HospitalInspections.org

Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an assessment and ongoing reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#13) of 23 Emergency Department (ED) records reviewed. The hospital also failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#6) of 23 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Requirements," dated 12/20/23, showed:
- An EMC was any condition that was a danger to the health and safety of the patient if not treated in the foreseeable future, or any condition that might result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future to include psychiatric disturbances, such as suicidal ideation (SI, thoughts of causing one's own death).
- A MSE was a process required to determine within reasonable clinical confidence whether an EMC existed. The screening must be completed within the capabilities of the hospital, must determine if any further medical examinations and/or treatments might be required to stabilize the patient, or to determine that the patient needed to be transferred to a different facility.
- In the case of a patient who was suffering from a psychiatric condition, the patient was stabilized when he or she was no longer considered to be a threat to themselves or others.
- The hospital may not discharge a patient with an EMC until the patient was stabilized or when the patient or his or her legal representative refused to consent to stabilizing treatment, and the refusal was documented on a hospital approved patient consent/refusal of treatment form.
- Until a covered person was transferred, the hospital must provide treatment to the covered person within the hospital's capacity and capability to minimize the risks to the person's health. A covered person meant a person who came to the ED.

Review of the hospital's policy titled, "Estimating Risk of Suicide (to cause one's own death) 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)," dated 06/26/25, showed:
- All patients should be assessed for suicide risk on admission using the C-SSRS.
- The C-SSRS was a clinically validated questionnaire that assessed the severity of SI and suicidal behaviors as predictors of imminent suicide.
- Staff should maintain the safety of patients with active suicidal thoughts at all times, until discontinued by the treating clinician.

Review of the hospital's policy titled, "Suicide Self-Harm Prevention-Non-Behavioral Health Unit (BHU)," dated 05/07/25, showed:
- All patients over 12 years of age evaluated or treated in the ED were screened for suicide and self-harm using the C-SSRS.
- Suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) were initiated on patients screened as moderate or high risk until a risk assessment was conducted and SP were confirmed. The RN may place the patient on an increased level of SP based on C-SSRS or clinical judgement and notify the provider for an order.
- Moderate risk patients would be placed in a dedicated BH area. Patients in that area receive behavioral health safety rounds (BHSR, 15-minute visualization and documentation of the safety of each patient).
- SP were steps taken to mitigate the risk of the patient harming themselves and included one-to-one (1:1, continuous visual contact with close physical proximity) monitoring, BHSR and an environmental risk assessment.
- One-to-one monitoring was an increased level of patient monitoring, utilizing a one patient to one coworker ratio to assure the safety of the patient in the care environment. An assigned observing coworker would remain within proximity to the patient to immediately intervene if risk behaviors were observed. The patient was observed by the coworker at all times to include when transporting, ambulating outside of their room, sleeping, using the bathroom, showering, dressing and during meals. The patient may not request privacy, and the coworker must remain in the room when visitors were present.
- BHSRs occurred at least every 15-minutes at irregular intervals, not to exceed 16 minutes between intervals, documented in real time.

Review of the hospital's policy titled, "Discharge Against Medical Advice (AMA) or Patient Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) by an Adult, Non-Behavioral Health (BH) Patient," dated 02/06/24, showed:
- The hospital acknowledged the right of the adult, non-BH patient to make an informed decision to leave the facility AMA, or it was also recognized the patient may choose to leave or "elope" from the facility without the knowledge of the healthcare team.
- An adult with capacity was alert and oriented and had the capability to understand the risks of leaving and the benefits of remaining at the facility.
- A person was incapacitated if they were unable by reason of any physical or mental condition to receive and evaluate information or to communicate decisions to such extent that they lacked capacity to meet essential requirements for food, clothing, shelter, safety or such that serious physical injury, illness or disease was likely to occur.
- If the provider or BH intake determined the patient was an imminent risk of harm to self or other, a BH involuntary (a legal process through which a person is hospitalized and treated for mental health disorders without their consent) commitment process would be initiated. The psychiatrist (physician who specializes in mental health disorders) would place the order for "an involuntary commitment hold" for the patient and BH intake would facilitate the performance of the capacity evaluation by a qualified provider. The patient would not be allowed to leave and would be admitted to BH.
- Elopement was a patient's absence from the facility without the knowledge of the patient's health care team. A patient was considered to have eloped after a thorough search had been completed and attempts had been made to contact the patient.
- Nursing leadership would contact public safety and security, the administrator on call (AOC) and the provider to determine if the adult patient had capacity. If the provider determined the patient had capacity they would be discharged. If the provider determined the patient did not have capacity, the provider would contact the family or support person of the patient's elopement. Public safety would notify law enforcement and request to assist in locating the patient and request for them to be brought back to the facility to be detained on an involuntary commitment.


