients under psychiatric observation will have limited visitors, and phone calls will be restricted without a witness. Review revealed that if it is determined by the ED physician's medical screening exam that the patient is in need of inpatient psychiatric care, and the patient is deemed a harm to self, others, or gravely disabled, a PEC will be executed by the ED physician. The ED physician must specify a specific level of observation based on the patient assessment. All OPC (order of protective custody)/PEC/CEC (Coroner's Emergency Certificate) patients will be placed under direct psychiatric observation status unless a higher level of observation is specified by the physician. All OPC/PEC/CEC patients are considered an elopement risk.

Review of the hospital policy titled "Providing Care for Psychiatric and Suicidal Patients Not in Psychiatry", revised October 2013 and presented as a current policy by S1COO, revealed that all suicidal PEC/CEC patients require staff to observe the patient. Sitters are to stay with the patient at all times (strict visual contact), including during toileting and off unit tests or procedures. Further review revealed that visitors are not allowed to bring in any belongings. Documentation should reflect that someone was in visual contact with the patient at all times. Further review revealed that a patient is considered to have eloped when a PEC or CEC patient leaves the hospital without permission. In the event of elopement, security will notify the police and will begin search for the patient. Further review revealed that security can pursue and detain a committed patient on campus, but security cannot pursue and/or detain any patient off campus. If the police become involved in a search for the patient following an elopement, the police record number is recorded in the nurses' notes.

Review of the hospital's Emergency Room Policy and Procedures titled "Behavioral Emergency Cases", reviewed 02/06/13, revised 08/31/09, and presented as a current policy by S3Director of ED, revealed that in the event a patient becomes verbally or physically aggressive, violent, or unable to physically control during his/her observation in the ED, the hospital will show a good faith effort by trying to control and/or restrain the patient by calling a "Code White". "Code White" shall be paged on the in-house paging system as a call for extra personnel to respond in an effort to calm or restrain the patient. In the event attempts to control or restrain the patient fail, and the patient is believed to be dangerous, local law enforcement will be called for assistance.

Review of the hospital policy titled "Code White", presented as a current policy by S3Director of ED, revealed that it is the policy of the hospital to maintain a safe and secure environment within the facility by having a team of employees respond to any crisis situation in which there is potential for a patient, visistor, or employee to become, or when someone has become, disruptive or assaultive. Further review revealed that guidelines for non-violent crisis intervention included that an attempt would be made to have the appropriate staff to respond in order to defuse or de-escalate the situation. Further review revealed that verbal acting out required verbal intervention, physical acting out required physical intervention, and staff was to avoid over-reaction and under-reaction.

Review of Patient #3's ED record revealed he was a 33 year old male who presented to the ED on 02/23/14 at 5:28 p.m. with family members who picked him up from the sheriff's office. Further review revealed the family members indicated they were told that he needed to be evaluated and was recently released from another behavioral health unit. Patient #3's upper torso and head was covered in mud, he had "flights of ideas", and stated that he was not suicidal or homicidal.

Patient #3 had a PEC executed by S4ED Physician on 02/23/14 at 6:30 p.m. due to being a danger to self and gravely disabled. Review of his medical record revealed S4ED Physician ordered Patient #3 to be under direct psychiatric observation on 02/23/14 at 5:53 p.m. Further review revealed S7RN called the sheriff's office as requested by S4ED Physician as back up when Patient #3 was told he was being PEC'd (the family reported that Patient #3 was capable of extreme violence).

Review of Patient #3's ED medical record revealed S8RN (Registered Nurse) conducted a sitter assessment on 02/23/14 at 5:59 p.m. and at 7:33 p.m. There was no documented evidence that a staff member maintained direct visual contact with Patient #3 at all times for 1 hour and 34 minutes as required by hospital policy for an ED patient ordered to be on direct psychiatric observation.

