HospitalInspections.org

26632

Based on record review, interview, security tape review, and policy review, the provider failed to ensure safety precautions for elopement were in place for two of two emergency department (ED) patients (1 and 2) placed on a mental health hold per physician's orders. Those elopements violated the patients' rights for safety while treated by the provider and included the failure to:
*Identify, assess, and implement interventions to prevent the elopement of two of two ED patients (1 and 2) identified as high-risk for elopement.
*Initiate a standardized practice for admission and assessment of a doctor ordered mental hold status for two of two ED sampled patients (1 and 2).
*Initiate communication to ancillary staff as well as ED staff about:
-The Forerun (patient census board) board.
-The controlled access points.
-The verification of patients/visitors entering or exiting the ED area.
Findings include:

1. The provider failed to implement safety measures, policies, and communicate with the provider's security officers to ensure the safety for two of two sampled patients (1 and 2).

Review of the provider's undated Patient Rights and Responsibilities pamphlet revealed "Your Rights; As a patient, you can expect: Provision of care in a safe setting..."

Refer to A144.

2. The provider failed to ensure ED nursing staff services identified, assessed, and implemented interventions to prevent the elopement of two of two sampled ED patients (1 and 2) identified as high-risk for elopement and self-harm.

Refer to A385.

3. The provider failed to:
*Ensure ED staff adequately monitored two of two sampled patients (1 and 2) who had been placed on a mental health hold and had a known potential for self-harm.
*Fully develop and implement:
-A timely plan of action after patient 1 had eloped to prevent the elopement of patient 2.
-Policies and procedures for patients on a mental health hold and identified as high-risk for self harm.
-A training program for temporary staff and the security staff on their responsibilities for the care of patients placed on mental health holds and one-to-one observation of those patients.
-An organized nursing staff in sufficient numbers to ensure patient care was provided to meet the needs of the patient.
-Provide quality assurance on the plan of action.
-Documentation and communication protocols between staff disciplines.

Refer to A1100.

20031

Based on record review, security tape review, interview, job description review, and policy review, the provider failed to:
*Implement safety measures, policies, and communicate with the provider's security officers the emergency department's physician's diagnoses for one of two sampled patients (1) placed on a mental health hold in the emergency department (ED).
*Communicate within the security department's officers (B, C, and N) for one of two sampled patient's (2) the safety precautions set in place by medical staff.
Findings include:

1a. Review of the security tape from 7/3/14 provided by and reviewed with the director of risk management and accreditation/certification and interview with her on 7/14/14 at 3:30 p.m. revealed and she confirmed:
*Patient 1 left her room in the ED and walked south to an exit door in the ED with her husband.
*Patient 1 left the ED through the north exit door by following staff member L.
*Staff member L returned patient 1 to the ED within approximately ten seconds.
*Patient 1 appeared to be exit seeking and started toward the ambulance bay door.
*Patient 1's husband redirected her toward the front ED door.
*Nurse I then walked toward the front door, left the screen, and appeared to have let patient 1 and her husband out the ED front door.
*Closer review of the security tape revealed patient 1 had a two by two gauze on her hand along with the admission bracelet at the time she was let out the front door.
*Security was not noted to be visible in any portion of the security tape.
*Security tape footage of patient 1 ended.

b. Review of the incident report for patient 1 who reported to the emergency department revealed:
*"Patient reported to the Emergency Department July 2, 2014 at 21:28 (9:28 p.m.) after overdosing on Motrin, Beer and Vodka. ____, MD (medical doctor) evaluated her and placed on a mental hold for suicidal ideation (thoughts)."
*"At 03:26 a.m. transportation was available to transfer the patient to the Behavioral Health Unit but patient was missing. Security was notified at that time."
*"Upon review of the security cameras it is noted that the patient tried to exit through the North access door by following a staff member. She returned a moment later and a nurse from the Emergency Department let the patient and her husband out of the unit at 02:56 (2:56 a.m.) through the Main Exit from the ED."
*Investigation:
-"The float pool nurse, ____ (E), and the traveler nurse, ____ (D), were caring for the patient during the night. Neither nurse was aware of processes related to placing the patient in scrubs, taking clothes and securing other belongings. Additionally, it was not communicated to security or the Critical Resource Nurse in charge of the ED that night that the patient was placed on a mental hold. The nurse (I) who let the patient and her husband out of the unit, thought that they were visitors, she did not notice a patient bracelet or anything else that would make her think she were a patient."

c. Review of the provider's root cause analysis report dated "8July2014" revealed:
*Description of event or condition under analysis: "Patient who was placed on a mental hold left without staff awareness."
*Initial Possible Root Causes:
-"Did not follow polices."
--Review of the provider's policies revealed an elopement policy for ED was not in effect. Elopement policies were in place for the behavioral health center, dated July 2011, and the hospital, dated August 2013.
*Sequence of Events that began on 7/9/14 at 11:25 p.m. included:
-"Doctor saw her and admitted her. Placed mental hold at 23:25 (11:25 p.m.). Patient was sad and cried."
-"HUC [health unit clerk] usually notifies security nursing places them in scrubs. She was in gown instead. Nurse ____ (E) caring for the patient was not aware of the process for mental hold patients. Security was not notified according to call logs."
-"____ (E) reported off at midnight to a travel nurse ____ (D). She provided routine VS [vital signs] and then got her ready for transfer. She was unaware that there was a process to place the patient in scrubs and secure belongings. She discontinued her IV [intravenous] at 0257 [2:57 a.m.]."
-"[___] RN (I) let patient out at 0256 [2:56 a.m.] (per video clock). Did not know that there was a patient on a hold. Did not notice wrist band, security or scrubs. Did not see DC [discharge] papers and thought they were visitors."
-"0326 [3:26 a.m.] transport arrived and patient was found to be missing."
-"0326 security guard (K) and psych tech [psychiatric technician] came to transport."
-"(____) (O) CRN [clinical resource nurse] notified security, who was in the unit, of the missing patient."
*Report of Root Cause Analysis Action Plan dated "8July2014":
-"Root Contributor or Improvement Opportunity
--Protocol or checklist to be developed to standardize process for care of the Hold patients.
---Action Due Date 7/11.
--Alert process on Forerun [staff communication board regarding patient status] to be developed to display a flag for HOLD patients.
---Action Due Date 7/11.
--Competency and training for all staff including travel and float pool.
---Action Due Date 'no date given.'
--Alert bracelet research
---Action Due Date 'no date given.'
--Communication to ancillary staff and ED staff about controlled access points-locked units.
---Action Due Date Complete 7/7 & 7/11."
-"Measurement Strategy
--Persons Responsible: no titles or names listed.
--Follow-up date: no dates listed."

d. Review of an e-mail sent 7/7/14 by the director of ED revealed an outline of procedures to take when a patient eloped from the ED. The e-mail had not addressed what procedures or guidelines to put in place when a patient was placed on a mental hold by a physician.

e. Interview on 7/14/14 at 4:00 p.m. with the ED medical director revealed he had a draft of the ED elopement policy that had been placed in effect after another elopement on 7/11/14. He stated the policy had not had a final review or approval of management as of the date and time of the interview.

2a. Review of a conversation on 7/11/14 between the provider and the South Dakota Department of Health Office of Licensure and Certification (SD DOH/OLC) hospital advisor documented via e-mail on 7/14/14 to the SD DOH/OLC complaint coordinator revealed:
*"Conversation this morning with Vice President of Risk Management and Accreditation/Certification revealed Friday (7/11/14):
-Patient 46 years old male on mental hold presented at 3:50 p.m. with his mother to the ER, Triaged at 4:24 p.m., left without staff knowledge around 6:00 p.m.
-7/11/14, had 3 patients with mental holds, a combative patient, security assigned to monitor patient went to assist with combative patient, patient's mother left room, and patient left."

b. Review of the security tape and interview with the director of risk management and accreditation/certification on 7/14/14 at 3:35 p.m. revealed and she confirmed:
*Patient 2 could not be seen for the first few seconds on the video.
*Officer C was then visible in tape.
*Officer C glanced down the hall where patient 2's room was located without checking on patient's status.
*Officer C positioned himself in the hallway by the family room.
*Patient 2 was shown walking toward the front ED exit door.
*Patient 2 walked out of the front door when what appeared to be visitors entering the ED.
*Closer review of the security tape revealed patient 2 had an admission bracelet on his wrist and had no discharge papers with him at the time he was let out the front door.
*Officer C was noted to view the patient as he walked out the door.
*Officer C walked to the front door after patient 2 exited. He then turned and glanced toward the hallway where patient 2's room was located.
*Officer C then stood in the hallway by the front door and made notes in what appeared to be a small notebook.
*Security tape footage of patient 2 ended.

c. Review of the root cause analysis of patient 2 who reported to the emergency department revealed:
*Description of event or condition under analysis: "Patient (____) [2] who was placed on a mental hold left without staff awareness."
*Initial Possible Root Causes:
-"Did not follow polices."
--Review of the provider's policies revealed an elopement policy for ED was not in effect. Elopement policies were in place for the behavioral health center, dated July 2011, and the hospital itself, dated "August 2013."
*Sequence of events:
-"Date July 11, 2014: Police had custody of patient (2) and transferred to [___] (N) and [___] (B) for safety. Placed patient into ED 6. Another BH [behavioral health] patient was in ED 12 that was very combative and severe DTs [delirium tremens] with a sitter. Sitter assumed patient was to be admitted. Family/Safe room was already in use with another patient. Room 13 was also needing some additional observation."
-"Date July 11, 2014; Time 1550 (3:50 p.m.): Patient [___] (2) was transferred to [___] (hospital) after being placed on a mental hold at [___] (hospital). The patient needed to be medically cleared prior to being placed at [___] (behavioral health unit). (hold was placed at 1440 (2:40 p.m.) at ____ [hospital] ) In room 6. Room 6 has 2 doors and are self closing. [___] (G) did know the patient personally. Mother was waiting in the waiting room and came back after [___] (G) allowed. Security continued to observe hallway and door. [___] (P) trains staff to be readily available but not in the doorway at all times."
--"Staff states that when the hold is identified the process is to place in scrubs. Often refused 50%. Scrubs may not be the right size. Belongings are removed immediately and set outside of the room."
--"Need to evaluate MOU [memorandum of understanding] with [___] (police department)."
-"1700 (5:00 p.m.)":
-"Standby ERD (emergency room disaster) called.
[Note: Review of policy EMERGENCY DEPARTMENT DISASTER PLAN dated "April 2014" revealed: "POLICY STATEMENT: [___] (hospital) has developed an Emergency Department Disaster (ERD) Plan to be followed when more patients will arrive or are arriving in the Emergency Department than can be handled by the on-duty staff."]
- 1804 (6:04 p.m.) patient walked out of room and walked out doors that were opened by triage opening for family/visitors.
- Black H had just been initiated as a way to identify patients on hold. Message had only just gone out to staff.
- ____ (B) did ask patient why he left....'I felt I was being ignored' when patient came back the second time.
- 1607 (4:07 p.m.) ____ (B) took patient to back..... VS [vital signs] taken.
- 1735 (5:35 p.m.) notes from the nurse mom in room 1809 (6:09 p.m.) 'eloped' security thinks mother left about 15 minutes earlier.
- 1823 (6:23 p.m.) notified security of elopement."

d. Report of Root Cause Analysis Action Plan dated "14July2014":
-"Root Contributor or Improvement Opportunity
--Alarm system with audible alarm when hold/elopement patients are attempting to leave.
---Action Due Date 7/18/14 (Price Quote).
--Investigate ____ (police department) responsibility to assist with high volumes - MOU review.
---Action Due Date 7/18/14.
--Complete all training to new processes/polices developed related to elopements. ED staff, float staff, ancillary staff, security staff, Hospitalists. ICU (intensive care unit) CIU (cardiac intensive unit) Coordinators and communications to ancillary staff (hospital wide).
---Action Due Date 7/18/14.
--BH (behavioral health) security to assist with high census of overflow in the ED. 3+BH patients.
---Action Due Date Complete 7/11.
--Meet with BH, Risk, security and transfer center to identify potential concerns with admission process and -reevaluate the policy on pysch tech accompanies patient until admission decision.
---Action Due Date 7/18/14.
--Finalization of policy for elopement policy in ED
---Action Due Date 7/14/14.
--Immediate notification of security to staff (HUC) if other security priorities come up and are not available to provide supervision.
---Action Due Date 7/14/14.
-Measurement Strategy:
--Persons Responsible: no titles or names listed.
--Follow-up date: no dates listed."

