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Based on observations, record, policy review, and staff interviews, the Governing Body failed to establish an effective monitoring mechanism to ensure the adequate oversight of the hospital as evidenced by failure to ensure that Medical Staff was in compliance with medical staff requirements (A-0044); failure to ensure contracted services were provided in a safe and effective manner (A-0084); failure to implement an effective mechanism for setting quality priorities to ensure performance improvement activities address problem-prone areas, related to involuntarily admitted patient elopements from the emergency department, and safety of the physical environment (A-0283); failure to ensure nursing staff assessed the care needs of patients (A-0395); failure to ensure the integration of emergency services with other hospital departments (A-1103); failure to ensure qualified staff to meet the needs of patients seen in the emergency department (A-1112).

Findings included ...

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation in the Governing Body.

Based on a review of medical staff rules and regulations, contract review, medical record review, and staff interview, the Governing Body failed to ensure the compliance of medical staff, with medical staff requirements, in two of two medical records reviewed (Patients #11 and #1).


Findings included ...

Review of the United Medical Center "Medical Staff Bylaws, Rules, and Regulations," last revised in 12/18 showed that, "Except for honorary members, each Medical Staff Member and each Practitioner exercising Privileges shall continuously meet all of the following responsibilities: Provide his or her patients with care of the generally recognized professional level of quality and efficiency."

Review of the contract between the United Medical Center and the Medical group, signed 03/13/19, showed that The Contracted Providers shall perform administrative duties in accordance with applicable Hospital, Medical Staff and Emergency Department policies and procedures including, managing Emergency Department issues related to the Service on a day-to- day basis. The Contracted Providers shall perform direct and/or consultative clinical duties necessary including assess and provide the necessary physician orders to stabilize, treat, and make decision about the need to admit and or discharge patients presenting to the Emergency Department. The contract also shows that the Contracted Provider must demonstrate compliance with Medical Staff Bylaws.

A. Patient #7 presented to the Emergency Department (ED) on 07/12/19 at 7:37 PM, for a psychiatric medication refill. She had a past medical history of Depression and was discharged from the hospital at 10:02 PM.

Patient #11 presented to the ED by ambulance on 07/12/19 at 10:57 PM, for a complaint of breathing issues.

Review of video footage dated 07/12/19 showed Patient #11 on a stretcher in a hallway outside of the ED core at 11:46 PM. At the same time, Patient #7 is seen entering the ED, behind a security guard, through a badge access entry door. Patient #7 walks toward the ED core, stops at the foot of Patient #11's stretcher, pulls out a lighter and attempts to set the patient's right foot on fire. She held the flame to Patient #11's foot for approximately 10 seconds, before lighting the stretcher sheet, at the foot of the stretcher, on fire. She then entered the ED core doors, as the staff is exiting. A staff member saw the flame and beat it out with her hand. The police took Patient #7 into custody.

Further review of the medical record for Patient #11 showed that she was discharged, without an assessment of her foot/feet by the medical provider or nursing staff, after the incident.

Security staff failed to ensure that only authorized persons entered the secured ED area, and the medical and nursing staff failed to evaluate Patient #11 following the fire incident that had the potential to lead to a change in status and cause harm.

The surveyor conducted a face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. Employee #4 explained staff is always to ensure patient safety. Employees #4 and #11 explained that nursing staff is expected to conduct an assessment whenever there is a change in patient status. They acknowledged the findings.


B. Review of Patient #1's medical record revealed nursing triage documentation dated, 7/23/19 at 2:35 AM, which showed the patient presented to the ED, under a FD-12 status (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness), in police custody, for medical clearance for psychiatric admission to the hospital. The documentation further revealed the patient verbalized "suicidal/homicidal" thoughts, for which the physician ordered sitter services for constant observation at 02:44 AM.

Review of the United Medical Center policy entitled, "Management of the Suicidal Patients", last reviewed 03/17, showed that a sitter must be at arm's length from the patient at all times, unless the patient is transferred or discharged. Once in the treatment area, all harmful objects must be bagged separately. Staff will be appropriately licensed and trained to provide quality care, and an adequate number of staff will be available to meet the needs of the patients, 24 hours a day. The Nursing Office should be notified immediately of the need for a sitter [for constant observation] and the ED Technician will remain with the patient, until a sitter is available.

Review of the ED video footage on 07/23/19 at approximately 1:45 PM, revealed Employee #24, ED Technician, the sitter, at the doorway entrance of the patient's room, not within arm's reach of the patient, per hospital policy. Approximately, 4:19 AM, the patient became agitated, going in and out of the room. He had his left hand wrapped with a black garment. Employee #24 summoned staff. The patient left the room, and nursing and security staff were within arm's reach, talking to the patient. The physician came to assist at 4:20 AM. At 4:21 AM, the patient ran towards the ED core door and punched through a reinforced glass window, with the wrapped hand. Staff subdued the patient, medicated him with Haldol and Ativan, and placed him in four-point restraints.

The nursing documentation, at 4:29 AM revealed, "Patient became agitated and attempted to run. He became violent when he was not able to leave. Patient punched the door to leave and breaks glass with his fist, wrapped with his shirt." The record lacked documented evidence of a nursing assessment of the patient's hand after this incident.

The physician documentation revealed the patient's course of treatment dated 7/23/19 at 4:22 AM that showed, "Pt attempted to leave the ED by wrapping towels around his fists and punching the ED door glass. Pt is agitated and will be placed in four-point restraints. Security notified." The reassessment notes at 5:43 AM revealed the patient was medically stable for psychiatric admission, for Suicidal Ideations; however, there was no evidence that the physician assessed or evaluated the patient's hand after he punched through the glass window.

The patient was transferred to the Behavioral Health Unit (BHU) on 07/23/19 at 7:22 AM.

Further review of the medical record revealed an admission history and physical, in the BHU, dated 07/23/19 at 1:41 PM that showed the patient complained of bilateral hand pain, for which the physician ordered bilateral hand x-rays. The hand x-rays were performed on 07/23/19 at 3:41 PM and showed fracture dislocations of the fourth and fifth left fingers. The physician ordered an Orthopedic consultation at 4:36 PM.

During a telephone interview on 07/24/19 at 3:35 PM with Employee #26, Registered Nurse assigned to the patient, he explained that he witnessed the patient punch through the glass window; however, he stated that he did not assess the patient's hand because he knew the patient was evaluated by the physician.

During a subsequent face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. When asked about the clinical practice and expectations of the physicians, Employee #2 explained that he does not have a clinical background. All of the employees acknowledged the findings.

