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Based on document review and staff interview, it was determined that the facility failed to develop, implement and maintain a data driven quality assessment and performance improvement program related to care of the psychiatric patients in the facility's Emergency Department (ED). Due to the failure to address this patient population in the facility's Quality Assessment Performance Improvement program, the Condition of Participation for Quality Assessment Performance Improvement is out of compliance.

Based on document review and staff interview, it was determined that the facility failed to track and trend quality indicators related to security and safety of patients held in the Emergency Department (ED) under the Baker Act (State of Florida 72 hour involuntary examination) for involuntary psychiatric evaluation and failed to evaluate incidents reported through the facility's Risk Manage program. This practice results in the failure to take action to improve safety and security of patients and placed them at risk for serious harm.

1. The Director of Clinical Informatics and Clinical Compliance presented meeting minutes from the Baker Act Task force. In May of 2010, a discussion regarding elopement of a patient under the Baker Act was discussed. The minutes from the June 2010 meeting indicated that the Director of the Senior Behavioral Health Unit recommended that the patients being held for involuntary evaluation under the Baker Act should be monitored very closely. The minutes indicated that the ED Director was to follow up on the recommendation. No further documentation regarding the issue of the care of these patients was found in the minutes from July, August and September. The Director of Clinical Informatics and Clinical Compliance was interviewed on 9/29/10 at approximately 2:00 p.m. She stated that the Baker Act Task force was not part of the Quality Improvement program and was not reported, along with other Quality Improvement data to the Governing Body. The Director of Clinical Informatics and Clinical Performance provided a list of elopements for 2010 from the Risk Management system. After review of e-mail messages from security, it was noted that at least two of the elopements were not included in the Risk Management data and was not included in a bar graph report presented by the Chief Nursing Officer that was to represent the trending of elopements. This bar graph was not included in the Quality report to the governing body. Although a concern regarding the safety of the involuntary patients was identified with a recommendation to take some action in June, no action to measure, analyze and track this area of concern through the QAPI process was implemented. The Chief Nursing Officer confirmed it was not presented to the QAPI committee for consideration during interview on 9/30/10 at approximately 2:00 p.m.

2. During interview on 9/29/10 at approximately 11:00 a.m., the Risk Manager designee confirmed that h/she had not investigated two incident reports completed by a staff member regarding the failure to adequately monitor 2 patients being held in the facility's ED on 8/21/10, stating it was " more of a personnel issue " and that he was waiting for the ED manager, who was on vacation, to return. Review of the medical records of patients #1 and #6 confirmed there was evidence in the medical record to validate the information present in the incident reports. Patient #1 had actually been able to leave the ED unnoticed. This placed the patient at considerable risk of self harm. This was confirmed by the Director of the ED during interview at approximately 3:00 p.m. on 9/29/10.

Based on observations. staff interviews, and review of clinical records, policies, procedures, and meeting minutes it was determined that the facility failed to provide care to patients presenting to the Emergency Department (ED) for emergency psychiatric care as evidenced by:

1. Failure to ensure care in the ED was integrated with the care provided in the facility's Senior Behavioral Care Unit (SBHU) to ensure consistent safe and therapeutic care of any psychiatric patient presenting to the ED (refer to A 1103).

2. Failure of the facility, in six of six sampled patients reviewed and potentially any psychiatric patients presenting to the ED, to follow policies and procedures approved by the Medical Staff regarding the use of restraints, assessment and reassessment of the ED psychiatric patient, provision of a timely mental health evaluation, and monitoring the patient being held under the Baker Act (the Florida Mental Health Act of 1971, commonly known as the "Baker Act", is a Florida statute allowing for involuntary examination of an individual. It can be initiated by judges, law enforcement officials, physicians or mental health professionals. There must be evidence that the person has a mental illness, is a harm to self, harm to others, or self neglectful. Examinations may last up to 72 hours and occur in designated receiving facilities statewide. Florida Hospital Zephyrhills is a receiving facility.

3. Failure of the Medical Staff to develop polices and procedures regarding suicide and elopement precautions (refer to A 1104), failure to provide sufficient number of qualified personnel to adequately monitor the patients with emergency psychiatric conditions, and failure to provide a safe environment in the ED for psychiatric patients resulting in the patients exposure to unsafe conditions (refer to A 1112).

4. Failure to act upon reports from the Baker Act Task force meeting minutes regarding patient elopements and failure to monitor the patients adequately.

Due to the cumulative effect of these systemic problems, the Condition for Participation for Emergency Services was determined to be out of compliance.