3a. Review of IN-HOUSE OFFICER CALL LOG for "11-Jul-14" for security officer N:
*"1607 (4:07 p.m.) - 1715 (5:15 p.m.)"
-Location: "ed."
--Incident: "hold in ed 6 1 adult male."
*"1608 (4:08 p.m.) - 1639 (4:39 p.m.)."
-Location: "ed."
--Incident: "hold in family room 1 adult female."
*"1700 (5:00 p.m.)."
-Location: "ed."
--Incident: "erd standby."
*"1820 (6:20 p.m.)."
-Location: "ed."
--Incident: "condition elopement."
*"1859 (6:59 p.m.)."
-Location: "ed."
--Incident: "hold in ed 1 adult male."

b. Review of OUT SECURITY LOG for what appeared to be 7/11/14 (notation on log states "Current as of 01 Nov 13") for security officer C
*"1805-1820 (6:05 p.m. - 6:20 p.m.).
-Location: "ed."
--Incident: "watching holds in ed-6 & ed-fam rm."
*"1815 (6:15 p.m.)."
-Location: "ed."
--Incident: "advised of elopement out of ed 6."
*"1830-1850 (6:30 p.m. - 6:50 p.m.)".
-Location: "office."
--Incident: "check camera's for elopement patient. Patient walked out of er at approx 1804 (6:04 p.m.) hrs."

c. Review of EVENING TRANSPORT SECURITY LOG for 7/11/14 for security officer B:
*"1610 (4:10 p.m.)."
-Location: "ED-6."
--Incident: "Hold in ED-6."
*"1815 (6:15 p.m.)."
-Location: "ED."
--Incident: "Advised of Elopement from ED-6 by RH #33 (security officer C)."

d. Review of staff records for the following provider's security officers revealed:
*Officer N was hired 6/25/14. As of 7/14/14 he had not completed orientation.
*Officer C was hired 9/19/13. As of 7/14/14 he had completed orientation but had not completed the initial nonviolent crisis intervention training (CPI).
*Officer B was hired 12/9/13. As of 7/14/14 he had completed orientation but had not completed the initial CPI training.
*Security officers B, C, and N were noted to be involved in the mental health holds for patients 1 and 2.

e. Review of the job description titled security officer revealed: "Position Summary: Officer has knowledge of all phases of the job related methods, techniques and skills necessary for effective performance. Officer is responsible for communicating and enforcing Administrative, Personnel and Department policies and procedures in association with the organization's vision and values."

f. Review of the policy titled GENERAL OPERATING PROCEDURES - PATROL revealed: "INTERNAL TOURS: 3. The officer will log all inconsistencies or unusual activities or situations with the Hospital or other facilities as assigned. Discrepancies such as security problems should be reported immediately." No direction was given to whom the security officer reported the discrepancy or problems.

g. Policy review titled RESTRAINT RESPONSE dated May 2014 revealed: *"EMERGENCY ROOM: Patients that are receiving treatment as a patient within the Emergency Room may need restraining, if they are combative or assistance may be requested to standby while a patient is given a psychiatric evaluation. Based on the situation, one or two officers may be required to accomplish the restraint/standby. It is not necessary for more than one officer to remain in the Emergency Room, if the patient has calmed down.
*"TRAINING: Restraint training is conducted by ____ (provider) In-service Education department (Defensive Tactics Course/PPCT (pressure point control tactics) Program/CPI, conducted yearly & review class). Included, are also Security Department Orientation Program, and other Departmental programs as they become available."

h. Review of the job description title Supervisor; department: "[___] (provider) Security revealed:
*"Position Summary: Provides supervision of the Security Department and it's operations for all shifts.
*Essential Job Functions:
-Arranges inservices as needed to keep members of the subcommittee up to date on current issues.
-Assists with inservice training for new Hospital employees at monthly Mandatory Inservices and General Orientation.
-Prepares and reviews incident reports, maintenance work requests hazard reports, ticket information, daily logs, etc. Follows up on issues in a timely manner."

i. Policy review titled SAFETY MANAGEMENT PLAN dated June 2014 revealed: "POLICY STATEMENT: [___] (provider) maintains a management plan that addresses Safety Management in order to provide a safe environment for patients, visitors, and staff."

4a. Interview on 7/15/14 at 8:00 a.m. with the security supervisor revealed:
*There were no formal reports from the security officers regarding the events that took place on 7/2/14 through 7/3/14 and on 7/11/14. There were only log notes.
*No additional training or safeguards had been put in place for the security department after either elopement. He had made his officers aware of the e-learning training regarding the new action plan for ED.
*No tracking and trending of incidents had ever been done.
*ED HUC or CRN was to advise security for observation of mental hold.
*A triage of priorities for assistance by security would have been combative patients first and mental patients second.
*Security officer N had requested assistance at a level three for a combative patient on 7/11/14.
*Camera placement for viewing had not been changed. No new cameras had been added to view all exits.
*It was standard operating procedure to pull the security officer from the behavioral health unit to the hospital or ED to assist.
*There were no guards on call. But officers knew they could call the lead officer or supervisor with questions or concerns.
*There was one officer out on medical leave and still one opening for an officer in security.

b. Interview on 7/15/14 at 3:15 p.m. with the director of risk management and accreditation/certification revealed she had spoken with the security supervisor regarding the security meeting minutes. He stated security never had a quarterly meeting with ED as requested in July, September, October, and November 2013 as no one would initiate the process. He also stated he could not recall what the issues were for mental holds/24 hour observational holds noted on 3/12/14. He stated the elopement policy discussed in the 4/23/14 meeting was related to the hospital elopement policy and not the ED.

5a. Review of the security department staff meeting minutes from 7/17/13 through 4/23/14 revealed:
*On 7/17/13 at 8:00 a.m. former security officer S asked if it was possible to have a meeting with ED staff similar to the quarterly meeting had at the behavioral health unit. The assistant director of the ED had been contacted, but no response yet.
*On 9/4/13 at 8:00 a.m. former security officer S asked if it was possible to have a meeting with ED staff similar to the quarterly meeting had at the behavioral health unit. The assistant director of the ED had been contacted, but no response yet.
*On 10/2/13 at 8:00 a.m. former security officer S asked if it was possible to have a meeting with ED staff similar to the quarterly meeting had at the behavioral health unit. The assistant director of the ED had been contacted, but no response yet.
*On 11/6/13 at 8:00 a.m. former security officer S asked if it was possible to have a meeting with ED staff similar to the quarterly meeting had at the behavioral health unit. The assistant director of the ED had been contacted, but no response yet. Eliminate ED security officer 1, add another day shift security officer for Monday through Friday. That officer would work ED if needed.
*On 11/6/13 at 8:00 a.m. a round table meeting was held with the ED HUCS. "Would like to set-up a quarterly meeting between the ED Staff and Security (no supervisors) to go over issues/concern. The ED director liked that suggestion and would get an RN, PCT and HUC. Security would have 3 Officers."
*No security staff meeting minutes were provided for August and December 2013, and January and February 2014.
*On 3/12/14 from 8:00 a.m. through 10:00 a.m. a security staff meeting was held. Items discussed included:
-Mental holds/24 hr observational holds: Discussed monitoring these due to the issues involved.
*On 4/23/14 the security department meeting minutes revealed:
-A policy update on the elopement policy was discussed. Hard Copies of the policies would have been put in a binder so they were available for everyone to review.
-Staff standardization item was discussed regarding the review of standard procedures for conducting patient searches. That included:
-If a patient had to be transported to the behavioral health unit with civilian clothes on, they would have been asked to empty their pockets. If the ED put the patient in scrubs their pockets would have needed to be emptied.
-The security supervisor stated he had tried to work with the legal department to get a policy in place. They had come up with the plan for ED to put the patient in scrubs. The director of plant operations would contact ED and legal for clarification.
-Security officer K stated that "He ran into a problem with ED not having the correct size of scrubs to put on the patient. Director of plant operations would speak with the ED director and director of environmental services about the scrub supply."

b. Review of the ED management, ED staff, ED CRN, and ED technician meeting minutes from 6/3/13 through 7/9/14 revealed a 12/9/13 ED CRN meeting concerns or questions had included night shift unsafe due to the high volume of new staff.

20031

Based on record review, interview, and policy review, the provider failed to ensure emergency services and its undated action plan regarding elopements of two of two sampled patients (1 and 2) on mental holds were incorporated into the comprehensive quality assurance performance improvement (QAPI) program. Findings include:

1. Review of the provider's root cause analysis report dated "8July2014" revealed:
*Description of event or condition under analysis: "Patient who was placed on a mental hold left without staff awareness."
*Initial Possible Root Causes:
-"Did not follow polices."
--Review of the provider's policies revealed an elopement policy for ED was not in effect. Elopement policies were in place for the behavioral health center, dated July 2011, and the hospital, dated August 2013.
*Sequence of Events starting on 7/2/14 at 11:25 p.m. included:
-"Doctor saw her and admitted her. Placed mental hold at 23:25 (11:25 p.m.). Patient was sad and cried."
-"HUC [health unit clerk] usually notifies security nursing places them in scrubs. She was in gown instead. Nurse ____ (E) caring for the patient was not aware of the process for mental hold patients. Security was not notified according to call logs."
-"____ (E) reported off at midnight to a travel nurse ____ (D). She provided routine VS [vital signs] and then got her ready for transfer. She was unaware that there was a process to place the patient in scrubs and secure belongings. She discontinued her IV [intravenous] at 0257 [2:57 a.m.]."
-"[___] (I) let patient out at 0256 [2:56 a.m.] (per video clock). Did not know that there was a patient on a hold. Did not notice wrist band, security or scrubs. Did not see DC [discharge] papers and thought they were visitors."
-"0326 [3:26 a.m.] transport arrived and patient was found to be missing."
-"0326 security guard (K) and psych tech [psychological technician] came to transport."
-"(____) (O) CRN [clinical resource nurse] notified security, who was in the unit, of the missing patient."
*Report of Root Cause Analysis Action Plan dated "8July2014":
-"Root Contributor or Improvement Opportunity
--Protocol or checklist to be developed to standardize process for care of the Hold patients.
---Action Due Date 7/11.
--Alert process on Forerun [staff communication board regarding patient status] to be developed to display a flag for HOLD patients.
---Action Due Date 7/11.
--Competency and training for all staff including travel and float pool.
---Action Due Date 'no date given.'
--Alert bracelet research
---Action Due Date 'no date given.'
--Communication to ancillary staff and ED staff about controlled access points-locked units.
---Action Due Date Complete 7/7 & 7/11."
-"Measurement Strategy
--Persons Responsible: no titles or names listed.
--Follow-up date: no dates listed."

2. Review of the provider's Report of Root Cause Analysis Action Plan dated "14July2014" revealed:
-"Root Contributor or Improvement Opportunity
--Alarm system with audible alarm when hold/elopement patients are attempting to leave.
---Action Due Date 7/18/14 (Price Quote).
--Investigate ____ (police department) responsibility to assist with high volumes - MOU review.
---Action Due Date 7/18/14.
--Complete all training to new processes/polices developed related to elopements. ED staff, float staff, ancillary staff, security staff, Hospitalists. ICU (intensive care unit) CIU (cardiac intensive unit) Coordinators and communications to ancillary staff (hospital wide).
---Action Due Date 7/18/14.
--BH (behavioral health) security to assist with high census of overflow in the ED. 3+BH patients.
---Action Due Date Complete 7/11.
--Meet with BH, Risk, security and transfer center to identify potential concerns with admission process and -reevaluate the policy on pysch tech accompanies patient until admission decision.
---Action Due Date 7/18/14.
--Finalization of policy for elopement policy in ED
---Action Due Date 7/14/14.
--Immediate notification of security to staff (HUC) if other security priorities come up and are not available to provide supervision.
---Action Due Date 7/14/14.
-Measurement Strategy:
--Persons Responsible: no titles or names listed.
--Follow-up date: no dates listed."

