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Based on the findings at A2407 the facility failed to ensure compliance with CFR 489.24.


26907

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 knows the whereabouts of the patient. If security was unable to find the patient the police department was notified and it was broadcast to the police officers to see if they were able to find the patient.
The Manager of Public Safety indicated if a patient eloped with AMS (altered mental status or was on an L2K, then they would call a "Code Walker". This would be announced over the call system of the facility and the Public Safety department would give a description to all employees who had the responsibility to look for the patient.

On 6/22/12 in the afternoon the Manager of Public Safety indicated an adult elopement procedure was followed in order to find Patient #22.

The Manager of Public Safety indicated Patient #22 was not found. The patient's six year old daughter who was placed in the pediatric ED was removed by Child Protective Services on 6/5/12.

On 6/22/12 in the afternoon, Security Officer #1 indicated he placed the four point soft restraints on Patient #22. The Officer indicated Patient #22 was a thin small person who weighed about 90 pounds. The officer indicated he did not want to put the restraints on too tight, he could understand how Patient #22 might have removed them. He indicated Patient #22 was more worried about her computer that was confiscated than anything else.

Policy #EDADM11-EMERGENCY DEPARTMENT-THE DIFFICULT PATIENT
"...Purpose
To provide guidelines for the management of the patients who may be manifesting behaviors due to the influence of alcohol, drugs or emotional problems.
Scope
Adult Emergency Department
Policy
A. Patients who may be manifesting behaviors due to the influence of alcohol, drugs or emotional problems will be treated with care and dignity in a safe secure environment.
1. A suicide risk assessment and a 15 minute checklist are required at the time of arrival to the Emergency Department (ED).
B. All patients will be triaged and assigned a room in accordance with patient care requirements and established policy.
C. Should restraints be necessary, they will be applied by the Public Safety staff and in accordance with the hospital policy, using the least restrictive method of restraint to maintain safety of the patient and others with stretcher/gurney siderails raised.
F. Patients who are placed on legal hold status (aka L2K) may have specialized care to maintain their safety and dignity:
1. All patient belongings are secured and stored by Public Safety staff unit.
2. after the patient is deemed "medically stable" by the attending physician, the patient may be held in a separate locked discharged observation unit pending completion of a mental health assessment.

In summary:

-On 6/4/12 at 10:50 PM Patient #22 arrived by ambulance to the Emergency Department, the patient was triaged at 11:09 PM and given an acuity level of 2.
-Patient #22 was seen by the Emergency Department physician at 11:12 PM and diagnosed with paranoid and persecutory delusions.
-The DOU and mini DOU were full and Patient #22 was first placed in a hall bed, then transferred to room 23 in the ED.
-Patient #22 was placed on a monitor with alarms, a pulse oximeter and an IV was started. Patient #22 was placed on four point restraints by security.
-Patient #22 was given a suicide risk assessment and scored an "11" (moderate risk) and was placed on suicide risk.
-Patient #22 had an order for Ativan IV 2 mg. (milligram) Haldol IV 5 mg. Benadryl IV 50 mg. The medication was not given.
-Patient #22 removed the four point restraints and eloped while the nurse went to get the medications.
-There was no documentation whether Patient #22 took out the IV before she eloped. -- -Patient #22 left in blue paper scrubs and hospital socks.
-The physician was unable to complete the papers for the L2K since the patient eloped.
-Patient #22's toxicology report came back positive for Amphetamine/Methamphetamine and Cannabinoids.
-The facility did follow the adult elopement procedure to find Patient #22. The patient was not found.
-Patient #22 eloped without a psychiatric stabilization screening.

Patient #35

Patient #35 was triaged in the ED on 6/2/12 at 20:57 (8:57 PM) at an acuity level of 3. Patient #35's chief complaint was abdominal pain and nausea. The patient's vital signs were taken and a sepsis screen was performed and was negative.
Patient #35 had a documented pain level at 10/10.

The Clinical Report-Nurses dated 6/2/12 at 8:57 PM documented, "...History onset x 3 hours. PAST MEDICAL HX (history) negative. SURGICAL HX: No history of previous surgery. ADDITIONAL PROBLEMS: No known problems. INTERVENTIONS: ID allergy band on patient. Fall risk assessment completed per protocol. Risk factors identified include severe pain. Fall interventions initiated. Patient identified as a fall risk by ID band. To treatment room--21:03 (9:03 PM).

Nursing Progress Notes IV start unsuccessful, site #1 left hand 20 gauge angiocath (catheter), using a topical anesthetic, with aseptic technique; one attempt. Blood drawn: rainbow set. Labeled in presence of of the patient and sent to lab. Lock flushed with 10 millimeters normal saline.--21:10 (9:10 PM).
(given specimen cup to provide urine specimen states cannot give urine at this time)--21:12 (9:12 PM).

