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Based on medical record review, hospital policy review and staff interviews, the hospital's administrative staff failed to ensure the hospital's emergency department (ED) staff followed hospital policies, ensuring 1 of 19 patients (Patient #10) selected for review, who presented to the hospital for emergency care from 4/1/23 through 10/22/23, received all appropriate stabilizing treatment. Failure to provide all appropriate stabilizing treatment at the ED resulted in Patient #10 eloping from the ED, which may have resulted in suicidal attempts, injury, or death. The hospital's administrative staff identified an average of 1,973 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.


Findings include:

1. Review of policy "TRANSFER AND EMERGENCY EXAMINATION - EMTALA", dated 9/21, revealed in part, "... Individuals exhibiting signs and symptoms of a psychiatric condition...should be provided a Medical Screening Examination including a mental health screening exam and further treatment within the Capability and Capacity of the Emergency Department..."

2. Review of policy "MISSING OR WANDERING PATIENT-ADULT", dated 6/22, revealed in part, "...Definitions At-Risk Patient...at-risk for harm to themselves...if not found and returned to a safe treatment environment if they were to...go missing from a care setting...Lack cognitive ability..(either permanently or temporarily) to make relevant decisions(e.g. ...intoxication)...Elopement:...leaves the department unauthorized before treatment is complete..."At-Risk" assessment is positive, patient will be placed under precautions and interventions initiated...patient changed into...pale green scrubs...for ED behavioral health patients so that all staff can easily identify a patient at risk...for leaving...Store "Triggers" such as clothing, shoes,...out of sight of the patient...Communicate with the entire care team on the unit that the patient is on precautions and at shift change that the patient is "At-Risk"..."

3. See A2407

The lack of hospital staff communication regarding the need to obtain a 48 hour hold should Patient # 10 attempt to leave the hospital, Patient #10's assessable clothing, and shoes resulted in hospital staff allowing Patient #10 to leave the hospital prior to receiving a psychiatric re-assessment, completed medical screening exam, and all stabilizing treatment.

Based on document review and staff interviews, the hospital's administrative staff failed to ensure 1 of 19 patients (Patient #10) selected for review, who presented to the hospital for emergency care from 4/1/23 through 10/22/23, received all appropriate stabilizing treatment. Failure to provide all appropriate stabilizing treatment at the Emergency Department (ED) resulted in Patient #10 eloping from the ED, which may have resulted in significant injury or death. The hospital's administrative staff identified an average of 1973 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:

1. See 2400 #1 and #2

2. Review of Patient #10's medical record revealed:

a. On 9/11/23 at 5:57 PM Patient # 10 presented to the ED intoxicated and with suicidal ideation. Police reported Patient #10 had called the police because they wanted to kill themselves and wanted treatment.

b. On 9/11/23 at 6:03 PM Triage RN Q completed a Columbia Suicide Risk assessment that place Patient #10 at high risk for suicide. Patient #10 was subsequently moved to ED Room 11, placed on suicide precautions with 1:1 observation, assigned a sitter, and changed into hospital scrubs.

c. On 9/11/23 at 6:08 PM Physician Assistant-Certified (PA-C) I medically evaluated Patient #10 and noted suicidal ideation (SI) with a plan to hang themselves under a bridge. Patient #10 reported intake of greater than 1000 milliliters (ml) of vodka and verbalized daily alcohol intake for more than 20 years. PA-C I documented Patient #10's affect as labile, speech slurred, thought content without suicidal content or plan. PA-C I ordered screening lab work including a drug screen, ethanol level, inpatient consult to psychiatry, and a bed request. The drug screen returned positive for cannabinoids, ethanol level 0.45%. (legal limit for driving 0.08%).

d. On 9/11/23 at 8:14 PM Psychiatric Resident Dr. M evaluated Patient #10 and documented, "unable to participate in safety planning due intoxicated state. Presented with symptoms of suicidal ideation in the context of recent alcohol use. Vital signs and lab findings are not concerning for acute life/limb threatening pathology. Acute concern for suicide, baseline/chronic risk for harm to self is elevated. Admit to psychiatry, recommend a 48 hour hold if patient attempts to leave AMA, while in ED recommend 1:1 Sitter for safety risk as well as acute intoxication."

