HospitalInspections.org

Based on review of the facility policies and procedure, Medical Staff Bylaws and Rules and Regulations, Medical Records (MR), Ambulance Run Report, and staff interviews, it was determined Baptist Medical Center South (BMCS) failed to ensure:

1. A Medical Screening Examination (MSE) including a psychiatric evaluation was performed prior to a patient leaving the facility. The facility failed to implement and document steps to prevent a patient at risk for suicide, Patient Identifier (PI) # 2, from leaving the facility prior to a psychiatric evaluation.

Refer to A 2406 for findings.

2. Stabilizing treatment was provided for a patient, PI # 2, who was brought to the ED after attempting to jump from a bridge and identified as a high risk for suicide.
Refer to A 2407 for findings.

3. PI # 1 was admitted for psychiatric treatment when Hospital A, Transferring Hospital, had the capacity and capability to treat the patient, and transferred the patient to another facility for admission.

Refer to A 2409 for findings.

Based on Medical Record (MR) review, Facility Policies, EMS (Emergency Medical Services) Run Report, and interviews it was determined the facility failed to ensure a Medical Screening Examination (MSE) was performed that was within the capability if the hospital's Emergency Department (ED) including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition existed; failed to provide proper 1:1 observation for a patient at risk for suicide and; failed to prevent a patient at risk for suicide from leaving the (Emergency Department) ED prior to a MSE.

This deficient practice affected 1 of 2 MR reviewed of patients who eloped from ED.

This did affect Patient Identifier (PI) # 2 and had the potential to affect all patients treated at this facility.

Findings include:

Facility Policy: EMTALA
Revised: 01/2020

Purpose: The purpose of this policy is to set forth guidelines to comply with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA); but not limited to the ...the transfer of a patient to another facility.

IV. Policy
A. Medical Screening Examination

a. If a person comes to the Hospital and request is made for emergency care...qualified medical personnel...will, within the Hospital's capability and capacity, conduct and document an appropriate MSE...

b. An appropriate MSE...should address the presenting symptoms and comply with current policies and procedures for assessment of those presenting symptoms. ...

Policy: AMA (Against Medical Advise), Patient Leaving

Date revised: 09/2017

Purpose: The purpose of this policy is to outline guidelines to assist Baptist Health staff members when a patient leaves or attempts to leave a Baptist Health facility against the medical advice of the Baptist Health staff.

...Patients who are not permitted to leave AMA

...c. Patients having Suicide Ideation (SI) or Homicidal Ideation (HI) or a lack of capacity (and presents as a danger to harm self or others).

Policy: Suicide Prevention

Date revised: 10/2020

The purpose of this policy is to provide guidelines on minimizing the risk of suicide by a patient...while under medical management in the non-psychiatric setting.

...Columbia Suicide Severity Risk Scale (C-SSRS): a validated screening tool used to identify individuals at risk for suicide who require further assessment and steps to protect them from attempting suicide.

...High or imminent risk level: When a suicide patient has made a serious or lethal suicide attempt, has a specific suicide plan, ...

...One to one continuous visual observation: One competent observer to one patient within line of sight and in close proximity with no physical barriers in the same room/area...

...Monitor and observe the patient by staff or sitters...

...Ongoing continued observation will be conducted every 15 minutes by attendant/sitter...and documented on the Suicide Precaution Flow Sheet.

...Patients who are or may become a danger to self or others cannot discharge themselves from the facility....

All appropriate efforts to hold the patient without his/her consent should be made to prevent the patient from leaving the facility...

1. PI # 2 presented to the Emergency Department (ED) via EMS on 10/3/2020 at 3:20 AM after being found on a bridge getting ready to jump off.

Review of the EMS Run Report submitted on 10/3/2020 at 4:01 AM revealed EMS arrived at patient on 10/3/2020 at 2:50 AM. Review of the Narrative Section revealed "Responded emergency with PD ( Police Department) and FR Fire Department) to address for person trying to jump from bridge...PT (patient) A&O (alert and oriented) x 4, ...PT c/o (complained of) SI (suicide ideations) for a long time. PT had a plan of jumping off a bridge, PD able to talk PT off side of bridge, PT states the medications he was taking made him feel worse so he quit taking them. PT requests to go to BMCS (Baptist Medical Center South), Hospital A, to be further evaluated."