Based on review of 4 (#1, #2, #3 and #6) of 6 clinical records, review of facility policies and staff interview, it was determined the facility failed to provide the level of observations and precautions for patients being held temporarily under the Florida Mental Health Act (Baker Act) and suicidal patients in the facility's Emergency Department (ED) that would be provided in the facility's secure Senior Behavioral Health Unit (secure psychiatric unit) for involuntary examination. This practice presented a potential for self harm and/or death for this population of patients, which resulted in findings for immediate jeopardy which are on-going.
Findings include:

1. A review of the Senior Behavioral Care Unit policy, "Observations and Precautions," policy # 220072.000, effective 10/09, documented that Suicide precautions are defined as awareness of a patient's mental status that places them at a high risk of self-injury. Suicide precautions will include a level of observation higher than routine. Elopement Precautions are defined as increased observations to ensure patient safety due to high elopement risk. The nurse and physician determine the degree of observation required to assure that the patient does not leave the unit without permission (15 minute checks or 1:1 observations). The same policy requires that, "If a patient is found to be "at risk" for self-harm, the registered nurse will initiate Constant Visual Observation until the physician has been consulted. If the patient is at "high risk" for self-harm, the registered nurse will initiate 1:1 observation of the patient and will consult the physician who will determine the need for further observations. A review of the Continuous Visual Observation section revealed: patients will be within visual observation of staff at all times. The patient's room door will remain open at all times and the precautions flow sheet will be used to document daily activities. A review of the 1:1 Observation section revealed that 1:1 Observation is defined as constant visual observation with a staff remaining in the same room with the patient at all times unless the physician specifies in order that the staff are to remain within arm's length, at which point staff maintain the above and remain within arm's length of the patient at all times."

2. A review of the ED Policy, "Standards of Care- Management of the Psychiatric and Baker Act Patient," policy #330206.0001, revised 1/09, revealed it is the facility's policy to "provide immediate safe and evidenced - based care for psychiatric/Baker Act patients." Under the section entitled, "High Risk Conditions," the ED (Emergency Department) physician will be notified immediately of all patients' presenting with a risk of harm to themselves or to others. Under the section of the policy entitled, "Safety" it is required that "upon arrival to the ED, the patient will be placed in a safe environment." The policy required that, if the patient is a danger to themselves or others, security will be called immediately. Side rails are required to be up at all times with the bed in the low position. The patient is not permitted to leave the ED except for diagnostic testing and/or treatment. If the patient needs continuous supervision, a sitter is to be obtained. The policy also required that the patient is to be "monitored continuously."

3. The facility's policy "Care of the Baker Act Patient," #850120.00, effective 4/10, required that, "One to One observation is determined based on an Interdisciplinary Clinical Assessment of the patient, unless ordered by a Physician."

4. A review of patient #1's clinical record facesheet revealed the patient presented to the ED per ambulance on 8/21/10 at 1:39 a.m. The patient had been assigned a level 2 acuity level, which is considered unstable per the triage documentation. A review of the ED nursing documentation for 8/21/10 at 1:39 a.m. revealed the patient had told an adult child that s/he was going to try to kill self again. The patient's chief complaint was an intentional overdose. A review of the ED physician's orders revealed an order for Suicide Precautions and Elopement Precautions on 8/21/10 at 1:37 a.m. These orders were reviewed and accepted by the ED Registered Nurse on 8/21/10 at 2:00 a.m. There was no documentation of Suicide and/or Elopement Precautions initiated by the staff even after the patient had verbalized a second time on 8/21/10 at 1:42 p.m. that s/he was going to kill self.

The facility failed to obtain an Interdisciplinary Clinical Assessment to determine the patient's need for one to one monitoring. The ED Nursing Staff failed to implement the ED Physician's orders for Suicide/ Elopement Precautions. The patient was not monitored continuously for self harm activities. There was no documentation that security was notified or a sitter was obtained to assist in the monitoring of the patient. The ED staff failed to follow the Standards of Care for a suicidal patient being held until placement was available on a secure unit and failed to provide an immediate safe environment for the patient. This practice placed the suicidal patient and surrounding ED patients at serious risk of harm to themselves and others. At no time did the ED staff integrate the Senior Behavioral Health Unit's Observations and Precautions for a Suicidal Baker Act patient, by placing the patient on continuous observations and 15 minute checks. The lack of continuous monitoring allowed this patient ample access and time to act upon the threats s/he had already stated about attempting to kill self.

5. A review of patient #2's clinical record (facesheet) revealed the patient presented to the ED (Emergency Department) on 8/20/10 at 8:55 p.m. The patient stated s/he had felt suicidal for the past week and had taken pills on the previous Sunday being 8/15/10. The acuity level was listed at a level 2 acuity, which is considered as unstable. An Involuntary Florida Mental Health Act (Baker Act) was initiated by the emergency room physician on 8/21/10 at 1:10 a.m. for depression and suicidal ideations. A review of ED physician's orders revealed Suicide Precautions and Elopement Precautions were ordered for the patient on 8/20/10 at 9:01 p.m. The ED Registered Nurse reviewed and accepted the orders on 8/20/10 at 10:34 p.m. There was no documentation that suicide and/or elopement precautions were initiated by the staff, although it was documented the patient felt suicidal and had attempted suicide within the past 2 weeks.

