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Based on observation, interview, and record review, the facility failed to ensure protection of the physical and emotional health for patients with a psychiatric diagnosis presenting to the Emergency Department (ED), when they allowed seven of seven patients reviewed to elope (leave without completion of evaluation and treatment) without intervening (Patients 1, 2, 5, 6, 9, 10, and 11) (Refer to A 144).

The cumulative effect of these systemic problems resulted in failure to ensure patient's rights were protected and promoted at all times.

Based on observation, interview, and record review, the facility failed to ensure protection of the physical and emotional health of patients when seven of seven patients reviewed (Patients 1, 2, 5, 6, 9, 10, and 11) diagnosed with a psychiatric disorder were allowed to elope (leave without completion of evaluation and treatment) from the Emergency Department (ED). This failed practice resulted in the potential for harm or death in patients and members of the community.

Findings:

[A 5150 hold is the involuntary confinement of a psychiatric patient who is a danger to themselves (suicidal), a danger to others (homicidal), or gravely disabled (unable to care for themselves)]

[An eight hour psychiatric hold is a period of involuntary detention in an ED for emergency psychiatric evaluation of a patient who, as a result of a mental disorder, presents a clear and present danger to themselves or others, or is gravely disabled]

1. During a tour of the ED on June 29, 2017, at 10:35 a.m., a sitter (Sitter 1 - a staff member assigned to maintain constant observation of a patient) was observed outside of a four bed room, monitoring patients that were inside the room.

During a concurrent interview, Sitter 1 stated he was assigned to monitor the patients who were there on a 5150 hold, and he was always in the line of sight of the patients (could visualize them at all times). Sitter 1 stated if a patient on a 5150 hold attempted to leave the ED, he would, "immediately," call security and notify the nurse. He stated he did not notify the ED physician. Sitter 1 stated he would not try to stop a 5150 patient from leaving the ED. He stated, "I prefer to stay out of the way." Sitter 1 stated he was not allowed to touch the patients and force them to stay.

During an interview with the Security Manager (SM) on June 29, 2017, at 10:50 a.m., the SM stated if a 5150 patient was leaving the ED (eloping), they would, "do everything in our power," to stop them, but they did not allow the security officers to physically touch or restrain the patients if they were walking out. He stated they would follow the patient to the edge of the property, call the police, and give them a description of the patient. The SM stated he was aware of Patient 1, a 5150 patient who eloped. He stated the patient, "left two or three times," and the police brought her back every time, "except for the last time."

During an interview with Patient 1's home (for developmentally disabled adults) caregiver on June 30, 2017, the caregiver stated staff from the home was in communication with the ED on June 25, 2017 (the day Patient 1 was taken to the ED), and they were told Patient 1 was being kept on a 5150 hold and would be transferred to a psychiatric facility for care. The caregiver stated after Patient 1 eloped from the ED (the third time), she was notified by a member of the public that a video was posted on facebook of Patient 1 walking down the street "nude", with a hospital gown in her hand, pushing a shopping cart. The caregiver stated she saw the video. According to the caregiver, Patient 1 had lived at the home since 2006 (11 years), but due to her developmental disability, she would not be able to find her way home.

The record for Patient 1 was reviewed. Patient 1, a 40 year old female, arrived at the ED by ambulance on June 25, 2017, at 3:32 a.m., on a 5150 hold written by the police, after having a physical altercation with staff at her care facility.

The 5150 report indicated Patient 1 became physical with staff at her care facility, causing injuries. Patient 1 was deemed, "A danger to others."

The ED record indicated the following:

On June 25, 2017:

Patient 1 had been treated at the hospital in the past, and since March 15, 2014, the hospital was aware that she had a diagnosis of "mental retardation."

The physician document titled "History of Present Illness" dated June 25, 2017, at 5:11 a.m., indicated Patient 1 had a past medical history of "Psychiatric, and mental retardation", and was brought in by ambulance because she was a danger to others.

At 5:41 a.m. physician's orders were entered to put Patient 1 in behavioral restraints due to violent behavior and a danger of harming herself or others. Further orders were entered to put Patient 1 on suicide precautions, and place a sitter at her bedside.

The "Psychosocial Assessment" dated June 25, 2017, at 8 a.m., indicated Patient 1 had a history of mental illness, was agitated, anxious, angry, aggressive, combative, and uncooperative. She was verbally threatening, with a plan for violence against others, and was on a 5150 hold. She was dressed in a hospital gown with slip resistant socks on, and a sitter was at the bedside watching her.

At 8:17 a.m., the ED physician note indicated Patient 1 was diagnosed with, "Aggressive behavior, danger to others, psychiatric hold." The physician indicated the patient's condition was, "Serious," and the plan was for the patient to be transferred to a psychiatric facility.