21:48 (9:48 PM) 6/2/12. (FAMILY CAME TO WINDOW, STATES PT. IN A LOT OF PAIN, FAMILY ADV (advised) WILL GET ROOM AS SOON AS POSSIBLE, NOT TOO LONG OF A WAIT. FAMILY CAME TO WINDOW A SECOND TIME STATING, "I NEED HELP MY HUSBAND IS IN A LOT OF PAIN" ADV SOON AS POSSIBLE. PT. SEEN LEANING ON FAMILY WALKING TOWARDS ER DOOR, TRIAGE RNS ADV PT IS LEAVING AND HAS IV IN HIS HAND. (Licensed Nurse #1) WENT OUTSIDE TO REMOVE PT'S IV AS PT GETTING INTO CAR, PT DID NOT HAVE A LONG WAIT BUT LEFT ANYWAY--21:57 (9:57 PM)
(RECEIVED RESULT OF CT (Computerized Tomography) SCAN AT 21:54 (9:54 PM). FAMILY LEFT WITHOUT PATIENT NOTIFYING NURSES. SEE ABOVE NOTE. ATTEMPTED TO CALL PT WITH NUMBER LISTED ON FACESHEET. NO ANSWER.--22:02 (10:02 PM)

DISPOSITION/DISCHARGE
01:21 (1:21 AM) 6/3/12. BP not taken due to pt not present:0 HR:0 RR:0 temp:0..02 saturation:0 Condition at departure: unchanged and critical. Patient reports a pain level on departure at 10/10. The goals identified in the patient's plan of care were partially met. The following issues were addressed: language and cultural issues, psychosocial issues and educational issues. All aspect of the patient's plan of care were not met because the patient left the emergency department against advice accompanied by a family member. The patient appears to be alert, oriented x 4 and coherent. The patient appears to be in distress. The patient did not notify the ED staff prior to leaving the department.. Notified ED physician and charge nurse of departure. Pt. left without signing form prior to leaving. The patient left the Emergency department carried and via private vehicle. (PT'S FAMILY WALKED PT OUT, ONE ON EACH SIDE WITH PT'S ARMS OVER SHOULDERS). Departure time: 2150 (9:50 PM) June 02 2012..."

The CT scan performed on Patient #35 on 6/2/12 revealed the patient had acute appendicitis with perforation. No abscess and a small shrunken non functioning left kidney.

Patient #35's lab work revealed a white blood cell count of 17.49 (normal 3.91-9.68).

On 6/22/12 at 2:45 PM, Licensed Nurse (LN) #1 indicated during a telephone conversation it was early evening when the Security Guard (did not remember his name) told LN #1, Patient #35 was in the driveway and still had the IV. The family of Patient #35 said they were taking him somewhere else. LN #1 indicated the family said the ED was not doing anything for the patient. The family indicated they had been up to the window two or three times. LN #1 indicated she removed the IV and placed a bandage on Patient #35 while he sat in the car.

On 6/22/12 in the afternoon, the Director of the ED indicated Patient #35 was in the waiting room then went to imaging and had the CT scan performed. The Director of ED indicated she was aware Patient #35 went AMA (Against Medical Advice). The Director of the ED indicated she personally called the number on the facesheet of Patient #35. The Director indicated a female answered the telephone and the Director told the female Patient #35 needed to go to the hospital.

On 6/22/12 in the afternoon, the ED Manager, indicated the Nurse Practitioner (NP) did a RME (Rapid Medical Examine) at 21:03 (9:03 PM). The Manager indicated the NP did not order pain medication. The Manager indicated the patient could have asked for something for pain when Patient #35 went back into the waiting room. The Manager indicated pain was subjective, sometimes a "10" was a "3".

On 6/22/12 in the morning, the telephone number on facesheet of Patient #35 was called. A female answered the telephone and indicated she did not speak English. The female put a young boy on the telephone. He interpreted what the female said. He indicated the family of Patient #35 took him right to Hospital B. The boy indicated Patient #35 had surgery at Hospital B and was doing fine.

Emergency Departmetn Pain Management Policy dated 05/2011 (#EDEMS04) documented the following:
"...Purpose: This policy will assure that all patients presenting to the (name of hospital) Emergency Department will be objectively evaluated and appropriately treated for pain while minimizing hte potential for divesion and bsue of narcotic pain medications...

Principles: A. Pain is the primary reason patients come to the emergency department. Many medical and traumatic conditions cause pain. The role of the health care provider is to assess the pain, determine the cause, and provide appropriate treatment...
B. Patient presenting to the (name of hospital) Emergency Department will be evaluated for pain using one of the following objective scoring systems: 1. Nurmerical Score (0-10) and 2. Visual Analog Score...
C. Following triage, all patients will receive a Rapid Medical Evaluation (RME) and appropriate pain management will be provided based upon the practitioner's assessment...

Assessing Pain: pain is a subjective complaint. However, it can be objectively evaluated with various pain scoring systems. At (name of hospital) we use the 0-10 scoring system where "0" represents the patient being pain free and "10" being the worst pain possible.

The policy included a, "Wong -Baker Faces Pain Rating Scale" and pain at a rating of "10" had a face crying with "hurts worst" underneath the face. This was a visual analog score for those with limited communication skills.

The policy indicated for severe pain the drugs of choice were Morphine 5 mg IM (intramuscularly) or IV; Hydromorphone 1 mg IM/IV or Fentanyl 100 mcg (micrograms) IM/IV.

