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Based on interview, record review and policy review, the hospital failed to provide within its capability and capacity, stabilizing treatment for one patient (#5) out of 33 Emergency Department (ED) records reviewed from 02/05/23 to 03/13/23. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's average monthly ED census over the past six months was 2,813.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Patient Transfer Policy," revised 04/27/2017, showed that an EMC was a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric [relating to mental illness] disturbances and/or symptoms of substance abuse) such that the absence of medical attention could reasonably be expected to result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. When an individual arrived to the hospital's ED, requested treatment and it was determined that an EMC existed, ED personnel would provide further examination and treatment to stabilize the medical condition. Treatment would continue until the patient was stable for discharge, where continued care could be performed as an outpatient, or the patient was stable for transfer, where care could be received at a second facility with no deterioration in the medical condition. A psychiatric patient was considered stable for transfer when he/she was protected from preventing injury to himself/herself or others.

Review of the hospital's policy titled, "Against Medical Advice (AMA)," last reviewed 12/11/21, showed that patients or family may demand discharge AMA prior to a written physician order or completion of recommended medical treatment. A nursing supervisor or attending physician would be immediately notified of the request, and if the physician or nursing failed to convince the patient to remain in the hospital, the patient was asked to sign "Discharge Against Medical Advice Form." If the patient refused to sign the AMA form, the nurse would document the refusal and patient's response in the medical record, along with nursing's response and efforts to involve family/significant others.

Review of the hospital's policy titled, "Suicide (to cause one's own death) Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting," dated 07/05/22, showed that all adults who presented for care would be screened for suicidal ideation (SI, thoughts of causing one's own death) and behavior using the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life). Based on the severity and immediacy of suicide risk, patient safety measures and interventions would be implemented as a means to keep patients from inflicting harm to themselves. When a patient scored high risk for suicide the RN would notify the physician and the patient would be placed on continuous one to one (1:1, continuous visual contact with close physical proximity) observation where staff (nursing or sitter) were able to see the patient in clear view and staff could respond immediately to assure safety at all times. Staff would utilize the Frequent Observation Flow Sheet to document visual surveillance and observations.

Review of the hospital's policy titled, "Event Reporting," dated 02/28/23, showed that a patient safety event was an event or incident that resulted, or could have resulted in harm to the patient. For the purposes of event reporting a person was considered a patient if they were in the process of receiving care at the time of the event. A behavioral patient safety event included a patient elopement (when a patient makes an intentional, unauthorized departure from a medical facility). If a patient safety event occurred, or had the potential to occur, staff would report the safety event to the immediate supervisor, would report the event in the Event Reporting System (ERS), as soon as possible, or by the end of the work shift and would briefly describe the event in the narrative text. Supervisors would review events within three calendar days and conduct a brief investigation. Risk/Quality leaders would review the investigation and see if additional investigation was needed.

Although requested the hospital failed to provide a policy related to the elopement of patients.

Observation on 03/15/23 at 8:30 AM, of the hospital ED showed the ED patient restroom was located approximately 15 feet from the unlocked ED ambulance entry doors.

1. Review of Patient #5's ED record, showed:
- He was a 49-year-old male who presented to the ED on 02/09/23 at 2:28 AM, with a chief complaint of SI with a plan to overdose on his medications.
- Past medical history included anxiety (a feeling of fear or worry experienced intermittently), depression (extreme sadness that doesn't go away), bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and chronic (long-term, ongoing) pain.
- At 2:34 AM, a C-SSRS was completed and the patient was identified as being high risk for suicide.
- There was no documentation that the patient was placed in a safe and monitoried environment upon arrival.
- A behavioral health consult with Staff P, Psychiatrist, was completed and orders were written to admit the patient to the behavioral health unit (BHU).
- An ED rounding note documented by Staff I, ED RN, at 6:26 AM, showed that the patient walked to the restroom unaccompanied and upon exiting the restroom walked toward the ambulance exit door and exited the building. The RN attempted to stop the patient but he was running across the parking lot. Security was notified.
- The local authorities were not notified.
- The patient was not returned to the ED.
- Discharge disposition was documented as patient left AMA at 6:46 AM.

Review of a hospital provided email, dated 03/14/23, from the patient's outpatient counseling service, showed that on 02/09/23 around 8:00 AM, the patient called his Certified Peer Support (CPS) and reported that he was walking from Poplar Bluff Regional Medical Center to the counseling center after walking out of the ED. He reported that he left after being told that "the doctor would be in shortly and 45 minutes later he still wasn't." The patient's CPS met him at a local store and transported him to the counseling center where he was evaluated. He was found to not be suicidal at that time. He was transported to Hospital B on 02/09/23 at approximately 4:00 PM.

