HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights. 

Based on interviews and records reviewed, the Hospital failed to ensure that one patient (#1) out of a sample of 10 patients was supervised per Hospital policy.

Cross Reference: Patient Rights: Care in a Safe Setting (Tag 0144).

Based on interviews and records reviewed, the Hospital failed to ensure that one Patient (#1) out of a sample of 10 patients was supervised per Hospital policy; Patient #1 was not supervised by Hospital staff in accordance with the Patient ' s plan of care for a 2:1 shared observation (2 patients:1 staff member) while on a section 12 (Emergency restraint and temporary involuntary hospitalization of a person posing risk of serious harm by reason of mental illness) psychiatric hold, and was able to elope from the Hospital ' s Emergency Center (EC) on 3/15/25.

Findings include:

Review of the Hospital ' s Behavioral/Psychiatric Complaints/Symptoms Adult and Pediatric Patients-extended stay behavioral patients Policy, revised 12/2023, indicated the following:
- All patients will be assessed by the Registered Nurse (RN). Patients presenting with a mental health emergency should be assigned an ESI level 2. The nurse is expected to take action as necessary and permitted by policy to protect the patient and the staff.
-All patients at risk will be requested to undress, placed in a hospital scrubs and have their belongings searched for weapons and placed in a secure cabinet. If a patient continues to refuse and safety of the patient or staff member is a concern, then Security will be called, and the Security Departments search, and seizure policy will be implemented.
-The patient as risk must be observed. This is a shared responsibility between the EC staff and the Patient Safety Monitors (PSM).
-The patient will be placed on Observation with documentation of observer ' s title and verbal hand off to the 1:1 observer will take place at all shift changes.

Review of Patient #1 ' s medical record indicated that he/she presented to the Hospital EC via Emergency Medical Services (EMS) from a group home after being found in a tree naked. Patient #1 was brought in under Section 12 due to behaving dangerously. Patient #1 was triaged as an ESI Emergency Service Index (ESI) level 2 (Emergent).

Review of Patient #1 ' s Progress Note documented by the Attending Physician, dated 3/15/25 at 12:37 A.M., indicated that Patient #1 was brought into the EC by EMS for intoxication. The note further indicated that Patient #1 will be monitored in the ED for sobriety and reassess for any emergent medical complaints, or SI/HI (suicidal ideation/homicidal ideation) on sobering.

Review of Patient #1 ' s Behavioral Health/Suicide Risk/Restraint/Patient Safety Intervention/Assessment/Treatment Plan of Care dated 3/15/25 at 6:31 A.M., indicated that Patient #1 was under section 12; safety observation was for shared observer 2:1 or 3:1 (2 patients:1 PSM or 3 patients:1 PSM) for Delirium/Restlessness, Confusion.

During an interview on 7/23/25 at 10:59 A.M., Public Safety Officer (PSO) #1 said while he was walking through the EC Patient #1 approached him to use the phone. The PSO said Patient #1 was dressed in street clothes and there was no PSM present. The PSO said patients who are under section 12 typically are changed into hospital scrubs and would be accompanied by a PSM.

During an interview on 7/23/25 at 11:44 A.M., the Senior Director of EC said she was involved in the investigation of Patient #1 ' s elopement event on 3/15/25. She said patients who come in with behavioral health complaints are considered at risk. She said patients identified to be at risk need to be changed into hospital scrubs per policy. She said if the patient refuses this should be documented in the chart and security called to do a search of the patient. The Senior Director of EC services said opportunities were identified for education to all EC staff on the importance of changing patients out of their street clothes, documenting if refused and for the RN to provide a thorough hand-off to the PSM ' s. She said she emailed the education to all EC staff but was unable to provide documentation that this was implemented.

During an interview on 7/23/25 at 1:12 P.M., PSM #2 said she was covering PSM #1 ' s break on 3/15/25. She said she was observing two patients at the time, including Patient #1. PSM #2 said she did not receive a handoff from PSM #1 regarding Patient #1. She said the patient safety monitoring form was missing a patient sticker, was not filled out by the RN and lacked information about Patient #1 ' s needs. She further said she was unaware Patient #1 was under section 12 and that he/she was dressed in street clothes. PSM #2 said she was distracted by the other patient she was assigned to observe and lost sight of Patient #1 for a few minutes. She said when she looked back, Patient #1 was no longer present, the stretcher had been cleaned, so she assumed they had been discharged.

During an interview on 7/24/25 at 8:31 A.M., PSM #1 said that on 3/15/25, she was assigned to provide 2:1 observation for two patients, including Patient #1. PSM #1 said she was unable to recall whether she received a handoff for Patient #1. She said the patient safety monitoring form did not have a patient sticker or identifying information and was not completed by the RN assigned to Patient #1. She further said Patient #1 was dressed in regular clothes. PSM #1 said she went on break, and PSM #2 assumed observation of Patient #1. She said when she returned Patient #1 was no longer present and upon inquiring with PSM #2, was told she believed Patient #1 was discharged.

During an interview on 7/24/25 at 10:19 A.M., the Risk Manager said she was involved in the investigation of Patient #1 elopement event. She said Patient #1 was on shared 2:1 observation. She said when a PSM is watching two patients the expectation is that both patients are visualized at all times and if this can ' t be maintained, assistance should be sought. The risk manager said the investigation concluded that PSM #2 was distracted by the other patient on shared observation and lost sight of Patient #1 for approximately five minutes, during which time he/she eloped. The risk manager said in response to Patient #1 ' s elopement event opportunities were identified for staff education including the importance of changing patients out of their street clothes or documenting if the patient refuses and ensuring that RNs provide a thorough handoff to PSMs, as well as a complete handoff between PSMs. She said spot checks are being conducted throughout the day to verify that PSM ' s know who they are observing and the reason for the observation. The Risk Manager was unable to provide documentation that the education was implemented.