Based on record review and staff interview, the Governing Body failed to ensure that contracted physicians provided care in a safe manner as evidenced by the failure of physician staff to conduct evaluations for 2 of 2 patients involved in unusual incidents while receiving services in the hospital's emergency department. One patient (#1) who broke a glass window with his fist and the other patient (#11) who was lying on a stretcher that was intentionally set afire by a patient with behavioral health diagnoses who was discharged from the emergency department.

Findings included ...

Crossreference §482.12(a) - A-0044

Based on observation, medical record review, policy review, video footage review, and staff interview, the hospital staff failed to ensure safety for patients, who were involuntarily admitted for psychiatric services, and patients seeking medical treatment, in the Emergency Department.

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with the condition of participation for Patient Rights.

Based on observation, medical record review, policy review, video footage review, and staff interview, hospital staff failed to protect and promote patient's rights to ensure safety for patients who presented to the Emergency Department (ED) for involuntary psychiatric admission and for one patient whose stretcher sheet was set on fire, by a discharged psychiatric patient; ensure that evaluations were completed for patients with possible injuries sustained, while in the ED; and ensure staff was competent to provide the services assigned, in six of 11 medical records reviewed (Patients #6, 10, 11, 1, 4, and 5).

Findings included ...

Review of the UMC Policy entitled, "Management of the Suicidal Patients", last reviewed 03/17, showed that a sitter must be at arm's length from the patient at all times, unless the patient is transferred or discharged. Once in the treatment area, all harmful objects must be bagged separately. Staff will be appropriately licensed and trained to provide quality care, and an adequate number of staff will be available to meet the needs of the patients, 24 hours a day. The Nursing Office should be notified immediately of the need for a sitter [for constant observation] and the ED Technician will remain with the patient, until a sitter is available.

Review of the hospital policy titled, "Responsibilities of Staff Nurses Assigned to Emergency Department", last reviewed 09/17, showed that ED nursing staff are to assess patients on arrival and at least every two hours, and reassess for change in condition.

A. Patient #6 presented to the Emergency Department (ED) on 07/11/19 at 8:26 PM, with a complaint of Suicidal Ideation, with police escort, under a FD12 status (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness). Review of the medical record showed the patient took an unknown amount of Fluoxetine (antidepressant) and migraine headache medication, and stated that she wanted to hurt herself.

Review of the ED documentation showed that the patient was alert and oriented. Review of the physician documentation showed an order dated, 07/11/19 at 9:08 PM, for a sitter. Review of the sitter documentation showed that Employee #20, ED Technician, sat with the patient until the end of her shift, at 11:30 PM, on 07/11/19.

The surveyor conducted a face to face interview on 07/18/19 at 3:09 PM, with Employee #20, ED Technician, regarding her sitter duties. She stated that she sits with the patient at arm's length and does not move. When asked who she gave report to at the end of her shift, she stated, "No one." She notified the Charge Nurse that she was leaving, and she left. The surveyor asked Employee #20 about the training she received, related to being a sitter for FD-12 patients. She stated she was not trained.

Further review of the record showed that Employee #29, Primary Nurse for the patient, documented that a sitter was requested on 07/12/19 at 12:42 AM. At 1:26 AM, Employee #29 completed the FD-12 Involuntary Admission checklist, which showed that the patient was immediately assigned a sitter, the patient changed into FD-12 attire, and the staffing office was notified of the need for a sitter.

The medical record lacked documented evidence of notification to the staffing office, regarding the need for a sitter.

Review of ED video footage, showed Patient #6 exiting ED Bay #3, at approximately 5:15 AM on 07/12/19, wearing a regular hospital gown. She is then seen exiting the ED Core at 5:16 AM, approximately one minute later with no engagement from staff. At 5:21 AM, the patient is seen at the Main Entrance to the Emergency Department, using the desk phone. At 5:22 AM, the patient exited the hospital, through the ED entrance doors. Further review of the footage showed that there was no security officer posted at the ED core entrance, per said hospital practice.

The surveyor conducted a face to face interview on 07/22/19 at 9:05 AM, with Employee #28, Security Officer, who stated that his post for that evening was in the ED Core at the door; however, he was not there at the time of the elopement and did not call for relief. He stated that while in the hallway, he encountered the patient and when he asked if she needed something, she stated that "she had to go get something from someone." Employee #28 stated that he could not identify Patient #6, as an FD-12, because she was not wearing the designated clothing.

The surveyor conducted a telephone interview on 07/22/19 at 1:00 PM, with Employee #29, regarding the process for caring for an FD-12 patient. She stated that when patients come in, they are disrobed and given a burgundy top with blue pants, to indicate their FD-12 status. After that a sitter is requested, typically the ED Technician. When asked who sat for Patient #6, after Employee #20's shift was over, she stated that the only technician on the unit was Employee #23, ED Technician, and she was busy taking care of other duties on the unit. There was no sitter at the bedside.

The surveyor conducted a face to face interview on 07/24/19 at 8:50 AM, with Employee #15, ED Charge Nurse. She stated that Employee #23, ED Technician, was the sitter assigned for the shift. There was a critical patient and Employee #23 went to help with the patient. At that time, the patient apparently left the unit.

The surveyor conducted a face to face interview on 07/24/19 at 9:16 AM, with Employee #23, ED Technician, regarding sitter services for Patient #6. She stated that Patient #6 did not have a sitter for a couple of hours, after Employee #20 ended her shift. She stated that at some point during the early morning, she was asked to sit for the patient. She left the bedside of another patient to notify another staff member that she needed to be relieved for a break and came back to the patient's bedside. Once the relief was on her way to the room, she motioned to Employee #14, ED Charge Nurse, that she was going on a break. She stated that she never went back to the room to relieve the other staff member and does not know if the other staff member remained at the bedside. The surveyor asked Employee #20 about her training for sitter duties. She stated that she has never been trained on what to do, related to those duties.

The surveyor conducted a face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. Employee #4 explained staff are to always ensure patient safety. They acknowledged the findings.

B. Patient #10 presented to the Emergency Department (ED) on 07/16/19, at approximately 3:21 PM, from the Comprehensive Psychiatric Emergency Program (CPEP), under a FD-12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness). Review of the ED physician documentation showed that the patient had a past medical history of Bipolar Disorder and was found on private property, carrying a firearm.

Review of ED video footage from 07/16/19 showed that at 5:22 PM, Employee #13, Primary ED Nurse, was walking the patient to the bathroom. Once she and Patient #10 reached the hallway to the bathroom, Employee #13 pointed down the hall, in the direction of the bathroom, then turned around and walked in the other direction, leaving Patient #10 unattended. At 5:23 PM, Patient #10 exited the ED core, behind Emergency Medical Personnel, and then exited the hospital. A security officer chased the patient but was unable to catch him.