At 8:30 a.m., documentation indicated efforts to transfer Patient 1 to a psychiatric facility were initiated.

At 10:15 a.m., Patient 1 had calmed down, and the restraints were removed.

At 8 p.m., Patient 1 was in the ED. She continued to be monitored by a sitter at her bedside, as she was a danger to herself and others, was on a 5150 hold, and had a, "very high risk of imminent suicide," and a, "chronic debilitating medical illness."

On August 26, 2017:

Documentation indicated at 12 p.m., Patient 1 was in the ED (awaiting transfer to a psychiatric facility), and she was anxious, restless, a danger to herself and others, on a 5150 hold, and still had a sitter at the bedside.

At 6:15 p.m., Patient 1 eloped from the ED.

At 7:29 p.m., Patient 1 was returned to the ED by police (one hour and 14 minutes without being monitored for safety). A sitter was present, "with direct site line to pt (patient)." She was irritable, restless, uncooperative, on a 5150 hold, and was at risk of harming herself or others.

At 7:45 p.m., Patient 1, "Ambulated from ER dept (ED) with steady gait and unassisted, security attempting to bring pt (patient) back into ER unsuccessfully. security called police to pick pt up" (the second elopement).

At 8:30 p.m., Patient 1 was brought back to the ED by police, placed back in her bed, and instructed not to leave. The notes indicated, "But pt doesn't comprehend." The notes indicated a sitter was present with, "direct observation of pt." The nurse documented, "We are not able to restrain her. Dr. (name of physician) is aware of patient leaving he ordered medication and RN (registered nurse) carried out."

Between 9 p.m. and 10:30 p.m., documentation indicated, Patient 1 was having, "Severe and uncontrollable outbursts/anger/tantrum behavior."

At 10:45 p.m., Patient 1 eloped (for a third time) from the ED. The nurse documented, "Pt ambulated from ER dept with steady gait and unassisted. security at bedside and followed patient out the ambulance door. pt kept walking and walked off the hospital property. Charge nurse aware. Police called."

There was no evidence of communication with the physician to determine whether intervention should be carried out to prevent the elopement.

There was no evidence in the record Patient 1 (determined to be violent and with a diagnosis of developmentally disabled) returned to the ED.

2. During a tour of the ED on August 28, 2017, at 11 a.m., a male patient (Patient 2) was observed handcuffed, on an ED gurney, with a police officer at the bedside.

During a concurrent interview with the patient's sitter (Sitter 2), the sitter stated Patient 2 arrived at the ED earlier in the morning, on a 5150 hold, after attempting suicide. Sitter 2 stated the patient eloped, security was present when he eloped, and a security officer contacted the police to attempt to find and return the patient to the ED. According to the sitter, Patient 2 had, "Just," been brought back in by police.

Sitter 2 stated she had seen 5150 patients elope in the past. She stated when a 5150 patient tried to leave, she would contact security and the nurse, and report it to them. Sitter 2 stated she did not report it to the ED physician. The sitter stated she was, "not allowed to pull them (the patient) back." According to Sitter 2, when 5150 patients eloped, they were dressed in a hospital gown, and they were either barefoot or they had a pair of hospital issued socks.

During an interview with the ED Director on August 28, 2017, at 11:15 a.m., the director stated the physician was the person who determined whether a 5150 patient was a danger to themselves or others, and they should be notified of a, "pending elopement," so they could determine whether intervention (such as restraining the patient) was necessary.

During an interview with the Director of Security on August 28, 2017, at 11:20 a.m., the Director of Security stated when a 5150 patient eloped, the security officers were, "not allowed," to put hands on them and bring them back. The director stated the security officer would follow the patient and try to talk them into coming back into the ED, and notify the police if the patient would not come back. He stated there had been seven 5150 patient elopements that he was aware of in the month of August.

The record for Patient 2 was reviewed. Patient 2, a 33 year old male, arrived at the ED by ambulance on August 28, 2017, at 10:04 a.m., on a 5150 hold written by the police, indicating the patient had suicidal ideations with a plan to commit suicide.

The 5150 report indicated Patient 2 was reportedly standing on the edge of a building with a rope around his neck. According to the report, when police arrived, Patient 2 was on the ground with rope marks around his neck and cuts on his arms, stating he wanted to die.

The ED record indicated the following:

At 10:08 a.m., the triage nurse indicated Patient 2 was a suicide risk (at risk for killing himself).

At 10:27 a.m., Patient 2 was, "An imminent risk," and a danger to himself. Security was at the bedside placing him in a hospital gown, and he eloped. According to the notes, security followed the patient, and the police were notified of the elopement.