Review of the ED Triage Form dated 10/3/2020 at 3:20 AM revealed "presents to the ED...after being found on bridge getting ready to jump off bridge. Reports wanting to talk to psychiatrist and not be placed on meds. Reports depression since age 13. Hasn't taken meds (medications) in years. Refuses to go to (Psychiatric Behavioral Health Unit of BMCS)" PI # 2 vital signs were; BP 133/87, HR 82, Respirations 18, Pulse oximetry 99 %, and Temperature 98.3.

Review of the ED Physician examination dated 10/3/2020 at 3:23 AM revealed PI # 2 "PMH (Prior Medical History) of bipolar, (Serious mental illness characterized by extreme mood swings) depression, anxiety, schizophrenia mental disorder characterized by delusions, hallucinations, disorganized speech, behavior), and HTN (Hypertension) presents to the ED with SI...Pt. states he was on a bridge tonight and was planning on jumping off. He says he has been off his medications for years."

Review of the C-SSRS (Columbia Suicide Severity Rating Scale) risk level assessment dated 10/3/2020 at 3:29 AM revealed PI # 2 was High Risk (5 or greater) CSSRS risk score: 12.

Review of the Nursing Adult Psychosocial Assessment dated 10/3/2020 at 3:51 AM revealed PI # 2 was calm, previous suicide attempt. Suicide interventions included: "1:1 observation, psych evaluation, attendant/sitter at bedside, safe room form completed, items not allowed form completed, alert physician...alert security"

Review of the Nursing Note dated 10/3/2020 at 4:05 AM revealed "PT refuses to change clothes to put on paper scrubs or non skid socks. Refuses to give up phone. Continues to say he does not want to go to Behaviorial Health Unit of BMCS, or any other facility. When asked what was his plan, reports he wants to talk to a psychiatrist. Also reports he wants to go to his house to be with his son. Reports not suicidal now. Made aware that he can talk to therapist but there is a process....charge nurse in to talk with pt."

Review of the Nursing Note dated 10/3/2020 at 4:41 AM revealed "Pt. eloped."
There was no documentation of staff seeing patient leave, no documentation of 1:1 observation, and no documentation of an attendant/sitter at bedside as indicated per suicide prevention policy.

The facility failed to ensure that an appropriate Medical Screening Examination was provided for PI #2 on 10/3/2020 as evidenced by the facility failing to maintain ongoing continuous monitoring/observation of the patient every 15 minutes by an attendant/sitter as stated in the facility's policy. As this resulted in the patient with suicidal ideations eloping from the facility and not receiving a psychiatric evaluation.

An interview was conducted on 12/9/2020 at 12:15 PM with Employee Identifier (EI) # 2, System Accreditation Coordinator, who confirmed there was no documentation of 1:1 observation by staff as indicated per policy and staff did not witness patient leaving prior to psychiatric evaluation.

Based on Medical Record (MR) review, Facility Policies, and interviews it was determined the facility failed to ensure:

1. Stabilizing treatment was provided for a patient with suicide ideations.

2. Steps to prevent a patient with suicide ideations from leaving prior to stabilizing treatment, including Suicide Precautions and 1:1 observation were implemented and performed.

This deficient practice affected 1 of 2 MRs reviewed of patients who eloped.

This did affect Patient Identifier (PI) # 2 and had the potential to affect all patients treated at this facility.

Findings include:

Facility Policy: EMTALA
Revised: 01/2020

Purpose: The purpose of this policy is to set forth guidelines to comply with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA); but not limited to the ...the transfer of a patient to another facility. ...

E. Stabilization Prior to Transfer. Any patient experiencing an emergency medical condition must be stabilized prior transfer or discharge...

Policy: AMA (Against Medical Advise), Patient Leaving

Date revised: 09/2017

Purpose: The purpose of this policy is to outline guidelines to assist Baptist Health staff members when a patient leaves or attempts to leave a Baptist Health facility against the medical advice of the Baptist Health staff.

...Patients who are not permitted to leave AMA

...c. Patients having Suicide Ideation (SI) or Homicidal Ideation (HI) or a lack of capacity (and presents as a danger to harm self or others).

Policy: Suicide Prevention

Date revised: 10/2020

The purpose of this policy is to provide guidelines on minimizing the risk of suicide by a patient...while under medical management in the non-psychiatric setting.

...Columbia Suicide Severity Risk Scale (C-SSRS): a validated screening tool used to identify individuals at risk for suicide who require further assessment and steps to protect them from attempting suicide.