3. The provider had no documentation that indicated they had incorporated the following into their QAPI:
*Alert process on Forerun was not completed until 7/14/14 after patient 2 had eloped.
*There had been no audit or follow-up that all ED staff, ancillary staff, and security staff had completed the education from the action plan.
*No staff had implemented or taken ownership of the action plan for the prevention of ED elopements.

4. Interview on 7/15/14 at 8:00 a.m. with the security supervisor revealed:
*There were no formal reports from the security officers regarding the events that took place on 7/2/14 through 7/3/14 and on 7/11/14. There were only log notes.
*No additional training or safeguards had been put in place for the security department after either elopement. He had made his officers aware of the e-learning training regarding the new action plan for ED.
*No tracking and trending of incidents had ever been done.
*ED HUC or CRN was to advise security for observation of mental hold patients.
*A triage of assistance for security would be combative first and mental second.
*Security officer N requested assistance at a level three for a combative patient on 7/11/14.
*Camera placement for viewing had not been changed. No new cameras had been added to view all exits.
*It was standard operating procedure to pull the security officer from the behavioral health unit to the hospital or ED to assist.
*There were no guards on call. But officers knew they could call the lead officer or supervisor with questions or concerns.
*There was one officer out on medical leave and still one opening for an officer in security.

5. Interview on 7/14/14 at 4:00 p.m. with the ED medical director revealed he had a draft of the ED elopement policy that had been placed in effect after another elopement on 7/11/14. He stated the policy had not had a final review or approval of management as of the date and time of the interview.

6. Review of an e-mail sent 7/7/14 by the director of ED revealed an outline of procedures to take when a patient eloped from ED. The e-mail had not addressed what procedures or guidelines to put in place when a patient was placed on a mental hold by a physician.

7. Review of the provider's revised June 2014 Performance Improvement Plan and Participation policy revealed:
*The provider had a defined process for the identification, management, and intensive analysis of serious adverse events.
*The provider would proactively identify and reduce risks to the safety of patients by selecting a high-risk process to be analyzed on at least an annual basis.
*The provider was committed to improving safety for all patients and staff at all sites.
*Patient safety would have been incorporated into performance improvement activities.
*The provider collected and analyzed data on patients' perceptions of care, treatment, services, and patient safety.
*The provider considered collecting staff opinions regarding patient safety.

26632

Based on record review, security tape review, observation, policy review, and interview, the provider failed to ensure emergency department (ED):
*Nursing staff identified, assessed, and implemented interventions to prevent the elopement of two of two sampled ED patients (1 and 2) who were identified as high-risk for self-harm and elopement.
*Nursing staff utilized the emergency severity index (ESI) triage algorithm for one of two sampled ED patients (1) identified as high-risk for self-harm and elopement.
*Nursing staff utilized the provider's SAD PERSONS assessment tool for two of two sampled ED patients (1 and 2) who were at high-risk for self-harm and elopement.
*Nursing staff communicated with other appropriate ED staff and ancillary staff regarding:
-The Forerun patient census board.
-Controlled access points to and from the ED.
-Verification of patients/visitors entrance and exit for the ED.
*Orientation on policy and procedure for patients at risk for elopement in the ED had been completed by one of one newly hired traveling RN (D) that worked in the ED.
*Was staffed and operated in a manner to provide safe care to all patients on all shifts.
Findings include:

1a. Review of patient 1's 7/2/14 through 7/3/14 ED record revealed:
*She had registered as a patient on 7/2/14 at 9:28 p.m.
*She had been triaged by RN E at 9:36 p.m. with complaints that she had consumed thirty to thirty-five Motrin tables, had drank seven beers, and a pint of vodka.
*She had stated she "Wanted to make things easier."
*The triage ended at 9:39 p.m. She had been assigned an ESI acuity of 3.
*Treatment orders were started at 10:01 p.m. Those orders included: An intravenous (IV) infusion bolus of normal saline (NS) of one liter and activated charcoal of 50 milligrams by mouth.
*Laboratory orders were given for Tylenol, salicylate (aspirin), ETOH (blood alcohol level), TSH (thyroid stimulating hormone), and FT (free thyroid) 4 blood levels.
*The petition for emergency commitment was signed by the physician on 7/2/14 at 11:25 p.m.
*A physician order on 7/3/14 at 12:23 a.m. for another IV infusion bolus of NS of one liter.
*On 7/3/14 at 2:35 a.m. a physician's order to transfer to the behavioral health unit. "Pt. (patient) is on a hold status."
*She had been seen by a physician on 7/2/14 at 10:00 p.m. and a decision to admit to the behavioral health hospital was made on 7/3/14 at 12:15 a.m.
*The physician note stated "It is my concern that she took this in a suicide attempt. It is especially concerning that she is unwilling to discuss anything with me. She was placed on a mental health hold."
*Nursing notes included:
-On 7/2/14 at 10:35 p.m. a note by RN E "Resting quietly, no apparent distress, Asleep, easy to around and IV infusing, no infiltration."
-On 7/3/14 at 12:30 a.m. a note by traveling RN D "Has had 1 liter NS iv per previous RN (E), bp (blood pressure) low, discussed w (with)/(physician's name), NS repeated, liter hung, husband at bedside, call light in reach, arouses to loud verbal stimuli."
-On 7/3/14 at 1:13 a.m. note by RN D "Resting, husband at bedside, call light w/in reach."
*Under disposition notes included:
-On 7/3/14 at 2:55 a.m. note by RN D "Admit to _____ (name of behavioral health unit), transfer condition stable, valuables sent with patient, nursing report: written, verbal report to ______ (nurse at _____ (behavioral health unit)."
-On 7/3/14 at 2:57 a.m. a note by RN D "IV dc'd (discontinued) w/catheter intact, reviewed w/pt and husband that she will be admitted to ____ (behavioral health unit). Does ask if she can go home, instructed that is not an option tonoc (tonight). States understanding. Crying, states she knows what she did was 'dumb' and that she doesn't know why she can't just move on. States she doesn't want to drink but does sometimes."
*Addendum on 7/3/14 at 3:26 a.m. by RN F "West transport here, Pt. gone-husband gone. Phoned telephone number-rang, then hung up. Security aware-is calling dispatch to make aware of pt. elopement."
*There was no documentation that she had been put in green scrubs per policy.
*There was no documentation that a SAD PERSONS scale had been completed.
*SAD PERSONS SCALE:
-Sex 1 if patient is male, 0 if female, -Age 1 if patient is (25-34; 35-44; 65+), Depression, Previous attempt 1 if present, Ethanol abuse 1 if present, Rational thinking loss 1 if patient is psychotic for any reason (schizophrenia, affective illness, organic brain syndrome), Social support lacking 1 If these are lacking, especially with recent loss of a significant other, Organized Plan 1 if plan made and method lethal, No spouse 1 if divorced, widowed, separated, or single (for males), and Sickness 1 especially if chronic, debilitating, severe (e.g.; non- localized cancer, epilepsy, MS, gastrointestinal disorders)
*Patterson WM, Dohn HH, et al: Evaluation of suicidal patients, THE SAD PERSONS Scale, Psychosomatics, 1983:
-One method to gather this information that has been useful for healthcare providers is the SAD PERSONS scale, the scale included:
-"S" stands for sex. Again, we know that males are likely to end life by suicide 2 xs that of females and females attempt 2x more than males.
-"A" stands for age. Remember the ages that have the highest suicide rates.
-"D" stands for depression. Does the patient have symptomatology or diagnosis of depression? Remember, depression is the mental illness with the closest link to suicide.
-"P", previous attempt. Has the person attempted before and if so, what means did they use and what factors where involved, how did they survive the attempt?
-"E" stands for ethanol abuse.
-"R" stands for rational thinking. Is the patient thinking rationally?
-"S" stands for social support deficit. Does the patient have a support system?
-"O" is for organized plan. Does the patient have a thought out plan for taking the steps to act on the thoughts? "N" is for no spouse. Is the patient without a spouse?
-"S" is for sickness. Does the person have a medical or physical illness?
-These letters represent 10 areas of assessment. The scoring for this is as follows- 0-2 equals little risk, 3-4 equals following patient closely, 5-6 equals strongly considering hospitalization, and 7-10 equals a very high risk, hospitalize or commit.

b. Review of the ESI Triage Algorithm used by the ED triage staff revealed patient who was suicidal, homicidal, psychotic, or violent or present an elopement risk should have been considered high risk. That score would be a 2.

c. Review of the provider's undated action plan that had been developed after the above incident revealed:
*A checklist was to have been developed to standardize the process for care of the mental health patient placed on an involuntary hold.
*Alert process or "flag" to be developed to display on patient census board for communication to all staff. This alert process had not been implemented until 7/14/14.
*Competency and training for all staff working in the ED including travel and float pool staff working in the ED. This training had not been completed by all staff that worked in the ED by 7/14/14.
*Communication to ancillary staff as well as ED staff about controlled access points and verification of patient/visitors entering or exiting the area. This communication had been sent by an e-mail and verification of the information had not been completed.

d. Review of the provider's June 2014 Behavioral Health patients in the ED policy revealed:*Patients who were identified to have a psychiatric or behavioral health problems upon presentation to the ED would have been interviewed by a nurse (using the SAD PERSONS assessment scale) to determine the patients capacity to harm self or others.
*Every effort would have been made to place the patient in a quiet room with a family member, if appropriate, to ensure safety.
*Security or trained sitter personnel might have been requested to assist in observation to ensure patient safety.
*Patients might have been asked to undress and placed in a gown or transfer scrubs, belongings might have been searched and kept outside of the room at the discretion of the primary nurse. The primary nurse would assess the patient in terms of safety and medical need and would ensure the patient was seen by the physician as soon as possible.
*After the patient was medically cleared the physician would determine if out-patient crisis counseling or inpatient treatment was needed or if the patient was appropriate for discharge to home/family.

2a. Review of patient 2's 7/11/14 ED record revealed:
*He had been placed on a mental health hold at 2:40 p.m. on 7/11/14 by the another provider's physician due to suicidal thoughts.
*He had been transferred from the other provider and registered at the ED at 3:50 p.m. to have been medically cleared before admission to the behavioral health unit.
*He had been triaged by RN G at 4:24 p.m. His ESI acuity was a 2.
*He had been seen by the ED physician at 5:08 p.m.
*Review of ED physician Q's notes revealed:
-"Nursing staff notified our security department but I had concerned patient would elope as he adamantly stated he did not want to go to ____(behavioral health unit). Security guard arrived and were apprised that he was on a hold from _______ (another provider.) Unfortunately patient was able to elope and nursing staff notified appropriate authorities."
*Review of the 7/11/14 nursing notes revealed:
-At 4:25 p.m. a nursing exam was completed. Patient 2 stated to RN G "Everything is going wrong....Doesn't have money or insurance to see doctor. Mom is at bedside. Hold in place. Security at door. Depressed affect, suicidal."
-At 5:35 p.m. "Remains calm and cooperative. Mom remains in room."
-At 6:23 p.m. "Condition elopement called via communications. Description of pt. and mother given to communications. Health unit coordinator (HUC) informed me (RN G) that she had told security guard B, who was over by room 12, that room 6 was a flight risk. His response was 'The mom's in the room'."
-At 6:27 p.m. "Security guard C told me (RN G) the mother left at 1700 (5:00 p.m.) and he switched out with security guard B at 5:15 p.m."
*Disposition of patient 2 on 7/11/14 at 6:09 p.m. by RN R included:
-"Eloped." "The patient has left the medical center unnoticed at some point after being seen by a physician, without informing medical center personnel or medical staff members."
-"Notified ED attending physician at 11 Jul 2014 18:00 (7/11/14 6:00 p.m.), police notified, security notified."
-"Pt. reported eloped by previous shift RN G. Appropriate channels and personnel notified of event."
*There was no documentation patient 2 had changed into green scrubs per policy.
*There was no documentation a SAD PERSONS scale had been completed.

3. Review of the provider's revised March 2014 Assessment and Documentation Patient policy revealed:
*Based on the initial assessment the RN would identify, prioritize, and document the specific patient problems.
*Ongoing assessments would be done by the RN as the patient's condition or length of stay warranted.
*Patients in the waiting room or in the department would have been rounded on each hour or more frequently if condition warranted.
*Rounding may have been accomplished by either nursing or patient care technician staff and would have been documented in the patients health record.

4. Review of the provider's reviewed August 2013 Assessment of Patient Elopement Risk policy revealed only procedures for the elopement of inpatients.