The surveyor conducted a face to face interview on 07/18/19 at 3:09 PM, with Employee #20, ED Technician, regarding Patient #10's elopement from the ED. She stated that on that day she was relieving a sitter that was sitting for FD-12 patients in Bays 11 and 13. She stated that Patient #10 was in Bay 13. He expressed that he had to go to the bathroom and she notified the nurse that she could not escort him because she was sitting with another patient. She observed the nurse walk with the patient to the bathroom. She then observed one of the two security officers run out of the ED, behind the patient. When asked about the sitter to patient ratio for FD-12 patients, she stated that if there are is no additional staff to sit for patients, the sitters often have to sit for two patients.

The surveyor conducted a face to face interview on 07/22/19 at 9:20 AM, with Employee #13, Primary Nurse, regarding the care of Patient #10. Employee #13 stated that she was the primary nurse for the patient and on that day, at that time, the ED had become very busy and she was helping another nurse with an unstable patient, when Patient #10 said he had to use the bathroom. She said that she walked with him and then showed him to the bathroom, but had to leave his side because of an emergency. Then she heard commotion and someone said the patient eloped.

The surveyor conducted a face to face interview on 07/22/19 at approximately 1:30 PM, with Employees #4, Chief Nursing Officer, and #11, ED Director, regarding sitter requests and staffing in the ED. Employee #11 stated that nursing staff is supposed to notify the Nurse Staffing Office, when there is a sitter need and that sitter cases are one patient to one sitter. When asked about the competencies completed to be a sitter, Employee #4 stated there were no competencies. Both employees acknowledged the findings.

C. Patient #7 presented to the Emergency Department (ED) on 07/12/19 at 7:37 PM, with a chief complaint for a psychiatric medication refill. She had a past medical history of Depression. Patient #7 was discharged from the hospital at 10:02 PM.

Patient #11 was brought in by ambulance to the ED on 07/12/19 at 10:57 PM, for a complaint of breathing issues.

Review of video footage dated 07/12/19 showed Patient #11 on a stretcher in a hallway outside of the ED core at 11:46 PM. At the same time, Patient #7 is seen entering the ED, behind a security guard, through a badge access entry door. Patient #7 walks toward the ED core, stops at the foot of Patient #11's stretcher, pulls out a lighter and attempts to set the patient's right foot on fire. She held the flame to Patient #11's foot for approximately 10 seconds, before lighting the stretcher sheet, at the foot of the stretcher, on fire. She then enters the ED core doors, as staff is exiting. A staff member sees the flame and beats it out with her hand. Patient #7 was then taken into custody.

Further review of the medical record for Patient #11 showed that she was discharged, without an assessment of her foot/feet by the medical provider or nursing staff, after the incident.

Security staff failed to ensure that unauthorized persons were prohibited from entering the secured ED area, and the medical and nursing staff failed to evaluate and assess the patient involved in the hospital incident that could have resulted in harm to the patient.

The surveyor conducted a face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. Employee #4 explained staff are to always ensure patient safety. Employees #4 and #11 explained that nursing staff are expected to conduct an assessment, whenever there is a change in patient status. Employee #2 explained that he does not have a clinical background. They acknowledged the findings.

D. Review of Patient #1's medical record revealed nursing triage documentation dated, 7/23/19 at 2:35 AM, which showed the patient presented to the ED, under a FD 12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness), in police custody, for medical clearance for psychiatric admission to the hospital. The documentation further revealed the patient verbalized "suicidal/homicidal" thoughts, for which the physician ordered sitter services for constant observation at 02:44 AM.

Review of the ED video footage on 07/23/19 at approximately 1:45 PM, revealed Employee #24, ED Technician, the sitter, at the doorway entry of the patient's room, not within arm's reach of the patient, per hospital policy, at 4:09 AM. Approximately, 4:19 AM, the patient became agitated, going in and out of the room. He had his left hand wrapped with a black garment. Employee #24 summoned staff. The patient left the room and nursing and security staff were within arm's reach, talking to the patient. The physician came to assist at 4:20 AM. At 4:21 AM, the patient ran towards the ED core door and punched through a reinforced glass window, with the wrapped hand. Staff subdued the patient, medicated him with Haldol and Ativan, and placed him in four point restraints.

The nursing documentation, at 4:29 AM revealed, "Patient became agitated and attempted to run. He became violent, when he was not able to leave. Patient punched the door to leave and breaks glass with his fist, wrapped with his shirt." The record lacked documented evidence of a nursing assessment of the patient's hand, after this incident.

The physician documentation revealed the patient's course of treatment dated 4:22 AM that revealed, "Pt attempted to leave the ED by wrapping towels around his fists and punching the ED door glass. Pt is agitated and will be placed in four point restraints. Security notified." The reassessment notes at 5:43 AM revealed the patient was medically stable for psychiatric admission, for Suicidal Ideations; however, there was no evidence that the physician assessed or evaluated the patient's hand, after he punched through the glass window.

The patient was transferred to the Behavioral Health Unit (BHU) on 07/23/19 at 7:22 AM.

Further review of the medical record revealed an admission history and physical, in the BHU, dated 07/23/19 at 1:41 PM that showed the patient complained of bilateral hand pain, for which bilateral hand x-rays were ordered. The hand x-rays were performed on 07/23/19 at 3:41 PM showed fracture dislocations of the fourth and fifth left fingers, for which the physician order Orthopedic consultation at 4:36 PM.

During a face to face interview with Employee #24, ED Technician assigned to the patient, she shared that she did not personally remove the patient's belongings or know where the belongings were but that one police officer gave her a small bag that was kept in the hallway and since it did not look like it was patient belongings, she never asked what was in the bag, but notified the nurse. She said she did not see the patient with items. She was not always in the room with the patient or at arm's length. She shared she did not receive sitter training to know her responsibilities for constant observation.

During a face to face interview with Employee #26, Registered Nurse assigned to the patient, he explained that he was not made aware of who removed the patient's clothing or where the clothing was placed; however, the patient was in FD12 attire. He personally witnessed the patient punch through the glass window; however, he did not assess the patient's hand because he knew the patient was evaluated by the physician.

The practice lacked evidence that ED hospital staff followed the hospital policies to secure the patient's belongings or sit within arm's length of the patient or conducted a reassessment, once the patient had a change in status, to ensure patient safety.

During a subsequent face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. Employee #4 explained staff are to always ensure patient safety. Employees #4 and #11 explained that nursing staff are expected to conduct an assessment, whenever there is a change in patient status. Employee #2 explained that he is does not have a clinical background. They acknowledged the findings.