...High or imminent risk level: When a suicide patient has made a serious or lethal suicide attempt, has a specific suicide plan, ...

...One to one continuous visual observation: One competent observer to one patient within line of sight and in close proximity with no physical barriers in the same room/area...

...Monitor and observe the patient by staff or sitters...

...Ongoing continued observation will be conducted every 15 minutes by attendant/sitter...and documented on the Suicide Precaution Flow Sheet.

...Patients who are or may become a danger to self or others cannot discharge themselves from the facility....

All appropriate efforts to hold the patient without his/her consent should be made to prevent the patient from leaving the facility...

1. PI # 2 presented to ED (Emergency Department) via EMS (Emergency Medical Services) on 10/3/2020 at 3:20 AM after being found on a bridge getting ready to jump off.

Review of the ED Triage Form dated 10/3/2020 at 3:20 AM revealed "presents to the ED...after being found on bridge getting ready to jump off bridge. Reports wanting to talk to psychiatrist and not be placed on meds. Reports depression since age 13. Hasn't taken meds in years. Refuses to go to Crossbridge." PI # 2 vital signs were; BP 133/87, HR 82, Respirations 18, Pulse oximetry 99 %, and Temperature 98.3.

Review of the ED Physician examination performed on 10/3/2020 at 3:23 AM and signed on 10/3/2020 at 4:31 AM revealed PI # 2 "PMH of bipolar, depression, anxiety, schizophrenia, and HTN (Hypertension) presents to the ED with SI...Pt. states he was on a bridge tonight and was planning on jumping off. He says he has been off his medications for years."

Review of the C-SSRS risk level assessment dated 10/3/2020 at 3:29 AM revealed PI # 2 was High Risk (5 or greater) CSSRS calculate score: 12.

Review of the Nursing Adult Psychosocial Assessment dated 10/3/2020 at 3:51 AM revealed PI # 2 was calm, previous suicide attempt. Suicide interventions included: "1:1 observation, psych (psychiatric) evaluation, attendant/sitter at bedside, safe room form completed, items not allowed form completed, alert physician...alert security"

Review of the Nursing Note dated 10/3/2020 at 4:05 AM revealed "PT refuses to change clothes to put on paper scrubs or non skid socks. Refuses to give up phone. Continues to say he does not want to go to Crossbridge (Behavioral Psychiatric Unit of Hospital A) or any other facility. When asked what was his plan, reports he wants to talk to a psychiatrist. Also reports he wants to go to his house to be with his son. Reports not suicidal now. Made aware that he can talk to therapist but there is a process....charge nurse in to talk with pt."

Review of the Nursing Note dated 10/3/2020 at 4:41 AM revealed "Pt. eloped."

There was no documentation of staff seeing patient leave, no documentation of 1:1 observation, and no documentation of an attendant/sitter at bedside. The facility failed to follow it's own policy for Suicide Prevention thereby allowing a suicidal patient to elope from the ED without stabilizing treatment.

An interview was conducted on 12/9/2020 at 12:15 PM with EI # 2, System Accreditation Coordinator, who confirmed steps to prevent patient from leaving prior to stabilizing treatment including 1:1 observation were not implemented as directed per facility policy.

Based on review of facility policies, medical records, EMS (Emergency Medical Services) Run Report, and interviews, it was determined the facility failed to admit a patient for psychiatric treatment when they had the capacity and capability to treat patient, and transferred the patient to another facility for admission.

This affected 1 of 1 psychiatric patients reviewed who were transferred from the facility and did affect Patient Identifier (PI) # 1, a patient who presented to Hospital A (Transferring Hospital) on 12/1/2020 for a court ordered psychiatric evaluation. PI # 1 was evaluated and an inpatient psychiatric admission was recommended. PI # 1 was transferred to Hospital B, Receiving Hospital, instead of being admitted to the facility's psychiatric unit, Crossbridge Behavioral Health (CBH) who had the capacity and capability to treat PI # 1.

Findings include:

Facility Policy: EMTALA
Revised: 01/2020

Purpose: The purpose of this policy is to set forth guidelines to comply with the requirements of the Emergency Medical Treatment and Labor Act (EMTALA); but not limited to the ...the transfer of a patient to another facility.

... C. For purposes of this policy, a transfer is defined as the movement (including the discharge) of a patient outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital...

... If after a MSE, it is determined that a patient has an emergency medical condition, the Hospital must:

...iii. if stabilization of the patient is beyond the capabilities or capacity of the Hospital, arrange for appropriate transfer of the patient to another medical facility in accordance with this policy.