5. Review of the ED management, ED staff, ED CRN (clinical resource nurse), and ED technician meeting minutes from 6/3/13 through 7/9/14 revealed:
*At a 6/3/13 ED CRN meeting the staffing plan was addressed. There were four open RN positions.
*At a 6/18/13 and 6/20/13 staff meeting the staffing update included:
-The open RN and tech positions were posted, and they were actively interviewing for qualified staff.
-They had been challenged by administration to work on creating a safe schedule not only for staff by for the patients. But they had been approved for two travelers.
*At a 9/23/13 ED CRN meeting staffing was addressed. This included the staffing changes that had occurred in the last month. There were three positions open.
*At a 12/9/13 ED CRN meeting concerns or questions included the following topics had been discussed:
-Night shift unsafe due to the high volume of new staff.
-Staff schedules would be reviewed closer to ensure the right experience mix on all shifts.
*At a 1/13/14 and 1/15/14 ED staff meeting staffing included one ED CRN position was open.
*At a 1/14/14 ED CRN staff meeting the topic of using a paramedic versus an RN was discussed. The possibility of turning the 7:00 a.m. to 3:00 p.m. medic shift into an RN shift and hiring RNs in the vacated medic shifts.
*At a 2/19/14 ED management meeting the ED staffing needs were discussed. There were holes in the schedules.
*At a 2/26/14 ED management meeting the ED staffing needs were discussed. There were holes in the schedules.
*At a 3/5/14 ED management meeting the ED staffing needs were discussed. There were holes in the schedules.
*At a 3/12/14 ED management meeting the ED staffing needs were discussed. There were holes in the schedules.
*At a 4/2/14 ED management meeting the ED staffing needs were discussed. There were holes in the schedules.
*At a 4/9/14 ED management meeting the ED staffing needs were discussed. There were holes in the schedules.
*At a 4/16/14 ED management meeting the ED staffing needs were discussed. There were holes in the schedules.
*At a 5/7/14 ED management meeting the ED staffing needs were discussed. There were holes in the schedules.
*At a 5/21/14 ED management meeting revealed RN interviews were on-going. There were holes in the schedules. There was approval for two traveler nurses.
*At a 5/28/14 ED management meeting revealed RN interviews were on-going. There were holes in the schedules. There was approval for two traveler nurses up to 180 days.
*At a 6/12/14 ED management meeting there were three new RNs starting in June 2014. Two traveler RNs were starting in June. Health unit coordinators (HUC) holes in schedule over the weekend. Central staffing stated they have many HUCs on over the weekend.

6. Review of the ED traveler RN orientation checklist revealed traveler RN D had completed it on 6/23/14. Review of that orientation checklist revealed:
*General orientation items that included:
-Location of reference materials i.e. policy and procedures.
-Meditech/Forerun electronic medical record (EMR) documentation.
*ED orientation included:
-Orientation of the ED.
-Forerun EMR.
-Trauma orientation.
-Stroke alert protocol.
-Sepsis screening tool/use.
-No specific information for patients on a mental health hold was on the orientation form.

7. Review of the contract for traveler RN D revealed:
*She had started on 6/23/14.
*The provider would have provided orientation to the traveler employee to areas that included: rules, regulations, policies, procedures, and emergency protocols.
*The provider would have been responsible for the establishment of staff clinical competence during the initial orientation period and on an ongoing basis during the contract period.
*In order to ensure a high quality of patient care delivery, orientation relevant to the unit, setting, or area. The length and extent of orientation would have been defined by the provider.

8. Review of the ED staffing schedule included:
*On 7/2/14 from 2:00 p.m. through 7:00 a.m. revealed there had been eight RNs scheduled from 6:00 p.m. through 6:30 a.m. (When patient 1 had eloped.) Two of those RNs had been on orientation, one was the CRN, one was a traveler RN, one was scheduled from 2:00 p.m. through 2:00 a.m., and one was scheduled from 3:00 p.m. through 3:00 a.m.
*On 7/11/14 from 6:00 a.m. through 3:00 a.m. on 7/12/14 revealed there had been ten RNs scheduled (When patient 2 eloped.) One was the CRN, one was on orientation, one was scheduled from 9:00 a.m. through 9:00 p.m., one was scheduled from 11:00 a.m. through 11:00 p.m., one was scheduled from 4:00 p.m. through 12:00 midnight, one was scheduled from 2:00 p.m. through 2:00 a.m., and one was scheduled from 3:00 p.m. through 3:00 a.m.
*Of those RNs scheduled it was noted that one of them would float to be the triage RN in four hour blocks of time.
*The 7/2/14 ED staffing schedule noted a "4-12 RN" was needed. There was no indication of the a.m. or p.m. time period.
*The 7/11/14 staffing schedule noted a 10:00 a.m. to 2:00 p.m. ED RN , 8:00 p.m. to 12:00 midnight ED RN, and a 12:00 midnight to 6:00 a.m. ED RN were needed. There was also a 4:00 p.m. to 12 midnight ED HUC and a 5:00 p.m. to 3:00 a.m. ED technician needed.

20031

Based on record review, interview, security tape review, and policy review, the provider failed:
*To ensure self-harm and elopement precautions were in place for two of two sampled emergency department (ED) patients (1 and 2) who had been placed on a physicians' ordered mental health hold.
*To have an adequate nursing staff to supervise patients placed on a mental health hold.
*Identify and ensure all staff were trained and had demonstrated competency on how to ensure a patient on a mental health hold would not elope. According to the provider's plan of action after the 7/3/14 patient 1 elopement.
*Fully develop and implement a timely plan of action for patient's 1 and 2 identified as eloped.
*Monitor the plan of action to ensure it was viable and staff were compliant with the plan.
*To ensure complete and comprehensive policies and procedures were in place for mental health hold patients and patients at risk for elopement.
*Prevent the occurrence of elopement for patients placed on a mental health hold putting patients at risk of harm without proper intervention.
*To ensure the ED staff:
-Resposnible for patient care adequately monitored patients who had a known potential for self-harm and had been placed on a mental health.
-Assigned patients with a mental health hold conducted "hand-off" communication for those patients waiting to be transferred to the behaviorial health unit.
-Consistently documented and communicated to the security staff when patients were placed on a mental health hold.

These failures represented an Immediate Jeopardy (IJ). On 07/15/2014 at 5:00 p.m., an IJ was declared regarding emergency services. The hospital's leadership staff (Chief Executive Office, Chief Operating Officer, Vice President of Risk Management and Accreditation/Certification, Director of Risk Management and Accreditation/Certification, Vice President of Ancillary Services, Director of ED Services, Medical Director of ED Services, and security officer A) were notified of the IJ situation. An acceptable corrective action plan was received and approved and the IJ was abated on 7/17/14 at 1:25 p.m.
This deficiency remained at a condition level after the abatement of the IJ and compliance with the immediate plan of correction. Findings include:

The provider's immediate plan of correction is as follows:
*Patient identification:
-1. The policy was revised to require the emergency department primary nurse to place a patient in green scrubs and to place a colored arm band on the patient upon initiation of hold rather than at time of transfer. (A blue arm band will be used until the permanent green arm bands arrive.) The arm band will be applied to all mental hold patients regardless of refusal to wear scrubs. All mental hold patients will have visual observation, an arm band, and will be identified with an " H " on the locator board. Completion date of 7/11/14
-2. Increased availability of scrubs by increasing par levels. (Quantities and sizes.) Environmental services is completing a daily evaluation of par levels and replenish as needed. Completion date of 7/17/14.
*Observation of hold patients:
-1. Provided additional support staff for hold patient observation. Completion date of 7/15/14.
-2. Defined and implemented a medical classification of Hold levels to include visual observation (in a room with door open with exit point within the observers line of sight) or 1:1 observation. Once a Petition of Emergency Commitment is placed, patients will have visual observation while in the Emergency Department. If the Emergency Department physician, who is a Qualified Mental Health provider by the State of South Dakota determines the patient needs increased monitoring, he/she will order 1:1 observation. Completion date of 7/16/14.
-3. Defined and implemented a process to obtain additional resources for county mental hold patient observation. Security is trained in CPI and will observe the patient and provide a safe environment by identification of escalation and de-escalation needs. Security will have primary responsibility for observing county mental hold patients in the Emergency Department. If security is experiencing capacity limitations he/she will notify ED staff, ED staff will observe while ED Clinical Resource Nurse notifies Hospital Coordinator; Hospital Coordinator will obtain additional staffing resources from an identified pool for observation coverage. (Observation will be completed by staff in the following sequence -security, ED staff, trained float pool observers who are unlicensed personnel include but are not limited to patient care techs (PCTs), supply purchasing distribution (SPD), and environmental services staff. There is always a CPI trained security of emergency department staff member immediately available to an observer within emergency department. This process will result in uninterrupted observation of emergency department county mental hold patients. Completion date of 7/16/14.
-4. " Observer " Staff education: Observation staff will have received the orientation currently used " constant observer education/orientation " prior to observing a county mental hold patient. Documentation of education will be retained by Central Staffing Office (CSO).
-5. Developed and implemented " Hold Patient Observation Flow Sheet " to document observation of patient behaviors and maintenance of environmental precautions. Completed flow sheet will become part of the patient ' s medical record.
-6. The ED Primary Nurse will ensure Flow Sheets are complete before they are placed in the medical record. (Initialed JG)
*Law Enforcement:
-1. Communication to police and county officers of increased security measure for County hold patients. Completion Date: 7/17/14
*Controlled Access:
-1. Security Personnel checked all cameras and doors for functionality and assured controlled access to the Emergency Department. Security Standard Operating Procedures re to check cameras and doors daily. Variation from normal functioning and remedial action taken will be documented by eon the In-House Officer Call Log. Completion Date: 7/15/14
-2. Removed Visitor Passes. Visitor and patient access is not only permitted by Emergency Department employee controlled bade swipe. Completion Date: 7/15/14
-3. Posted signage all doors to increase employee, patient and visitor awareness restriction. Signage states, " Controlled Access-Patients and Visitors must check with Emergency department Staff before entering/exiting. Thank you for your Cooperation. "
Completion Date: 7/15/15
*Policy Development and Revision:
-1. In response to the elopement events, a new Emergency Department policy developed and approved. ( " Elopement Preventive Measures in the ED " (EDMED-6231-55). Completion Date: 7/14/14
-2. The policy was further revised to incorporate new processes, such as obtaining additional resources and documentation of patient observations and care. Completion Date: 7/14/14
-3. The policy was further revised to incorporate processes including the establishment of levels of observation, primary nurse responsibility for patient change into scrubs, Security responsibility for observation of patients, and use of arm bands. Completion Date: 7/17/14
*Education:
-1. Education packet developed and distributed for completion by ED staff and staff who float to the ED. (7/18/14 or prior to any shift worked I ED).
Completion Date: Education to be completed prior to any worked shift in the Emergency Department 7/15/14 (To be documented and returned to ED Director by 7/18/14)
-2. Distributed to Department Directors communication and acknowledgement for all Ancillary staff regarding controlled access to the Emergency Department. Completion Date: 7/15/14.
-3. Distribute updated education to be completed by staff prior to working a shift or observing mental hold patients in the Emergency Department. Education to include updated process of arm band utilization, hold level classification, flow sheet, ad obtaining additional observer resources. Emergency Department Director or designee and Security Supervisor or designee will complete education of their respective staffs and notify the CSO of trained individuals. The CSO will train staff who float to the Emergency Department and observers from other departments will retain these records. Completion Date: 7/17/14
-4. Education will be updated and presented as best practices are identified by Emergency Department, Security, and/or Behavioral Health team members or as processes are revised. Completion Date: 7/17/14
*Communication:
-1. Implemented notification tag " H " on patient locator board. Completion date 7/11/14.
*Safety Huddle:
-1. Implement a safety huddle between security staff ED CRN, and when available, hospital coordinator or designee, 3 times per day to discuss any the number and status of county mental holds. The huddle will be conducted for 2 weeks to evaluate the effectiveness of the plan and the need for frequency of huddles. Completion date of 7/16/14.
*Monitoring:
-1. Emergency department director and chief of the emergency department or designees will monitor patient identification and observation documentation daily and report to VP of Quality who will report to performance improvement risk management safety (PIRMS committee) monthly until PIRMS authorizes discontinuation of measurement. Completion date of 7/17/14.
-2. Emergency department director will monitor completion of the initial education for emergency department staff and clinical staff who float to the emergency department. Completion date of 7/15/14.