Review of Patient #5's ED record from Hospital B, showed:
- He was admitted to the hospital on 02/09/23 with a chief complaint of SI and the need for alcohol detoxification (the process of removing drugs or alcohol from the body).
- A Psychiatric Evaluation note, dated 02/10/23, showed that he presented to the hospital accompanied by his outpatient CPS. He reported that he had a plan to intentionally overdose and had access to medication. He reported a history of a suicide attempt in 2009. His suicide risk was documented as high.
- He was discharged from inpatient treatment on 02/17/23.

Although requested no event reports related to Patient #5 were provided.

During a telephone interview on 03/15/23, at 7:00 AM, Staff H, ED RN, stated that Patient #5 was brought in by his outpatient counselor who stayed with him until he was roomed. She stated that suicidal patients were typically put on 15 minute observation. She then stated, "technically they should be on 1:1 observation. If it's ordered by the doctor then we do that, but most generally not." She stated that suicidal patients were not always put into the designated psychiatric safe room (a room that has been cleared of any objects a patient might use to harm themselves or others), even if they were available, as those rooms were located near an exit door that didn't lock. This patient was not placed in a psych safe room, he was in a trauma room, which was approximately 20 feet from the ambulance door. The ambulance door was locked from the outside but only required a button to be pushed from the inside to open. She stated that if a patient left the ED treatment area, suicidal or not, staff would not attempt to retrieve them. They would notify security, who would go to area and attempt to talk to the patient but would not follow them beyond the property. The authorities would only be notified if a person were court ordered to be hospitalized. Staff did not call the authorities for Patient #5 as he was voluntary.

During a telephone interview on 03/15/23, at 7:15 AM, Staff I, ED RN, stated that when a patients whose C-SSRS score was high risk would have their belongings removed and the patient "should have a sitter but the hospital never has any to provide us." Patient #5 was placed in a trauma room, which was directly across from the nurse's station, and the curtain was left open. His outpatient counselor stayed with the patient briefly but left about 30 minutes before the patient left. She stated that she was assigned four patients that night and she "missed filling out the 15 minute observations sheets and that was my mistake. I just couldn't do them." She stated that the ambulance door was not alarmed and did not require badge access to open, only a button on the wall to open the door. She stated that the patient asked if he could go to the bathroom and when he left the bathroom he "smacked that button and ran right out the door." She stated that she attempted to follow him, and radioed security, but it was dark and once he ran into the parking lot between the cars he was hard to see. She stated that authorities were only notified if a patient had a court order and that staff were not required to fill out an event report when a suicidal patient left the treatment area.

During a telephone interview on 03/16/23, at 1:00 PM, Staff Z, Security Officer, stated that patients left the ED "all the time" so she could not specifically recall Patient #5. She stated that security would not attempt to retrieve patients who exited the ED, or notify authorities, unless the patient was court ordered. She stated that security was not expected to follow patients and that they were only required to fill out event reports if they were to go hands on with a patient or if a "serious situation" occurred.

During a telephone interview on 03/16/23, at 5:00 PM, Staff AA, Security Officer, stated that he was on duty the evening of 02/09/23 but could not recall Patient #5. He stated that patients leaving the ED was "not uncommon" and that hospital staff had been told by the local authorities that they would not bring back patients who eloped, even if there was a court order. He was trained not to pursue any patients that attempted to leave.

During a telephone interview on 03/15/23, at 7:30 AM, Staff J, ED Physician, stated that patients whose C-SSRS was high risk would be placed in a room in direct view of the nurse's station, were put into a paper gown and had their belongings and items of possible self-harm removed from the room. He determined Patient #5 was suicidal with a plan, consulted with the psychiatrist on-call who agreed to accept the patient, and he put the admission order in. Patient #5 was in the first trauma room, which was near the ambulance door, and he "had been watching that door." After using the restroom "he just pushed the button and ran out the door." He stated that when patients exited the ED staff would attempt to see where they went. "Sometimes security, if they are around, would go after them." Other times the authorities were called but those calls had not been successful recently as "they are busy with other things." He stated that "ideally he would've had a sitter, or been in a room where patients could be monitored, kind of a locked room, until they could get over to behavioral health to be treated. We just don't have enough people to sit with patients."




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