HospitalInspections.org

Based on interview, record review, and policy review, the hospital failed to follow its policies and provide within its capability and capacity stabilizing treatment for one patient (#7) out of 25 Emergency Department (ED) records reviewed from 01/15/24 to 07/15/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition)," revised 11/05/23, showed:
- EMTALA obligates the hospital to provide a medical screening examination (MSE), treatment and/or transfer of individuals with an EMC. If an EMC is determined to exist, the hospital must provide any necessary stabilizing treatment or arrange appropriate transfer.
- An EMC is a medical condition with acute symptoms of sufficient severity (including psychiatric [related to mental illness] disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious dysfunction or impairment of a bodily part, acute psychiatric or substance abuse symptoms are revealed or the individual is expressing suicidal/suicidal ideation (SI, thoughts of causing one's own death) or homicidal ideation (HI, thoughts or attempts to cause another's death) that endanger themselves or others.
- A MSE is the process required to reach the point where it can be determined whether or not an EMC exists. The MSE includes both a generalized assessment and a focused assessment based on the patient's chief complaint. The MSE is ongoing and must continue until the patient is stabilized, admitted or appropriately transferred.
- A stabilized EMC means no material deterioration of the condition is likely to result from transfer or discharge. The patient has reached the point where continued care could reasonably be performed as an outpatient, the patient is given a plan for appropriate follow-up care or the patient requires no further treatment and the treating physician has provided written documentation of their findings.
- A psychiatric patient is considered stable when they are prevented from injuring themselves or others.
- Stabilized patients are not transferred and stabilization of a patient ends the hospital's EMTALA obligation. If a patient needs follow up care, they are discharged with instructions.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," approved 05/22/23, showed:
- A patient suspected to be suicidal in intent shall be admitted to an appropriate room consistent with the patient's medical needs. If these accommodations are not available, the patient shall be transferred, if possible, to another institution where suitable facilities are available. When transfer is not possible, the patient may be admitted to a general area of the hospital as a temporary measure, while providing all reasonable care appropriate to the situation. Appropriate restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) may be used as permitted by these Rules and Regulations and hospital policy. The patient will be afforded psychiatric consultation as necessary and appropriate. The hospital social worker can be consulted for assistance.
- Any individual who presents to the ED for care shall be provided with a MSE to determine whether the individual is experiencing an EMC.
- Any individual experiencing an EMC must be stabilized prior to transfer or discharge unless the patient is determined stable for discharge.
- Stable for discharge is considered the patient has reached a point where continued care could reasonably be performed as an outpatient, they are provided with an appropriate follow-up plan and discharge instructions, or the patient requires no further treatment and the physician has provided written documentation of the examination findings.

Although requested, the hospital could not provide a policy outlining the care of psychiatric patients in the ED.

Review of the hospital's policy titled, "Involuntary Admission (a legal process through which a person is hospitalized and treated for mental health disorders without their consent)," revised 11/16/23, showed:
- Patients who are a harm to themselves or someone else, require constant supervision to remain safe and are not willing to seek treatment will be placed on an involuntary commitment to an appropriate placement.
- The procedure for 96-hour detention included: patients found to have a mental disorder or at harm to themselves or others should be encouraged to seek voluntary treatment; if the patient refuses and is not considered safe to return to home, involuntary commitment should be pursued.
- An affidavit (a written statement confirmed by oath, for use as evidence in court) is completed noting evidence of harm to self or others and evidence of a mental disorder or substance abuse.
- If the patient is 55 or older and is believed to have a mental disorder, the Senior Mental Health unit should be contacted for possible placement on Moberly Regional Medical Center (MRMC) psychiatric unit. If the patient will be admitted to MRMC psychiatric unit, a staff member will complete an Application for Detention. If the patient was voluntary and becomes involuntary, State of Missouri Department of Mental Health forms must be completed.
- If the patient will not be admitted to MRMC, affidavits must be taken to the probate judge in the county in which the patient resides. If after hours, the police or sheriff department will take the application to the probate judge. The judge will determine appropriateness and placement for the individual.