Policy: Crossbridge Behavioral Health Policy and Procedure Manual

Topic: Admission Criteria

Date of Approval: 07/2018

Purpose: CBH Process for admission to the psychiatric unit is based on each patient's assessed needs. The purpose of this policy is to outline admission and exclusionary criteria. ...

Policy: CBH accepts for care, treatment and services only those patients whose identified care, treatment, and services needs it can meet.

Admission Criteria:

A. Admission to the Psychiatric Program is indicated for patients...meet the severity of illness and intensity of service criteria (at least one form each) listed here. ...

C. Severity of illness:
...4. Homicidal ideation, threat to others, requires 24 hours professional observation.
5. Assaultive behavior threatening others...
8. Psychiatric symptoms...severe enough to cause disordered, bizarre behavior (...mania...)...

Treatments: Continuous observation and control of behavior to protect self, others, and/or property (e.g. isolation, restraint, and other suicide/homicide precautions.) ...

Exclusion Criteria: Each case is evaluated on an individual basis by the program leaders.

1. Patients with a substantiated diagnosis of dementia...
2. Patients with life threatening acute medical or surgical illnesses...
3. Patients with terminal diseases without a treatable psychiatric disorder...
4. Patients who are bedfast or who cannot participate in the treatment program...
5. Patients with complex medical/surgical procedures...
6. Patients with ... medical conditions may be excluded until further medical treatment is provided. ...
7. Patients with a primary AXIS II disorder (personality disorders)
8. Patients with a primary substance use disorder.

1. PI # 1 was brought to the Emergency Department (ED) by Montgomery Police on 12/1/2020 at 9:23 AM for a court ordered psychiatric evaluation.

Review of the court order dated 11/30/2020 revealed "...(PI # 1) is to be released at 9:00 AM on Tuesday, December 1, 2020, to the custody of staff of the Federal Defender's office. While on release, defendant (PI # 1) is to be brought to the emergency room at Baptist Medical Center South to be evaluated for inpatient treatment and psychiatric stabilization. If defendant...is referred for inpatient treatment following this evaluation, (he/she) is to remain at the emergency room...until a bed is available for (him/her) at an inpatient facility..."

Review of the ED Triage Form dated 12/1/2020 at 9:30 AM revealed the nurse documented "patient brought in by the court for a mental evaluation recently released from prison". Vital signs: Blood Pressure 130/75, Pulse 73, Respirations 18, and Temperature 98.5. The patient's weight per bedscale was 70 kg (kilograms) and the height was 5 feet 10 inches.

Review of the MD (Medical Doctor) assessment performed by EI # 8, ED Physician, on 12/1/2020 at 9:33 AM revealed the patient had been off his/her psychiatric medication for several months while in jail, the patient got into a physical altercation with his/her mother after release from jail due to his/her psychosis/mania, and now needs to see a psychiatrist to get back on his/her medications. PI # 1 admitted to assaulting another inmate before release from jail "while throwing a fake punch in the air and pointing to his biceps". PI # 1 was cooperative, manic, bragging about assault, not suicidal, not homicidal, and no hallucinations.

Review of the nursing ED Adult Assessment, Adult Psychosocial Assessment, dated 12/1/2020 at 9:34 AM revealed PI # 1 was calm and cooperative.

Review of the Clinical Assessment Coordinator (CAC) from Crossbridge Behavioral Health (CBH) Quick Intake conducted by EI # 9, Clinical Assessment Coordinator, on 12/1/2020 at 12:29 PM revealed PI # 1 denied Suicide Ideations (SI), Homicidal Ideations (HI), paranoia and Audio Visual hallucinations. Patient presented with a flight of ideas and appeared manic. Patient also reported he/she had assaulted someone while in jail. Patient reported he/she was prescribed Trazadone, Prozac, and Wellbutrin before. The CAC documented the patient "assaulted someone this morning at the Extended Stay. When the CAC asked PT.(patient) about the incident PT stated, "it was a TKO (technical knockout)".

Further review of the CAC dated 12/1/2020 revealed at 3:56 PM, EI # 9 contacted the facility on-call psychiatrist for CBH EI # 10, who verbalized the "PT (patient) is not appropriate for the milieu at Crossbridge. (EI # 10, Psychiatrist) recommends other inpatient psych (psychiatric) facility for patient".

