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Based on review of facility policies, medical record (MR) and staff (EMP) interview, it was determined the facility failed to ensure an involuntarily committed patient did not elope from the Intensive Care Unit (ICU) for one of one applicable medical records reviewed (MR1); failed to ensure a suicide risk assessment was completed for one of three applicable medical records reviewed (MR1); and failed to ensure a Code White was initiated for one of one applicable medical records reviewed (MR1).

Findings include:

1)A request was made on December 17, 2019, at approximately 11:15 AM to the facility for an involuntarily commitment policy (302). None was provided.

Review on December 17, 2019, of the facility "Notice Of Patient Rights and Responsibilities," revised September 2018, revealed, "You have the right to: ... An environment that is safe, preserves dignity ..."

Review on December 17, 2019, of MR1 revealed MR1 presented to the Emergency Department on December 8, 2019, at 2101 via ambulance. Triage note revealed patient complained of drug withdrawal and chest pain. Continued review revealed documentation at 2200 that MR1 was pulling the intravenous (IV) out and wanted to leave. Unable to re-direct patient. MR1 not making sense, clearly without capacity to make his own medical decisions. OTH1 initiated 302 to ensure patient gets evaluated. Police at bedside as patient was escalating and concern for his and staff's safety. MR1 was intubated and placed on the ventilator for protection of his airway and sedation. MR1 was admitted to ICU on December 9, 2019.

Further review on December 17, 2019, of MR1 revealed MR1 was extubated (removed from the ventilator) on December 9, 2019, at approximately 1015. Patient Observer Monitoring Checklist dated December 9, 2019, noted a 1:1 sitter was in place with MR1.

Documentation on December 10, 2019 from OTH5 revealed he along with OTH3 assessed MR1 and a 302 was initiated on MR1 and explained to MR1.

Continued review on December 17, 2019, of MR1 revealed MR1 eloped from the ICU on December 10, 2019, at 1100.

MR1's application for Involuntary Emergency Examination and Treatment (302) was reviewed on December 17, 2019. OTH1 was noted to be the petitioner for treatment for MR1 and completed the form on December 8, 2019. Section VI Physician's examination was completed on December 10, 2019, by OTH3 and noted MR1 was severely mentally disabled and in need of treatment. He should be admitted to a facility designated by the County Administrator for a period of treatment not to exceed 120 hours.

Interview on December 17, 2019, with EMP2 confirmed MR1 was brought to the facility on December 8, 2019, with complaints of drug withdrawal and chest pain; MR1 pulling IV out; wanting to leave; unable to re-direct. EMP2 confirmed MR1 intubated and placed on the ventilator for protection of his airway and sedation. EMP2 confirmed MR1 was admitted to the ICU on December 9, 2019. EMP2 confirmed MR1 was extubated on December 9, 2019, at approximately 10:15. EMP2 confirmed a 1:1 sitter was in place. EMP2 confirmed MR1 eloped from the ICU at 1100 on December 10, 2019.

Interview on December 17, 2019, with EMP3, at approximately 1230 PM revealed the 302 involuntary commitment process starts with a petitioner. MR1's 302 was petitioned by OTH1 on December 8, 2019, when MR1 arrived in the ED. EMP3 explained a petitioned 302 patient must then be examined by another physician. MR1 was examined by OTH3 on December 10, 2019, after MR1 was extubated. EMP3 explained after the patient was examined the patient was considered a 302 involuntary commitment and MR1 should not have eloped from the facility. EMP3 continued to explain the facility considers a patient a 302 involuntary commitment at the time of petition to ensure patient safety.