Review of the hospital's policy titled, "Post Elopement (when a patient makes an intentional, unauthorized departure from a medical facility)," revised 01/2022, showed:
- In the event of a patient elopement; the charge nurse immediately notifies security, house supervisor and police.
- The charge nurse completes an incident report.
- Appropriate restraint may be used to detain an involuntary patient who has eloped off the unit or hospital grounds. The police may be summoned to assist in returning the patient, if necessary.
- Appropriate restraint is not used to detain a voluntary patient who has eloped.
- In the event a voluntary patient is assessed by the physician and found to need involuntary admission, steps are taken to seek involuntary status for the patient.
- The incident necessitates a quality improvement review.

See A-2407 for additional information.

Based on interview, record review, and policy review, the hospital failed to provide within its capability and capacity, stabilizing treatment for one patient (#7) out of 25 Emergency Department (ED) records reviewed from 01/15/24 to 07/15/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC).

Findings included:

Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC)," revised 11/05/23, showed:
- EMTALA obligates the hospital to provide a medical screening examination (MSE), treatment and/or transfer of individuals with an EMC. If an EMC is determined to exist, the hospital must provide any necessary stabilizing treatment or arrange appropriate transfer.
- An EMC is a medical condition with acute symptoms of sufficient severity (including psychiatric [related to mental illness] disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious dysfunction or impairment of a bodily part, acute psychiatric or substance abuse symptoms are revealed or the individual is expressing suicidal ideation (SI, thoughts of causing one's own death) or homicidal ideation (HI, thoughts or attempts to cause another's death) that endanger themselves or others.
- A MSE is the process required to reach the point where it can be determined whether or not an EMC exists. The MSE includes both a generalized assessment and a focused assessment based on the patient's chief complaint. The MSE is ongoing and must continue until the patient is stabilized, admitted or appropriately transferred.
- A stabilized EMC means no material deterioration of the condition is likely to result from transfer or discharge. The patient has reached the point where continued care could reasonably be performed as an outpatient, the patient is given a plan for appropriate follow-up care or the patient requires no further treatment and the treating physician has provided written documentation of their findings.
- A patient is stable for transfer if the treating physician has determined the patient is expected to leave the hospital and be received at a second facility with no material deterioration in their medical condition and believes the receiving facility has the capability to manage the patient's medical condition and any foreseeable complication of that condition. A psychiatric patient is considered stable when they are prevented from injuring themselves or others.
- Stabilized patients are not transferred and stabilization of a patient ends the hospital's EMTALA obligation. If a patient requires follow up care, they are discharged with instructions. Transfer to another medical facility by appropriate means may occur after stabilization if the individual requires specialized treatment not available at the hospital and another hospital has the capability of specialized care and space to treat the patient or if a stabilized individual requests transfer to the hospital of their choice.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," approved 05/22/23, showed:
- A patient suspected to be suicidal in intent shall be admitted to an appropriate room consistent with the patient's medical needs. If these accommodations are not available, the patient shall be transferred, if possible, to another institution where suitable facilities are available. A suicidal patient in the ED will not be transferred absent an appropriate MSE, stabilization, and certification per the hospital's EMTALA policy. When transfer is not possible, the patient may be admitted to a general area of the hospital as a temporary measure, while providing all reasonable care appropriate to the situation. Appropriate restraints (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) may be used as permitted by these Rules and Regulations and hospital policy. The patient will be afforded psychiatric consultation as necessary and appropriate. The hospital social worker can be consulted for assistance.
- Any individual who presents to the ED for care shall be provided with a MSE to determine whether the individual is experiencing an EMC.
- Any individual experiencing an EMC must be stabilized prior to transfer or discharge unless the patient is determined stable for discharge.
- Stable for discharge is considered the patient has reached a point where continued care could reasonably be performed as an outpatient, they are provided with an appropriate follow-up plan and discharge instructions, or the patient requires no further treatment and the physician has provided written documentation of the examination findings.

Although requested, the hospital did not provide a policy outlining the care of psychiatric patients in the ED.