Review of Patient #3's ED medical record revealed S7RN documented on 02/23/14 at 7:35 p.m. that Patient #3's cousin came out his room and "says patient is about to lose it." Further review revealed Patient #3 exited his room and proceeded to walk out of ED with the security guard in pursuit of the patient, and Patient #3 left in his car. Further review revealed the sheriff's office was notified of Patient #3's elopement. At 8:50 p.m. S7RN documented that "security reviewed tape of pt (patient) room. Patients family member handed patient the keys to his car." There was no documented evidence that a Code White was called to use physical intervention to keep him from eloping when Patient #3 was walking down the hall. There was no documented evidence that the police record number was documented in Patient #3's ED record.

Observation on 04/10/14 at 1:30 p.m. of the hospital-provided recorded tape of Patient #3's elopement on 02/23/14 revealed no observation of Patient #3 being searched upon his arrival and when changing into paper scrubs. Further observation revealed Patient #3's female visitor, who was allowed to enter and exit his ED room several times, carried a large purse into the room each time. There was no observation of a staff member present to provide continuous direct visual observation at all times while Patient #3 was in the ED. At 6:05 p.m. S11PCT (Patient Care Tech) entered the room, placed a set of paper scrubs on the counter, and left the room. At 6:25 p.m. S11PCT walked Patient #3 and his male family member down the hall to the bathroom. Further observation of the tape revealed S11PCT left the bathroom area, leaving Patient #3 with his male family member alone in the bathroom (no direct visual observation of Patient #3 by a staff member for 6 minutes). At 6:31 p.m. Patient #3 and his male family member return to his ED room. At 6:32 p.m. Patient #3 was observed putting something in the pocket of his scrub top (unable to see who handed the object to Patient #3 or what it was). At 6:37 p.m. the male family member was observed handing Patient #3 a set of keys. Further observation of the events leading to Patient #3's elopement were as follows:
7:39 p.m. - female family member exits the ED room; male family member closes the door;
7:40 p.m. - male family member speaking to female family member and both leave Patient #3's ED room door;
7:41 p.m. - Patient #3 walks out his room; S6Security Guard follows Patient #3 around the corner of the nursing station (leading to the door of the triage room that is unlocked and provides a means of exiting the ED into the lobby);
7:41 p.m. - observation of the camera view pointing from the registration area to the door leading to outside the building revealed the male family member exiting the building and looking in all directions and walks toward the front of the hospital;
7:41 p.m., 3 seconds later - Patient #3 walks outside the hospital with S6Security Guard behind him, and the male family member gets between Patient #3 and S6Security Guard;
7:41 p.m., 13 seconds later - the female family member walked out the building while Patient #3 was seen walking with a distance between himself and S6Security Guard;
7:42 p.m. - female family member ran into the hospital;
7:44 p.m. - male and female family members and S6Security Guard walk back into the hospital.

In an interview on 04/10/14 at 4:10 p.m., S10Biomed/IT Coordinator indicated the camera security system is set to keep recording until the drive is full, and then it starts erasing as space is needed to re-record. He further indicated that about 1 and 1/2 months' data is available before re-recording takes place. S10Biomed/IT Coordinator indicated the hospital recorded the elopement that was viewed, but he didn't have the section covered by the camera in the hall that would have shown Patient #3 leaving the ED through the triage door. He further indicated the original tape had been erased and recorded over.

In an interview on 04/10/14 at 9:00 a.m., S4ED Physician indicated that Patient #3 was a "very peculiar case". He further indicated that Patient #3 was ex-military and found walking on the side of the road covered in mud. He further indicated that the male family member reported that he (male family member) was a police officer and told staff of Patient #3's history of violence. S4ED Physician indicated he had police officers and hospital security standing outside the door when he told Patient #3 that he was being PEC'd. He further indicated that Patient #3 "acted cordial." He further indicated that the police officers left, and security maintained a presence somewhere in the ED. S4ED Physician indicated that Patient #3 stepped in the doorway and asked where the bathroom was, but before anyone could answer him, Patient #3 ran outside the ED through the triage door. When asked where the nurse was who was providing direct visual observation at the time of the elopement, S4ED Physician answered he "didn't have direct perspective, was treating other patients, didn't witness when that occurred."