The plan of correction was signed by the Chief Executive Officer on 7/17/14 at 12:17 p.m.

1. Review of patient 1's 7/2/14 through 7/3/14 ED record revealed:
*She had registered as a patient on 7/2/14 at 9:28 p.m.
*She had been triaged by registered nurse (RN) E at 9:39 p.m. with complaints that she had consumed thirty to thirty-five Motrin tables, and had drank seven beers, and a pint of vodka.
*She had stated she "Wanted to make things easier."
*She had been triaged by RN E at 9:36 p.m. with complaints that she had consumed thirty to thirty-five Motrin tables, had drank seven beers, and a pint of vodka.
*She had stated she "Wanted to make things easier."
*The triage ended at 9:39 p.m. She had been assigned an emergency severity index (ESI) acuity of 3.
*Treatment orders were started at 10:01 p.m. Those orders included: An intravenous (IV) infusion bolus of normal saline (NS) of one liter and activated charcoal of 50 milligrams by mouth.
*Laboratory orders were given for Tylenol, salicylate (aspirin), ETOH (blood alcohol level), TSH (thyroid stimulating hormone), and FT (free thyroid) 4 blood levels.
*The petition for emergency commitment was signed by the physician on 7/2/14 at 11:25 p.m.
*A physician order on 7/3/14 at 12:23 a.m. for another IV infusion bolus of NS of one liter.
*On 7/3/14 at 2:35 a.m. a physician's order to transfer to the behavioral health unit. "Pt. (patient) is on a hold status."
*She had been seen by a physician on 7/2/14 at 10:00 p.m. and a decision to admit to the behavioral health hospital was made on 7/3/14 at 12:15 a.m.
*The physician note stated "It is my concern that she took this in a suicide attempt. It is especially concerning that she is unwilling to discuss anything with me. She was placed on a mental health hold."
*Nursing notes included:
-On 7/2/14 at 10:35 p.m. a note by RN E "Resting quietly, no apparent distress, Asleep, easy to around and IV infusing, no infiltration."
-On 7/3/14 at 12:30 a.m. a note by traveling RN D "Has had 1 liter NS iv per previous RN (E), bp (blood pressure) low, discussed w (with)/(physician's name), NS repeated, liter hung, husband at bedside, call light in reach, arouses to loud verbal stimuli."
-On 7/3/14 at 1:13 a.m. note by RN D "Resting, husband at bedside, call light w/in reach."
*Under disposition notes included:
-On 7/3/14 at 2:55 a.m. note by RN D "Admit to _____ (name of behavioral health unit), transfer condition stable, valuables sent with patient, nursing report: written, verbal report to ______(nurse at _____ (behavioral health unit)."
-On 7/3/14 at 2:57 a.m. a note by RN D "IV dc'd (discontinued) w/catheter intact, reviewed w/pt and husband that she will be admitted to ____ (behavioral health unit). Does ask if she can go home, instructed that is not an option tonoc (tonight). States understanding. Crying, states she knows what she did was 'dumb' and that she doesn't know why she can't just move on. States she doesn't want to drink but does sometimes."
*Addendum on 7/3/14 at 3:26 a.m. by RN F "West transport here, Pt. gone-husband gone. Phoned telephone number-rang, then hung up. Security aware-is calling dispatch to make aware of pt. elopement."
*There was no documentation that she had been put in green scrubs per policy.
*There was no documentation that a SAD PERSONS scale had been completed.
*SAD PERSONS SCALE
-Sex 1 if patient is male, 0 if female, -Age 1 if patient is (25-34; 35-44; 65+), Depression, Previous attempt 1 if present, Ethanol abuse 1 if present, Rational thinking loss 1 if patient is psychotic for any reason (schizophrenia, affective illness, organic brain syndrome), Social support lacking 1 If these are lacking, especially with recent loss of a significant other, Organized Plan 1 if plan made and method lethal, No spouse 1 if divorced, widowed, separated, or single (for males), and Sickness 1 especially if chronic, debilitating, severe (e.g.; non- localized cancer, epilepsy, MS, gastrointestinal disorders)
Patterson WM, Dohn HH, et al: Evaluation of suicidal patients, THE SAD PERSONS Scale, Psychosomatics, 1983.
-One method to gather this information that has been useful for healthcare providers is the SAD PERSONS scale, the scale included:
-"S" stands for sex. Again, we know that males are likely to end life by suicide 2 xs that of females and females attempt 2x more than males.
-"A" stands for age. Remember the ages that have the highest suicide rates.
-"D" stands for depression. Does the patient have symptomatology or diagnosis of depression? Remember, depression is the mental illness with the closest link to suicide.
-"P", previous attempt. Has the person attempted before and if so, what means did they use and what factors where involved, how did they survive the attempt?
-"E" stands for ethanol abuse.
-"R" stands for rational thinking. Is the patient thinking rationally?
-"S" stands for social support deficit. Does the patient have a support system?
-"O" is for organized plan. Does the patient have a thought out plan for taking the steps to act on the thoughts? "N" is for no spouse. Is the patient without a spouse?
-"S" is for sickness. Does the person have a medical or physical illness?
-These letters represent 10 areas of assessment. The scoring for this is a follows- 0-2 equals little risk, 3-4 equals following patient closely, 5-6 equals strongly considering hospitalization, and 7-10 equals a very high risk, hospitalize or commit.

Review of the provider's undated incident report under immediate actions revealed:
*Communication to staff had occurred regarding the patient elopement policy and actions required.
*Signatures were required by staff stating they had reviewed the procedures.
*Discussion of the above incident would also occur during the ED shift huddles.

Review of an e-mail sent on 7/10/14 at 12:23 p.m. from the ED director to the ancillary support staff supervisors was "We recently had a psych (psychiatric) pt. (patient) who was on an emergency hold elope from our department. It was an ED staff member who let the pt. out of the doors but our risk management team witnessed on the video both lab (laboratory) and rad (radiology) personnel letting pt's out. We have instructed our staff to escort their pt.'s out when discharging and I would ask both of you to have your staff not let anyone out but instead refer the pt. back to ED staff."

Review of the provider's July 2014 Elopement Preventative Measures in the ED policy revealed it had been developed after patient 1's elopement. But it had not been initiated until after patient 2's elopement.

Review of the provider's Hold patients education sign-in sheet revealed ED staff had not begun signing the sheet until 7/14/14.

Review of the provider's undated action plan that had been developed after the 7/2/14 elopement of patient 1 revealed:
*A checklist was to be developed to standardize process for care of the mental health patient placed on an involuntary hold.
*Alert process or "flag" to be developed to display on patient census board for communication to all staff.
*Competency and training for all staff working in the ED including travel and float pool staff working in the ED.
*Communication to ancillary staff as well as ED staff about controlled access points and verification of patient/visitors entering or exiting the area.

Provider's report of root cause analysis report dated "8July2014" revealed:
*Description of event or condition under analysis: "Patient who was placed on a mental hold left without staff awareness."
*Initial Possible Root Causes:
-"Did not follow polices."
--Review of the provider's policies revealed an elopement policy for ED was not in effect. Elopement policies were in place for the behavioral health center, dated July 2011, and the hospital, dated August 2013.
*Sequence of Events:
-"July 9, 2014. [____] (E) was taking care the patient. Her first husband had killed himself and occasionally struggles. She was embarrassed to be there. Stated she 'wanted to make things easier.' "
-"Doctor saw her and admitted her. Placed mental hold at 23:25 (11:25 p.m.). Patient was sad and cried."
-"HUC [health unit clerk] usually notifies security nursing places them in scrubs. She was in gown instead. Nurse ____ (E) caring for the patient was not aware of the process for mental hold patients. Security was not notified according to call logs."
-"____ (E) reported off at midnight to a travel nurse ____ (D). She provided routine VS [vital signs] and then got her ready for transfer. She was unaware that there was a process to place the patient in scrubs and secure belongings. She discontinued her IV [intravenous] at 0257 [2:57 a.m.]."
-"[___] (I) let patient out at 0256 [2:56 a.m.] (per video clock). Did not know that there was a patient on a hold. Did not notice wrist band, security or scrubs. Did not see DC [discharge] papers and thought they were visitors."
-"0326 [3:26 a.m.] transport arrived and patient was found to be missing."
-"0326 security guard (K) and psych tech [psychological technician] came to transport."
-"(____) (O) CRN [clinical resource nurse] notified security, who was in the unit, of the missing patient."
*Report of Root Cause Analysis Action Plan dated "8July2014":
-"Root Contributor or Improvement Opportunity
--Protocol or checklist to be developed to standardize process for care of the Hold patients.
---Action Due Date 7/11.
--Alert process on Forerun [staff communication board regarding patient status] to be developed to display a flag for HOLD patients.
---Action Due Date 7/11.
--Competency and training for all staff including travel and float pool.
---Action Due Date 'no date given.'
--Alert bracelet research
---Action Due Date 'no date given.'
--Communication to ancillary staff and ED staff about controlled access points-locked units.
---Action Due Date Complete 7/7 & 7/11."
-"Measurement Strategy
--Persons Responsible: no titles or names listed.
--Follow-up date: no dates listed."

2. Review of the undated incident report and report of root cause analysis of patient 1 who reported to the emergency department revealed:
*Initial Information
-"Patient reported to the Emergency Department July 2, 2014 at 21:28 (9:28 p.m.) after overdosing on Motrin, Beer and Vodka. ____, MD (medical doctor) evaluated her and placed on a mental hold for suicidal ideation."
-"At 03:26 a.m. transportation was available to transfer the patient to the Behavioral Health Unit but patient was missing. Security was notified at that time."
-"Upon review of the security cameras it is noted that the patient tried to exit through the North access door by following a staff member. She returned a moment later and a nurse from the Emergency Department let the patient and her husband out of the unit at 02:56 (2:56 a.m.) through the Main Exit (South end) from the ED."
*Investigation
-"The float pool nurse, ____ (E), and the traveler nurse, ____ (D), were caring for the patient during the night. Neither nurse was aware of processes related to placing the patient i scrubs, taking clothes and securing other belongings. Additionally, it was not communicated to security of the Critical Resource Nurse in charge of the ED that night that the patient was placed on a mental hold. The nurse (I) who let the patient and her husband out of the unit, thought that they were visitors, she did not notice a patient bracelet or anything else that would make her think she were a patient."

Review of a 7/7/14 at 12:59 p.m. e-mail from the ED director to the provider's staff and physicians revealed:
*A refresher outline of the procedures to take when a patient was placed on a mental health hold in the ED.
*That policy was to be read and the roster signed in the ED break room by all staff.
*That policy included procedures to take when a patient had already eloped from the ED.

5. Interview on 7/15/14 at 1:05 p.m. with security officer H revealed:*Was on duty when patient 1 was placed on a mental health hold.
*Had been made aware she had taken an overdose but had been told she was compliant.
*Was not told she was on a mental health hold or needed to be watched.
*Was not told there was an elopement. Checked security camera footage for co-worker when the co-worker came to transport her to the behavioral health unit.
*Did not do one-to-one monitoring of mental health hold patients.
*After the 7/2/14 incident with patient 1 the only implementation change for security was they could call the security officer from the behavioral health unit if additional officers were needed.

6. Interview on 7/15/14 at 1:43 p.m. with RN I regarding patient 1 revealed:
*She was surprised to hear that patient 1 had been on a mental health hold.
*She had been assigned as the triage nurse, and then was moved to the ED to provide patient care.
*It had not been reported to her that patient 1 was on a mental health hold.
*She stated patient 1 did not have scrubs on, no ID band, and did not appear to be an "escaper."
*She was told later that a patient on a mental health hold had eloped.
*She had not been told of the description of the patient.
*Staff informed her that she had let patient 1 out of the main ED doors.
*HUC was to call security when a patient was placed on a mental health hold.
*She was not aware of any training or changes to the department since the incident involving patient 1.
*She stated when a patient was placed "On hold" it would have been assumed security kept an eye on them. A visual with the door open to the patient room.
*Depending on the severity the RN might or might not give direction to security.
*ED nurses would not accept a patient's family as an overseer of a patient. There would still need to be security with a visual.