The facility failed to obtain an Interdisciplinary Clinical Assessment to determine the patient's need for one to one monitoring. The ED Nursing Staff failed to implement the ED Physician's orders for Suicide/ Elopement Precautions. Additionally, the patient was not monitored continuously for self harm activities. There was no documentation that security was notified or a sitter was obtained to assist in the monitoring of the patient. The ED staff failed to follow the Standards of Care for a Florida Mental Health Act patient and to provide an immediate safe environment as well. This practice placed the suicidal patient and surrounding ED patients at risk of harm to themselves and others. At no time did the ED staff integrate the Senior Behavioral Health Unit's observations and precautions for a Suicidal patient, by placing the patient on continuous observations and 15 minute checks. The lack of monitoring for this patient allowed the patient ample time and access to attempt to harm self again.

6. A review of patient #3's clinical record (facesheet) revealed the patient presented to the ED on 8/22/10 9:16 p.m., for the chief complaint of wanting to kill self and receive help for his/her drug problem. The acuity level was entered as a level 2 which is listed as unstable. An involuntary Florida Mental Health Act (Baker Act) was initiated on 8/22/10 at 8:21 p.m., by the police department prior to the patient presenting to the emergency department. A review of the ED physician's orders revealed Suicide and Elopement Precautions were ordered on 8/22/10 at 9:18 p.m. These orders were reviewed and accepted by the ED Registered Nurse on 8/22/10 at 9:21 p.m. There was no documentation these orders were ever initiated by the staff, although the patient indicated s/he wanted to kill self.

The facility failed to obtain an Interdisciplinary Clinical Assessment to determine the patient's need for one to one monitoring. The ED Nursing Staff failed to implement the ED Physician's orders for Suicide/ Elopement Precautions. The patient was not monitored continuously for self harm activities. There was no documentation that security was notified or a sitter was obtained to assist in the monitoring of the patient. The ED staff failed to follow the Standards of Care for a involuntary Florida Mental Health Act patient and to provide an immediate safe environment for the patient. This placed the suicidal patient and the surrounding ED patients at risk harm to themselves and others. At no time did the ED staff integrate the Senior Behavioral Health Unit's observations and precautions for a suicidal patient, by placing the patient on continuous observations and 15 minute checks. The lack of continuous monitoring of this patient allowed the patient ample access and time to act upon the threat of killing self.

7. A review of patient #6's clinical record (facesheet) revealed the patient presented to the ED on 8/19/10 at 8:49 p.m., by ambulance. The patient stated s/he was assaulted by a stranger and sustained a laceration to the right side of the abdomen. An Involuntary Florida Mental Health Act (Baker Act) was initiated by the sheriff's department on 8/19/10 at 9:30 p.m., because the patient cut self with a razor in an attempt to falsify a robbery then stated s/he caused the injuries to relieve stress. A review of the ED physician's orders revealed Suicide and Elopement Precautions were ordered on 8/19/10 at 9:33 p.m. The ED Registered Nurse reviewed and accepted the orders on 8/21/10 at 11:39 a.m. There was no documentation these orders were ever initiated by the staff, although, the patient had sustained a self-inflicted laceration to the abdomen.

The facility failed to obtain an Interdisciplinary Clinical Assessment to determine the patient's need for one to one monitoring. The ED Nursing Staff failed to implement the ED Physician's orders for Suicide/ Elopement Precautions. The patient was not monitored continuously for self harm activities. There was no documentation that security was notified or a sitter was obtained to assist in the monitoring of the patient. The ED staff failed to follow the Standards of Care for a Baker Act patient and to provide an immediate safe environment for the patient. This practice and omissions placed the suicidal patient and surrounding ED patients at risk of harm to themselves and others. At no time did the ED staff integrate the Senior Behavioral Health Unit's observations and precautions for a suicidal patient, by placing the patient on continuous observations and 15 minute checks. The lack of continuous monitoring of the patient allowed the patient ample time and access to attempt to harm self again.

Based on record review, policy review and staff interview it was determined that the facility's Emergency Department medical staff failed to ensure compliance with facility policies governing (1) the use of restraints for one (#3) of six patients, (2) assessment and reassessment for six (#1,#2,#3,#4,#5,#6) of six sampled patients, (3) regarding the provision of a mental health evaluation for patients in the ED under the Baker Act for involuntary evaluation for five (#1,#2,#4,#5,#6) of six patients, (4) monitoring of patients under the Baker Act for five (#1.#2,#3,#5,#6) of six patients, (5) the items to be included on meal trays for patients at risk for self harm and (6) failed to establish policies and procedures for the implementation of suicide and elopement precautions, which were ordered for four (#1, #2,#3,#6) of six sampled patients. These practices do not ensure that patients with an emergency psychiatric condition receive all services needed in a safe and secure environment and does not ensure that changes in the patient's condition are identified to ensure appropriate interventions are implemented therefore placing any Baker Acted patient at risk of serious harm or death to self or others. These findings resulted in the determination of on-going Immediate Jeopardy.


Findings include:

1. The Florida Mental Health Act of 1971 (commonly known as the "Baker Act") is a Florida statute allowing for involuntary examination of an individual

The Baker Act allows for involuntary examination (what some call emergency or involuntary commitment). It can be initiated by judges, law enforcement officials, physicians. or mental health professionals. There must be evidence that the person

* has a mental illness (as defined in the Baker Act) and
* is a harm to self, harm to others, or self neglectful (as defined in the Baker Act)."