In an interview on 04/10/14 at 10:05 p.m., S6Security Guard indicated when he came into the ED, Patient #3 was coming toward him, looked confused, and then turned and went toward the triage door. He further indicated that Patient #3 was walking and not running at all. S6Security Guard indicated he thought he could "talk down and de-escalate" Patient #3. He further indicated that when he got outside the building, he continued to try to talk with Patient #3, but that's when the male family member put his arm out and put his hand to try and stop S6Security Guard. S6Security Guard indicated he went past the male family member's hand while Patient #3 was still on hospital property and not running. He further indicated that Patient #3 got into a vehicle and backed toward S6Security Guard. He further indicated that he (S6Security Guard) didn't know if Patient #3 was trying to hit him, so he had to jump on the side to get out of the way of the vehicle. When asked why he didn't attempt to physically restrain Patient #3 before he left the ED, S6Security Guard answered, "he was a trained killer." He further indicated he was the only guard, and if the patient had been able to disarm him (S6Security Guard), the whole hospital would have been vulnerable. S6Security Guard indicated that all the staff members in the ED saw Patient #3 leave, and no one called a Code White which would have provided assistance, because CPI (Crisis Prevention Intervention) is a team effort and doesn't train you to handle patients alone. S6Security Guard indicated he didn't think Code White should have been called in this instance, because Patient #3 was not a combative patient. S6Security Guard indicated he hadn't had any formal training to handle such an event as an elopement. He indicated the event was discussed, but he had not had any training since the event occurred. S6Security Guard indicated that since the event the hospital had 2 guards on each shift, and one guard was assigned to watch the video camera if a psychiatric patient was in Room 3 of the ED. He further indicated if patients were placed in any of the other rooms in the ED, the guards can't be relied on to observe those patients, because only Room 3 had a video camera in the room.

In an interview on 04/10/14 at 10:30 a.m., S7RN indicated that she assumed "limited visitors" as stated in the hospital's policy meant 2 visitors at a time. She further indicated that if the ED door swings open (such as when the ambulance drivers bring a patient into ED), anyone can come in, and if she's busy with patients, she can't control the flow. S7RN indicated she was assigned as Patient #3's nurse, but she also had other patients during the time Patient #3 was in the ED. S7RN indicated that at the time of Patient #3's elopement, no one was being assigned as the sitter. She further indicated that when Patient #3 exited his room to elope, she was getting medication for another patient (in the medication room with the door open) and saw when he walked out the ED. When asked how she could provide direct visual observation of Patient #3 and care for other patients, she answered, we "all take responsibility for observation." S7RN indicated staff would sit at the nursing station desk and put the video camera on, but staff didn't continuously monitor the camera. She confirmed that Patient #3 was not constantly in the vision of a staff member at all times. S7RN indicated she watched Patient #3 walk out his room, and she asked him where he was going. She indicated that he told her he was going to the bathroom. S7RN indicated she told Patient #3 that the bathroom was in the other direction, but when he got to the corner of the nursing station, he ran toward and through the triage room door. She further indicated S6Security Guard followed Patient #3 out the ED while she called the sheriff's office requesting that they send a deputy. When asked why she and S6Security Guard didn't physically intervene to keep Patient #3 from leaving the ED, S7RN answered, "I was more interested in trying to get the cops back." S7RN indicated that now they have someone assigned to sit by the door to observe psychiatric patients. She confirmed that during a recent night shift since the elopement event, she had a PEC'd pediatric patient who she had to place in Room 4 (not in visual sight from the nursing station and no video camera in room), because the PEC'd adult patient in Room 3 was violent. She confirmed that she had to leave the pediatric patient with the parent, and thus the pediatric patient was not continuously monitored by a staff member (could not remember the name of the patient). When asked if it's possible for her to continually observe PEC'd patients and have other patients to care for, she answered, "with the amount of staff we have now, it's very difficult."