E. During a tour of the ED on 07/23/19 at approximately 3:45 PM, in the presence of Employee #8, Director of Security, the surveyor observed Patient #4, who was under a FD 12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness), in the bed, in ED Bay #3.

The nursing triage documentation showed the patient presented to the ED on 7/23/19 at 3:02 PM, from the Comprehensive Psychiatric Emergency Program (CPEP), for medical clearance for psychiatric admission to the hospital. The room was equipped with the following items on the wall, within the patient's reach: cardiac monitor cords, a suction canister with dangling tubing, temperature probe wires, removable oxygen and medical air apparatus, sharps holder, and a glove rack.

The practice lacked evidence that staff maintained a safe patient environment that minimized ligature and hazardous risks.

During a face to face interview with Employee #11, Nursing Director of the ED, she was queried how the environment prevented ligature and hazardous risks. She explained that normally staff would remove all items that they can reasonably remove, to ensure patient safety. She was asked to provide the policy or protocol to address how staff ensured environmental safety for FD 12 patients, assigned in the regular ED rooms. She could not provide a policy or protocol. She explained the topic was discussed last week, during huddle meetings. Employee #8, demonstrated how the items could be removed from the wall. Both employees acknowledged the findings.

F. During a tour of the ED on 07/24/19 at approximately 10:40 AM, in the presence of Employee #12, Charge Nurse, the surveyor observed Patient #5, who was under a FD 12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness), in the bed, in ED Bay #16.

The nursing triage documentation showed the patient presented to the ED on 7/24/19 at 12:40 AM, in police custody, for medical clearance for psychiatric admission to the hospital. The room was equipped with the following items on the wall, within the patient's reach: a suction canister with dangling tubing, temperature probe wires, ophthalmology equipment with dangling wires, removable oxygen and medical air apparatus, sharps holder, and a glove rack.

The practice lacked evidence that staff maintained a safe patient environment that minimized ligature and hazardous risks.

During a face to face interview with Employees #12 and 25, ED Technician, who provided sitter services for constant observation, the surveyor queried how the practice ensured patient safety. Employee #12 moved the bed away from the wall. Employee #25 explained she did not know the oxygen and medical air apparatus could be detached from the wall. When queried about the training the hospital staff provided, regarding environmental safety for FD12 patients, she explained that on 07/23/19, Employee #11, Nursing Director of the ED held staff training and she was told to make sure all cords were out of the room.

Employees #12 and 25 acknowledged the findings.

Based on Quality Assessment Performance Improvement (QAPI) Program review, record review, policy review, and staff interview, the hospital failed to set priorities for its performance improvement activities that focus on problem-prone areas related to elopement of patients presenting the Emergency Department for involuntary psychiatric admission and safety of the physical environment. (A-283).

The findings included...

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation in Quality Assessment and Performance Improvement Program.

Based on quality program review and staff interviews, it was determined the hospital failed to implement an effective mechanism for setting quality priorities to ensure performance improvement activities address problem-prone areas, related to involuntary admitted patient elopements from the emergency department, and safety of the physical environment.


Findings included ...


Review of the United Medical Center policy entitled, "Management of the Suicidal Patients", last reviewed 03/17, showed that a sitter must be at arm's length from the patient at all times unless the patient is transferred or discharged. Once in the treatment area, all harmful objects must be bagged separately. Staff will be appropriately licensed and trained to provide quality care, and an adequate number of staff will be available to meet the needs of the patients, 24 hours a day. The Nursing Office should be notified immediately of the need for a sitter [for constant observation], and the ED Technician will remain with the patient until a sitter is available.


Review of the hospital policy titled, "Responsibilities of Staff Nurses Assigned to Emergency Department," last reviewed 09/17, showed that ED nursing staff are to assess patients on arrival and at least every two hours and reassess for change in condition.


A. Patient #6 presented to the Emergency Department (ED) on 07/11/19 at 8:26 PM, with a complaint of Suicidal Ideation, and a police escort, under a FD12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness). Review of the medical record showed the patient took an unknown amount of Fluoxetine (antidepressant) and migraine headache medication, and stated that she wanted to hurt herself.


Review of the ED documentation showed that the patient was alert and oriented. Review of the physician documentation showed an order dated, 07/11/19 at 9:08 PM, for a sitter. Review of the sitter documentation showed that Employee #20, ED Technician, sat with the patient until the end of her shift, at 11:30 PM, on 07/11/19.


The surveyor conducted a face to face interview on 07/18/19 at 3:09 PM, with Employee #20, ED Technician, regarding her sitter duties. She stated that she sits with the patient at arm's length and does not move. When asked who she gave report to at the end of her shift, she stated, "No one." She notified the Charge Nurse that she was leaving, and she left. The surveyor asked Employee #20 about the training she received, related to being a sitter for FD-12 patients. She stated she was not trained.


Further review of the record showed that Employee #29, Primary Nurse for the patient, documented that a sitter was requested on 07/12/19 at 12:42 AM. At 1:26 AM, Employee #29 completed the FD-12 Involuntary Admission checklist, which showed that the patient was immediately assigned a sitter, the patient changed into FD-12 attire, and the staffing office was notified of the need for a sitter.


The medical record lacked documented evidence of notification to the staffing office, regarding the need for a sitter.


Review of ED video footage, showed Patient #6 exiting ED Bay #3, at approximately 5:15 AM on 07/12/19, wearing a regular hospital gown. She is then seen exiting the ED Core at 5:16 AM, about one minute later, with no engagement from staff. At 5:21 AM, the patient is seen at the Main Entrance to the Emergency Department, using the desk phone. At 5:22 AM, the patient exited the hospital through the ED entrance doors. Further review of the footage showed that there was no security officer posted at the ED core entrance, per said hospital practice.


The surveyor conducted a face to face interview on 07/22/19 at 9:05 AM, with Employee #28, Security Officer, who stated that his post for that evening was in the ED Core at the door; however, he was not there at the time of the elopement and did not call for relief prior to leaving his post. He stated that while in the hallway, he encountered the patient and when he asked if she needed something, she stated that "she had to go get something from someone." Employee #28 stated that he could not identify Patient #6 as an FD-12, because she was not wearing the designated clothing.


The surveyor conducted a telephone interview on 07/22/19 at 1:00 PM, with Employee #29, regarding the process for caring for an FD-12 patient. She stated that when patients come in, they are disrobed and given a burgundy top with blue pants, to indicate their FD-12 status. After that, a sitter is requested, typically the ED Technician. When asked who sat for Patient #6, after Employee #20's shift was over, she stated that the only technician on the unit was Employee #23, ED Technician, and she was busy taking care of other duties on the unit. There was no sitter at the bedside.


