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Based on interview and record reviews, the facility failed to ensure patients who presented to the Emergency Department (ED) with a suicidal risk received stabilizing treatment prior to being informed he could leave the hospital for one of six sampled patients (Patient #6).

Patient #6 was under suicide precautions awaiting an inpatient hospital bed and was informed he could leave the hospital.

Patient #6 left the hospital on 05/09/2021 without informing medical staff he was leaving.

The deficient practice had the potential to cause harm to all patients presenting to the ED with suicidal risks.

Findings included:

Record review of 05/06/2021at1615 Medical Screening for Patient #6 conducted by Physician # A revealed the following: "Patient is a 17 year old male that is in the custody of juvenile authorities brought to the ED for a seizure while he was at his hearing today. Patient brought by EMS (Emergency Medical Servivces). Patient is uncooperative upon arrival in the ED. patient will not answer questions. Patient is awake and alert and making purposeful movements and watching everyone in the room. Patient did not want to answer questions. RN #1 (Registered Nurse) attempted to perform an in and out catheter for urine sample and he stated the patient was aware of his surroundings and was awake and alert and orietned X3 and refused the catheter and refused to give a urine sample. I then walked into the room shortly thereaafter and the patient would not answer any questions. Revaluation #1: Patient being assessed by MHMR (Mental Health Mental Retardation), will transfer to Hill Country psych facility. Addendum: There are no psychiatric beds available currently. Patient on a wait list. We did speak with MHMR and patient is cleared to be released to authorities who will place him on suicide watch until he has bed placement. He will then be transferred to psychiatric facility when bed is available."

Review of 05/06/2021 2333 to 05/07/2021 0515 Nursing Notes by Nurse #3 revealed that Patient #6 was evaluated by MHMR Caseworker #1 and deemed appropriate for in-patient psychiatric hospitalization due to suicidal ideation. There were no beds available at that time.

Review of 05/07/2021 time 1507 Medical Screening exam conducted by Physician #1 revealed the following: "Chief Complaint: Seizures HPI Narrative: Patient was just sent back to the GEO (juvenile detention) a couple of hours ago on suicide watch, pending admission by MHMR to a psychiatric facility for some suicidal ideation last night. Patient now brought in by ambulance after a supposedly seizure in the jail about half an hour ago. I have not been able to confirm the seizure with any eyewitness. Patient does have a history listed as seizures. He is on Keppra, however looking back at his chart he also has a history of pseudo seizures that have been evaluated in the ED before. Patient is not postictal, no confusion, no biting the tongue, no tongue abrasions, no incontinence, no physical evidence of seizures. Patient denies any pain at this time, no other complaints. Physician reviewed all systems. Medical decision-making narrative: Patient is medically clear, has been evaluated by MHMR, pending bed placement to a psychiatric facility. There is no evidence that patient had a seizure, I did give him a dose of Keppra here, he does have a history of pseudo seizures. Father states patient has only ever had a seizure while he has been in jail. Patient has never had a seizure at home. Patient clinically cleared, pending reassessment by MHMR and placement. Care transitioned to Physician #2. Physician #3 documented at 0700 05/08/2021. Physician #2 addendum 1600 05/08/2021: patient has witnessed pseudo seizures. Patient "seizes" when he does not want to speak and when the person who is speaking to him leaves, he stops seizing, patient has been watched through a camera and patient has no seizures when not being questioned by anyone. It is my medical opinion that his symptoms are from severe anxiety/depression. Patient is "acting out" and is using these pseudo-seizures as a poor coping mechanism. Patient needs psychiatric evaluation for assistance. Pateint has not been cooperative with MHMR representative. Patient has a "seizure" when the MHMR representative speaks to him and the "seizure" stops when she leaves. Patient is medically stable for transfer with MHMR. Physician #2 addendum 1700 05/09/21: patient eloped. He was seen by security to have left via the back doors of the hospital. Police, MHMR and parents were alerted that the patient. eloped."

Review of #2 Nurse Note dated 05/07/2021 at 1507 revealed the following: "Patient presents for possible seizure, awake and alert, oriented times 4. Patient was recently discharged in custody of parole officer who made arrangements with MHMR to closely monitor on suicide precautions. Was pending placement at a mental health facility meanwhile pat arrived at this time no longer in custody. Denies thought of suicide at this time. Called MHMR hotline and spoke with Lauren who will be contacting on-call caseworker."