7. Interview on 7/15/14 at 2:05 p.m. with security officer K regarding patient 1 revealed:
*He was assigned to transport duty for the behavioral health unit.
*He had been called to transport a staff person from the behavioral health unit to accompany patient 1 back to the behavioral health unit.
*When they got to the ED they were told patient 1 was missing.
*He asked if patient 1 was on "Hold", and the RN stated she was not aware of a "Hold."
*He was not aware of any changes or training for security.
*When ED notified security, security would then come and do a watch. Security would position themselves to see all doors.
*Could call the behavioral health unit security officer over to the hospital if needed now.

8. Interview on 7/15/14 at 3:55 p.m. with phlebotomist L and phlebotomist supervisor M regarding patient 1 revealed:
*Patient 1 had followed her out the north ED doors.
*Patient 1's husband had not made it through the doors in time and remained on the other side still in the ED.
*Patient 1 was yelling and cursing "How the hell to I get out of here."
*She saw patient 1's wrist band and brought her back into the ED.
*Patient 1 had keys in her hand.
*She told patient 1 she would have to go through the main ED exit.
*She had received an e-mail about a week ago regarding education to not let any patients out of the ED. Only ED staff were to let them out.

Review of the provider's undated incident report regarding patient 1 revealed phlebotomist L had not been interviewed by the provider.

Interview on 7/15/14 at 10:00 a.m. with the ED director revealed:
*He had interviewed RN D who was a traveling nurse. He stated she had not been aware of the mental health hold policy or any procedures related to it.
*Phlebotomist L had not been identified on the security tape until the surveyors asked to interview her.
*No elopement drills had been conducted in the ED.

Interview on 7/15/14 at 10:10 a.m. with the director of risk management and accreditation/certification revealed there had been no formal report completed by security regarding the elopement of patient 1.

Review of the security tape from 7/3/14 and interview with the director of risk management and accreditation/certification on 7/14/14 at 3:30 p.m. revealed and she confirmed:
*Patient 1 left her room in the ED and walked south to an exit door in the ED with her husband.
*Patient 1 left the ED through the north exit door by following staff member L.
*Staff member L returned patient 1 to the ED within approximately ten seconds.
*Patient 1 appeared to be exit seeking and started toward the ambulance bay door.
*Patient 1's husband redirected her toward the front ED door.
*Nurse I then walked toward the front door, left the screen, and appeared to have let patient 1 and her husband out the ED front door.
*Closer review of the security tape revealed patient 1 had a two by two gauze on her hand along with the admission bracelet at the time she was let out the front door.
*Security was not noted to be visible in any portion of the security tape.
*Tape ended

Review of patient 2's 7/11/14 ED record revealed:
*He had been placed on a mental health hold at 2:40 p.m. on 7/11/14 by the another provider's physician due to suicidal thoughts.
*He had been transferred from the other provider and registered at the ED at 3:50 p.m. to have been medically cleared before admission to the behavioral health unit.
*He had been triaged by RN G at 4:24 p.m. His ESI acuity was a 2.
*He had been seen by the ED physician at 5:08 p.m.
*Review of ED physician Q's notes revealed:
-"Nursing staff notified our security department but I had concerned patient would elope as he adamantly stated he did not want to go to ____(behavioral health unit). Security guard arrived and were apprised that he was on a hold from _______ (another provider.) Unfortunately patient was able to elope and nursing staff notified appropriate authorities."
*Review of the 7/11/14 nursing notes revealed:
-At 4:25 p.m. a nursing exam was completed. Patient 2 stated to RN G "Everything is going wrong....Doesn't have money or insurance to see doctor. Mom is at bedside. Hold in place. Security at door. Depressed affect, suicidal."
-At 5:35 p.m. "Remains calm and cooperative. Mom remains in room."
-At 6:23 p.m. "Condition elopement called via communications. Description of pt. and mother given to communications. Health unit coordinator (HUC) informed me (RN G) that she had told security guard B, who was over by room 12, that room 6 was a flight risk. His response was 'The mom's in the room'."
-At 6:27 p.m. "Security guard C told me (RN G) the mother left at 1700 (5:00 p.m.) and he switched out with security guard B at 5:15 p.m."
*Disposition of patient 2 on 7/11/14 at 6:09 p.m. by RN R included:
-"Eloped." "The patient has left the medical center unnoticed at some point after being seen by a physician, without informing medical center personnel or medical staff members."
-"Notified ED attending physician at 11 Jul 2014 18:00 (7/11/14 6:00 p.m.), police notified, security notified."
-"Pt. reported eloped by previous shift RN G. Appropriate channels and personnel notified of event."
*There was no documentation patient 2 had changed into green scrubs per policy.
*There was no documentation a SAD PERSONS scale had been completed.

11. Review of the 7/11/14 In-House Officer Call Log revealed:
-4:07 p.m. through 5:15 p.m. Hold in ED 6 1 adult male.
-6:20 p.m. condition elopement in the ED.
*Review of the 7/11/14 out security log revealed:
-6:05 p.m. through 6:20 p.m. watching holds in ED 6 and family room.
-6:15 p.m. advised of elopement out of ED-6.
-6:30 p.m. through 6:50 p.m. check camera's for elopement patient. Patient walked out of ED at approximately 6:04 p.m.
*Review of the 7/11/14 evening transport security log revealed:
-6:15 p.m. Advised of elopement from ED-6.

12. Interview on 7/15/14 at 1:20 p.m. with security officer B revealed:
*He was on duty when patient 2 was admitted to the ED.
*The police department (PD) had brought patient 2 to the ED from another provider hospital.
*Another security officer had received the mental health hold paperwork from the PD.
*Patient 2 spoke with his mother who was in the waiting room before he was taken back to room 6 in the ED.
*RN G approached patient 2 in a friendly manner and asked "What are you doing here?"
*RN G then took patient 2 into room 6 and did an assessment. "I was in the room too."
*Patient 2's mother then entered room 6. She had stated it had been approved by RN G.
*He then left the room and took another patient out of the safe room to be transferred to the behavioral health unit.
*Security officer C went to another alarm call in the building.
*Security officer N was dealing with a combative patient in the ED.
*He made a motion for security officer N to "Keep an eye" on room 6.
*He then left and was gone for approximately one-half hour for the patient transfer.
*When he came back he was told by security officer C that patient 2 had left.
*After patient 2 had been discovered missing a walk-through of ED, waiting room, and parking lot was completed.
*He and security officer C then checked the security video and discovered patient 2 had been gone for over an hour.
*There was a verbal policy on not doing one-to-one observations. It was not to be eye-to-eye as that may seem threatening. With family with the patient they seem to be calmer.
*He was not aware of any policy or procedure for one-to-one observation of mental health hold patients.

13. Interview on 7/15/14 at 2:20 p.m. with security officer C regarding patient 2 revealed:
*He had started his shift at 3:20 p.m. and relieved the previous shift with two holds in the ED.
*Patient 2 came into the ED waiting room at 3:50 p.m. with a police officer. Two other security officers took patient 2 back to room 6 between 4:05 p.m. and 4:10 p.m.
*He was called to an alarm in the building and had taken care of that.
*He had returned at 6:00 p.m. and the door to room 6 was closed. He assumed patient 2's mother was still in the room with him. He was also watching a patient in the safe room.
*At 6:15 p.m. an RN went into room 6 and discovered patient 2 was not there.
*He checked the ED and waiting room and could not locate patient 2.
*At 6:30 p.m. the local Police Department was called along with the Security supervisor.
*Patient 2's physician had not relayed to security that he was a "flight" risk.
*He had not made any visual of patient 2 and his mother.
*He had not checked the room patient 2 was in.
*No one had relayed information regarding the situation in ED to him, and he had not asked.
*The ED nursing staff might assume there was a one-to-one visual by security, but they did not do one-to-one visuals.

Interview on 7/15/14 at 4:15 p.m. with ED physician Q revealed:
*She had felt that patient 2 was at risk for elopement.
*She had not communicated that risk to the staff.
*She had put patient 2 on a mental health hold.
*She thought the staff would have put the mental health hold process into effect.

14. Interview on 7/15/14 at 10:35 a.m. with RN/clinical resource nurse (CRN) J regarding patient 2 revealed:
*She was the RN/CRN on duty when patient 2 was admitted. She worked from 6:00 a.m. to 6:30 p.m. that day.
*She was

26632

Based on record review, interview, security tape review, and policy review, the provider failed to ensure safety precautions for elopement were in place for two of two emergency department (ED) patients (1 and 2) placed on a mental health hold per physician's orders. Those elopements violated the patients' rights for safety while treated by the provider and included the failure to:
*Identify, assess, and implement interventions to prevent the elopement of two of two ED patients (1 and 2) identified as high-risk for elopement.
*Initiate a standardized practice for admission and assessment of a doctor ordered mental hold status for two of two ED sampled patients (1 and 2).
*Initiate communication to ancillary staff as well as ED staff about:
-The Forerun (patient census board) board.
-The controlled access points.
-The verification of patients/visitors entering or exiting the ED area.
Findings include:

1. The provider failed to implement safety measures, policies, and communicate with the provider's security officers to ensure the safety for two of two sampled patients (1 and 2).

Review of the provider's undated Patient Rights and Responsibilities pamphlet revealed "Your Rights; As a patient, you can expect: Provision of care in a safe setting..."

Refer to A144.

2. The provider failed to ensure ED nursing staff services identified, assessed, and implemented interventions to prevent the elopement of two of two sampled ED patients (1 and 2) identified as high-risk for elopement and self-harm.

Refer to A385.

3. The provider failed to:
*Ensure ED staff adequately monitored two of two sampled patients (1 and 2) who had been placed on a mental health hold and had a known potential for self-harm.
*Fully develop and implement:
-A timely plan of action after patient 1 had eloped to prevent the elopement of patient 2.
-Policies and procedures for patients on a mental health hold and identified as high-risk for self harm.
-A training program for temporary staff and the security staff on their responsibilities for the care of patients placed on mental health holds and one-to-one observation of those patients.
-An organized nursing staff in sufficient numbers to ensure patient care was provided to meet the needs of the patient.
-Provide quality assurance on the plan of action.
-Documentation and communication protocols between staff disciplines.

Refer to A1100.

20031

Based on record review, security tape review, interview, job description review, and policy review, the provider failed to:
*Implement safety measures, policies, and communicate with the provider's security officers the emergency department's physician's diagnoses for one of two sampled patients (1) placed on a mental health hold in the emergency department (ED).
*Communicate within the security department's officers (B, C, and N) for one of two sampled patient's (2) the safety precautions set in place by medical staff.
Findings include:

1a. Review of the security tape from 7/3/14 provided by and reviewed with the director of risk management and accreditation/certification and interview with her on 7/14/14 at 3:30 p.m. revealed and she confirmed:
*Patient 1 left her room in the ED and walked south to an exit door in the ED with her husband.
*Patient 1 left the ED through the north exit door by following staff member L.
*Staff member L returned patient 1 to the ED within approximately ten seconds.
*Patient 1 appeared to be exit seeking and started toward the ambulance bay door.
*Patient 1's husband redirected her toward the front ED door.
*Nurse I then walked toward the front door, left the screen, and appeared to have let patient 1 and her husband out the ED front door.
*Closer review of the security tape revealed patient 1 had a two by two gauze on her hand along with the admission bracelet at the time she was let out the front door.
*Security was not noted to be visible in any portion of the security tape.
*Security tape footage of patient 1 ended.

b. Review of the incident report for patient 1 who reported to the emergency department revealed:
*"Patient reported to the Emergency Department July 2, 2014 at 21:28 (9:28 p.m.) after overdosing on Motrin, Beer and Vodka. ____, MD (medical doctor) evaluated her and placed on a mental hold for suicidal ideation (thoughts)."
*"At 03:26 a.m. transportation was available to transfer the patient to the Behavioral Health Unit but patient was missing. Security was notified at that time."
*"Upon review of the security cameras it is noted that the patient tried to exit through the North access door by following a staff member. She returned a moment later and a nurse from the Emergency Department let the patient and her husband out of the unit at 02:56 (2:56 a.m.) through the Main Exit from the ED."
*Investigation:
-"The float pool nurse, ____ (E), and the traveler nurse, ____ (D), were caring for the patient during the night. Neither nurse was aware of processes related to placing the patient in scrubs, taking clothes and securing other belongings. Additionally, it was not communicated to security or the Critical Resource Nurse in charge of the ED that night that the patient was placed on a mental hold. The nurse (I) who let the patient and her husband out of the unit, thought that they were visitors, she did not notice a patient bracelet or anything else that would make her think she were a patient."