The surveyor conducted a face to face interview on 07/24/19 at 8:50 AM, with Employee #15, ED Charge Nurse. She stated that Employee #23, ED Technician, was the sitter assigned for the shift. There was a critical patient and Employee #23 went to help with the patient. At that time, the patient apparently left the unit.


The surveyor conducted a face to face interview on 07/24/19 at 9:16 AM, with Employee #23, ED Technician, regarding sitter services for Patient #6. She stated that Patient #6 did not have a sitter for a couple of hours, after Employee #20 ended her shift. She said that at some point during the early morning, she was asked to sit for the patient. She left the bedside of another patient to notify another staff member that she needed to be relieved for a break and came back to the patient's bedside. Once the relief was on her way to the room, she motioned to Employee #14, ED Charge Nurse, that she was going on a break. She stated that she never went back to the room to relieve the other staff member and does not know if the other staff member remained at the bedside. The surveyor asked Employee #20 about her training for sitter duties. She stated that she has never received training on sitter duties.


The surveyor conducted a face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. Employee #4 explained staff is always to ensure patient safety. They acknowledged the findings.


B. Patient #10 presented to the Emergency Department (ED) on 07/16/19, at approximately 3:21 PM, from the Comprehensive Psychiatric Emergency Program (CPEP), under a FD-12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness). Review of the ED physician documentation showed that the patient had a past medical history of Bipolar Disorder and was found on private property, carrying a firearm.


Review of ED video footage from 07/16/19 showed that at 5:22 PM, Employee #13, Primary ED Nurse, was walking the patient to the bathroom. Once she and Patient #10 reached the hallway to the bathroom, Employee #13 pointed down the hall, in the direction of the bathroom, then turned around and walked in the other direction, leaving Patient #10 unattended. At 5:23 PM, Patient #10 exited the ED core, behind Emergency Medical Personnel, and then exited the hospital. A security officer chased the patient but was unable to catch him.


The surveyor conducted a face to face interview on 07/18/19 at 3:09 PM, with Employee #20, ED Technician, regarding Patient #10's elopement from the ED. She stated that on that day, she was relieving a sitter that was sitting for two FD-12 patients in Bays 11 and 13. She indicated that Patient #10 was in Bay 13. He expressed that he had to go to the bathroom, and she notified the nurse that she could not escort him because she was sitting with another patient. She observed the nurse walk with the patient to the bathroom. She then watched one of the two security officers run out of the ED behind the patient. When asked about the sitter to patient ratio for FD-12 patients, she stated that if there are is no additional staff to sit for patients; the sitters often have to sit for two patients.


The surveyor conducted a face to face interview on 07/22/19 at 9:20 AM, with Employee #13, Primary Nurse, regarding the care of Patient #10. Employee #13 stated that she was the primary nurse for the patient and on that day. At the time of the elopement, the ED was very busy, and she was helping another nurse with an unstable patient when Patient #10 said he had to use the bathroom. She said that she walked with him and then showed him to the bathroom, but had to leave his side because of an emergency. Suddenly she heard a commotion and someone said the patient eloped.


The surveyor conducted a face to face interview on 07/22/19 at approximately 1:30 PM, with Employees #4, Chief Nursing Officer, and #11, ED Director, regarding sitter requests and staffing in the ED. Employee #11 stated that nursing staff is supposed to notify the Nurse Staffing Office, when there is a sitter need and that sitter cases are one patient to one sitter. When asked about the competencies completed to be a sitter, Employee #4 stated there were no competencies. Both employees acknowledged the findings.


C. Patient #7 presented to the Emergency Department (ED) on 07/12/19 at 7:37 PM, for a psychiatric medication refill. She had a past medical history of Depression. Patient #7 was discharged from the hospital at 10:02 PM.


Patient #11 was brought in by ambulance to the ED on 07/12/19 at 10:57 PM, for a complaint of breathing issues.


Review of video footage dated 07/12/19 showed Patient #11 on a stretcher in a hallway outside of the ED core at 11:46 PM. At the same time, Patient #7 is seen entering the ED, behind a security guard, through a badge access entry door. Patient #7 walks toward the ED core, stops at the foot of Patient #11's stretcher, pulls out a lighter and attempts to set the patient's right foot on fire. She held the flame to Patient #11's foot for approximately 10 seconds, before lighting the stretcher sheet, at the foot of the stretcher, on fire. She then enters the ED core doors, as the staff is exiting. A staff member sees the flame and beats it out with her hand. Police took Patient #7 into custody.


Further review of the medical record for Patient #11 showed that she was discharged, without an assessment of her foot/feet by the medical provider or nursing staff, after the incident.


Security staff failed to ensure that unauthorized persons entered the secured ED area, and the medical and nursing staff failed to evaluate and assess the patient involved in the hospital incident that could have resulted in harm to the patient.


During a face to face interview on 07/22/19 at approximately 10:00 AM, with Employee #7, Quality Director, and Employee #21 Vice President of Support Services, regarding the plan implemented to ensure the safety of patients in the Emergency Department. Both employees stated that they were off on the day that the initial incidents happened, and aside from timelines completed by the quality department, there was no investigation into the safety events, and no interviews with staff involved to identify areas of improvement. Both Employees acknowledged that there was no documented plan to address the safety concerns. When asked what was implemented after the second elopement from the Emergency Department, both Employees acknowledged that they spoke ED staff about the incident. However, there was no documented action plan or collaboration with involved departments to ensure the safety of patients moving forward.

Based on record review, video footage review, and staff interview, nursing staff failed to deliver safe and appropriate care to patients involved in incidents in the Emergency Department, with the potential to cause injury (A-0395).

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with conditions of participation Nursing Services.

Based on record review and staff interview, nursing staff failed to perform a patient assessment, after an incident in the Emergency Department, where the potential for injury was likely in two of two medical records reviewed (Patient #1and 11).


Findings included ...


The United Medical Center policy entitled, "Responsibilities of Staff Nurses Assigned to Emergency Department," last reviewed 09/17 showed that the Emergency Department nurse is responsible for facilitating patient care and throughput by collaborating with the team to maintain quality and safe care. " ...Assess patients on arrival and at least every two hours and reassess for change in condition ...Immediately report changes in patient's condition ...Collaborate with physician for appropriate treatment and plan of care ..."


A. Review of Patient #1's medical record revealed nursing triage documentation dated, 7/23/19 at 2:35 AM, which showed the patient presented to the ED, under a FD 12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness), in police custody, for medical clearance for psychiatric admission to the hospital. The documentation further revealed the patient verbalized "suicidal/homicidal" thoughts, for which the physician ordered sitter services for constant observation at 02:44 AM.