Review of Plan of Care update, dated 05/07/2021 at 1840 revealed the following documentation: "Is patient having suicidal ideations: No. Risk Assessment: Previous suicide attempts Suicide precautions taken 1:1 supervision initiated. All personal belongings removed from the room and secured. No drink cans in room. Disposable meal tray Patient restricted from harmful objects. Patient and/or family educated on necessary precautions. Patient placed in paper scrubs (no strings or ties) Will call MHMR for revaluation."

Continued reveiw of Nurse Notes written by Nurse #3 on 05/07/2021 at 2013 revealed the following: "Patient pending hospitalization for psych/SI. No bed assignment available at this time. MHMR will attempt again in the morning. Patient is to be held for SI and placement. No complaints at this time. Patient resting/sleeping. Dinner provided at bedside"

Reveiw of Nurse Notes writtten by Nurse #4 on 05/08/2021 at 1423 revealed the following: "(Caseworker #1) MHMR was contacted and informed that the patient is not being compliant and states "not right now too tired" to talk to talk with MHMR he was informed he's able to leave if he wants. We cannot detain patient here forcefully. Patient's dad was informed to come back and at least stay outside the hospital."

Review of Nurse Notes written by Nurse #4 on 05/09/21 at 1624 revealed the following: "Patent left at this time (1605) Patient ran out of other front doors. Caseworker #2 at MHMR, Police Department and parents were notified."

Review of Notes from Hill Country Mental Health Mental Retardation (MHMR) during patient's hospitalization revealed but was not limited to the following: "Crisis Assessment and Recommendations for Treatment: 05/06/2021: (Patient #6) is a 17-year-old male at Juvenile Center. He reports that he has suicidal thoughts about killing himself due to not wanting to be restricted. He did not want to engage in further information over his suicidal plans. States felling hopeless and depressed. He reports not wanting to get up daily and states that his plan is to end his life by hanging although at this time he cannot do that because he is in the hospital. He mentioned even if he is under suicidal watch, he will find a way to end my life.

Date not known: Patient #6 is a 17-year-old male currently released from Juvenile Detention center and is currently no longer in the custody of the juvenile probation office and states not answering any questions in front of dad. When asked if he has any suicidal thoughts, he answered "I don't know". He was not communicating how he is feeling although dad was not present. During assessment asked Who I am because I don't know who I am. CS was not able to continue with assessment due to patient #6 informing CC that he di not feel well. CS stepped out to call nurses. He was having a seizure.

11:13 AM: CC discontinued assessment and start when he is medically stable. Assessment was started at 2:45 limited engagement since he was under the covers and cooperation was limited. Mentioned having suicidal ideation with a plan although did not want to discuss.

05/07/2021 at 1226 PM signed by Caseworker #2 LCSW (MCOT Team Lead): Probation Officer, called and asked if not finding beds if he could go back to juvenile detention center and they are willing to place him in suicidal watch, he was explained by this writer it could take days to find a bed.

Called different psychiatric hospitals for possible admission based on recent disposition of crisis: Hospital B -do not take individuals from juvenile detention, Hospital C-no capability for treatment based on previous experiences with him, Hospital D denied acceptance based on previous hospitalizations (not participating in sessions) Sherlyn stated RC was not a good fit for him., Hospital E-not having capacity until Monday., Hospital F-placed on wait list.

Explained to patient what the plan is. He did not agree to inform staff about risk of harm, because he does not know about his thoughts or when he would have them "I am stuck" he stated he understood what would happen but did not make any comment about keeping safe. Reviewed with Parole Officer safety measures, including they will keep him in suicide watch and activate the protocol, follow up tomorrow for crisis intervention.

05/08/2021 QMHP-CS Caseworker #1engaged limited with patient during the assessment and attempted to provide skills training and guidance of further services. Although patient did not engage much and had a seizure this limited the ability to continue talking over interventions. Patient had difficulty making eye contact his head was under the covers and would mention Suicide Ideation with a plan although not wanting to disclose. Safety plan will be hard to be developed due to father mentioned not feeling qualified to care for him and his needs. Patient also mentioned suicidal ideation and inability to complete a safety plan for those reasons. During assessment had four pseudo-seizures that cause patient distress.

05/09/2021 at 9:45 AM: Caseworker #2 activated to do a crisis assessment for Patient #6 who is present at the facility ED due to suicide ideation with thoughts about hanging himself. HE stated the last time he had thoughts were yesterday before the reassessment and denied SI, HI or AVH. Denied having thoughts about killing himself since yesterday. Reported he is ready to go home. He is willing to go back home with a safety plan.

