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Based on record review and interviews, the Hospital failed to ensure that:1) one of 10 patients (Patient #9) was appropriately monitored while in the Emergency Department (ED) and 2) the Missing Patients Policy was not followed for two of ten patients (Patient #1 and Patient #9) who eloped from the ED.

Findings include:

1) The ED Nurses Note, dated 4/2/12, indicated that Patient #9 was transported to the ED from a local court under a temporary involuntary hospitalization order (Section 12).

The Section 12 Form, dated 4/5/12, indicated that Patient #9 was at substantial risk of physical harm to him/herself and others. The Section 12 indicated that Patient #9 had been self inflicting injuries, making suicidal threats and had a history combative behavior related to substance abuse.

The ED Nurses Notes dated 4/2/12 indicated that Patient #9 arrived in the Emergency Department at 3:47 P.M. and placed in a treatment room. At 3:53 P.M. Public Safety Officer #2 conducted a search of Patient #9's person, clothes and belongings for contraband for safety with no identified items noted. The Surveyor interviewed Public Safety Officer #2 on 5/22/12 at 2:50 P.M. and he said that he did not remember Patient #9.

The nurse assigned to Patient #9 (ED Nurse #4) was interviewed on 5/22/12 at 3:30 P.M. ED Nurse #4 said that Patient #9 was cooperative and denied suicidal ideation. ED Nurse #4 said that ED Physician #1 and the Psychiatric Emergency Service were notified of Patient #9's arrival and need for evaluation.

The Emergency Department Nurses Note, dated 4/2/12, indicated that at 3:47 P.M., ED Physician #1 examined Patient #9.

The Hospital's Policy/Procedure titled Restraint and Seclusion indicated that all patients under a Section 12 must have a patient observer.

The ED Nurses Note, dated 4/2/12, indicated that at 4:44 P.M., Patient #9 was no longer in the in the ED treatment room. The ED Nurses Note indicated that ED Physician #1, the Department of Public Safety and the local police department were notified of Patient #9's elopement.

ED Nurse #4 said that Patient #9 was not being monitored by a patient observer at the time he/she eloped from the ED.


2) The Policy/Procedure titled Missing Patients indicated that when a patient is considered to be "at risk" was reported as missing, the Hospital was to attempt to locate the patient in the Hospital and on the grounds. The Policy indicated that a Code Green was to be announced through the Hospital's overhead paging system to alert staff and to activate Hospital staff to search for the missing/eloped patient. Code Green Level 2 was to be announced if the missing/eloped patient was a psychiatric patient on a Section 12 or on the inpatient psychiatric unit.

A) Patient #1:
The Emergency Department (ED) Nurses Notes, dated 5/10/112, indicated that Patient #1 was brought to the ED by ambulance after a night of drinking and punching a window, sustaining severe lacerations to both forearms. The ED Nurses Notes indicated that Patient #1's family member reported that Patient #1 had been in a manic state all week, saying he/she wanted to die and refusing to take his/her prescribed psychiatric medicines. The ED Nurses Notes indicated that Patient #1's psychiatric history was significant for polysubstance abuse, Bipolar Disorder and post-traumatic stress syndrome.

The Surveyor interviewed the ED's Unit Secretary on 5/22/12 at 12:25 P.M. The Unit Secretary said that on 5/11/12, she started working at 10:00 A.M. The Unit Secretary said that around midday (unsure of the time), Patient #1 came to the desk and requested something to eat and drink. The Unit Secretary said she asked Patient #1 to return to his/her room and she would send the nurse in to assist him/her. The Unit Secretary said she observed Patient #1 return to his/her room. The Unit Secretary said that a short time later, she got a call from the receptionist asking her if the ED had a patient missing and provided a description. The Unit Secretary said that she went and checked on Patient #1 and found he/she was gone. The Unit Secretary said she came back to the desk and notified ED Nurse #2.

The Surveyor interviewed ED Nurse #2 on 5/22/12 at 12:45 P.M. ED Nurse #2 and the Unit Secretary said that a Code Green was not announced when it was discovered that Patient #1 eloped.

The Surveyor interviewed the Complainant on 5/21/12 at 2:00 P.M. The Complainant said that Patient #1 was later observed walking down the main street of town dressed in undergarments with one arm wrapped in an ace bandage and an intravenous line attached to a needle inserted into his/her other arm. Blood was observed on the arm with the tubing. The Complainant said that he/she called the local police department to inform them about Patient #1, the police responded and returned Patient #1 to the Hospital on a Section 12.

B) Patient #9:

Please refer to background information regarding Patient #9 in Tag A 144, Section #1.

The Hospital did not activate a Code Green when Patient #9 eloped from the Hospital's ED.