Review of the hospital's policy titled, "Involuntary Admission (a legal process through which a person is hospitalized and treated for mental health disorders without their consent)," revised 11/16/23, showed:
- Patients who are a harm to themselves or someone else, require constant supervision to remain safe and are not willing to seek treatment will be placed on an involuntary commitment to an appropriate placement.
- The procedure for 96-hour detention included: patients found to have a mental disorder or at harm to themselves or others should be encouraged to seek voluntary treatment; if the patient refuses and is not considered safe to return to home, involuntary commitment should be pursued.
- An affidavit (a written statement confirmed by oath, for use as evidence in court) is completed noting evidence of harm to self or others and evidence of a mental disorder or substance abuse.
- If the patient is age 55 or older and is believed to have a mental disorder, the Senior Mental Health unit should be contacted for possible placement on Moberly Regional Medical Center (MRMC) psychiatric unit. If the patient will be admitted to the MRMC psychiatric unit, a staff member will complete an Application for Detention. If the patient was voluntary and becomes involuntary, State of Missouri Department of Mental Health forms must be completed.
- If the patient will not be admitted to MRMC, affidavits must be taken to the probate judge in the county in which the patient resides. If after hours, the police or sheriff department will take the application to the probate judge. The judge will determine appropriateness and placement for the individual.

Review of the hospital's policy titled, "Post Elopement (when a patient makes an intentional, unauthorized departure from a medical facility)," revised 01/2022, showed:
- In the event of a patient elopement; the charge nurse immediately notifies security, house supervisor and police.
- The charge nurse completes an incident report.
- Appropriate restraint may be used to detain an involuntary patient who has eloped off the unit or hospital grounds. The police may be summoned to assist in returning the patient, if necessary.
- Appropriate restraint is not used to detain a voluntary patient who has eloped.
- In the event a voluntary patient is assessed by the physician and found to need involuntary admission, steps are taken to seek involuntary status for the patient.
- The incident necessitates a quality improvement review.

Review of the medical record for Patient #7 on 06/02/24 at 10:15 PM showed:
- She was a 56-year-old female brought to the ED by ambulance with complaints of anxiety (a feeling of fear or worry experienced intermittently).
- At 10:35 PM, Staff M, Registered Nurse (RN), documented the patient reported she was having chest pain and a panic attack (specific periods of sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom) and called for an ambulance.
- At 10:47 PM, Staff V, ED Physician, documented the patient denied currently having chest pain or shortness of breath. The patient took clonazepam (medication used to treat anxiety) for anxiety and felt her current symptoms were related to her uncontrolled anxiety.
- Staff V completed a physical examination including assessment of heart, lungs and psychiatric. The electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) was negative for acute coronary concerns and the patient refused to proceed with laboratory tests. The ED physician discussed the risks and benefits of not proceeding with the testing. The patient was deemed competent to make her own decisions. She continued to refuse laboratory testing and was discharged Against Medical Advice (AMA).
- At 10:50 PM, Patient #7 signed a completed AMA form.

Review of the medical record for Patient #7 on 06/02/24 at 11:42 PM showed:
- She was a 56-year-old female with complaint of paranoia (excessive suspiciousness without adequate cause) and confusion.
- At 11:49 PM, Staff M, RN, documented Patient #7 was seen in the ED approximately one hour before this presentation with complaint of anxiety and chest pain. She left AMA. Patient #7 now reported "I want to go to [Hospital B] Psych Ward. I'm confused."
- At 11:53 PM, Staff M documented a Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person's risk to self-inflicted harm and desire to end one's life) Assessment for Patient #7. The patient denied wishing she was dead and denied any thoughts of killing herself. Her assessed suicide risk was low.
- At 11:59 PM, Staff V, ED Physician, documented Patient #7 was sitting in the ED waiting room and felt like she heard people talking about her. The patient reported she heard voices threatening her. Patient #7 requested to go to Hospital B's Psychiatric Unit. She did not want to be admitted to MRMC's senior behavioral health unit (BHU) because she did not "trust" the hospital. Patient #7 reported she had attempted suicide in the past and currently had thoughts of harming herself by cutting her wrists.
- On 06/03/24 at 12:02 AM, Staff V documented an examination of Patient #7 which was normal other than slow response to questioning, flat affect, irritable mood and thoughts of suicide. The patient reported her plan for suicide was cutting. Patient #7's judgement and insight was assessed as impaired with delusions (false ideas about what is taking place or who one is) and auditory hallucination (hearing things that are not heard by others, imaginary).
- At 12:06 AM, Staff V documented differential diagnoses considered were psychosis (a serious mental illness characterized by defective or lost contact with reality), volume depletion, drug use, hypoglycemia (low blood sugar) and paranoia.
- At 12:10 AM, Staff V documented an attempted blood draw was not successful and Patient #7 refused further attempts. Staff V talked with Patient #7 and told her before she could talk with a psychiatrist to approve a transfer, she had to have results of the laboratory tests. Patient #7 told Staff V she did not trust her and did not believe the tests were necessary. Staff V explained to Patient #7 that because she had reported a plan to harm herself and had previously attempted suicide, a 96-hour involuntary hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others) would be initiated to keep Patient #7 in the ED until test results were obtained.
- Patient #7 walked out of the ED and the discharge disposition was recorded as "Eloped." Discharge diagnoses were listed as suicidal ideations and delusional disorders. Staff V's documentation included "Due to staffing and safety issues, we were not able to prevent her from leaving." The local police department was notified.