2. The facility's policy titled "Restraints and Seclusion" # 850011.003 revised 01/09, requires that all episodes of restraint require a physician's order. The facility's policy allows up to 12 hours to obtain the order, however, this is not in compliance with 42 CFR 482.13(e)(5), which requires the order be obtained immediately after the application of restraint. The policy also requires that the patient in restraint is to be assessed every 2 hours by the registered nurse responsible for the patient. Documentation of monitoring is to include:
proper size and fit of the restraint to prevent entanglement; strangulation and restriction of movement,: vascular constriction and skin irritation; eligibility for release or continued need of the restraint; exercise,repositioning and range of motion; addressing hydration, nourishment, hygiene and elimination needs;emotional support of the patient; assessment of the patient's level of distress; respirations and vital signs.
a. Review of the medical record of patient #4 revealed that the patient was placed in bilateral wrist restraint and a lap belt restraint at 2:00 p.m. on 9/9/10. The reason for initiation of restraint was not noted by the nurse. There was also no documentation of alternative measures prior to the initiation of the restraint. A nursing assessment documented at 2:15 p.m. noted the patient was alert and oriented. Review of nursing documentation revealed no assessment or monitoring of the required elements after the restraints were implemented until 9/9/10 at 7:30 p.m. At this time nursing documentation included the condition of skin, response to restraint and assessment of need to continue restraint, but failed to include correct fit of the restraint, exercise and repositioning of the patient, meeting hydration and nourishment needs, meeting of hygiene and elimination needs and the provision of emotional support and level of distress. The patient was assessed as being agitated, confused and disoriented. The Glasgow Coma Score was assessed as 12. This documentation demonstrated a decline in the patient's condition during the time restraints were in use and the patient was not monitored appropriately. There was no additional documentation of the restraint use after this time.

The patient was transferred from the ED to the senior behavioral care unit at 9:13 p.m. on 9/9/10. The patient was not assessed for any physical or emotional adverse effects of the use of the restraint for 4 hours. There was a documented decline in the patient's status during this time. In addition, there was no evidence that the basic needs of hydration, nourishment and elimination were met, nor that the patient received any emotional support.
b. Review of the physician orders revealed that the order for the restraint was entered by the physician at 6:57 p.m., while the medical record revealed the patient was restrained at 2:00 p.m. The physician order was received four hours and 57 minutes after the patient was placed in restraints. In addition, the type of restraint was not documented in the order. The physician indicated only "soft" restraint, but did not specify bilateral wrist or application of a lap belt.

