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Based on observation, interviews, medical record and policy review, the facility failed to ensure two patients had completed and stabilized psychiatric (#22) and medical treatment (#35) before their disposition.

Patient #22

The Clinical Report- Nurses for Patient #22 indicated the patient arrived by ambulance on 6/4/12 at 10:50 PM and was triaged at 11:09 PM at an acuity level 2.

The Clinical Report-Nurses for Patient #22 dated at 11:18 PM, documented,"...The patient exhibited bizarre behavior. Patient #22 was found at (name of casino) and called 911. The patient indicated someone was trying to kidnap her and her daughter..."
The notes indicated Patient #22 pulled the fire alarm at the casino. Patient #22 then ran from the police with her six year old daughter. The notes documented Patient #22 told the EMS (Emergency Medical Services) her daughter was poisoned by the child's grandfather.

The Clinical Report-Nurses for Patient #22 dated 6/4/12 at 11:18 PM revealed the following:

- "...EMS unable to obtain vital, IV (intravenous) BS (blood sugar ?) due to patient paranoia.

- Abuse history: patient reports, physical abuse by significant other and parent against patient and patient's daughter ED (Emergency Room) physician notified and police.

- Security at bedside for 4 point restraints. Nurse took belongings away from patient and put at nurses station. Patient was changed into blue scrubs.

- 23:25 (11:25 PM) - INTERVENTIONS ID (identification) and allergy band on patient. To treatment room.

- PHYSICAL ASSESSMENT 23:26 (11:26 PM) 06/04/2012. To room via stretcher. Alert. Affect appears normal. Patient appeared calm and cooperative. Patient appears well-nourished and unkempt. Respirations not labored. Breath sound within normal limits. Abdomen soft and nontender. Bowel sounds within normal limits. Capillary refill less than 2 seconds. Skin warm and dry skin within normal limits.

- NURSE PROGRESS NOTES 23:27 (11:27 PM) 06/04/2012. Patient identifiers checked. The initial plan of care for this patient had been created. Pulse oximeter and NIBP monitor placed on patient; monitor alarms on. (PATIENT IN FOUR POINT RESTRAINTS BY SECURITY). Call light in reach. Side rails up x (times) 2. Bed placed in lowest position. Breaks of bed on.

- 23:39 (11:39 PM) IV (intravenous) access: site #1 left antecubital space, 18g (gauge) angiocath (catheter), with aseptic technique and good blood return; one attempt. Blood drawn. Labeled in presence of patient and sent to lab (laboratory). Lock flushed with 10 ml (milliliters) of saline (child protective services at bedside).

- 00:14 (12:14 AM) 6/5/2012 (Patient removed restraints, nurse went to get medications for patient and patient left the ED)..."

A Nurses Note dated 6/5/12 at 12:19 AM documented, "Missing from room 23 seen running out of the fire exit a few minutes earlier by a visitor."

An Initial Order Form (first 24 hours) Non-Violent/Non-Self Destructive Restraint Order dated 6/4/12 at 11:09 PM, for Patient #22 was written and signed by a physician.
The restraint justification box on the form documented, "...Impulsive or unpredictable behavior i.e. traumatic brain injury... The restraint limit was for 24 hours. The restraint devices included full siderails. In the box that indicated check which device in use the box on the form checked was, bilateral wrist restraints..."

On 6/4/12 at 23:12 (11:12 PM), The Clinical Report-Physicians/Mid levels for Patient #22 indicated the following:

"...Arrived by ambulance. Historian patient and EMS personnel.

- History of present illness-Chief Complaint-BEHAVIOR CHANGE. This started today.

- The patient has exhibited a behavioral change. (Pt. (patient) called 911 at (name of casino) and presented bizarre behavior trying to run from police and stating people are after her and her daughter. Pt. states her father hired an assassin to kill her). She has anxiety. Has exhibited unusual behavior and been paranoid. The patient has had persecution delusions. No suicidal attempts.

- The symptoms are described as moderate. No injury present.

- Similar symptoms previously: none.

- Past History-See nurses notes unknown. Unobtainable due to patient's uncooperativeness.