Review of the ED video footage on 07/23/19 at approximately 1:45 PM, revealed Employee #24, ED Technician, the sitter, at the doorway entry of the patient's room, not within arm's reach of the patient, per hospital policy, at 4:09 AM. Approximately, 4:19 AM, the patient became agitated, going in and out of the room. He had his left hand wrapped with a black garment. Employee #24 summoned staff. The patient left the room and nursing and security staff were within arm's reach, talking to the patient. The physician came to assist at 4:20 AM. At 4:21 AM, the patient ran towards the ED core door and punched through a reinforced glass window, with the wrapped hand. Staff subdued the patient, medicated him with Haldol and Ativan, and placed him in four-point restraints.


The nursing documentation, at 4:29 AM revealed, "Patient became agitated and attempted to run. He became violent when he was not able to leave. Patient punched the door to leave and breaks glass with his fist, wrapped with his shirt." The record lacked documented evidence of a nursing assessment of the patient's hand after this incident.


The physician documentation revealed the patient's course of treatment dated 4:22 AM that showed, "Pt attempted to leave the ED by wrapping towels around his fists and punching the ED door glass. Pt is agitated and will be placed in four point restraints. Security notified." The reassessment notes at 5:43 AM revealed the patient was medically stable for psychiatric admission, for Suicidal Ideations; however, there was no evidence that the physician assessed or evaluated the patient's hand after he punched through the glass window.


Review of the restraint documentation showed that Employee #26, Registered Nurse, documented restraint monitoring every 15 minutes, starting on 7/23/19 at 4:45 AM until 6:15 AM. The documentation included a circulation check.


The patient was transferred to the Behavioral Health Unit (BHU) on 07/23/19 at 7:22 AM.


Further review of the medical record revealed an admission history and physical, in the BHU, dated 07/23/19 at 1:41 PM that showed the patient complained of bilateral hand pain, for which bilateral hand x-rays were ordered. The hand x-rays were performed on 07/23/19 at 3:41 PM showed fracture dislocations of the fourth and fifth left fingers, for which the physician order Orthopedic consultation at 4:36 PM.


During a telephone interview with Employee #26, Registered Nurse assigned to the patient, he explained that he witnessed the patient punch through the glass window; however, did not assess the patient's hand because he knew the patient was evaluated by the physician. When asked about additional assessments on the patient after he punched his hand through the window, Employee #26 stated that he did not assess the patient because he had other patients in the Emergency Department to care for. When asked how he was able to document a restraint monitoring assessment including circulation when he didn't perform any additional assessments on the patient, he stated he checked circulation by looking at the color of the patient's hands.


The practice lacked evidence that nursing staff followed the hospital to conduct a reassessment, once the patient had a change in status.


B. Patient #7 presented to the Emergency Department (ED) on 07/12/19 at 7:37 PM, for a psychiatric medication refill. She had a past medical history of Depression. Patient #7 was discharged from the hospital at 10:02 PM.


Patient #11 was brought in by ambulance to the ED on 07/12/19 at 10:57 PM, for a complaint of breathing issues.


Review of video footage dated 07/12/19 showed Patient #11 on a stretcher in a hallway outside of the ED core at 11:46 PM. At the same time, Patient #7 is seen entering the ED, behind a security guard, through a badge access entry door. Patient #7 walks toward the ED core, stops at the foot of Patient #11's stretcher, pulls out a lighter and attempts to set the patient's right foot on fire. She held the flame to Patient #11's foot for approximately 10 seconds, before lighting the stretcher sheet, at the foot of the stretcher, on fire. She then enters the ED core doors, as the staff was exiting. A staff member sees the flame and beat it out with her hand. The police took Patient #7 into custody.


Further review of the medical record for Patient #11 showed that she was discharged, without an assessment of her foot/feet by the medical provider or nursing staff, after the incident.


During a subsequent face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. Employees #4 and #11 explained that nursing staff is expected to conduct an assessment whenever there is a change in patient status. They acknowledged the findings.

Based on observation, medical record review, and staff interview, the hospital staff failed to ensure a safe environment, in the Emergency Department (ED), to minimize hazardous risks, for two of six patients, who were involuntarily admitted for psychiatric services (A-0701).

The effect of the systemic practices resulted in the hospital failure to comply with conditions of participation for physical environment.

Based on observations, record review and staff interview, the Emergency Department (ED) staff failed to ensure a patient environment that minimized hazardous risks to patient safety; and ensure the development of policies and procedures to address the safety needs of involuntarily admitted psychiatric patients, for two of six patients (Patients #4 and 5).

Findings included ...

Record review of hospital policy titled, "Patient Rights and Responsibilities," revised 04/15 showed that patients have the right to receive care in a safe setting.

A. During a tour of the ED on 07/23/19 at approximately 3:45 PM, in the presence of Employee #8, Director of Security, the surveyor observed Patient #4, who was under a FD 12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness), in the bed, in ED Bay #3.

The nursing triage documentation showed the patient presented to the ED on 7/23/19 at 3:02 PM, from the Comprehensive Psychiatric Emergency Program (CPEP), for medical clearance for psychiatric admission to the hospital. The room was equipped with the following items on the wall, within the patient's reach: cardiac monitor cords, a suction canister with dangling tubing, temperature probe wires, removable oxygen and medical air apparatus, sharps holder, and a glove rack.

The practice lacked evidence that staff maintained a safe patient environment that minimized ligature and hazardous risks.

During a face to face interview with Employee #11, Nursing Director of the ED, she was queried how the environment prevented ligature and hazardous risks. She explained that normally staff would remove all items that they can reasonably remove, to ensure patient safety. She was asked to provide the policy or protocol to address how staff ensured environmental safety for FD 12 patients, assigned in the regular ED rooms. She could not provide a policy or protocol. She explained the topic was discussed last week, during huddle meetings. Employee #8, demonstrated how the items could be removed from the wall. Both employees acknowledged the findings.

B. During a tour of the ED on 07/24/19 at approximately 10:40 AM, in the presence of Employee #12, Charge Nurse, the surveyor observed Patient #5, who was under a FD 12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness), in the bed, in ED Bay #16.

The nursing triage documentation showed the patient presented to the ED on 7/24/19 at 12:40 AM, in police custody, for medical clearance for psychiatric admission to the hospital. The room was equipped with the following items on the wall, within the patient's reach: a suction canister with dangling tubing, temperature probe wires, ophthalmology equipment with dangling wires, removable oxygen and medical air apparatus, sharps holder, and a glove rack.

The practice lacked evidence that staff maintained a safe patient environment that minimized ligature and hazardous risks.