3. The facility's policy titled "Assessment/Reassessment of the Patient Time Frames" #620124.003, last revised 8/10 was reviewed. The policy requires the initial assessment to be completed upon admission to the ED. Reassessments are to be completed a minimum of every 2 hours for critical and unstable patients and a minimum of every 4 hours for stable and routine patients. Vital signs are to be recorded every 1 hour and as necessary for critical and unstable patients and every 4 hours for stable and routine patient. The policy also requires an assessment to be completed within 30 minutes of the patient's transfer or discharge from the ED.
a. Review of the medical record for Patient # 1 revealed s/he was admitted to the facility's ED on 8/21/10 at 1:39 a.m. with the chief complaint of Xanax overdose. The Emergency Department Triage Form, printed 9/30/10 at 8:84 a.m., page 13 indicated the patient was assigned an acuity (triage level) "2- Unstable." The initial assessment was performed upon admission to the ED. A second nursing assessment was performed at 2:33 a.m. The patient was determined to be medically stable at 4:00 a.m. Which would now require assessments to be performed every 4 hours, per the ED policy and procedure. The next nursing assessment was performed at 8:09 a.m. on 8/21/10. This was 5 1/2 hours between assessments. No nursing assessments were performed after the assessment at 8:09 a.m. The patient remained in the ED until 10:53 p.m. on 8/23/10. This was a period of 62 hours without a documented nursing assessment. In addition, there was no assessment prior to the patient's being discharged.
b. Review of the medical record for Patient # 2 revealed s/he was admitted to the ED on 8/20/10 at 8:55 p.m. with the chief complaint of suicidal ideation. The patient was assigned an acuity (triage) level of "2- Unstable" per the Emergency Department Triage Form, printed 9/30/10, 8:50 a.m., page 11. The initial assessment was performed upon arrival to ED. The next assessment was performed at 9:27 p.m., 8/10/10. The patient was medically cleared on 8/21/10 at 4:00 a.m. by the ED physician. The ED policy and procedure requires unstable patients are reassessed every 2 hours. The next nursing assessment was performed on 8/21/10 at 8:54 a.m., which was 11 hours 27 minutes since the previous assessment. The patient was transferred to a psychiatric facility from the ED at 5:32 p.m. No nursing assessments had been performed from 8:54 a.m. to 5:32 p.m., an elapsed time of 8 hours 38 minutes. In addition, no assessment was performed, as required by the ED policy and procedure, within 30 minutes of transfer or discharge from the ED.
c. Review of medical records for Patient #3 revealed s/he was admitted to the facility's ED on 8/22/10 at 9:16 p.m. with the chief complaint of wishing to kill self and seeking help for a drug problem. The patient was assigned an acuity (triage) level of "2 - Unstable" on 8/22/10 at 21:16 per the Emergency Department Triage Form, page 11, printed on 9/30/10, 8:49 a.m. The nursing assessment was performed at 9:27 p.m. The patient should be assessed every 2 hours until determined to be stable per the ED policy and procedure. The were no documented assessments until 8:00 a.m. on 8/23/10. The patient was medically cleared by the ED physician at 1:30 a.m. The patient should be assessed every four hours per the ED policy and procedure. A total of 10.5 hours lapsed between nursing assessments. The patient was transferred to a psychiatric facility on 8/24/10 at 5:47 p.m. No nursing assessments were performed during the 33 hours from 8:00 a.m. On 8/23/10 and 5:47 p.m. on 8/24/20. In addition there was no assessment within 30 minutes of the patient's transfer from the ED.
d. Review of medical records for Patient #4 revealed s/he was admitted to the facility's ED on 9/9/10 at 1:38 p.m. with the diagnosis of schizophrenia and being non-verbal for 1 week, following discharge from the psychiatric unit. The patient was assigned an acuity (triage) level of "3-Urgent" per the Emergency Department Triage Form, page 10, printed 9/30/10 at 9:18 a.m. The initial nursing assessment was performed at 2:14 p.m. The nurse documented that the patient was alert and oriented at that time, however, restraints had been applied at 2:00 p.m. The next nursing assessment was at 7:28 p.m., which was 5 1/2 hours after the previous assessment. The nurse documented that the patient was disoriented and had a Glasgow coma score of 12. The patient had been in bilateral wrist restraint and lap belt restraint without any assessment for 5 1/2 hours, during which time the patient's mental status changed. The patient was transferred to the facility's psychiatric unit at 9:20 p.m. An assessment was documented at the time of transfer.
e. Review of medical records for Patient #5 revealed s/he was admitted to the facility's ED on 9/13/10 AT 6:11 p.m. The patients chief complaint was that s/he had not taken prescribed psychiatric medication for 2 days and wanted to hurt self. The patient was assigned an acuity (triage) level of "3-Urgent." The initial nursing assessment was performed at 6:11 p.m. on 9/13/10. Per the ED policy and procedure, the patient should be reassessed every 4 hours. The next nursing assessment was not performed until 10:04 a.m. on 9/14/10. A total of 16 hours had elapsed. The next assessment was performed at 9:00 p.m. on 9/14/10. A total of 11 hours elapsed between assessments. The patient was admitted to the facility's behavioral health unit at 11:50 p.m. In addition, there was no assessment within 30 minutes of the time if transfer.
f. Review of medical records for Patient #6 revealed s/he was admitted to the facility on 8/19/10 at 8:49 p.m. with the initial chief complaint of assault resulting in a laceration of the abdomen. Soon after arrival, it was learned that the wound was self inflicted. The patient was assigned an acuity (triage) level of "4-Stable" per the Emergency Department Triage Form, page 17, printed 9/30/10 at 9:01 a.m. The initial nursing assessment was performed at 8:53 p.m. The next assessment was performed at 7:05 p.m. on 8/20/10. A total of 11 hours had elapsed. The next nursing assessment was performed at 11:06 a.m. on 8/21/10. A total of 28 hours elapsed. No other nursing assessment were documented during the patient's stay in the ED. The patient was transferred to another facility on 8/22/10 on 8/22/10 at 2:13 p.m. A total of 27 hours elapsed from the last assessment until the patient left the ED. The patient was in the ED for 3 days and had only three nursing assessment performed. During that time the abdominal wound was assessed 2 times. The wound was not assessed during the last 27 hours the patient was in the ED. Any change in the patient's status regarding the wound would not have been noted.