- Social history-Smoker current status unknown.

- Physical exam: Psych/Neuro (psychiatric/neurology) Oriented x 3 Appears to have persecution delusions. Denies suicidal thoughts. The patient does not feel treatment is necessary. No motor deficit. No sensory deficit.

- PROGRESS AND PROCEDURES
Course of care: BP (blood pressure) 136/82 lying down r (right) arm auto. (automatic) HR: (heart rate) 119. RR: (respiratory rate) 20. Temp (temperature) 98.0 oral. 02 (oxygen) saturation on room air 100%.

- 00:14 (12:14 AM) Ativan IV 2 mg. (milligram) Haldol IV 5 mg. Benadryl IV 50 mg

- 1:02 AM- Patient removed 4-pt. (point) restraints (restraints on wrists and ankles) and eloped from the ED.

- pt. delusional, abnormal thought pattern. Seems very nervous as well. Will uphold L2K (Legal 2000-The State of Nevada's legal civil commitment).

- pt. eloped prior to being able to fill out L2K.

- Transfer orders written.

- Disposition: Transfer to DOU (Discharge Observation Unit for psychiatric patients awaiting completion of mental health assessments). Condition stable

CLINICAL IMPRESSION
Acute psychosis with paranoia..."

The Toxicology lab results of Patient #22 collected at 6/4/2012 at 23:37 (11:37 PM) and message received as final results on 6/5/12 at 2:05 AM indicated, positive for Amphetamine/Methamphetamine and Cannabinoids.

The T-System Order Summary-Order Sheet for Patient #22 dated 6/4/12 at 22:31 (11:31 PM) documented the patient was placed on suicide precautions.

Patient #22's Suicide Risk Factor Scale and Observation Intensity Trigger dated 6/4/12 at 23:09 (11:09 PM) was assessed at an "11" (4-11 moderate risk precautions) which required hourly welfare checks. The form was incomplete, not all the risk factors were filled out.

The Precaution Monitoring Flow Sheet (11 PM-7 AM) dated 6/4/12 to 6/5/12, for Patient #22 indicated the following:

Visual Appearance: Behavior
2315 (11:15 PM) WORRIED ANXIOUS
2330 (11:30 PM) WORRIED ANXIOUS
2345 (11:45 PM) WORRIED ANXIOUS
0000 (12:00 AM) WORRIED ANXIOUS
0015 (12:15 AM) WORRIED ANXIOUS

Patient #22 was listed as being in room 23. The Registered Nurse signed her initials after each entry in the visual appearance/anxious boxes.

On 6/21/12, review of the ED log dated 6/4/12, indicated Patient #22 was placed in the mini DOU.

On 6/21/12 in the afternoon, the Manager of Emergency Services indicated the mini DOU was an area in the ED with six beds where psychiatric patients were placed when there was no room in the DOU. There was one Registered Nurse (RN) for four patients and a RN and a Certified Nurses Assistant for six patients. The expectations for observation of the patients were the same as the DOU. which included continuous monitoring.

On 6/22/12 in the afternoon, the Director of the ED indicated Patient #22 was on a gurney located on Hall 10 (in the ED hallway between room 39 and the ED anteroom). They were waiting to move the patient into a room. Patient #22 had changed into blue scrubs ( colors used for psychiatric patients) and hospital socks.
The Director of the ED indicated Patient #22 was transferred to Room 23 due to the DOU and the mini DOU were filled on 6/4/12.
The Director of the ED indicated there was no policy for the mini DOU.
The Director of the ED indicated Patient #22 was not on a one on one. The Director of the ED indicated Patient #22 was on every 15 minute checks and visual checks.

Room 23 was observed on 6/22/12 in the afternoon, the room consisted of one bed. There were approximately 27 steps from room 23 to the fire exit which led out to the area where the ambulances parked. The fire door was on a delayed alarm.

On 6/22/12 in the afternoon, The Manager of Public Safety explained the procedure when a patient who was unstable eloped. When an adult patient eloped a call was placed to security to inform them a patient was missing. A copy of the facesheet was given to security in order to assess if the patient's family k