e. Patient #10 slept throughout the night and remained on suicide precautions with 1:1 sitter observation. Patient #10 awakened at approximately 8:00 AM.

f. On 9/12/23 at approximately 10:00 AM RN J documented patient #10 began to put on their clothes and stated they were leaving. RN J asked Patient #10 to stay due to the suicidal statements made. Patient #10 stated that the patient was not suicidal and the patient was leaving. RN J documented security and ED Dr. D notified. Patient #10 left the hospital. RN J also documented per Psychiatric Resident Dr. M's note a 48 hold is recommended if patient attempted to leave facility. RN J documented that staff notified the local police department and the hospital Social Worker (SW) was obtaining as 48 hour hold.

g. 9/12/23 at 10:15 AM ED Charge RN G documented "Pt becoming escalated d/t (due to) waiting in ED - in nurse's station yelling that (the patient) wants to leave. ED staff and PSO (Patient Safety Officer) to bedside. Pt ran past staff and eloped from ED. (Local police department) notified and court order placed, awaiting pt return. ED leadership notified."

h. 9/12/23 at 10:04 AM ED DR. D documented, " Patient #10 was signed out to him by ED Dr. F. The patient is awaiting placement/psychiatric evaluation. BP 117/73 | Pulse 76 | Temp 36.1 °C (96.9 °F) | Resp 16 | Ht 190.5 cm (6' 3") | Wt 81.6 kg (180 lb) | SpO2 97%...Patient became agitated and eloped. Declined SI to nurse prior to elopement. Police contacted by nursing. Court hold placed per psych recommendations."


3. Review of "Incident Report" dated 9/12/23, completed by Public Safety Officer R, revealed in part, "...Incident Occurred Date 9/12/2023 at 1005...Incident Occurred End Date 9/12/2023 at 1006...Incident Discovered/Called in 9/12/2023 1004...Specific Location ER 11 WENT AMA LAST SEEN THRU PKG LOT WEST ON U... Report Synopsis/Overview AGAINST MEDICAL ADVICE RM 11, LATER DISCOVERED TO HAVE 48 HOUR COURT HOLD...while in are dealing with an unrelated event...heard yelling coming from ER 11...flagged down by nurse...needed help with patient in ER 11 who was trying to leave against medical advice...yelling "don't [profanity] touch me"...I observed [Officer S] walking behind [Patient #10]...followed patient as...went north through the ER, onto the outer hallway and finally leaving the hospital through the ER entrance/exit. [Patient #10] was not detained... because we were informed there was no court order...hold...and was free to leave...After [Patient #10] had left the hospital, it was discovered that the doctor notes...recommended that a court order/hold should be obtained if [Patient #10] attempted to leave before being seen by a psychiatrist ...(the local) police were contacted and given...last direction of travel for an attempt to locate..."


4. During an interview on 10/31/23 at 12:00 PM, Triage RN Q reported they completed a Columbia Suicide Screening that placed Patient #10 at high risk for suicide. Patient #10 placed in ED room #11 and handed off care to RN H.

5. During an interview on 10/26/23 at 9:16 AM, RN H reported they assisted with triage of Patient #10 in room 11 and assigned a Patient Care Tech (PCT) for 1:1 observation suicide precautions. Patient #10 denied suicidal ideation at that time.

6. During an interview on 10/26/23 at 9:30 AM, PA-C I reported Patient #10 had come in with the police and the police told them Patient #10 wanted to hang themselves as an art demonstration under the bridge. Patient #10 denied suicidal ideation at the time of PA-C's medical screening examination. PA-C I verbalized they didn't feel comfortable that Patient #10 was not suicidal and that Patient #10 was pretty intoxicated. PA-C I ordered a psychiatric consult. A psychiatry resident did the psychiatric assessment. They recommended admission, so the patient had to sit in the ER until a bed is available. PA-C I acknowledged they read the psych consult note and talked with Psychiatric Resident Dr. M. If the patient attempted to leave, staff were to obtain a 48 hour hold; no hold was needed at the time of the consult. PA-C verbalized they verbally reported off to ED Dr. F at the end of their shift. PA-C I described the half page hand-off sheets utilized to relay patient information to the next provider. PA-C I reported they would have written 48 hour hold if patient tried to leave, but then stated they were not confident that information was documented or relayed to Dr. F. The report slips of paper are not kept.