Spoke with parents over the phone who are not in agreement with a safety plan, due to his behavior, state of mind, previous threats and attempts of suicide and drug use. They reported he is not mentally stable and asked for hospitalization. They were explained about the admitting criteria for hospitalization and how psychiatric hospitals are saying they cannot meet his needs due to seizures. Parents asked this writer to call hospitals again for possible admission. Patient identified reasons for being alive, he denies SI and reports willing to get professional help. Nevertheless, during the reassessment, he turns agitated and upset with parents and this writer for his perception of the intention of assessment.

05/09/2021: Patient is open to develop a safety plan but during the re-assessment showed he gets easily frustrated when thinking assessor was asking questions that he understood were not related to the assessment. Gets upset and is focused on feelings of abandonment towards mother. Although he is denying risk of harm at the moment, parents don't feel they are equipped to deal with current symptoms presentation and are concerned he would leave the house again, and he would be at risk again if sent home."

Interview with facility administrative staff on 05/17/2021 during entrance conference revealed that if a patient is considered a psychiatric patient, the local MHMR is utilized for the psychosocial assessment. Once the patient is medically cleared, the local MHMR is contacted for further evaluation and potential transfer to an inpatient psychiatric facility if that is determined to be appropriate. They confirmed that Patient #6 was medically cleared and awaiting a bed in a psychiatric hospital when he eloped. They stated the local MHMR is the primary driver of placing the patient in a psychiatric bed once the patient is medically cleared. They confirmed there was no written contract with the local MHMR. They indicated that is just how it always done with a psychiatric patient.

Interview on 05/17/2021 at 2:44 PM with Physician #3confirmed that he was one of the attending physicians during Patient #6's ED visits. He described Patient #6 as having anxiety, depression and having trouble with the law. He stated the Patient #6 was monitored by cameras in the ED rooms. He stated he was okay unless somebody walked into the room and then he would appear to have a seizure. He stated he gave him Keppra for the seizures. He believed the seizures were "fake" or pseudo seizures and he used them as a poor coping mechanism. He stated the entire time he was in the ED, the attempt to get a urine specimen was thwarted most likely due to the patient knowing he would have a "dirty" urine. He stated that he personally spoke with a psychiatrist at a psychiatric hospital in another city who agreed to take the patient. He then stated that apparently that information didn't get to the admission staff at that hospital and therefore, he continued to be denied admission due to "seizures". He stated that a hospital in yet another city refused to admit him because he had become aggressive during his last hospitalization at that hospital and hurt some staff resulting in the staff being hospitalized.

Interview on 05/18/2021 with facility Director of Emergency Department revealed but was not limited to the following: "She stated that if an ED patient verbalizes suicidal ideation, the ED staff initially contact the local MHMR to alert them that the patient will need to be assessed. She stated that when a patient is medically cleared by the ED physician, the local MHMR is contacted to evaluate the patient as to whether the patient needs to be admitted to a psychiatric hospital. When asked about obtaining an Emergency Detention Order to legally hold the patient, she stated this is always done by the local MHMR. She explained that MHMR only gets an Emergency Detention Order if it is within 24 hours of the patient being transferred by the sheriff's department to the psychiatric hospital. In other words, MHMR doesn't get the Emergency Detention Order until they have obtained a psychiatric bed for the patient. She was asked about the nursing documentation from the ED nurse that stated, "he was informed he is able to leave if he wants, we cannot detain patient here forcefully". She stated that Patient #6 may have been told that because it is true. She stated we have no legal authority to keep him at the hospital if he wants to leave. She further stated our Security Guards cannot physically restrain the patient to keep him in the ED because there was no Emergency Detention Order to legally keep him at the hospital.

Interview on 05/21/2021 at 10:30 AM with ED Nurse #4 confirmed written information she had documented in medical record. She stated that she understood from MHMR staff (Caseworker #1) on 05/08/2021 that Patient #6 was not suicidal but then was told by MHMR staff (Caseworker #2) on 05/09/2021 that he remained suicidal. She understood that MHMR was attempting to locate inpatient psychiatric hospitalization for Patient #6 due to his suicidal ideations. She believed that Juvenile Detention had dismissed his charges. She stated that MHMR had attempted to get his father to take him home after making a safety plan, but his father did not feel comfortable taking him home because he did not think he could manage his behaviors. She stated he was not discharged because MHMR was looking for an inpatient psychiatric bed.