2) Review on December 17, 2019, of the facility policy, "Suicide Policy," last revised April 26, 2015, revealed " Policy: Regional Hospital of Scranton will make every effort to identify patients who are at risk for suicide. With this in mind, patients being treated for emotional or behavioral disorders should have a suicide risk assessment completed upon patient arrival and at any time during the patient's hospital stay when mental health issues are verbalized by the patient or emotional or behavioral mannerisms are observed. ... Top Five Groups at High Risk for Suicide ... 4. Persons with mental and substance abuse disorders ... General Suicide Risk Factors That May Apply to any Age Group or Demographic ... 6. Alcohol or other substance abuse ... Patients who arrive with suicidal ideations, once medically cleared, will be seen by a mental health delegate who will then make the determination as to whether they need to have a voluntary or involuntary commitment. ... Involuntary Commitment to a Psychiatric Institution - Inpatient areas. When a patient appears to be a clear and present danger to themselves and/or others, an involuntary Emergency Examination and Treatment Form (Section 302) of the Mental Health Procedures Act can be initiated, once the patient is evaluated by a Psychiatrist and he/she determines that an Involuntary Commitment is needed. The case Management Department of the Regional Hospital of Scranton is consulted and coordinates the case with the physician and the mental health system. The person observing the patient's behavior, preferably the physician, must document the specific behavior observed in detail on the 302 Form. ... The mental health delegate's responsibilities are: ... To evaluate the case and approve the need for the involuntary warrant. ... To assure that while the patient is detained, the health and safety needs of any dependents are met, and that the person's personal property and premises are secure ... Case Management Patients will be assessed by the Case Manager according to high risk screens, The high risk screen includes criteria to assess patients with a history of drug or alcohol abuse, history of suicide attempts, psychiatric disorders and/or psychiatric commitments, or psychotic symptoms. ..."

Review on December 17, 2019, of facility policy, "Suicide Risk Assessment and Interventions Columbia Protocol in Non-Behavioral Health Setting," revised November 1, 2019, revealed "Policy: All adolescents and adult patients (ages greater than or equal to 11 y.o.) who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol, also known as the Columbia-Suicide Severity Rating Scale (C-SSRS) excluding patients who present for Obstetrical Services. ... Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflicting harm to self. This policy is applicable to non - behavioral health settings including the Emergency Department (hospital and free-standing) and all acute inpatient and outpatient hospital settings. ..."

Review on December 17, 2019, of MR1 revealed no documentation that a Columbia-Suicide Severity Rating Scale (C-SSRS) was completed on MR1 after being extubated and removed from the ventilator on December 9, 2019, and with a 302 commitment in place.

Interview on December 17, 2019, with EMP2 confirmed MR1 had no documentation that a Columbia-Suicide Severity Rating Scale was completed after MR1 was extubated and removed from the ventilator on December 9, 2019, and with a 302 commitment in place.

3) Review on December 17, 2019, of facility, "Code White Policy," revised January 8, 2019, revealed, "Policy It is the policy of Regional Hospital of Scranton to follow written procedures in the event of a security incident when a patient, visitor or employee becomes disruptive. Purpose It is the purpose of this policy to provide and maintain a safe environment for patients, visitors and employees. The hospital "Code White" alert is utilized in emergency situations when a patient, visitor or employee becomes disruptive and demonstrates the potential to: Inflict physical harm on themselves or others Damage the physical property of Regional Hospital of Scranton or other's property ... Responsibility The "Code White" response team includes select members from the following departments: Security...Nursing Supervisors and others, as determined appropriate by the Safety Committee. ... Response team members shall undergo training in the following areas: Management of Aggression/Conflict Resolution Restraint technique, applications and limitations ... Procedure 1. The decision to implement a "Code White " alert is made by the Nursing Director/Facilitator, staff nurse or any individual who feels there is immediate threat of harm or injury to themselves, the patient or others. ..."

Review on December 17, 2019, of MR1 revealed OTH3 and residents arrived at 1100 AM to assess MR1. MR1 became combative with 1:1 sitter after discussion, ran towards the back door and successfully eloped through the back doors. Security notified who notified the police.

Interview on December 17, 2019, with EMP2 confirmed no Code White was called when MR1 became combative with the 1:1 sitter after discussion with OTH3 and residents; MR1 ran towards the back door and successfully eloped through the back doors. EMP2 confirmed security was notified who notified the police.