Please refer to A-2406 and A-2407 for further details.

Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an assessment and ongoing reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#13) of 23 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Requirements," dated 12/20/23, showed:
- An EMC was any condition that was a danger to the health and safety of the patient if not treated in the foreseeable future, or any condition that might result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future to include psychiatric (relating to mental illness) disturbances, such as suicidal ideation (SI, thoughts of causing one's own death).
- A MSE was a process required to determine within reasonable clinical confidence whether an EMC existed. The screening must be completed within the capabilities of the hospital, must determine if any further medical examinations and/or treatments might be required to stabilize the patient, or to determine that the patient needed to be transferred to a different facility.
- Until a covered person was transferred, the hospital must provide treatment to the covered person within the hospital's capacity and capability to minimize the risks to the person's health. A covered person meant a person who came to the ED.

Review of the hospital's policy titled, "Estimating Risk of Suicide (to cause one's own death) 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)," dated 06/26/25, showed:
- All patients should be assessed for suicide risk on admission using the C-SSRS.
- The C-SSRS was a clinically validated questionnaire that assessed the severity of SI and suicidal behaviors as predictors of imminent suicide.
- Staff should maintain the safety of patients with active suicidal thoughts at all times, until discontinued by the treating clinician.

Review of the hospital's policy titled, "Suicide Self-Harm Prevention-Non-Behavioral Health Unit (BHU)," dated 05/07/25, showed:
- All patients over 12 years of age evaluated or treated in the ED were screened for suicide and self-harm using the C-SSRS.
- Suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) were initiated on patients screened as moderate or high risk until a risk assessment was conducted and SP were confirmed. The RN may place the patient on an increased level of SP based on C-SSRS or clinical judgement and notify the provider for an order.
- Moderate risk patients would be placed in a dedicated BH area. Patients in that area receive behavioral health safety rounds (BHSR, 15-minute visualization and documentation of the safety of each patient).
- SP were steps taken to mitigate the risk of the patient harming themselves and included one to one (1:1, continuous visual contact with close physical proximity) monitoring, BHSR, and an environmental risk assessment.
- One-to-one monitoring was an increased level of patient monitoring, utilizing a one patient to one coworker ratio to assure the safety of the patient in the care environment. An assigned observing coworker would remain within proximity to the patient to immediately intervene if risk behaviors were observed. The patient was observed by the coworker at all times to include when transporting, ambulating outside of their room, sleeping, using the bathroom, showering, dressing, and during meals. The patient may not request privacy, and the coworker must remain in the room when visitors were present.
- BHSRs occurred at least every 15-minutes at irregular intervals, not to exceed 16 minutes between intervals, documented in real time.

Review of Patient #13's medical record showed:
- On 02/15/25 at 1:56 PM, he was a 38-year-old who arrived at the ED and reported he was suicidal.
- At 2:08 PM, he was listed as left without being seen (LWBS). His final diagnosis was listed as SI.
- Nursing documentation showed the ED triage nurse called his name multiple times. He was not in the waiting room, bathroom or outside.
- No C-SSRS examination or BHSR documentation was included in the medical record.

During an interview on 07/29/25 at 3:37 PM, Staff N, Chief Medical Officer (CMO), and Staff O, Chief Nursing Officer (CNO), stated Patient #13 did not receive an appropriate MSE.

During a telephone interview on 07/29/25 at 2:06 PM, Staff H, Physician, stated that front desk staff should have kept eyes on Patient #13 because they had reported SI and had not been evaluated by medical personnel. He did not believe security should necessarily "tackle" them to prevent them from leaving, but Patient #13 did not receive an appropriate MSE.