During a face to face interview with Employees #12 and 25, ED Technician, who provided sitter services for constant observation, the surveyor queried how the practice ensured patient safety. Employee #12 moved the bed away from the wall. Employee #25 explained she did not know the oxygen and medical air apparatus could be detached from the wall. When queried about the training the hospital staff provided, regarding environmental safety for FD12 patients, she explained that on 07/23/19, Employee #11, Nursing Director of the ED held staff training and she was told to make sure all cords were out of the room.

Employees #12 and 25 acknowledged the findings.

Based record review, staff interview, video footage review, and hospital policy, the hospital staff failed to ensure: integration of services to include communication with Behavioral Health to facilitate the transfer of an involuntarily admitted psychiatric patient (A-1103); and failed to ensure adequate staff to provide a safe environment for patients requiring one to one observation (A-1112)


The cumulative effect of these systemic practices resulted in the hospital's failure to comply with Conditions of Participation for Emergency Services.

Based on record review, video footage review, policy review, and staff interview, hospital staff failed to ensure the integration of emergency services for transfer of an involuntarily admitted patient, to the Behavioral Health Unit, in one of one medical record reviewed (Patient #6).


Findings included ...


Review of the United Medical Center policy entitled, "Management of the Suicidal Patients", last reviewed 03/17, showed that a sitter must be at arm's length from the patient at all times, unless the patient is transferred or discharged. Once in the treatment area, all harmful objects must be bagged separately. Staff will be appropriately licensed and trained to provide quality care, and an adequate number of staff will be available to meet the needs of the patients, 24 hours a day. The Nursing Office should be notified immediately of the need for a sitter [for constant observation] and the ED Technician will remain with the patient, until a sitter is available.


Review of the United Medical Center policy entitled, "Psychiatric Admissions from the Emergency Department," last reviewed 03/17, showed that the Emergency Department Physician will contact the Psychiatric Intake Coordinator, who will contact the on-call Psychiatrist or patient's private Psychiatrist for acceptance and inpatient admission orders. The Psychiatric Intake Coordinator will obtain a bed assignment.


Patient #6 presented to the Emergency Department (ED) on 07/11/19 at 8:26 PM, with a complaint of Suicidal Ideation, with police escort, under a FD12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness). Review of the medical record showed the patient took an unknown amount of Fluoxetine (antidepressant) and migraine headache medication, and stated that she wanted to hurt herself.


Review of the ED documentation showed that the patient was alert and oriented. Review of the physician documentation showed an order dated, 07/11/19 at 9:08 PM, for a sitter. Review of the sitter documentation showed that Employee #20, ED Technician, sat with the patient until the end of her shift, at 11:30 PM, on 07/11/19.


The surveyor conducted a face to face interview on 07/18/19 at 3:09 PM, with Employee #20, ED Technician, regarding her sitter duties. She stated that she sits with the patient at arm's length and does not move. When asked who she gave report to at the end of her shift, she stated, "No one." She notified the Charge Nurse that she was leaving, and she left. The surveyor asked.


Review of ED video footage, showed Patient #6 exiting ED Bay #3, at approximately 5:15 AM on 07/12/19, wearing a regular hospital gown. She is then seen exiting the ED Core at 5:16 AM, about one minute later, with no engagement from staff. At 5:21 AM, the patient is seen at the Main Entrance to the Emergency Department, using the desk phone. At 5:22 AM, the patient exited the hospital through the ED entrance doors. Further review of the footage showed that there was no security officer posted at the ED core entrance, per said hospital practice.


The surveyor conducted a face to face interview on 07/18/19 at 11:13 AM with Employee #16, Behavioral Health Manager, regarding the admission process and time for a patient admitted to the Behavioral Health Unit (BHU). He stated that according to the data from June, the time from entry to the Emergency Department to the BHU is three to four hours. The goal is to get psychiatric patients to the inpatient unit as quickly as possible. When asked about the role of the Intake Coordinator in the admission of patients, he stated that the current policy is no longer the practice for admitting patients. The current practice is for Emergency Department physicians to contact the Psychiatrist directly, for admission acceptance. The Psychiatrist then contacts the Intake Coordinator, who contacts the Department of Behavioral Health for a tracking number (for involuntarily admitted patients), and obtains a bed. When asked if there is an Intake Coordinator staffed in the hospital 24 hours a day, he stated no. He went on to say that when the intake coordinator is that available, the Registered Nurses in the BHU assume the responsibility.


The surveyor conducted a face to face interview on 07/18/19 at 4:16 PM with Employee #18, BHU Registered Nurse. She stated that during the night shift of 07/11/19 to 07/12/19, she was the Charge Nurse and responsible for intake. She stated that there is a new process that includes scanning information to the Department of Behavioral Health when admitting an involuntary patient. She went on to say that she received no training on the new process. When the Nursing Supervisor for the night shift notified Employee #18 that there was one involuntary patient admission and one voluntary patient admission in the Emergency Department that needed beds, she told the Nursing Supervisor that she could only admit voluntary patient, because she was not aware of the process for involuntary admissions.


The surveyor conducted a telephone interview on 07/22/19 at 11:15 AM, with Employee #30, Nursing Supervisor. She stated that there was a patient who had been in the Emergency Department for a while. Employee #30 went to the BHU to speak to Employee #18, who stated there was no intake coordinator for the night. Employee #18 then asked Employee #30 if the patient waiting was a voluntary admission or an involuntary. Employee #30 stated that the patient was a voluntary admission. Employee #30 went on to say that she did not know there was an involuntary patient waiting in the ED for a bed.


The surveyor conducted a face to face interview on 07/22/19 at 2:09 PM with Employee #6, Emergency Department Medical Director, regarding admission of involuntary psychiatric patients, and the delay in transfer. He stated that it was not a physician issue, and once the order for admission is placed the physician is no longer involved in the process related to transfer to the BHU.


The surveyor conducted a face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. They acknowledged the findings.

Based on record review, staff interview, policy review, and video footage review, hospital staff failed to ensure that there was adequate qualified staff , in the Emergency Department, to ensure safety of patient presenting for involuntary psychiatric admissions, requiring one to one constant monitoring in two of two medical records reviewed (Patients #6 and 10).


Findings included ...


Review of the United Medical Center Policy entitled, "Management of the Suicidal Patients", last reviewed 03/17, showed that a sitter must be at arm's length from the patient at all times, unless the patient is transferred or discharged. Once in the treatment area, all harmful objects must be bagged separately. Staff will be appropriately licensed and trained to provide quality care, and an adequate number of staff will be available to meet the needs of the patients, 24 hours a day. The Nursing Office should be notified immediately of the need for a sitter [for constant observation] and the ED Technician will remain with the patient until a sitter is available.