c. Review of the provider's root cause analysis report dated "8July2014" revealed:
*Description of event or condition under analysis: "Patient who was placed on a mental hold left without staff awareness."
*Initial Possible Root Causes:
-"Did not follow polices."
--Review of the provider's policies revealed an elopement policy for ED was not in effect. Elopement policies were in place for the behavioral health center, dated July 2011, and the hospital, dated August 2013.
*Sequence of Events that began on 7/9/14 at 11:25 p.m. included:
-"Doctor saw her and admitted her. Placed mental hold at 23:25 (11:25 p.m.). Patient was sad and cried."
-"HUC [health unit clerk] usually notifies security nursing places them in scrubs. She was in gown instead. Nurse ____ (E) caring for the patient was not aware of the process for mental hold patients. Security was not notified according to call logs."
-"____ (E) reported off at midnight to a travel nurse ____ (D). She provided routine VS [vital signs] and then got her ready for transfer. She was unaware that there was a process to place the patient in scrubs and secure belongings. She discontinued her IV [intravenous] at 0257 [2:57 a.m.]."
-"[___] RN (I) let patient out at 0256 [2:56 a.m.] (per video clock). Did not know that there was a patient on a hold. Did not notice wrist band, security or scrubs. Did not see DC [discharge] papers and thought they were visitors."
-"0326 [3:26 a.m.] transport arrived and patient was found to be missing."
-"0326 security guard (K) and psych tech [psychiatric technician] came to transport."
-"(____) (O) CRN [clinical resource nurse] notified security, who was in the unit, of the missing patient."
*Report of Root Cause Analysis Action Plan dated "8July2014":
-"Root Contributor or Improvement Opportunity
--Protocol or checklist to be developed to standardize process for care of the Hold patients.
---Action Due Date 7/11.
--Alert process on Forerun [staff communication board regarding patient status] to be developed to display a flag for HOLD patients.
---Action Due Date 7/11.
--Competency and training for all staff including travel and float pool.
---Action Due Date 'no date given.'
--Alert bracelet research
---Action Due Date 'no date given.'
--Communication to ancillary staff and ED staff about controlled access points-locked units.
---Action Due Date Complete 7/7 & 7/11."
-"Measurement Strategy
--Persons Responsible: no titles or names listed.
--Follow-up date: no dates listed."

d. Review of an e-mail sent 7/7/14 by the director of ED revealed an outline of procedures to take when a patient eloped from the ED. The e-mail had not addressed what procedures or guidelines to put in place when a patient was placed on a mental hold by a physician.

e. Interview on 7/14/14 at 4:00 p.m. with the ED medical director revealed he had a draft of the ED elopement policy that had been placed in effect after another elopement on 7/11/14. He stated the policy had not had a final review or approval of management as of the date and time of the interview.

2a. Review of a conversation on 7/11/14 between the provider and the South Dakota Department of Health Office of Licensure and Certification (SD DOH/OLC) hospital advisor documented via e-mail on 7/14/14 to the SD DOH/OLC complaint coordinator revealed:
*"Conversation this morning with Vice President of Risk Management and Accreditation/Certification revealed Friday (7/11/14):
-Patient 46 years old male on mental hold presented at 3:50 p.m. with his mother to the ER, Triaged at 4:24 p.m., left without staff knowledge around 6:00 p.m.
-7/11/14, had 3 patients with mental holds, a combative patient, security assigned to monitor patient went to assist with combative patient, patient's mother left room, and patient left."

b. Review of the security tape and interview with the director of risk management and accreditation/certification on 7/14/14 at 3:35 p.m. revealed and she confirmed:
*Patient 2 could not be seen for the first few seconds on the video.
*Officer C was then visible in tape.
*Officer C glanced down the hall where patient 2's room was located without checking on patient's status.
*Officer C positioned himself in the hallway by the family room.
*Patient 2 was shown walking toward the front ED exit door.
*Patient 2 walked out of the front door when what appeared to be visitors entering the ED.
*Closer review of the security tape revealed patient 2 had an admission bracelet on his wrist and had no discharge papers with him at the time he was let out the front door.
*Officer C was noted to view the patient as he walked out the door.
*Officer C walked to the front door after patient 2 exited. He then turned and glanced toward the hallway where patient 2's room was located.
*Officer C then stood in the hallway by the front door and made notes in what appeared to be a small notebook.
*Security tape footage of patient 2 ended.

c. Review of the root cause analysis of patient 2 who reported to the emergency department revealed:
*Description of event or condition under analysis: "Patient (____) [2] who was placed on a mental hold left without staff awareness."
*Ini

20031

Based on record review, interview, and policy review, the provider failed to ensure emergency services and its undated action plan regarding elopements of two of two sampled patients (1 and 2) on mental holds were incorporated into the comprehensive quality assurance performance improvement (QAPI) program. Findings include:

1. Review of the provider's root cause analysis report dated "8July2014" revealed:
*Description of event or condition under analysis: "Patient who was placed on a mental hold left without staff awareness."
*Initial Possible Root Causes:
-"Did not follow polices."
--Review of the provider's policies revealed an elopement policy for ED was not in effect. Elopement policies were in place for the behavioral health center, dated July 2011, and the hospital, dated August 2013.
*Sequence of Events starting on 7/2/14 at 11:25 p.m. included:
-"Doctor saw her and admitted her. Placed mental hold at 23:25 (11:25 p.m.). Patient was sad and cried."
-"HUC [health unit clerk] usually notifies security nursing places them in scrubs. She was in gown instead. Nurse ____ (E) caring for the patient was not aware of the process for mental hold patients. Security was not notified according to call logs."
-"____ (E) reported off at midnight to a travel nurse ____ (D). She provided routine VS [vital signs] and then got her ready for transfer. She was unaware that there was a process to place the patient in scrubs and secure belongings. She discontinued her IV [intravenous] at 0257 [2:57 a.m.]."
-"[___] (I) let patient out at 0256 [2:56 a.m.] (per video clock). Did not know that there was a patient on a hold. Did not notice wrist band, security or scrubs. Did not see DC [discharge] papers and thought they were visitors."
-"0326 [3:26 a.m.] transport arrived and patient was found to be missing."
-"0326 security guard (K) and psych tech [psychological technician] came to transport."
-"(____) (O) CRN [clinical resource nurse] notified security, who was in the unit, of the missing patient."
*Report of Root Cause Analysis Action Plan dated "8July2014":
-"Root Contributor or Improvement Opportunity
--Protocol or checklist to be developed to standardize process for care of the Hold patients.
---Action Due Date 7/11.
--Alert process on Forerun [staff communication board regarding patient status] to be developed to display a flag for HOLD patients.
---Action Due Date 7/11.
--Competency and training for all staff including travel and float pool.
---Action Due Date 'no date given.'
--Alert bracelet research
---Action Due Date 'no date given.'
--Communication to ancillary staff and ED staff about controlled access points-locked units.
---Action Due Date Complete 7/7 & 7/11."
-"Measurement Strategy
--Persons Responsible: no titles or names listed.
--Follow-up date: no dates listed."

2. Review of the provider's Report of Root Cause Analysis Action Plan dated "14July2014" revealed:
-"Root Contributor or Improvement Opportunity
--Alarm system with audible alarm when hold/elopement patients are attempting to leave.
---Action Due Date 7/18/14 (Price Quote).
--Investigate ____ (police department) responsibility to assist with high volumes - MOU review.
---Action Due Date 7/18/14.
--Complete all training to new processes/polices developed related to elopements. ED staff, float staff, ancillary staff, security staff, Hospitalists. ICU (intensive care unit) CIU (cardiac intensive unit) Coordinators and communications to ancillary staff (hospital wide).
---Action Due Date 7/18/14.
--BH (behavioral health) security to assist with high census of overflow in the ED. 3+BH patients.
---Action Due Date Complete 7/11.
--Meet with BH, Risk, security and transfer center to identify potential concerns with admission process and -reevaluate the policy on pysch tech accompanies patient until admission decision.
---Action Due Date 7/18/14.
--Finalization of policy for elopement policy in ED
---Action Due Date 7/14/14.
--Immediate notification of security to staff (HUC) if other security priorities come up and are not available to provide supervision.
---Action Due Date 7/14/14.
-Measurement Strategy:
--Persons Responsible: no titles or names listed.
--Follow-up date: no dates listed."

3. The provider had no documentation that indicated they had incorporated the following into their QAPI:
*Alert process on Forerun was not completed until 7/14/14 after patient 2 had eloped.
*There had been no audit or follow-up that all ED staff, ancillary staff, and security staff had completed the education from the action plan.
*No staff had implemented or taken ownership of the action plan for the prevention of ED elopements.

4. Interview on 7/15/14 at 8:00 a.m. with the security supervisor revealed:
*There were no formal reports from the security officers regarding the events that took place on 7/2/14 through 7/3/14 and on 7/11/14. There were only log notes.
*No additional training or safeguards had been put in place for the security department after either elopement. He had made his officers aware of the e-learning training regarding the new action plan for ED.
*No tracking and trending of incidents had ever been done.
*ED HUC or CRN was to advise security for observation of mental hold patients.
*A triage of assistance for security would be combative first and mental second.
*Security officer N requested assistance at a level three for a combative patient on 7/11/14.
*Camera placement for viewing had not been changed. No new cameras had been added to view all exits.
*It was standard operating procedure to pull the security officer from the behavioral health unit to the hospital or ED to assist.
*There were no guards on call. But officers knew they could call the lead officer or supervisor with questions or concerns.
*There was one officer out on medical leave and still one opening for an officer in security.

5. Interview on 7/14/14 at 4:00 p.m. with the ED medical director revealed he had a draft of the ED elopement policy that had been placed in effect after another elopement on 7/11/14. He stated the policy had not had a final review or approval of management as of the date and time of the interview.

6. Review of an e-mail sent 7/7/14 by the director of ED revealed an outline of procedures to take when a patient eloped from ED. The e-mail had not addressed what procedures or guidelines to put in place when a patient was placed on a mental hold by a physician.

7. Review of the provider's revised June 2014 Performance Improvement Plan and Participation policy revealed:
*The provider had a defined process for the identification, management, and intensive analysis of serious adverse events.
*The provider would proactively identify and reduce risks to the safety of patients by selecting a high-risk process to be analyzed on at least an annual basis.
*The provider was committed to improving safety for all patients and staff at all sites.
*Patient safety would have been incorporated into performance improvement activities.
*The provider collected and analyzed data on patients' perceptions of care, treatment, services, and patient safety.
*The provider considered collecting staff opinions regarding patient safety.