During an interview on 07/29/25 at 11:00 AM, Staff C, ED Nurse Manager, stated that Patient #13 did not receive appropriate care. Front desk staff should have immediately taken him back for evaluation. Staff should have continuously watched Patient #13 until he was fully assessed for SI. The nurse who could not find Patient #13 should have called the police to attempt to locate him. The care provided to Patient #13 did not meet her expectations.

During an interview on 07/29/25 at 11:55 AM, Staff L, Patient Access Representative (PAR) Manager, stated that she expected her staff to know that patients who reported SI needed to be constantly monitored. Her staff received training that would direct them to do so. It was not acceptable for Patient #13 to have left without staff knowledge. That showed Patient #13 was not monitored.

During a telephone interview on 07/29/25 at 11:27 AM, Staff F, RN, stated that she would not have expected the PAR to watch Patient #13, even though they reported that patients were suicidal, because they were non-clinical. PARs usually did monitor patients who report SI, she just did not expect them to do so, nor did she feel they were responsible to do so. If a patient reported SI they should receive an assessment. Patients who reported SI should be treated as suicidal until they were ruled to not be suicidal. If a patient who reported SI left without an assessment she would call her charge nurse. She would not document that she had called the charge nurse. She was not expected to notify the police that a suicidal patient had left the ED, that would be the responsibility of the charge nurse. She stated that she and a Patient Care Technician (PCT) checked the waiting room, bathroom, and the parking lot when Patient #13 was found to have left. She recalled that she did call the charge nurse, but did not document it, nor did she complete an incident report.

Although requested, an interview with Staff K, PAR, who registered Patient #13 was not provided as they were no longer employed with the hospital.

During an interview on 07/29/25 at 11:51 AM, Staff M, PAR, stated that when patients arrived at the ED and reported SI she immediately called for a nurse. She was expected to monitor the patient either by direct visualization, or on camera view at all times. She received training and education to know that patients who reported SI should be directly observed until they were assessed by a nurse. Anyone in her position would know that. Based on what was documented in Patient #13's chart, she agreed that the PAR present had not appropriately monitored Patient #13. She would have called both the nurse and security if a suicidal patient left without assessment.

Based on interview, record review, video review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for one patient (#6) of 23 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) Requirements Policy," dated 12/20/23, showed:
- An EMC was any condition that was a danger to the health and safety of the patient if not treated in the foreseeable future, or any condition that might result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future to include psychiatric (relating to mental illness) disturbances, such as suicidal ideation (SI, thoughts of causing one's own death).
- A Medical Screening Exam (MSE) was a process required to determine within reasonable clinical confidence whether an EMC existed. The screening must be completed within the capabilities of the hospital, must determine if any further medical examinations and/or treatments might be required to stabilize the patient, or to determine that the patient needed to be transferred to a different facility.
- In the case of a patient who was suffering from a psychiatric condition, the patient was stabilized when he or she was no longer considered to be a threat to themselves or others.
- The hospital may not discharge a patient with an EMC until the patient was stabilized or when the patient or his or her legal representative refused to consent to stabilizing treatment, and the refusal was documented on a hospital approved patient consent/refusal of treatment form.
- Until a covered person was transferred, the hospital must provide treatment to the covered person within the hospital's capacity and capability to minimize the risks to the person's health. A covered person meant a person who came to the ED.

Review of the hospital's policy titled, "Discharge Against Medical Advice (AMA) or Patient Elopement (when a patient makes an intentional, unauthorized departure from a medical facility) by an Adult, Non-Behavioral Health (BH) Patient," dated 02/06/24, showed:
- The hospital acknowledged the right of the adult, non-BH patient to make an informed decision to leave the facility AMA, or it was also recognized the patient may choose to leave or "elope" from the facility without the knowledge of the healthcare team.
- An adult with capacity was alert and oriented and had the capability to understand the risks of leaving and the benefits of remaining at the facility.
- A person was incapacitated if they were unable by reason of any physical or mental condition to receive and evaluate information or to communicate decisions to such extent that they lacked capacity to meet essential requirements for food, clothing, shelter, safety or such that serious physical injury, illness or disease was likely to occur.
- If the provider or BH intake determined the patient was an imminent risk of harm to self or other, a BH involuntary (a legal process through which a person is hospitalized and treated for mental health disorders without their consent) commitment process would be initiated. The psychiatrist (physician who specializes in mental health disorders) would place the order for "an involuntary commitment hold" for the patient and BH intake would facilitate the performance of the capacity evaluation by a qualified provider. The patient would not be allowed to leave and would be admitted to BH.
- Elopement was a patient's absence from the facility without the knowledge of the patient's health care team. A patient was considered to have eloped after a thorough search had been completed and attempts had been made to contact the patient.
- Nursing leadership would contact public safety and security, the administrator on call (AOC), and the provider to determine if the adult patient had capacity. If the provider determined the patient had capacity they would be discharged. If the provider determined the patient did not have capacity, the provider would contact the family or support person of the patient's elopement. Public safety would notify law enforcement and request to assist in locating the patient and request for them to be brought back to the facility to be detained on an involuntary commitment.