4. The facility's policy "Care of the Baker Act Patient" #820120.000, effective date 04/10 requires that the patient be cleared medically before the patient is transferred to a receiving facility. It further requires that once the patient is medically cleared, the patient must be evaluated for mental health services within 12 hours.
a. A review of patient #1's clinical record revealed the patient presented to the emergency department per ambulance on 8/21/10 at 1:42 a.m. under the Baker Act. The patient's chief complaint was an intentional overdose. The patient was medically cleared by the emergency room physician on 8/21/10 at 4:00 a.m. This Baker Act was rescinded on 8/23/10 at 10:30 p.m. by the facility's psychiatrist during the Mental Health Services Evaluation after the patient had been in the emergency department for 64 hours.
b. A review of patient #2's clinical record revealed the patient presented to the emergency department on 8/20/10 at 8:55 p.m. The patient had stated s/he had felt suicidal for the past week and had taken pills on the previous Sunday, 8/15/10. The triage nurse reported the patient was tearful in the triage area. The acuity level was listed at a level 2 acuity, which is considered as unstable. An Involuntary Baker Act was initiated by the emergency room physician on 8/21/10 at 1:10 a.m. for Depression and suicidal ideations. The patient was medically cleared on 8/21/10 at 1:20 a.m. The patient was transferred at 5:32 p.m., on 8/21/10. A review of the clinical record did not reveal any evidence that a Mental Health service assessment was completed from the time of the patient being medically cleared at 1:20 a.m. to the time the patient was transferred at 5:32 p.m., for a total of 16 hours after the patient was medically cleared.
c. A review of patient #3's clinical record revealed the patient presented to the emergency department on 8/22/10 at 9:16 p.m.., for the chief complaint of wanting to kill self and receive help for his/her drug problem. The acuity level was entered as a level 2 which is listed as unstable. An Involuntary Baker Act was initiated on 8/22/10 at 8:21 p.m., by the police department prior to the patient presenting to the emergency department. The patient was medically cleared by the emergency room physician at 1:30 a.m., on 8/23/10. The patient was transferred to an acute care psychiatric facility on 8/24/10 at 5:43. A review of the clinical record did not reveal any evidence that a Mental Health service assessment was completed from the time of the patient being medically cleared on 8/23/10 at 1; 30 a.m. to the time the patient was transferred on 8/24/10 at 5:43 p.m.., for a total of 40 hours after the patient was medically cleared.
d. A review of patient #5's clinical record revealed the patient presented to the emergency department on 9/13/10 at 6:03 p.m. per ambulance. The patient's chief complaint was s/he had not taken home medications in the last 2 days and also told significant other s/he wanted to hurt self. The significant other called 911. An Involuntary Baker Act was initiated on 9/13/10, no time indicated. The patient was medically cleared on 9/13/10 at 1:00 p.m., by the emergency room physician. The patient was admitted to the facility's behavioral health unit on 9/14/10 at 11:50 p.m., 22 hours after the patient was medically cleared, with no mental health services assessment completed while in the emergency department.
e. A review of patient #6's clinical record revealed the patient presented to the emergency department on 8/19/10 at 8:49 p.m.., per ambulance. The patient alleged that s/he was assaulted by a stranger and sustained a laceration to the right side of the abdomen. An Involuntary Baker Act was initiated by the sheriff's department on 8/19/10 at 9:30 p.m., when it was learned that s/he cut self with a razor in an attempt to falsify a robbery then stated s/he caused the injuries to relieve stress. The patient was medically cleared by the emergency room physician on 8/19/10 at 11:00 p.m. A review of the clinical record did not reveal any evidence that a Mental Health Service evaluation was completed from the time the patient was determined to be medically cleared on 8/19/10 at 11:00 p.m. to the time the patient was transferred on 8/22/10 at 2:40 p.m., for a total of 39 hours.

5. The facility's policy "Standards of Care - Management of Psychiatric and Baker Act Patient" # 330206.0001 last reviewed 1/09 requires that the a sitter will be provided if the patient requires constant observation. It further requires that the patient be monitored continuously. Patients #1,#2,#3,#5,#6 were admitted with suicide attempt, suicide ideation or threatening to hurt self. There was no evidence of evaluation of the need to provide a sitter for the patient's care. In addition there was no documentation of continuous monitoring of the patients.

During interview on 9/29/10 at approximately 3:00 p.m. with the Director of the ED, the director stated that she tries to place a sitter with the patient who is admitted under the Baker Act whenever possible. The Documentation on the Baker Act form dated 8/21/10 for patient #1, dated 8/20/10 for patient #2, dated 8/22/10 fr patient #3, dated 9/13/10 for patient #5, and dated 8/19/10 for patient #6 indicated the patient was a danger to self or others. The Director confirmed there was no protocol to determine the need for use of a sitter for continuous monitoring.

The interim nursing manager for the ED was interview on 9/30/10 at approximately 2 p.m. She indicated that they rely on ED staff being aware of which patients are under the Baker Act and monitor their activity, however, no one person is assigned to perform this monitoring. The ED director confirmed that patient #1 was able to leave both the ED and the hospital building undetected on 8/21/10.