7. During an interview on 10/31/23 at 9:25 AM, ED Dr. F reported they do not remember this patient at all as Patient #10 was asleep when they got them and Patient #10 was asleep when they left. ED Dr. F verbalized they had no recall of the hand off content. Hand off slips with pertinent patient information are utilized for report but these are not kept. Dr. F handed off to Dr D at change of shift, approximately 6 AM.

8. During an interview on 10/26/23 at 12:30 AM, Psychiatric Resident Dr. M reported they received the psychiatric consult for Patient #10 and attempted to complete the psychiatric evaluation. Dr. M acknowledged they read Patient #10's medical record and attempted to talk with Patient #10. Patient #10 was unable to participate due to acute intoxication, the uncompleted assessment to be repeated the following day by another psychiatric provider. Dr. M verified they believed Patient #10 needed to be admitted due their back ground and desire to hang themselves while intoxicated. Admission orders placed, signed and held for later release, a bed request placed, if a bed is available they would go there. Dr. M recommended a 48 hour hold be obtained if Patient #10 attempted to leave prior to completion of a follow up psychiatric evaluation. Psychiatric Resident Dr. M placed the psychiatric recommendations in the medical record and attempted verbal communication with the provider. Dr. M reported they could not recall if they actually spoke with the provider in this case.

9. During an interview on 10/30/23 at 11:50 AM, PCT T reported they were told Patient #10 was on suicide precautions, fall risk, and elopement precautions but no court hold. Patient #10 was wide awake for a few hours then slept the whole night. PCT escorted Patient #10 to the bathroom in the hall by the nurses station once. PCT T verified that Patient #10 was in hospital scrubs but could not recall where Patient #10's clothes were located, but added they were usually kept in a box just outside the of the room or with the nurse.

10. During an interview on 10/30/23 at 4:00 PM, RN P reported Patient #10 was pleasant and cooperative and had no problems during the night.

11. During an interview on 10/26/23 at 11:00 AM, Patient Care Technician (PCT) L reported they started their shift at approximately 7 AM and had received in report from PCT T that Patient #10 was on suicide precautions and had been intoxicated. Patient #10 had been very pleasant and cooperative that morning. Patient #10 requested to go to the bathroom so PCT L escorted Patient #10 to the bathroom in the hall by the nurses' station. Upon return to ED room 11, Patient #10 reached down into the box outside ED room 11 door, where Patient #10's clothes were kept, and stated they wanted to get their socks. PCT L replied no. Patient #10 responded yes, grabbed their bag of clothes and got dressed. RN J walked by and attempted to dissuade Patient #10 from leaving until seen by the provider. Patient #10 was adamant they were leaving. Security was called, it all happened quickly, not even 5 minutes and Patient #10 was gone. PCT L reported they did not know staff was to obtain a 48 hour hold if Patient #10 attempted to leave AMA.

12. During an interview on 10/26/23 at 10:00 AM, RN J reported they remembered Patient #10 coming out of their room that morning saying I am leaving, I am not suicidal, you can't hold me. RN J claimed the interaction lasted about 5 seconds. RN J notified Dr. D and the public safety officer that Patient #10 was leaving the ED. RN J reported they were not aware of the psychiatric recommendation that a 48 hour hold be obtained if Patient #10 attempted to leave. RN J replied they were told in report that Patient #10 was intoxicated and they had come to the ED voluntarily. RN J verified Patient #10 had a 1:1 sitter continuously, and that RN J themselves did a suicide safety check at 7:15 AM and 8:00 AM, and provided medications at 8:52 AM and 8:53 AM. Patient #10 gave no indication they wanted to leave the ED prior 10:00 AM. RN J verified Patient #10's clothes were in a green bag right outside ED room 11, visible to Patient #10 when they ambulated in and out of the ED room, such as when they went to the bathroom.