Review of the hospital's incident report, dated 07/12/25, showed:
- At 9:10 PM, a Patient Care Technician (PCT) attempted to take Patient #6 to his admission room in the BH unit (BHU) and discovered he eloped.
- Security reviewed video footage and discovered he eloped at approximately 8:20 PM, in paper scrubs and hospital socks.
- The house supervisor, BH intake assessor and law enforcement were notified.
- The boxes for leadership prevention and standard of care determinations were not completed.

Although requested, no Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) was provided related to Patient #6's elopement.

Review of the hospital's video titled, "ED Rooms 24-19-2025-07-12_20hr17min37s000ms," dated 07/12/25, showed at 8:17:37 PM, Patient #6 was in the doorway of a room dressed in a blue paper scrub top, green paper scrub pants and yellow socks. He exited and walked to a hallway to his right.

Review of the hospital's video titled, "MOC South - Lot D-2025-07-12_20hr19min00s000ms," dated 07/12/25, showed at 8:19:02 PM, Patient #6 walked away from the hospital dressed in a blue paper scrub top, green paper scrub pants, and yellow socks toward and into a parking lot. At 8:20:17 PM, he left hospital premises.

Review of Patient #6's medical record, dated 07/12/25, showed:
- At 3:32 PM, he was a 38-year-old who arrived at the ED with a chief complaint of SI.
- At 5:24 PM, he received a psychological evaluation (observes and measures a patient's behaviors, thoughts, and emotions to determine a diagnosis and appropriate treatment plan) and was to be admitted to a BHU. On assessment, he had SI since the day prior and felt he was a burden to others. He felt unsafe and refused to safety plan. He did not have a plan or intent; however, he had thoughts of wishing to be dead, had a suicide attempt two years prior, with a history of auditory hallucination (hearing things that are not heard by others, imaginary), major depression (a long period of feeling worried or empty with a loss of interest in activities once enjoyed), schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) and substance abuse. He was to be admitted because he was an imminent danger to himself, had severe psychiatric or comorbid conditions and a modifiable risk factor that could be addressed by acute (a sudden onset) behavioral admission.
- At 7:44 PM, 5 milligrams (mg) of diazepam (a medication used to treat anxiety, muscle spasms and alcohol withdrawal symptoms) and 10 mg of Haldol (a medication used to treat mental disorders by decreasing excitement of the brain) was administered intramuscularly (IM, within the muscle).
- At 9:11 PM, Staff R, Registered Nurse (RN), called report to the BHU.
- At 9:23 PM, law enforcement was called in regard to his elopement. Security reviewed video footage that showed he had exited the hospital at approximately 8:20 PM.
- Though his parents were listed as his support system, there was no documentation they were called.
- At 9:26 PM, his disposition was set to elopement.
- At 9:30 PM, physician documentation showed he had eloped at some point in the last hour. He was a voluntary admission with SI but no specific plan. They were unable to contact him, and he left his personal belongings. His medical decision-making component evaluation showed his risk of complication and morbidity, or mortality was a high risk due to SI and potential mood fluctuations.