6. During interview on 9/29/10 at approximately 1:00 p.m., the Director of Clinical Informatics and Clinical Compliance confirmed that there are no policies or protocols for the implementation of Suicide and Elopement precautions. During interview with the ED interim nursing manager on 9/30/10 at approximately 2:00 p.m., the manager stated that an order for suicide precautions and elopement precautions would have to be clarified since there are no protocols for such precautions. The nurse manger stated she had not asked for such clarification.
a. Patient #1 was admitted to the facility on 8/21/10 following a suicide attempt. The physician ordered Elopement and Suicide precautions. Review of nursing documentation revealed no evidence that such precautions were implemented or that the order was clarified.
During interview on 9/29/10 at approximately 3:00 p.m. The ED nursing director confirmed that patient had been able to leave the ED and hospital building on 8/21/10. No change in monitoring is evident in the nursing documentation. In addition, the nurse documented that the patient was overheard telling a family member that s/he intended to try to kill self again. No nursing intervention was documented regarding this. There was also documentation that the patient was permitted to be ambulatory in the ED corridors independently, in spite of the fact that the physician had ordered the patient was to stay in her/his own room and not permitted to roam in the corridors.
b. Patient #2 was admitted to the facility's ED on 8/20/10 with suicidal ideation and history of suicide attempt. The ED physician ordered Suicide Precautions and Elopement precautions. There was no documentation of implementation of such precautions. There was no evidence that the nurse attempted to clarify the order.
c. Patient #3 was admitted to the facility on 8/22/10 with suicide ideation and threat. The physician ordered Elopement and Suicide precautions. Review of nursing documentation revealed no evidence that any precautions were implemented or that the order was clarified.
d. Patient #6 was admitted to the facility on 8/18/10 with a self inflicted abdominal wound. Nursing documentation revealed that the patient had frequent thoughts of attempting suicide, had the means, had a plan and had prior attempt. Suicide and Elopement precautions were ordered by the ED physician. There was no evidence in the medical record that any precautions were implemented or that the order was clarified.

7. The Director of Clinical Informatics and Clinical Compliance and the Physician Liaison were in attendance during the record reviews documented above and confirmed the findings documented.

8. The facility's policy "Care of the Baker Act Patient" #850120.000 dated 4/10, requires that the patient held under the Baker Act are to have a security tray from the dietary department. The policy also requires that only a plastic spoon is to supplied on the tray. After conferring with the dietary department on 9/30/10 at approximately 2:00 p.m., the Chief Nursing Officer (CNO) stated that knifes and forks are provided on the security tray. The CNO confirmed there is a disconnect between the administrative policy on care of the Baker Act patient and definition of security tray by the dietary department. This does not insure safety for the patient at risk for self harm. Review of Risk Management documentation revealed that patient #6 had been found with a plastic knife in her/his possession. The patient had a history of self harm and evidence of self inflicted wound.

Based on record review and staff interviews, it was determined that the facility failed to have sufficient staff to appropriately monitor the patients in the Emergency Department (ED) who were being held under the Baker Act for an involuntary psychiatric evaluation for five (#1, #2, #3, #5, #6) of six sampled patiens and potentially any psychiatric patient presenting to the ED. This practice results in the inability to insure a safe environment for the patient, who by definition from the Baker Act are a danger to self or to others posing an immediate threat to the safety of the patients.

Findings include:

1. During an interview with the Nursing Director of the ED on 9/29/10 at approximately 3:00 p.m., the Director stated that she attempts to place a sitter with the Baker Act patients whenever possible. The interview revealed due to the lack of trained sitters this was not always possible.

2. Patient #1 presented to the ED under the Baker Act on 8/21/10 at 1:30 a.m.. The triage record indicated the patient had taken an intentional overdose of Xanax. The ED physician documented an impression of a "suicide attempt". The documentation noted the patient's mood was "depressed". The physician's order dated 8/21/10 at 1:37 a.m. and 1:38 a.m. instructed for suicide and elopement precautions, that the patient was to remain in her/his ED room and not be permitted to roam in the hallways. Review of nursing documentation revealed no evidence the suicide or elopement precautions were implemented or that a sitter had been provided from admission to discharge. Nursing documentation dated 8/22/10 at 8:16 a.m. and 7:52 p.m. indicated that the patient was ambulating in the hallway, independently. The patient was in the ED from 8/21/10 at 1:39 a.m. until 8/23/10 at 10:53 p.m. for a total sixty eight hours.

Interview with the ED Director on 9/29/10 at 3:00 p.m. revealed that the patient would have been able to exit the ED and the hospital building on 8/21/10. There was no evidence in the medical record that any additional monitoring was implemented following the elopement.

3. Patient #2 presented to the ED under the Baker Act on 8/20/10 8:55 p.m. The patient indicated s/he had taken several pills on 8/15/10 in a suicide attempt. The nurse documented the patient was suicidal and tearful. The ED physician's impression was suicidal ideation. The ED physician ordered on 8/20/10 at 9:01 p.m. suicide and elopement precautions. Review of nursing documentation revealed no evidence that the precautions had been implemented or that a sitter had been provided from admission to discharge. The patient was in the ED from 8/20/10 at 8:55 p.m. until 8/21/10 at 5:24 p.m., for a length of stay of twenty hours.

4. Patient #3 presented to the ED on 8/22/10 at 9:16 p.m. under the Baker Act. Review of the Baker Act form showed the patient stated s/he wanted to kill self. The ED physician's impression was suicidal ideation and substance abuse. The ED physician ordered on 8/22/10 at 9:18 p.m. suicide and elopement precautions. There was no evidence in nursing documentation that the ordered precautions were implemented or that a sitter was provided from admission to discharge. The patient was in the ED from 8/22/10 at 9:16 p.m. until 8/24/10 at 5:47 p.m., for a length of stay of forty four hours.