Review of the hospital's undated, incomplete document included in Patient #7's medical record titled, "Order for 96 Hour Detention, Evaluation and Treatment and Warrant," showed:
- An outline of procedures for completing 96-hour detention paperwork and showed the county required a completed and notarized 96 Hour Detention, Evaluation and Treatment form, a completed and notarized affidavit in support of 96-hour hold, completed list of witnesses, and a completed confidential case filing information form. Contact information was included with the instructions on how to process the application during normal business hours and after hours.
- Staff V started the application for submission to the probate court for 96-hour hold including documentation of Patient #7's statements of auditory hallucinations, persecutorial (when someone believes a person or group wants to hurt them despite the lack of proof) delusions, admission to suicidal ideation with a plan to cut herself and had had previous suicide attempts that required psychiatric admission. The application was not completed, signed, notarized, nor submitted.
- Staff V initiated an affidavit which showed Patient #7 presented to the ED for confusion, delusions and requested to be sent to Hospital B. The patient reported she believed she hallucinated while in the waiting room, denied drug use, reported current suicidal thoughts of cutting herself and had a history of suicidal actions and subsequent hospitalization. Patient #7 exhibited paranoia about hospital staff. The affidavit was not signed, notarized, nor submitted.
- A form titled, "List of Witnesses" was started with Staff V's name and contact information included. The form was not completed, signed, nor submitted.

Review of Patient #7's medical record from Hospital B dated 06/03/24 showed:
- Patient #7 was a 56-year-old female with a history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly).
- She was brought to the hospital by ambulance with reports of suicidal ideation, auditory and visual hallucinations (seeing things which are not there), and a plan to cut herself.
- At 2:53 AM, she was evaluated for medical clearance, was cleared of medical concerns before laboratory results and transferred for psychiatric evaluation.
- At 3:55 AM, psychiatry notes showed Patient #7 presented voluntarily with a chief complaint of erratic behavior (behaving in a wild and unpredictable manner). Patient #7 stated "I'm suicidal." She exhibited paranoid tendencies about the staff trying to hurt her. The patient was reluctant to answer questions, verbalized paranoid comments and ultimately became agitated (a state of feeling irritated or restless). The evaluation was hindered due to the patient's paranoid delusions and disorganized behavior. It was determined Patient #7 was at risk of imminent harm to herself or others and required further evaluation.
- The medical record contained paperwork titled, "Application for 96-hour Imminent Harm Admission," and she was placed on 96-Hour Hold for further psychiatric observation.
- Initial diagnoses were listed as unspecified schizophrenia, rule-out schizoaffective disorder, bipolar type (mental illness that is characterized by symptoms of mania, depression and mood disturbances) and rule-out substance induced psychosis (a serious mental illness characterized by defective or lost contact with reality, caused by taking or stopping a drug).

Although requested, the hospital did not provide incident reports or security events regarding Patient #7's elopement from the ED on 06/02/24.