Review of the Facility to Facility Transfer Record dated 12/2/2020 at 12:30 AM revealed EI # 12, ED Medical Director, contacted Hospital B, Receiving Hospital for acceptance of the transfer of PI # 1 for Psychiatry.

Review of the ED Nursing Note dated 12/2/2020 at 2:11 AM revealed EI # 11, ED RN, documented "pt. transported to (Hospital B) ... via ... ambulance, patient chart and property sent with (ambulance)... pt awake and alert, in nad (no acute distress), vss (vital signs stable). No medications given".

Review of the Ambulance Run Report dated 12/2/2020 revealed EMS (Emergency Medical Services) arrived at Baptist Medical Center South at 1:55 AM for a non-emergent transport of PI # 1, a 160 pound patient, to Hospital # B, Receiving Hospital. The chief complaint was documented as psychotic/psychosis. Review of the narrative documentation revealed PI # 1 was found by the EMS personnel at Baptist Medical Center South in the "...semi fowlers position and in no obvious distress. He/She is alert and oriented x 4 although seems agitated. GCS (Glasgow Coma Scale) = 15. An initial assessment was performed finding nothing abnormal...." At 2:16 AM, the EMS personnel documented a mental status assessment as "normal baseline for patient." Further review of the narrative documentation revealed the patient walked to the EMS stretcher and sat down. The patient was secured to the stretcher and the patient's condition remained unchanged through the arrival to Hospital # B at 4:01 AM when the patient got up and walked to the hospital stretcher.

A tour of the CBH, a part of Baptist Medical Center South, was conducted on 12/11/2020 at 8:15 AM. The adult psychiatric unit had a total of 24 semi-private patient beds. The psychiatric unit also had 2 seclusion rooms located in the facility for the adult psychiatric unit.

Interviews:

An interview was conducted on 12/9/2020 at 8:35 AM with EI # 18, Emergency Department (ED) Registered Nurse (RN) who provided care to PI # 1. When asked about PI # 1, EI # 18 stated the patient came to the ED under a court order for an evaluation to go to Crossbridge Behavioral Hospital (CBH). EI # 18 verbalized she/he did not recall any agitated and/or aggressive behavior while PI # 1 was in the ED. EI # 18 was then asked if she/he were aware of other cases where a violent patient had been admitted to CBH. EI # 18 stated, " ...I have seen them take violent patients before. The person with him/her said he/she had beat someone up while in prison. So, I think it may have been because of his/her violent history, not because of psychosis."

An interview was conducted on 12/9/2020 at 9:35 AM with EI # 12, Physician, Facility Medical Director for the ED. EI # 12 was asked what type of patients would be referred to CBH and responded patient who are "Suicidal, homicidal patients, patients with hallucinations, Geriatric with severe dementia." EI # 12 was asked if he/she recalled PI # 1 and after looking at the patient MR (medical record) responded, PI # 1 was seen by another ED physician who put in the orders. EI # 12 also verbalized PI # 1 could not go to CBH due to violent behavior. EI # 12 stated, "I think I was the one who spoke with Hospital B, Receiving Hospital. I don't think they ever asked me why we had to transfer patient. Crossbridge had already arranged the transfer, the intake just asked me to call a report. The reason for transfer was because he was violent." EI # 12 was asked if they recalled any agitated and/or aggressive behavior while PI # 1 was in the ED. EI # 12 stated, "He/She did not show any agitation while in the ER (Emergency Room). I don't remember any major issues."

An interview was conducted on 12/9/2020 at 11:15 AM with EI # 9, Clinical Assessment Coordinator for CBH, who stated he/she remembered PI # 1 after looking at the chart. EI # 9 stated "I went up to assess him/her... attorney was present. He/she was rambling...denied suicide or homicidal ideations....(the attorney) provided me with the court order. He/she had a fight with someone before coming to ER. The evaluation was by court order, it stated to evaluate and recommend for inpatient care if needed..." When EI # 9 was asked about PI # 1 demeanor and agitation, EI # 9 responded he/she was calm, but guarded and was not agitated. EI # 9 stated "I called (facility on-call Psychiatrist identified), presented the intake, age, information from the attorney, and his/her assault history. EI # 10 said he/she (PI # 1) needed inpatient care, but was not appropriate for the milieu of Crossbridge (CBH)". EI # 9 was then asked if Crossbridge accepts other violent patients, EI # 9 responded "yes, all the time".