26632

Based on record review, security tape review, observation, policy review, and interview, the provider failed to ensure emergency department (ED):
*Nursing staff identified, assessed, and implemented interventions to prevent the elopement of two of two sampled ED patients (1 and 2) who were identified as high-risk for self-harm and elopement.
*Nursing staff utilized the emergency severity index (ESI) triage algorithm for one of two sampled ED patients (1) identified as high-risk for self-harm and elopement.
*Nursing staff utilized the provider's SAD PERSONS assessment tool for two of two sampled ED patients (1 and 2) who were at high-risk for self-harm and elopement.
*Nursing staff communicated with other appropriate ED staff and ancillary staff regarding:
-The Forerun patient census board.
-Controlled access points to and from the ED.
-Verification of patients/visitors entrance and exit for the ED.
*Orientation on policy and procedure for patients at risk for elopement in the ED had been completed by one of one newly hired traveling RN (D) that worked in the ED.
*Was staffed and operated in a manner to provide safe care to all patients on all shifts.
Findings include:

1a. Review of patient 1's 7/2/14 through 7/3/14 ED record revealed:
*She had registered as a patient on 7/2/14 at 9:28 p.m.
*She had been triaged by RN E at 9:36 p.m. with complaints that she had consumed thirty to thirty-five Motrin tables, had drank seven beers, and a pint of vodka.
*She had stated she "Wanted to make things easier."
*The triage ended at 9:39 p.m. She had been assigned an ESI acuity of 3.
*Treatment orders were started at 10:01 p.m. Those orders included: An intravenous (IV) infusion bolus of normal saline (NS) of one liter and activated charcoal of 50 milligrams by mouth.
*Laboratory orders were given for Tylenol, salicylate (aspirin), ETOH (blood alcohol level), TSH (thyroid stimulating hormone), and FT (free thyroid) 4 blood levels.
*The petition for emergency commitment was signed by the physician on 7/2/14 at 11:25 p.m.
*A physician order on 7/3/14 at 12:23 a.m. for another IV infusion bolus of NS of one liter.
*On 7/3/14 at 2:35 a.m. a physician's order to transfer to the behavioral health unit. "Pt. (patient) is on a hold status."
*She had been seen by a physician on 7/2/14 at 10:00 p.m. and a decision to admit to the behavioral health hospital was made on 7/3/14 at 12:15 a.m.
*The physician note stated "It is my concern that she took this in a suicide attempt. It is especially concerning that she is unwilling to discuss anything with me. She was placed on a mental health hold."
*Nursing notes included:
-On 7/2/14 at 10:35 p.m. a note by RN E "Resting quietly, no apparent distress, Asleep, easy to around and IV infusing, no infiltration."
-On 7/3/14 at 12:30 a.m. a note by traveling RN D "Has had 1 liter NS iv per previous RN (E), bp (blood pressure) low, discussed w (with)/(physician's name), NS repeated, liter hung, husband at bedside, call light in reach, arouses to loud verbal stimuli."
-On 7/3/14 at 1:13 a.m. note by RN D "Resting, husband at bedside, call light w/in reach."
*Under disposition notes included:
-On 7/3/14 at 2:55 a.m. note by RN D "Admit to _____ (name of behavioral health unit), transfer condition stable, valuables sent with patient, nursing report: written, verbal report to ______ (nurse at _____ (behavioral health unit)."
-On 7/3/14 at 2:57 a.m. a note by RN D "IV dc'd (discontinued) w/catheter intact, reviewed w/pt and husband that she will be admitted to ____ (behavioral health unit). Does ask if she can go home, instructed that is not an option tonoc (tonight). States understanding. Crying, states she knows what she did was 'dumb' and that she doesn't know why she can't just move on. States she doesn't want to drink but does sometimes."
*Addendum on 7/3/14 at 3:26 a.m. by RN F "West transport here, Pt. gone-husband gone. Phoned telephone number-rang, then hung up. Security aware-is calling dispatch to make aware of pt. elopement."
*There was no documentation that she had been put in green scrubs per policy.
*There was no documentation that a SAD PERSONS scale had been completed.
*SAD PERSONS SCALE:
-Sex 1 if patient is male, 0 if female, -Age 1 if patient is (25-34; 35-44; 65+), Depression, Previous attempt 1 if present, Ethanol abuse 1 if present, Rational thinking loss 1 if patient is psychotic for any reason (schizophrenia, affective illness, organic brain syndrome), Social support lacking 1 If these are lacking, especially with recent loss of a significant other, Organized Plan 1 if plan made and method lethal, No spouse 1 if divorced, widowed, separated, or single (for males), and Sickness 1 especially if chronic, debilitating, severe (e.g.; non- localized cancer, epilepsy, MS, gastrointestinal disorders)
*Patterson WM, Dohn HH, et al: Evaluation of suicidal patients, THE SAD PERSONS Scale, Psychosomatics, 1983:
-One method to gather this information that has been useful for healthcare providers is the SAD PERSONS scale, the scale included:
-"S" stands for sex. Again, we know that males are likely to end life by suicide 2 xs that of females and females attempt 2x more than males.
-"A" stands for age. Remember the ages that have the highest suicide rates.
-"D" stands for depression. Does the patient have symptomatology or diagnosis of depression? Remember, depression is the mental illness with the closest link to suicide.
-"P", previous attempt. Has the person attempted before and if so, what means did they use and what factors where involved, how did they survive the attempt?
-"E" stands for ethanol abuse.
-"R" stands for rational thinking. Is the patient thinking rationally?
-"S" stands for social support deficit. Does the patient have a support system?
-"O" is for organized plan. Does the patient have a thought out plan for taking the steps to act on the thoughts? "N" is for no spouse. Is the patient without a spouse?
-"S" is for sickness. Does the person have a medical or physical illness?
-These letters represent 10 areas of assessment. The scoring for this is as follows- 0-2 equals little risk, 3-4 equals following patient closely, 5-6 equals strongly considering hospitalization, and 7-10 equals a very high risk, hospitalize or commit.

b. Review of the ESI Triage Algorithm used by the ED triage staff revealed patient who was suicidal, homicidal, psychotic, or violent or present an elopement risk should have been considered high risk. That score would be a 2.

c. Review of the provider's undated action plan that had been developed after the above incident revealed:
*A checklist was to have been developed to standardize the process for care of the mental health patient placed on an involuntary hold.
*Alert process or "flag" to be developed to display on patient census board for communication to all staff. This alert process had not been implemented until 7/14/14.
*Competency and training for all staff working in the ED including travel and float pool staff working in the ED. This training had not been completed by all staff that worked in the ED by 7/14/14.
*Communication to ancillary staff as well as ED staff about controlled access points and verification of patient/visitors entering or exiting the area. This communication had been sent by an e-mail and verification of the information had not been completed.

d. Review of the provider's June 2014 Behavioral Health patients in the ED policy revealed:*Patients who were identified to have a psychiatric or behavioral health problems upon presentation to the ED would have been interviewed by a nurse (using the SAD PERSONS assessment scale) to determine the patients capacity to harm self or others.
*Every effort would have been made to place the patient in a quiet room with a family member, if appropriate, to ensure safety.
*Security or trained sitter personnel might have been requested to assist in observation to ensure patient safety.
*Patients might have been asked to undress and placed in a gown or transfer scrubs, belongings might have been searched and kept outside of the room at the discretion of the primary nurse.

20031

Based on record review, interview, security tape review, and policy review, the provider failed:
*To ensure self-harm and elopement precautions were in place for two of two sampled emergency department (ED) patients (1 and 2) who had been placed on a physicians' ordered mental health hold.
*To have an adequate nursing staff to supervise patients placed on a mental health hold.
*Identify and ensure all staff were trained and had demonstrated competency on how to ensure a patient on a mental health hold would not elope. According to the provider's plan of action after the 7/3/14 patient 1 elopement.
*Fully develop and implement a timely plan of action for patient's 1 and 2 identified as eloped.
*Monitor the plan of action to ensure it was viable and staff were compliant with the plan.
*To ensure complete and comprehensive policies and procedures were in place for mental health hold patients and patients at risk for elopement.
*Prevent the occurrence of elopement for patients placed on a mental health hold putting patients at risk of harm without proper intervention.
*To ensure the ED staff:
-Resposnible for patient care adequately monitored patients who had a known potential for self-harm and had been placed on a mental health.
-Assigned patients with a mental health hold conducted "hand-off" communication for those patients waiting to be transferred to the behaviorial health unit.
-Consistently documented and communicated to the security staff when patients were placed on a mental health hold.

These failures represented an Immediate Jeopardy (IJ). On 07/15/2014 at 5:00 p.m., an IJ was declared regarding emergency services. The hospital's leadership staff (Chief Executive Office, Chief Operating Officer, Vice President of Risk Management and Accreditation/Certification, Director of Risk Management and Accreditation/Certification, Vice President of Ancillary Services, Director of ED Services, Medical Director of ED Services, and security officer A) were notified of the IJ situation. An acceptable corrective action plan was received and approved and the IJ was abated on 7/17/14 at 1:25 p.m.
This deficiency remained at a condition level after the abatement of the IJ and compliance with the immediate plan of correction. Findings include:

The provider's immediate plan of correction is as follows:
*Patient identification:
-1. The policy was revised to require the emergency department primary nurse to place a patient in green scrubs and to place a colored arm band on the patient upon initiation of hold rather than at time of transfer. (A blue arm band will be used until the permanent green arm bands arrive.) The arm band will be applied to all mental hold patients regardless of refusal to wear scrubs. All mental hold patients will have visual observation, an arm band, and will be identified with an " H " on the locator board. Completion date of 7/11/14
-2. Increased availability of scrubs by increasing par levels. (Quantities and sizes.) Environmental services is completing a daily evaluation of par levels and replenish as needed. Completion date of 7/17/14.
*Observation of hold patients:
-1. Provided additional support staff for hold patient observation. Completion date of 7/15/14.
-2. Defined and implemented a medical classification of Hold levels to include visual observation (in a room with door open with exit point within the observers line of sight) or 1:1 observation. Once a Petition of Emergency Commitment is placed, patients will have visual observation while in the Emergency Department. If the Emergency Department physician, who is a Qualified Mental Health provider by the State of South Dakota determines the patient needs increased monitoring, he/she will order 1:1 observation. Completion date of 7/16/14.
-3. Defined and implemented a process to obtain additional resources for county mental hold patient observation. Security is trained in CPI and will observe the patient and provide a safe environment by identification of escalation and de-escalation needs. Security will have primary responsibility for observing county mental hold patients in the Emergency Department. If security is experiencing capacity limitations he/she will notify ED staff, ED staff will observe while ED Clinical Resource Nurse notifies Hospital Coordinator; Hospital Coordinator will obtain additional staffing resources from an identified pool for observation coverage. (Observation will be completed by staff in the following sequence -security, ED staff, trained float pool observers who are unlicensed personnel include but are not limited to patient care techs (PCTs), supply purchasing distribution (SPD), and environmental services staff. There is always a CPI trained security of emergency department staff member immediately available to an observer within emergency department. This process will result in uninterrupted observation of emergency department county mental hold patients. Completion date of 7/16/14.
-4. " Observer " Staff education: Observation staff will have received the orientation currently used " constant observer education/orientation " prior to observing a county mental hold patient. Documentation of education will be retained by Central Staffing Office (CSO).
-5. Developed and implemented " Hold Patient Observation Flow Sheet " to document observation of patient behaviors and maintenance of environmental precautions. Completed flow sheet will become part of the patient ' s medical record.
-6. The ED Primary Nurse will ensure Flow Sheets are complete before they are placed in the medical record. (Initialed JG)
*Law Enforcement:
-1. Communication to police and county officers of increased security measure for County hold patients. Completion Date: 7/17/14
*Controlled Access:
-1. Security Personnel checked all cameras and doors for functionality and assured controlled access to the Emergency Department. Security Standard Operating Procedures re to check cameras and doors daily. Variation from normal functioning and remedial action taken will be documented by eon the In-House Officer Call Log. Completion Date: 7/15/14
-2. Removed Visitor Passes. Visitor and patient access is not only permitted by Emergency Department employee controlled bade swipe. Completion Date: 7/15/14
-3. Posted signage all doors to increase employee, patient and visitor awareness restriction. Signage states, " Controlled Access-Patients and Visitors must check with Emergency department Staff before entering/exiting. Thank you for your Cooperation. "
Completion Date: 7/15/15
*Policy Development and Revision:
-1. In response to the elopement events, a new Emergency Department policy developed and approved. ( " Elopement Preventive Measures in the ED " (EDMED-6231-55). Completion Date: 7/14/14
-2. The policy was further revised to incorporate new processes, such as obtaining additional resources and documentation of patient observations and care. Completion Date: 7/14/14
-3. The policy was further revised to incorporate processes including the establishment of levels of observation, primary nurse responsibility for patient change into scrubs, Security responsibility for observation of patients, and use of arm bands. Completion Date: 7/17/14
*Education:
-1. Education packet developed and distributed for completion by ED staff and staff who float to the ED. (7/18/14 or prior to any shift worked I ED).
Completion Date: Education to be completed prior to any worked shift in the Emergency Department 7/15/14 (To be documented and returned to ED Director by 7/18/14)
-2. Distributed to Department Directors communication and acknowledgement for all Ancillary staff regarding controlled access to the Emergency Department. Completion Date: 7/15/14.
-3. Distribute updated education to be completed by staff prior to working a shift or observing mental hold patients in the Emergency Department. Education to include updated process of arm band utilization, hold level classification, flow sheet, ad obtaining additional observer resources. Emergency Department Director or designee and Security Supervisor or designee will complete education of their respective staffs an