During a telephone interview on 07/26/24 at 1:00 PM, Staff V, ED Physician, stated that Patient #7 initially presented to the hospital on 06/02/24 with complaint of panic attack and chest discomfort. The patient did not report any intent to harm herself during that ED visit. Staff V attempted to do an appropriate work-up to rule-out a heart attack or other cardiac-related issue. The patient refused laboratory work, repeated back to Staff V that she understood the risks associated with leaving before her evaluation was complete, signed an AMA form and left the treatment area. Patient #7 never left the hospital and sat in the ED waiting area after signing the AMA form. Staff V stated that about 45 minutes later, Patient #7 told the registration clerk she needed to be seen in the ED again. The patient was screened by nursing and told the nurse and the physician that she wanted to go to Hospital B for psychiatric care. During the provider's assessment, Patient #7 reported that she heard people talk about harming her or "get rid of her." With more detailed questioning, Patient #7 told her that she had thought of harming herself using a knife and she knew where she could get one. Staff V discussed with the patient that she felt she was high-risk for SI and needed psychiatric treatment. Staff V explained that the ED would need to perform certain lab tests before they could transfer Patient #7 to Hospital B. The patient agreed to blood work, but the attempt to draw was unsuccessful and the patient then refused further blood draws. Staff V stated that the transfer centers for the psychiatric facilities in their area required that complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection), COVID-19 (highly contagious, and sometimes fatal, virus) and a drug screen at a minimum were complete before they would entertain any discussion regarding transfer of a patient for further evaluation. Staff V told Patient #7 she would be bound to get a 96-hour hold from the judge to keep the patient for the necessary testing and transfer. Patient #7 refused further testing and walked out of the ED. Patient #7 was never left alone after she reported SI to Staff V, but ED staff had not had an opportunity to begin one to one (1:1, continuous visual contact with close physical proximity) observation or placement in the psychiatric safe room (a room that has been cleared of any objects a patient might use to harm themselves or others). Staff V stated that Patient #7's behaviors were not considered dangerous or combative. The ED had the capability to administer a chemical restraint (a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient) and access to some psychiatric stabilization medications. The ED was fully staffed to competently care for the volume of its patients; but the number of staff was not enough to safely physically restrain patients, combative or not. It was felt that the risk of harm to Patient #7 or to hospital staff trying to physically restrain her for a chemical restraint were greater than the risk of Patient #7 actually harming herself. The police were notified and 96-hour hold paperwork was started, but not completed. Staff V stated that she could not have forwarded a 96-hour hold request to the judge for approval until an accepting destination had agreed to take the patient and required lab testing completed. Staff V stated that if the police found Patient #7, their process for a 96-hour hold was different and they could take the patient directly to a psychiatric ED for evaluation without necessary labs and referral. Staff V stated that the BHU within the hospital also had the same laboratory requirements before an intake representative would discuss if a patient was appropriate for inpatient care. Staff V stated that the hospital had social workers available during weekday daytime hours that could complete "Imminent Harm" paperwork. Otherwise after a nurse did an initial screening for SI/HI, the provider in the ED performed mental health evaluations (MHE) and determined if transfer was pursued.

During a telephone interview on 07/22/24 at 8:00 AM, Staff M, RN, stated that she remembered the events that occurred with Patient #7 on 06/02/24. The patient did not report to her during triage or her assessment that she was suicidal, but she told the ED physician that she was suicidal. The physician told Staff M and she called the house supervisor to get a sitter for 1:1 observation. Staff M stated that she heard the physician discuss the 96-hour hold and the patient left the ED within three minutes following that conversation; before 1:1 or the 96-hour hold paperwork were completed. Security and the police were called, but she did not believe that the patient was returned to the ED that night. The protocol for a patient who presented with SI/HI was to get a sitter and start 96-hour hold paperwork, if needed. If an active SI/HI patient eloped or was violent, staff would not put themselves in danger. They would call security and the police.

During an interview on 07/17/24 at 11:45 AM, Staff I, ED Physician/ED Medical Director, stated that Hospital B did require certain labs and radiology testing before they would accept a patient for psychiatric transfer. Providers sometimes called the on-call provider if they had concerns that the patient would not meet admission criteria for the hospital's own BHU before running tests on patients aged 55 and older. The hospital's BHU would not accept patients with a urine drug screen result positive for illicit drugs. With regards to Patient #7's visit and elopement on 06/02/24, he felt it was appropriate to initiate a 96-hour hold on a patient who had expressed SI. He reviewed Patient #7's medical record and the documented statement regarding not enough staff and safety concerns as reason not to deter the patient from elopement. He had not discussed this patient nor this visit with Staff V, ED Physician; but wondered if Staff V considered inquiring for assistance from other ED providers on-call if the census or acuity within the ED was overwhelming at the time and if additional presence may have been beneficial.