A. Patient #6 presented to the Emergency Department (ED) on 07/11/19 at 8:26 PM, with a complaint of Suicidal Ideation, with police escort, under a FD12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness). Review of the medical record showed the patient took an unknown amount of Fluoxetine (antidepressant) and migraine headache medication, and stated that she wanted to hurt herself.


Review of the ED documentation showed that the patient was alert and oriented. Review of the physician documentation showed an order dated, 07/11/19 at 9:08 PM, for a sitter. Review of the sitter documentation showed that Employee #20, ED Technician, sat with the patient until the end of her shift, at 11:30 PM, on 07/11/19.


The surveyor conducted a face to face interview on 07/18/19 at 3:09 PM, with Employee #20, ED Technician, regarding her sitter duties. She stated that she sits with the patient at arm's length and does not move. When asked who she gave report to at the end of her shift, she stated, "No one." She notified the Charge Nurse that she was leaving, and she left. The surveyor asked Employee #20 about the training she received, related to being a sitter for FD-12 patients. She stated she was not trained.


Further review of the record showed that Employee #29, Primary Nurse for the patient, documented that a sitter was requested on 07/12/19 at 12:42 AM. At 1:26 AM, Employee #29 completed the FD-12 Involuntary Admission checklist, which showed that the patient was immediately assigned a sitter, the patient changed into FD-12 attire, and the staffing office was notified of the need for a sitter.


The medical record lacked documented evidence of notification to the staffing office, regarding the need for a sitter.


Review of ED video footage, showed Patient #6 exiting ED Bay #3, at approximately 5:15 AM on 07/12/19, wearing a regular hospital gown. She is then seen exiting the ED Core at 5:16 AM, about one minute later, with no engagement from staff. At 5:21 AM, the patient is seen at the Main Entrance to the Emergency Department, using the desk phone. At 5:22 AM, the patient exited the hospital through the ED entrance doors. Further review of the footage showed that there was no security officer posted at the ED core entrance, per said hospital practice.


The surveyor conducted a face to face interview on 07/22/19 at 9:05 AM, with Employee #28, Security Officer, who stated that his post for that evening was in the ED Core at the door; however, he was not there at the time of the elopement and did not call for relief. He stated that while in the hallway, he encountered the patient, and when he asked if she needed something, she stated that "she had to go get something from someone." Employee #28 said that he could not identify Patient #6 as an FD-12 because she was not wearing the designated clothing.


The surveyor conducted a telephone interview on 07/22/19 at 1:00 PM, with Employee #29, regarding the process for caring for an FD-12 patient. She stated that when patients come in, they are disrobed and given a burgundy top with blue pants, to indicate their FD-12 status. After that, a sitter is requested, typically the ED Technician. When asked who sat for Patient #6, after Employee #20's shift was over, she stated that the only technician on the unit was Employee #23, ED Technician, and she was busy taking care of other duties on the unit. There was no sitter at the bedside.


The surveyor conducted a face to face interview on 07/24/19 at 8:50 AM, with Employee #15, ED Charge Nurse. She stated that Employee #23, ED Technician, was the sitter assigned for the shift. There was a critical patient, and Employee #23 went to help with the patient. At that time, the patient left the unit.


The surveyor conducted a face to face interview on 07/24/19 at 9:16 AM, with Employee #23, ED Technician, regarding sitter services for Patient #6. She stated that Patient #6 did not have a sitter for a couple of hours after Employee #20 ended her shift. She said that at some point during the early morning, she was asked to sit for the patient. She left the bedside of another patient to notify another staff member that she needed to be relieved for a break and came back to the patient's bedside. Once the relief was on her way to the room, she motioned to Employee #14, ED Charge Nurse, that she was going on a break. She stated that she never went back to the room to relieve the other staff member and does not know if the other staff member remained at the bedside. The surveyor asked Employee #20 about her training for sitter duties. She stated that she has never been trained on what to do, related to those duties.


The surveyor conducted a face to face interview on 07/24/19 at 11:30 AM, with Employees #2, Chief Medical Officer, #4, Chief Nursing Officer, #11, Director of the Emergency Department, and #7, Director of Quality. Employee #4 explained staff is always to ensure patient safety. They acknowledged the findings.


B. Patient #10 presented to the Emergency Department (ED) on 07/16/19, at approximately 3:21 PM, from the Comprehensive Psychiatric Emergency Program (CPEP), under a FD-12 (authorization to detain a person, involuntarily, who is believed to be likely to injure self or others, as a result of mental illness). Review of the ED physician documentation showed that the patient had a past medical history of Bipolar Disorder and was found on private property, carrying a firearm.


Review of ED video footage from 07/16/19 showed that at 5:22 PM, Employee #13, Primary ED Nurse, was walking the patient to the bathroom. Once she and Patient #10 reached the hallway to the bathroom, Employee #13 pointed down the hall, in the direction of the bathroom, then turned around and walked in the other direction, leaving Patient #10 unattended. At 5:23 PM, Patient #10 exited the ED core, behind Emergency Medical Personnel, and then exited the hospital. A security officer chased the patient but was unable to catch him.


The surveyor conducted a face to face interview on 07/18/19 at 3:09 PM, with Employee #20, ED Technician, regarding Patient #10's elopement from the ED. She stated that on that day, she was relieving a sitter that was sitting for FD-12 patients in Bays 11 and 13. She indicated that Patient #10 was in Bay 13. He expressed that he had to go to the bathroom, and she notified the nurse that she could not escort him because she was sitting with another patient. She saw the nurse walk with the patient to the bathroom. She then observed one of the two security officers run out of the ED behind the patient. When asked about the sitter to patient ratio for FD-12 patients, she stated that if there are is no additional staff to sit for patients; the sitters often have to sit for two patients.


The surveyor conducted a face to face interview on 07/22/19 at 9:20 AM, with Employee #13, Primary Nurse, regarding the care of Patient #10. Employee #13 stated that she was the primary nurse for the patient and on that day, at that time, the ED had become very busy, and she was helping another nurse with an unstable patient when Patient #10 said he had to use the bathroom. She said that she walked with him and then showed him to the bathroom, but had to leave his side because of an emergency. Suddenly she heard a commotion, and someone said the patient eloped.


The surveyor conducted a face to face interview on 07/22/19 at approximately 1:30 PM, with Employees #4, Chief Nursing Officer, and #11, ED Director, regarding sitter requests and staffing in the ED. Employee #11 stated that nursing staff is supposed to notify the Nurse Staffing Office when there is a sitter need, and that sitter cases are one patient to one sitter. When asked about the competencies completed to be a sitter, Employee #4 stated there were no competencies. Both employees acknowledged the findings.