5. Patient #5 presented to the ED on 9/13/10 at 6:11 p.m. via ambulance. Documentation by the Emergency Medical Service personnel indicated that the patient had told a significant other that s/he wanted to hurt self. The ED physician's impression was that the patient was suicidal and the Baker Act was initiated. Nursing staff documented the patient was suicidal. There was no indication in the medical record that the patient was placed on suicide watch or that a sitter was provided. The patient was in the ED from 9/13/10 at 6:11 p.m. until 9/13/10 at 11:50 p.m., for a length of stay of five and one half hour hours.

6. Patient #6 presented to the ED 8/19/10 at 8:49 p.m. with a chief complaint of having been assaulted, resulting in a laceration of the abdomen, which required sutures and staples to close. During the Medical Screening Examination, the physician learned that the patient's injury was self inflicted. The ED physician documented that the patient was Suicidal and in need of an emergency psychological evaluation. Suicide and elopement precautions were ordered by the physician on 8/19/20 at 8:33 p.m. Nursing documentation on 8/21/10 indicated that the patient had frequent suicidal thoughts, had a plan and the means to act on the plan. The note indicated that the patient had prior suicide attempts. Review of nursing documentation revealed no evidence that suicide or elopement precautions had been implemented or that a sitter had been provided from admission to discharge. Nursing documentation revealed that the patient was ambulating in the hallways on 8/22/10 at 8:14 a.m. The patient was in the ED from 8/19/10 at 8:49 p.m. until 8/22/10 at 2:29 p.m., for a length of stay of sixty five and one half hours hours.

7. The Director Clinical Informatics and Clinical Compliance and the Physician Liaison were in attendance during the record reviews documented above and confirmed the documented findings.

8. During interview on 9/29/10 at approximately 3:30 p.m. the Interim Nursing Manager of the ED indicated a nursing assistant had been working the day shift on 8/21/10 and had been providing sitter service. The interview revealed day shift is from 7:00 a.m. to 7:00 p.m. The interview noted the the Interim Manager of the ED was not able to say if the nursing assistant was there for the twelve hour shift, a part of the twelve hours shift, or what assignment the nursing assistant had. Patients #1, #2, and #6 presented to the ED on 8/21/10. There was no documentation available that indicated which if any of the patients were assigned to sitter.

9. During tour of the ED on 9/29/10 at approximately 3:00 p.m. four ED exits were observed. Three of the four exits had double doors that swing open with key pad locks. The fourth exit was the ambulance exit, which has sliding glass doors that are opened by a key pad lock. The doors that lead from the registration area into the ED were observed opening and closing. There was a 30 second delay in closing. This could allow a patient to exit from the ED behind a staff person into the registration area. The area was located in a corridor that leads to the main hospital. The door has a push plate opening mechanism with no lock. The registration person on duty at the time of the tour was interviewed. She stated that the registration desk was not manned at all times. The interview revealed that when the ED was busy, it would be left unmanned for hours at a time. Therefore a patient could easily walk out into the main hospital undetected. Observation during the tour revealed an elevator, in the ED on the back corridor away from the nurses' station, that was accessible to anyone in the area. The elevator was entered and taken to the second floor cardiac catheterization department. There was an unlocked exit that leads to the outside physician parking lot. Interview with the Director of the ED on 9/29/10 at approximately 3:00 p.m. revealed she had no knowledge of the elevator leading to the outside.

Observation on 9/30/10 at approximately 1:00 p.m. reveled a set of doors that also had a 30 second delay that would allow a patient to exit behind a staff person. This set of doors was located in the back corridor, away from the nurses' station. When opened the doors allow access to the main hospital with only a short distance to an unlocked exit. Therefore, suicidal patients with no close observation in place were able to exit the ED, have access to the main hospital, and access to the outside. This creates an unsafe situation for a patient with an emergency psychiatric condition and suicidal or homicidal ideation.

10. During the tour on 9/30/10 at approximately 1:00 p.m. unsafe conditions were identified. In an ED corridor two carts were found unattended and accessible to anyone who would pass by. The first cart was labeled "suture". The cart had no locking mechanism. The top drawer was opened and several packaged disposable scalpels and needles were found. The second cart was labeled "ortho". A large pair of scissors was noted to be in a metal holder on the side of the cart. The cart did not have a locking mechanism. The top drawer contained two pairs of scissors. The Director of Clinical Informatics and Clinical Compliance, who was in attendance during the tour confirmed the items should be secured. The soiled utility room was observed to be propped open. Several containers of cleaning and disinfection chemicals were observed in the room. The room was observed also during the tour on 9/29/10 and was noted to be propped open at that time. These findings provide evidence that the psychiatric patient with intent to harm her/himself or others would have access to items that could be used for such purpose.

11. During interview with the Interim Nurse Manager of the ED on 9/30/10 at approximately 1:00 p.m. revealed the staff nurse would be assigned a total of 4 patients. Therefore it is not possible to ensure that a suicidal patient could be monitored at all times by the assigned nurse and therefore the patient's safety is at risk.