There was no evidence of communication with the physician to determine whether intervention should be carried out to prevent the patient from leaving.

A second triage assessment, completed at 11:19 a.m., indicated Patient 2 was returned to the ED, in handcuffs, in custody of the police.

The ED nurse's notes indicated behavioral restraints were applied at 11:30 a.m., and the physician ordered suicide precautions at 12:09 p.m.

3. The record for Patient 5 was reviewed. Patient 5, a 40 year old male, presented to the ED on August 27, 2017, at 11:44 a.m., stating he overdosed on Tylenol the previous day, and wanted treatment.

The ED record indicated the following:

Between 4:33 p.m. and 8 p.m., the ED physician indicated Patient 5 attempted suicide by overdosing on Tylenol, and he was medically stable for placement (in a psychiatric facility). A 5150 hold was written on Patient 5, then the patient "Left the emergency department," and the police were called.

At 5:24 p.m., the psychiatric nurse evaluated the patient and documented, "Dr. (doctor)...came with me and stressed the importance of him (Patient 5) staying here to see psychiatrist...then wrote 5150 hold...patient said he was going to leave and walked out...police were called."

At 6:08 p.m., Patient 5 was back in the ED, and the physician and psychiatric nurse re-evaluated him for, "hold status." A decision was made to hold the patient pending a psychiatrist evaluation the next morning. According to the notes, "As soon as Dr. left room, patient left AMA (against medical advice)...PD (police department) notified."

There was no evidence of communication with the physician to determine whether intervention should be carried out to prevent the elopement.

There was no evidence in the record Patient 5 (deemed as suicidal) ever returned to the ED.

4. The record for Patient 6 was reviewed. Patient 6, a 35 year old male, arrived at the ED by ambulance on August 2, 2017, at 6:52 a.m., with complaints of an anxiety attack after an altercation.

The ED record indicated the following:

At 7 a.m., the triage nurse documented, "Bizarre behavior noted."

At 9:08 a.m., physician's orders were entered to place Patient 6 on an eight hour psychiatric hold and suicide precautions, place a sitter at the bedside, and have the patient evaluated for a 5150 hold.

At 7:20 p.m., a second psychiatric hold was written (while waiting for the 5150 evaluation to be done), and when Patient 6 was informed, he became agitated and eloped, accompanied by security. The notes indicated the police were notified.

There was no evidence of communication with the physician to determine whether intervention should be carried out to prevent the elopement.

According to the record, Patient 6 was returned to the ED in the custody of police at 7:40 p.m., and was hearing voices telling him to kill himself. Patient 6 was placed on a 5150 hold for, "A danger to himself, a danger to others, and gravely disabled adult."

5. The record for Patient 9 was reviewed. Patient 9, a 47 year old male with a history of schizophrenia (a psychiatric disorder), arrived at the ED by ambulance on August 14, 2017, at 10:28 p.m., on a 5150 hold for acting erratically and aggressively.

The 5150 report, written by the police, indicated Patient 47 was, "A danger to himself."

The ED record indicated the following:

On August 15, 2017, at 56 minutes after midnight, the triage nurse indicated Patient 9 wanted to leave and security was at his bedside.

At 1:06 a.m., the nurse documented, "pt walked out of front door, security walking with him trying to get him to stay.

At 1:16 p.m., the police were notified of Patient 9's elopement.

There was no evidence of communication with the physician to determine whether interventions should be initiated to prevent the elopement.

There was no evidence in the record Patient 9 (who was deemed a danger to himself) ever returned to the ED.

6. The record for Patient 10 was reviewed. Patient 10, a 22 year old female, arrived at the ED by ambulance on August 21, 2017, at 3:42 p.m., with an altered level of consciousness after a possible drug overdose.

The ED record indicated the following:

On August 21, 2017:

At 3:45 p.m., Patient 10's family reported she sent a text message threatening to commit suicide;

At 5:07 p.m., the ED physician placed the patient on a psychiatric hold;

At 8:09 p.m., the ED physician diagnosed Patient 10 with a drug overdose and suicide attempt, and indicated she was medically stable for transfer to a psychiatric facility;

At 10:31 p.m., the patient was moved to a room where she could have a sitter at the bedside, and was changed into a hospital gown and hospital issued slipper socks. Documentation indicated she was at high risk for suicide and on one-to-one observation;

At 11:45 p.m., Patient 10 was getting out of bed and threatening to leave. She was placed in bilateral (both sides) wrist restraints, and a sitter was at her bedside.