Review of Patient #6's medical record, dated 07/15/25, showed:
- At 11:05 AM, he arrived at the ED with a chief complaint of SI. He was seen on 07/13/25 and still experienced delusional thoughts (false ideas about what is taking place or who one is). He asked for medications to help him relax, which were administered, but he no longer wanted those medications. He was seen, but left on his own and did not get admitted.
- Physician documentation showed he experienced auditory and visual hallucinations (seeing things which are not there). On 07/13/25, he visited the hospital but left after he received an injection, which he claimed worsened his condition. He reported he had very close attempts at self-harm.
- At 1:45 PM, he was evaluated by an intake assessor. He endorsed SI without a plan and admitted he had taken eight clonazepam (medication used to treat anxiety) pills five days prior. He had attempted suicide in 08/2022 by cutting his wrists to "release the demons inside." He had several in-patient behavioral health admissions. He had not taken his medication for 10 days. His father was called who shared that Patient #6 was very suicidal, would not take his medications and stated, "he definitely needs to be admitted, no doubt about it." He was to be voluntarily admitted to inpatient BHU due to the presence of severe psychiatric or comorbid conditions, severe dysfunction in daily living and a modifiable risk factor that could be addressed by acute BH admission.
- At 3:04 PM, he was admitted to the BHU.

During an interview on 07/29/25 at 3:37 PM, Staff N, Chief Medical Officer (CMO), and Staff O, Chief Nursing Officer (CNO), stated that they expected suicidal patients to be monitored. They agreed that Patient #6 left before he was stabilized because he was to be admitted to the BHU. On 07/15/25, he was admitted to the BHU when he returned to the hospital and was discharged after five days.

Staff S, Physician, was not available to interview, but did provide a written statement related to Patient #6's 07/12/25 ED visit and subsequent elopement.

Review of Staff S's undated written statement showed Patient #6 came in with suicidal thinking without a plan. He seemed anxious and depressed and admitted to "thinking about it [suicide]." He asked several times for "something for my nerves," but Staff S advised him to wait for the intake assessor's evaluation. At 2:32 PM, the intake assessor informed Staff S that Patient #6 would be voluntarily admitted to the BHU. At 4:23 PM, Staff S ordered Haldol and diazepam per Patient #6's request. After 6:00 PM, Patient #6 was seen in his room, calm with a dinner tray. Staff S did not have further contact with Patient #6. After 9:00 PM, the charge nurse notified Staff S that Patient #6 had left the ED without telling anyone. She contacted law enforcement. "He was a voluntary admission, so if he had insisted to being discharged, at that time we did not have grounds to hold him against his will."

During a telephone interview on 07/30/25 at 4:00 PM, Staff I, Physician, stated that if a patient was initially a voluntary admission and wanted to go AMA, he would request the intake assessor evaluate the patient before they would be allowed to leave AMA. He leaned on intake assessors because they knew the patients well and provided valuable insight. They typically had a better grasp on the patient's mental condition. In general patients who were voluntary that decided to go home were typically okay to go AMA after assessment, however, he would be concerned if the patient could not contract for safety and was deemed an imminent danger to themself by the intake assessor. A patient described as such would likely need to be kept involuntarily, but it would depend on the assessment at the time. He expected a moderate suicide risk patient to have been supervised by nursing staff, though he was unfamiliar with the specific details of how they would implement supervision. There had been elopements at the ED before, as could happen. They did not lock patients in rooms because that would be seclusion, and the ED was not locked down.

During a telephone interview on 07/29/25 at 4:10 PM, Staff P, Intake Assessor, stated that she was surprised Patient #6 had been able to leave without anyone knowing. She would have expected staff to notify her if a patient such as Patient #6 wanted to leave, even if their admission was voluntary. If a patient was initially a voluntary admission and then changed their mind, she would have spoken to the physician and decided whether the patient could leave, or if they then met criteria for an involuntary admission. The patient should not have been allowed to leave without an assessment first.

During a telephone interview on 07/30/25 at 12:00 PM, Staff R, RN, stated that she took over care for Patient #6 at about 7:00 PM. She visually saw him during shift report and at about 8:00 PM. At about 9:00 PM, she called report and requested for a PCT and security to escort Patient #6 to the BHU. The PCT then informed her that he was not in his room. She called the charge nurse and security. The charge nurse called law enforcement to attempt to locate him. Security reviewed video footage and noted he had left at about 8:20 PM. If a patient was to be admitted to the BHU and requested to leave she would contact her charge nurse for assistance, even if they were to be voluntarily admitted. She was not interviewed by the hospital after the event, and did not receive any education. Her charge nurse had only asked that she check on her patients more often.