In an interview on 04/10/14 at 11:20 a.m., S8RN indicated he was working in the ED when Patient #3 arrived. He further indicated that he triaged Patient #3, and his "thought process was scattered." S8RN indicated every bed in the ED was full when Patient #3 was present, and the ED was very busy. He further indicated he constantly had Patient #3 within his sight. When told that Patient #3's record review revealed no documented evidence that a staff member was continuously monitoring Patient #3, S8RN indicated it doesn't mean he's not watching the patient, but if the patient is sleeping, he (S8RN) may not have anything to write. After reviewing Patient #3's ED record, S8RN confirmed that there was no evidence in the record that Patient #3 was observed continuously and documentation of the observation was not done every 15 minutes as required by hospital policy. He further indicated that every 15 minutes observation and documentation was difficult if he had to start 3 IVs (intravenous) for example. S8RN did not explain how he could keep a patient under continuous visual observation if he had to leave the patient to start IVs on other patients. S8RN indicated that CPI required that everything should be tried to de-escalate a patient before using physical force. S8RN indicated that when someone's trying to escape the ED once they have been PEC'd, a Code White should be called.

In an interview on 04/10/14 at 2:55 p.m. while watching the tape, S3Director of ED confirmed there was no evidence that Patient #3 was searched by a staff member. She also confirmed that the female family member was allowed to take her purse into the ED room when she visited Patient #3.

In an interview on 04/11/14 at 11:05 a.m., S3Director of ED indicated there was no way to determine that a sitter was in constant visual observation of Patient #3 by reviewing his ED record. She further indicated that review of the video recording also showed no evidence that a staff member was present to visually observe Patient #3 the entire time he was in the ED. She confirmed that the video review also revealed that no staff member remained with Patient #3 when he went to the bathroom as required by hospital policy. When asked about Patient #3 being allowed in the bathroom without staff present as required by hospital policy, she answered, "there's a concern for the employee's safety in a closed bathroom", and they're looking at ideas to address this issue. S3Director of ED indicated that staff should have used physical interventions to keep Patient #3 from leaving the ED, and Code White should have been called. She indicated that she had conducted one-to-one conferences with each ED staff member for re-education since the event. She further indicated that no policy change had occurred, and a committee had been formed to look at changes that may be needed. S3Director of ED indicated the only thing that had been instituted was to have a staff member assigned to observe PEC'd patients in the ED and to begin interviewing to fill sitter positions. She further indicated that she didn't see the elopement event as a staffing issue but more that staff did not follow hospital policy. S3Director of ED confirmed that the hospital did not attempt to get the police record to document in the ED record of Patient #3 as required by hospital policy.

2) Failure to ensure that continuous direct visual observation was conducted and documented every 15 minutes as required by hospital policy for patients with an executed PEC in the ED:
Review of the hospital policy titled "Care of the Psychiatric Patient in the Emergency Department", revised March 2013 and presented as the current policy by S1COO, revealed that all patients presenting to the ED for psychiatric evaluation will be placed under a direct psychiatric observation status (a staff member will maintain direct visual contact with the patient at all times; movement from the designated room will require staff escort at all times) unless ordered otherwise by the physician. Documentation of observation will be completed at a minimum of every 15 minutes on the precautionary measures flow sheet and be retained as part of the medical record. Further review revealed that routine psychiatric observation required a staff member to make visual contact with the patient every 15 minutes.

Review of the ED records for Patients #1, #2, #3, #5, #7, #8, #9, #10, and #11 revealed they were all psychiatric patients who were PEC'd due to being suicidal, homicidal, a danger to self, and/or gravely disabled. Further review revealed no documented evidence that the patients were observed continuously within sight of a staff member with documentation in the medical record every 15 minutes as required by hospital policy.