Nursing Standing Orders
1. Registered nurses as approved by (name of facility), may administer analgesic therapy who present to the emergency room in acute pain.
2. The nurse will:
a. Assess pain and determine whether the pain is considered mild, moderate or severe.
b. determine whether the patient has any medication allergies and select the most appropriate analgesic to which the patient is not allergic.
c. may administer an initial dose of medication as indicated in (name of facility) pain management table if a physician is not readily available...
d. will monitor the patient for any beneficial or untoward effects that result from medication administration.
3. The medication will be considered a "verbal order" from the Emergency Department physician who is ultimately responsible for the patient's care.
4. Subsequent doses of narcotics will not be administered without physician evaluation and order..."

Review of the ED records for Patient #35 from Hospital B dated 6/2/12 revealed the following:
-Patient #35 arrived at the ED via wheelchair at 10:40 PM.
-The patient was triaged at 10:40 PM and given Dilaudid 1 mg. IV push (P) and Zofran (for nausea) 4mg. IVP. At 12:20 PM the patient was administered Zosyn (an antibiotic) 4.5 grams every 8 hours IV piggy back.
-Patient #35 had a laboratory work-up, a CT scan of the abdomen and pelvis and an electrocardiogram (EKG) on 6/2/12.
-The CT completed on 6/2/12 for Patient #35 reported acute appendicitis with peritoneal abscess.
-Patient #35 underwent surgery on 6/3/12 at 2:58 PM.
-Patient #35 was diagnosed on 6/3/12 at 12:22 AM with acute appendicitis and hypoglycemia.

In summary

-Patient #35 arrived at the ED of Hospital A on 6/2/12 at 8:57 PM with complaints of abdominal pain and nausea. The patient was given an acuity level of 3
-Patient #35's pain was assessed at a 10/10 during the nurses assessment.
-Patient #35 had a RME by the Nurse Practitioner. however, the patient did not have a complete medical screening.
-Patient #35 had lab work and a CT scan completed.
-Patient #35 was sent to the waiting room after the CT scan was performed.
-Patient #35's family member complained to the triage nurse that the patient needed something for pain several times. The family indicated Hospital A was not doing anything for the patient and left the ED
-A Security Officer notified the nurse Patient #35 was in the parking lot with his IV still in place. The nurse removed the IV and Patient #35 left the ED by car.
-The documentation on disposition indicated Patient #35 was in distress, had a pain level of 10/10 and the CT scan reported Patient #35 had an acute appendix with perforation.
-Patient #35 was taken to Hospital B. There patient arrived at 10:40 PM was assessed and given pain medication and medication for nausea at 10:40 PM.
-Patient #35 had lab work a CT scan and an EKG on 6/2/12.
-The CT scan reported acute appendicitis with peritoneal abscess.
-Patient #35 was admitted to inpatient on 6/2/12 at 12:20 AM
-The patient underwent surgery on 6/3/12 for ruptured appendicitis.
-Patient #35 was discharged from Hospital B on 6/8/12.



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 knows the whereabouts of the patient. If security was unable to find the patient the police department was notified and it was broadcast to the police officers to see if they were able to find the patient.
The Manager of Public Safety indicated if a patient eloped with AMS (altered mental status or was on an L2K, then they would call a "Code Walker". This would be announced over the call system of the facility and the Public Safety department would give a description to all employees who had the responsibility to look for the patient.

On 6/22/12 in the afternoon the Manager of Public Safety indicated an adult elopement procedure was followed in order to find Patient #22.

The Manager of Public Safety indicated Patient #22 was not found. The patient's six year old daughter who was placed in the pediatric ED was removed by Child Protective Services on 6/5/12.

On 6/22/12 in the afternoon, Security Officer #1 indicated he placed the four point soft restraints on Patient #22. The Officer indicated Patient #22 was a thin small person who weighed about 90 pounds. The officer indicated he did not want to put the restraints on too tight, he could understand how Patient #22 might have removed them. He indicated Patient #22 was more worried about her computer that was confiscated than anything else.

Policy #EDADM11-EMERGENCY DEPARTMENT-THE DIFFICULT PATIENT
"...Purpose
To provide guidelines for the management of the patients who may be manifesting behaviors due to the influence of alcohol, drugs or emotional problems.
Scope
Adult Emergency Department
Policy
A. Patients who may be manifesting behaviors due to the influence of alcohol, drugs or emotional problems will be treated with care and dignity in a safe secure environment.
1. A suicide risk assessment and a 15 minute checklist are required at the time of arrival to the Emergency Department (ED).
B. All patients will be triaged and assigned a room in accordance with patient care requirements and established policy.
C. Should restraints be necessary, they will be applied by the Public Safety staff and in accordance with the hospital policy, using the least restrictive method of restraint to maintain safety of the patient and others with stretcher/gurney siderails raised.
F. Patients who are placed on legal hold status (aka L2K) may have specialized care to maintain their safety and dignity:
1. All patient belongings are secured and stored by Public Safety staff unit.
2. after the patient is deemed "medically stable" by the atte