An interview was conducted on 12/10/2020 at 10:15 AM with EI # 10, Psychiatrist on-call for CBH, who stated he did not recall the PI # 1 but per the chart he was denied because of his violent history. EI # 10 was asked what type of patients with a violent history would be denied admission. EI # 10 responded "it would depend on how strong, how large, how aggressive, and how controlled they are. Most of our staff are not capable of handling someone with a punching behavior. There would be a significant amount of time for help to arrive with any problems when a Code R (CBH code for emergency help is needed to address agitated and/or aggressive behavior of a patient) is called. We don't have the staff to handle large patient's like this with most of our staff small."

An interview was conducted on 12/10/2020 at 12:50 PM with EI # 11, ED RN, who provided care to PI # 1. EI # 11 verbalized the ED refers patient who are SI, HI, paranoia, drug overdose, court ordered admissions, pretty much any psych (psychiatric) to CBH. When asked if they were aware of any violent patient being admitted to CBH, EI # 11 stated, "we have had some go to Crossbridge who were violent." EI # 11 was asked about PI # 1's demeanor while in the ED. EI # 11 stated, "he/she went back and forth from angry to calm. Later that night I heard him/her yelling at the police ... He/She was verbally agitated at times, he/she did not have any violent physical episodes while in the ED. Following the interview question, EI # 11 stated, "I would like to state that the patient did not display any violent episodes while in ER and that is the reason why Crossbridge gave why they could not admit him/her. We have admitted violent patients over there before, we even sent one over there in restraints one time."

In an interview conducted on 12/11/2020 at 9:04 AM EI # 13, unit clerk and MHT (Mental Health Tech) for CBH, was asked how often does a patient become violent/assaultive on the adult unit. EI # 13 responded once a week or every other week. He/she was asked what is done when the staff needs extra assistance with a violent patient. EI # 13 responded, "Code R is the code and 2 people from each unit respond for a total of 8...sometime we need that many because the patient is large". When asked what the timeframe for other staff to respond to a code was EI # 13 responded "they come immediately".

In an interview conducted on 12/11/2020 at 9:18 AM EI # 14, RN for CBH, was asked about the facility policy for when a patient becomes violent/assaultive. EI # 14 responded all floor staff wears an audible alarm on their badge that when pulled "it will alert and the whole unit can hear it and we can call a code R. We get all the males and security. Usually about 10 people. Usually there are 2 male techs on west, the units come too but if they are wrestling with us they try to get all the males. It takes no time, probably a minute, if we also get security from South (Baptist South Hospital) it will take them 4 to 5 minutes". He/she explained the security is alerted by walkie talkie and start coming over immediately when a code is called. When asked about Crisis Prevention training EI # 14 responded he/she received Secure Training at the facility in March (2020) and "all staff, especially on the floor are trained. You don't go on the floor until you are trained".

In an interview conducted on 12/11/2020 at 9:32 AM EI # 15, MHT for CBH, was asked about the facility policy/procedure for when a patient becomes violent/assaultive on the unit. EI # 15 responded "we call a code R to get as many people to keep the patient from hurting self or others...we take other patients to the day room or somewhere to keep them safe. Once the patient calms down we will bring the other patients out".

In an interview conducted on 12/11/2020 at 9:42 AM EI # 16, RN, Nurse Manager for CBH, was asked about the facility policy/procedure for when a patient becomes violent/assaultive. EI # 16 responded "we use Secure training. Secure works with de-escalating patient. We do everything to verbally de-escalate, if we feel that is not going to work we offer to sit the patient in their room and let them talk to someone. If the patient becomes violent, punching and hitting, we can do a manual hold. We also have a seclusion room. We do have soft restraints if needed". EI # 16 was asked how often a patient becomes violent/assualtive on the adult unit, he/she responded "maybe once a month for actual hitting violent". EI # 16 was asked about Crisis Prevention training, he/she responded, "we do Secure Training. We have staff members who are trained to be trainers...All staff are trained in Secure. Anyone in this building including EVS (environmental services). We train everyone during orientation". EI # 16 was asked for reasons a patient would be denied admission to Crossbridge, he/she responded, "if we don't have beds or could be the patient refuses to come. I really don't know of another reason they wouldn't come".

An interview was conducted on 12/11/2020 at 12:45 PM with EI # 5, CBH Administrator, who confirmed bed # 223-1 was available for patient admission at 3:56 PM on 12/1/2020 and the adult psychiatric unit had normal staffing.