In an interview on 04/10/14 at 9:35 a.m., S5RN indicated a staff member has to always watch the patient who has been PEC's either by video camera, seated outside the room, or while seated at the nursing station desk. He indicated that when seated at the nursing station desk, you can see into Room 3 if you're seated at the right side of the desk, but you have to "stand up and poke your head by standing up every now and then." When asked how he would have a patient continuously within his sight at all times when doing the observation in the manner he described, S5RN answered, I "probably don't." When asked if he provides care to other ED patients when he was assigned direct visual observation of a PEC'd patient, he answered, "Yes." S5RN indicated that he didn't always notify the security guard to monitor the video camera when he (S5RN) had to walk away from observing a PEC'd patient. When asked about not seeing that sitter assessments were performed and documented every 15 minutes as required by hospital policy, S5RN answered, "I might have got busy and forgot to put it in, sometimes I'm busy and didn't chart, and sometimes I'm busy and didn't do (the assessment)." S5RN indicated that it's not possible to do direct visual observation of a PEC'd patient 100% (per cent) of the time.

In an interview on 04/10/14 at 10:30 a.m., S7RN indicated that staff would sit at the nursing station and put the video camera on when a patient had been PEC'd, but the staff didn't continuously monitor the camera and did not keep the patient within constant sight at all times. When asked about the ED record not having every 15 minutes observations as well as evidence that the PEC'd patient was in constant visual observation of the staff member, S7RN answered, I "don't go outside the flowsheet (set up in the computer system) to say that the patient's in constant visual observation." S7RN indicated that recently on the night shift (since the elopement event) she had to place a PEC'd pediatric patient in Room 4 (no video camera in this room) with the parent present and no staff member keeping the patient within his/her sight at all times. When asked if it's possible to have PEC'd patients continually observed and have other patients to care for in the ED, S7RN answered, "with the amount of staff we have now, it's very difficult."

In an interview on 04/10/14 at 11:20 a.m., S8RN indicated there was no evidence in the record of Patient #3 ,that Patient #3 was observed continuously and documentation of the observation was not done every 15 minutes as required by hospital policy. He further indicated that every 15 minutes observation and documentation was difficult if he had to start 3 IVs (intravenous) for example. S8RN did not explain how he could keep a patient under continuous visual observation if he had to leave the patient to start IVs on other patients.

In an interview on 04/10/14 at 12:50 p.m., S9RN, when asked how one could tell by reviewing the ED record that a PEC'd patient was continuously monitored with a staff member having the patient within their sight, she answered, "I guess we need to document who's sitting and that they're outside the door." She indicated that when a PEC'd patient was placed in Rooms 1, 2, 4, or 5 (not psychiatric-safe rooms), the door to the room remained open at all times. She confirmed that inside Room 4 was not visible from the nursing station, and when a patient was in Room 5, the staff member could not visibly see the patient in Rooms 1 and 2 without turning their head from the sight of one of the patients.

In an interview on 04/11/14 at 11:05 a.m., S3Director of ED indicated there was no way to determine that a sitter had the patient in continuous sight at all times when she reviewed the ED records of Patients #1, #2, #3, #5, #7, #8, #9, #10, and #11. She confirmed that Room 4 in the ED had been used when Rooms 1, 3, and 5 were full, and it was not possible to see inside Room 4 from the nursing station.

3) Failure to ensure the ED physician ordered a patient with an executed PEC to be on direct visual observation as required by hospital policy:
Review of the hospital policy titled "Care of the Psychiatric Patient in the Emergency Department", revised March 2013 and presented as the current policy by S1COO, revealed that all patients presenting to the ED for psychiatric evaluation will be placed under a direct psychiatric observation status (a staff member will maintain direct visual contact with the patient at all times; movement from the designated room will require staff escort at all times) unless ordered otherwise by the physician. Documentation of observation will be completed at a minimum of every 15 minutes on the precautionary measures flow sheet and be retained as part of the medical record. Further review revealed that routine psychiatric observation required a staff member to make visual contact with the patient every 15 minutes.