13. During an interview on 10/31/23 at 9:30 AM, Public Safety Officer (PSO) S reported they were at the Behavioral Health Access Center in the ED when he heard a bunch of yelling, cussing, and screaming. PSO walked over to the hallway area in front of ED room 11 to see what was going on and to make sure everyone was safe. The Patient #10 wanted to leave, was dressed in their clothes, and refused to listen to attempts to de-escalate and encouragement to stay until a provider could see them. PSO S verbalized they heard Dr. D say the patient could leave, so PSO S watched Patient #10 as they walked out the door. Shortly after Patient #10 walked out the door, they found what was documented in the chart. Dr. D asked PSO S to stop patient #10 as Dr .D was ordering a 48 hour hold for Patient #10, but it was too late. PSO S acknowledged if Dr. D had said earlier, stop Patient #10, I am getting a 48 hour hold, we would have stopped them as they are focused on keeping the staff and the patient safe. Patient #10 refused to take no for an answer, was upset, and just wanted to leave.

14. During an interview on 10/31/23 at 10:00 AM, PSO R reported they were in the ED at the time of the elopement dealing with an unrelated event. They heard yelling, so walked over to ED room 11 area to see what was going on. PSO R witnessed Patient #10 yelling profanity and telling staff don't touch me. PSO R watched Patient #10 as they walked down the hall and out the main ER entrance as there was no hold order. PSO R followed at a distance. The ED staff looked at Patient #10's medical record and discovered a note that they should have gotten a hold order if Patient #10 tried to leave, but at the time no one, not even the nurse, knew about that. The PSO's looked for Patient #10, but the PSO staffed outside the hospital reported Patient #10 had already exited the hospital campus. Hospital staff notified the local police department to locate Patient #10 and return them to the ED. PSO R acknowledged there should be a better way for staff to know when a patient needs a court hold as once the doctor says we are going to get a hold, that is legal grounds to hold a person.

15. During an interview on 10/26/23 at 10:30 AM ED Charge RN G reported the Behavioral Health area of the ED was full so Patient #10 was held in ED room 11, the main area of the ED. About 10:00 AM Patient #10 exited their room and entered the hallway with the sitter, RN, and public safety officer. RN J attempted to de-escalate telling Patient #10 psych would be there shortly and hopefully they would be cleared to go home, noting the psych RN was on the unit. Charge RN G reported Dr. D and RN J searched Patient #10's medical record for the psychiatric recommendations to determine if Patient #10 could leave. It all happened so quickly, public safety officers don't want to get their hands on a patient unless we have a court hold or it is determined we need to get a court hold. By the time it was identified a court hold was needed Patient #10 was out the door.

16. During an interview on 10/30/23 at 8:30 PM, ED Dr. D reported they had assumed care of Patient #10 from Dr. F. Hand off relayed Patient #10 was suicidal due to substance abuse, recommended patient stay and psychiatry was going to re-eval in the AM when Patient #10 sobered up. RN J approached Dr. D that morning and told them Patient #10 had recanted and said the patient was no longer suicidal and the patient was going to leave.
"We needed to look at the psych note and see what was recommended before we held Patient #10 against their will. That information usually gets passed on. We had 14 or 16 psych holds that morning, it is difficult to keep them all straight when there were so many ...we needed to check the record." Recalled Dr. F reported this might be more of a substance abuse issue and if the patient was no longer suicidal when sober Patient #10 could probably be discharged. Dr. D acknowledged they had not been in to see Patient#10 yet and did not think the psych nurse had been in when the RN told them the patient wanted to leave. Dr. D verbalized they were looking in Patient #10's record when Patient #10 left. Dr. D requested a 48 hour hold and hospital staff notified the police of the hold and to bring Patient #10 back to the ED.

17. During an interview on 10/30/23 at 11:00 AM ED Nurse Manager RN U acknowledged ED Staff discuss patients on a hold or needing a hold in the morning during a staff huddle. ED Manager RN R could not explain why staff were not aware of the need for a 48 hour hold if Patient #10 attempted to leave, and had staff known, they could have prevented the elopement of Patient #10. ED Nurse Manager RN U reported the mental health patient is placed in safety scrubs and the patient's clothes are placed outside the room in storage tubs when patients are housed in the main ED area. These tubs are out of sight as patients are encouraged to use a urinal or commode instead of the restroom. Nurse Manager U lacked awareness that staff utilized the hall bathroom in the staff/nurse hallway rather than a urinal or commode.

18. During an interview on 10/31/23 at 2:00 PM, ED Medical Director acknowledged the RN and ED Provider should have been aware of the psychiatric recommendation for a 48 hour hold for Patient #10, if the patient attempted to leave. The rapid elopement of Patient #10 could have been prevented with good hand-off communication between providers and nurses.