On August 22, 2017 (while waiting for an available bed at a psychiatric facility):

Patient 10 was remained restraints for her safety, the safety of staff, and due to her being a, "flight risk," until 9:45 a.m.;

At 12:21 p.m., she was "Demonstrating confused behavior" and was reoriented by the nurse;

At 3:17 p.m., Patient 10, "Continues to exhibit bizarre behavior." The documentation indicated the nurse explained that she was on a 5150 hold, and a mental health provider was coming in to evaluate her;

At 6:56 p.m., the nurse again explained to Patient 10 she was on a 5150 hold and told her she could not leave;

At 8:41 p.m., a psychiatrist evaluated the patient, and indicated she may have taken one month's worth of pills in a suicide attempt, was demonstrating periods of agitation and hallucinations, had poor self control, and her insight and judgement were, "Substantially impaired at this time." Patient 10 was diagnoses included recurrent severe, major depressive disorder with psychotic features. The psychiatrist recommended antipsychotic medications, and they were ordered. The 5150 hold was not removed;

At 8:57 p.m., Patient 10 was, "Upset saying she doesn't want to be here and that there is no reason for her to be here;"

At 10:39 p.m., she refused to take the antipsychotic medications.

On August 23, 2017:

At 2:35 a.m., Patient 10 had, "several times throughout the night expressed desire to leave and has threatened to walk out." The patient was told she was on a 5150 hold and could not leave the hospital;

At 7:30 a.m., documentation indicated Patient 10 was depressed and on suicide precautions with a sitter at the bedside. She was anxious, restless, uncooperative, inappropriate, delusional, and wandering from her bed. She remained on a 5150 hold because she was a danger to herself;

At 11:14 a.m. (the next entry in the medical record), Patient 10 (a suicidal patient) had eloped from the ED, and her mother was notified.

There was no evidence of communication with the physician to determine whether intervention should be carried out to prevent the patient from leaving the facility.

7. The record for Patient 11 was reviewed. Patient 11, a 28 year old female, arrived at the ED by ambulance on August 23, 2017, at 2:56 a.m., with complaints of hallucinating, hearing voices, and seeing people.

The ED record indicated the following:

At 3:42 a.m., the ED physician determined Patient 11 had a, "long history of schizophrenia disorder," and was hearing voices. She was placed on a psychiatric hold, and was medically stable for transfer to a psychiatric facility.

At 4:07 a.m., Patient 11 was moved to an area where a sitter could remain at the bedside to monitor her. She was fearful, withdrawn, and hallucinating. Documentation indicated she was on a psychiatric hold because she was gravely disabled;

At 7:30 a.m., Patient 11 remained withdrawn and would not communicate with staff. She remained on a psychiatric hold and a sitter was at the bedside;

At 8:11 a.m., Patient 11, "Eloped from the ER after multiple attempts to persuade her to stay." There was no evidence of communication with the physician to determine whether interventions should be carried out to prevent the elopement.

At 8:37 a.m., she returned to the ED. She was, "Unreasonable and continues to state that she needs to leave."

At 9:50 a.m., "Pt (patient) eloped again..."

There was no evidence of communication with the physician to determine whether interventions should be carried out to prevent the elopement.

The facility policy titled, "Holds - Involuntary (5150)," was reviewed on August 29, 2017. The policy indicated the following:

1. Upon identification of a 5150 patient, staff and/or security staff would advise the patient they were on an involuntary hold, remove their belongings, and place them in a hospital gown;

2. If the patient attempted to leave, law enforcement would be contacted immediately; and,

3. No attempts should be made to physically restrain the patient.

The facility policy titled, "Management of Psychiatric Patients in the Emergency Department," was reviewed on August 29, 2017. The policy indicated the following:

a. If a patient on a 5150 hold wanted to leave the ED, the physician would intervene with the patient and if necessary, family members, to help maintain the patient until an appropriate transfer to a psychiatric facility could be effectuated. If necessary, a 911 call would be made to obtain support from local authorities; and,

b. Pending a 5150 evaluation, the ED physician could detain the patient in the ED if:

aa. The patient could not be safely released from the hospital because, in the opinion of the treating physician, the person, as a result of a mental disorder, presented a danger to themselves or others, or was gravely disabled;

bb. The hospital staff had made and documented repeated, unsuccessful attempts to find appropriate mental health treatment for the person;

cc. The person was not detained for more than 24 hours; and,

dd. There was probable cause for detention.

Patients who were identified as a danger to themselves (suicidal), a danger to others (violent/homicidal), or gravely disabled (unable to care for themselves) were allowed to walk away from the hospital, without intervention by physicians or staff, resulting in a risk of injury or death to the patient and members of the community.