Review of the hospital policy titled "Providing Care for Psychiatric and Suicidal Patients Not in Psychiatry", revised October 2013 and presented as a current policy by S1COO, revealed that all suicidal PEC/CEC patients require staff to observe the patient. Sitters are to stay with the patient at all times (strict visual contact), including during toileting and off unit tests or procedures.

Review of Patient #5's ED record revealed he was a 57 year old male who was PEC'd on 03/10/14 at 3:24 p.m. by S12ED Physician due to being suicidal and a danger to self. Further review revealed at 2:54 p.m. S12ED Physician ordered Patient #5 to be on routine psychiatric observation rather than direct psychiatric observation status. There was no documented evidence that S12ED Physician ordered Patient #5 to be on direct psychiatric observation at 3:24 p.m. when he executed Patient #5's PEC.

In an interview on 04/10/14 at 1:20 p.m., S3Director of ED confirmed that Patient #5 was not ordered to be on direct psychiatric observation by S12ED Physician when she executed his PEC. She indicated that hospital policy required a physician's order for direct psychiatric observation of all patients who were PEC'd in the ED.

Based on record reviews and interviews, the hospital failed to ensure that the Registered Nurse (RN) supervised and evaluated the nursing care for each patient. The RN failed to ensure that the patient care tech (PCT) continuously observed within sight each patient in the ED (Emergency Department) who had an executed Physician Emergency Certificate (PEC) and documented such observation in the ED record every 15 minutes as required by hospital policy for 3 of 10 patients' records reviewed who were PEC'd in the ED from a total of 11 sampled patients (#7, #10, #11). Findings:

Review of the hospital policy titled "Care of the Psychiatric Patient in the Emergency Department", revised March 2013 and presented as the current policy by S1Chief Operations Officer (COO), revealed that all patients presenting to the ED for psychiatric evaluation will be escorted to a treatment room for physician evaluation as soon as possible. All patients will be placed under a direct psychiatric observation status (a staff member will maintain direct visual contact with the patient at all times; movement from the designated room will require staff escort at all times) unless ordered otherwise by the physician. Documentation of observation will be completed at a minimum of every 15 minutes on the precautionary measures flow sheet and be retained as part of the medical record. The ED physician must specify a specific level of observation based on the patient assessment. All OPC (order of protective custody)/PEC/CEC (Coroner's Emergency Certificate) patients will be placed under direct psychiatric observation status unless a higher level of observation is specified by the physician. All OPC/PEC/CEC patients are considered an elopement risk.

Patient #7 was PEC'd on 03/10/14 at 4:00 p.m. due to being suicidal, a danger to self, and gravely disabled.

Patient #10 was PEC'd on 03/22/14 at 2:00 p.m. due to being suicidal, a danger to self, and gravely disabled.

Patient #11 was PEC'd on 03/22/14 at 5:30 p.m. due to being homicidal, a danger to self, and gravely disabled.

Review of the ED medical records for Patients #7, #10, and #11 revealed the continuous visual observation was assigned to S11PCT. Further review revealed no documented evidence in each record that Patients #7, #10, and #11 were continuously monitored visually by S11PCT. There was no documented evidence that an observation was recorded in each patient's record every 15 minutes as required by hospital policy.

In an interview on 04/10/14 at 9:35 a.m., S5RN indicated a staff member has to always watch the patient who has been PEC's either by video camera, seated outside the room, or while seated at the nursing station desk. He indicated that it could be a security guard, a nurse, or a PCT observing the patient, because they "work as a team."

In an interview on 04/11/14 at 11:05 a.m., S3Director of ED confirmed there was no way to determine that the staff member had the patient continuously within their sight when she reviewed the ED records of Patients #7, #10, and #11. She indicated that the ED staff were re-educated since the elopement event of 02/23/14 on the hospital policy regarding continuous visual observation and every 15 minutes documentation in the record. She could offer no explanation for the observations and documentation not being performed and documented in the records of Patients #7, #10, and #11 who were treated in the ED after the event of 02/23/14 (treated on 03/10/14 and 03/22/14).