During an interview on 07/15/24 at 11:15 AM and 07/17/24 at 8:35 AM Staff E, ED Director, stated that the hospital did not have access to telehealth (remote delivery of healthcare services while the health care provider is at a separate location, including exams and consultations, through video and telephone communication) services for psychiatry. The hospital had a BHU that could admit eligible patients over the age of 55. If a patient in the ED was above age 55, the ED provider would decide if consultation with the psychiatrist on-call for the BHU was warranted. Nurses from the BHU could come to the ED and perform a MHE on a patient older than 55 as well; but this was rarely utilized. The hospital's BHU staff could also complete "Imminent Harm" paperwork. Affidavits could be completed by any staff and nurses could start the application process for 96-hour hold request form, but the provider had to sign the form before it was forwarded through the court system. ED providers often consulted with providers at Hospital B regarding potential transfer of psychiatric patients. Admission to the hospital's BHU would only occur after required lab and radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) testing was complete. Transfer to another facility before the labs and other diagnostic tests were completed could be accomplished; but it was "frowned upon." The ED had a psych safe room and a patient deemed as high-risk after CSSR was placed in the room with a 1:1 observer. If a high-risk patient attempted to elope the ED, nurses were encouraged to de-escalate the patient with verbal techniques but told not to put themselves in a harmful situation to physically detain a patient. The house supervisor and security were notified, but security was limited as to their capability to put "hands on" patients as well. A physician might decide to chemically restrain a patient and security might be involved in that process. Sometimes local law enforcement was requested as a "presence of force." If a high-risk patient did elope the ED, law enforcement was notified, and they brought the patient back to the ED until the MSE was completed and a transfer was arranged. In the case of Patient #7's visit on 06/02/24, she was not placed in the psych safe room and 1:1 observation had not begun because her CSSR in triage was determined low-risk. Patient #7 then told the provider she was suicidal and left the ED almost immediately after, before high-risk measures were implemented.

During a telephone interview on 11/23/24 at 11:00 AM, Staff T, House Supervisor, stated that she was the house supervisor on duty on 06/02/24 when Patient #7 eloped from the ED. When a high-risk patient eloped the ED, she and security were notified. Security searched the immediate hospital premises and if they were unable to locate the patient, security called the police for assistance. When 96-hour hold paperwork was needed, the provider and ED nursing staff completed the paperwork. She did not fill out an event form when a patient eloped the ED, but she notified the administrator-on-call (AOC) if she felt that the situation warranted due to a patient at-risk. She did not recall notifying the AOC on 06/02/24.

During a telephone interview on 11/23/24 at 12:00 PM, Staff U, Security Officer, stated that he was the security officer on duty on 06/02/24. He was unsure if he was notified that Patient #7 eloped on 06/02/24. Security was trained to not chase an individual that was attempting to elope. Sometimes they were asked to come to the ED as a "show of force" for someone who was "out of control"; but most times they do no put hands on a patient and instead called police. He was very familiar with Patient #7 because she was known to wander the halls and property of the hospital after she had been seen in the ED. When security approached her to leave, she wanted them to call police because she was "scared to go outside." She had never been violent toward him. Staff U stated that Patient #7 was well-known in the community for walking around and when people tried to help her, she often said "the hospital just wants to do brain surgery on me." No one had ever asked him to complete an affidavit about her statements of seeing people who were not there or hearing voices of individuals that were not present.

During a telephone interview on 07/31/24 at 11:00 AM, Staff X, Police Officer Facility D, stated that just after midnight on 06/03/24 he was notified by the hospital that Patient #7 had eloped from the ED. He spoke with the physician regarding concerns for the patient. A short time after leaving the ED, he responded with another officer to a call that someone was attempting to enter homes without permission and Patient #7 was apprehended. Patient #7 reported to officers that she wanted to go to Hospital B for a psychiatric evaluation. Patient #7 did not necessarily appear to be experiencing a "psychiatric emergency" at that time and never reported SI or HI; but he had had frequent previous encounters when she appeared to be responding to hallucinations or was felt to be altered by recent drug use. The decision to take the patient to Hospital B rather than MRMC was made by his supervisor; but "Why would we take her back when they just let her leave?" The police department experienced frequent elopements from MRMC, but most of the time it was individuals who requested narcotics from the ED or were heavily intoxicated and then just "left" when they wanted to.

During a telephone interview on 07/23/24 at 9:00 AM, Staff R, ED Physician, stated that the hospital's BHU providers have seen patients in the ED in the past, but they are not "on-call" to perform MHEs. Staff R stated that other facilities will not consider admission of a psychiatric patient in transfer unless all labs and radiologic tests have been completed. If a patient refused testing, the provider would not be able to proceed with a transfer for admission. Staff R stated that a 96-hour hold would be initiated by a provider when the patient exhibited SI, HI, active psychosis, acts of self-harm, or when they were unable to care for themselves related to a mental illness. She was familiar with Patient #7 from previous ED encounters. When asked if Patient #7 was felt capable of making appropriate decisions and caring for herself, Staff R stated that "It depends on the day. Some days I feel she would benefit from a mental health evaluation."

During a telephone interview on 07/30/24 at 7:30 AM, Staff W, ED Physician, stated that the providing physician performed the MHE in the ED. Before any outside facilities would discuss placement of a patient with psychiatric concerns, providers must provide lab results. He was unaware that they were required before 96-hour hold paperwork could be completed. Staff W stated that during other encounters with Patient #7, she had come to the ED usually by EMS, was screened for the presence of a medical problem and did not want further evaluation or tests. There were other conditions in which a patient could be detained for 96-hour hold other than SI or HI; but though she often appeared to be responding to internal stimuli or voices, he did not consider Patient #7 a danger to herself or to others.

During a telephone interview on 07/22/24 at 5:20 PM, Staff Q, Paramedic from Facility C, stated that she had encountered Patient #7 multiple times in transport to the ED. Patient #7 often presented with paranoid ideas and appeared to be hallucinating. Staff Q stated that she was never approached by hospital staff to write an affidavit in support of a 96-hour hold for Patient #7. She was very concerned about Patient #7's ability to care for herself and considered submitting a hotline for Patient #7's well-being.

During a telephone interview on 07/18/24 at 1:30 PM, Staff L, RN, stated that Patient #7 was seen frequently in the ED for anxiety. She was seen, treated, released, and ED staff obtained a taxi pass to take her home. Patients who presented with SI received a suicide risk assessment and if the suicide risk was determined as high-risk, the patient was placed in 1:1 observation. If a patient was high-risk and attempted to elope; security, the house supervisor and the police were notified. Staff L stated that a 96-hour hold was utilized when a patient was not willing or did not possess the capacity to make decisions regarding their own well-being. A nurse could write an affidavit in support of a 96-hour hold, but the provider had to initiate the process and sign the request. The police took the completed form to the county judge, approval was returned via fax to the hospital and the patient was either admitted to their hospital or transferred to another. Other hospitals wanted all preadmission labs and typically a chest x-ray completed before a transfer was completed for a patient with psychiatric complaints.

During an interview on 07/15/24 at 11:50 AM, Staff G, RN, stated that patients with a psychiatric emergency were sometimes placed in a regular ED room until a psychiatric diagnosis was obtained and a suicide risk completed. High-risk suicidal patients were moved to the psych safe room, if appropriate and available, and placed on 1:1 observation. The ED used their own Patient Care Technician for 1:1 observation until the house supervisor provided a sitter from elsewhere in the hospital. High-risk psychiatric patients deemed to have SI/HI on suicide screening were also changed into scrubs, their clothing and belongings secured, and every 15-minute checks were documented. If a patient was potentially going to be admitted to the hospital's psychiatric unit, one of the BHU nurses and/or the psychiatrist might do a MHE on the patient. If the patient was not likely appropriate for admission and not SI/HI, the ED physician performed the MHE.

During an interview on 07/16/24 at 1:00 PM, Staff H, RN, stated that patients with a high-risk rating on their suicide screening were encouraged to stay and security was notified if the patient attempted to leave the ED. However, if the hospital did not have a 96-hour hold on the patient, they could not physically detain the patient or prevent their departure. ED staff called law enforcement to have them secure a patient once the patient was determined incompetent.

During a telephone interview on 07/23/24 at 10:00 AM, Staff S, RN, stated that a patient who reported SI would have a CSSR completed, changed into scrubs and placed in the psychiatric safe room. If the CSSR revealed high-risk, the psych safe room had a camera for observation and 1:1 observation would be started. If a high-risk patient attempted to elope, staff called security, the house supervisor, and the police. A 96-hour hold should probably be completed after an elopement of a pa