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Based on review of facility policy, medical record review, review of facility video recordings, and interviews, the facility failed to inform a patient's representative of an elopement and failed to ensure a patient with suicidal ideations did not elope for 1 patient with suicidal ideations (Patient #1) of 5 patients reviewed for suicidal ideations of 10 patients reviewed.

The findings included:

During the investigation it was found Patient #1 was admitted to Facility's A's Emergency Department (ED) on 9/18/2021 with suicidal ideations. The patient had a history of previous suicide attempts and schizophrenia (mental disorder). The patient was brought to the ED after he had jumped from a balcony into a river. A medical screening examination was completed on the patient by a Qualified Medical Provider (QMP). The patient was placed under a 6404 (involuntary psychiatric commitment) and was held in the ED awaiting transfer to an inpatient psychiatric facility. On 9/19/2021 at 2:04 AM, the patient eloped from the ED, he was located and brought back into the ED, and given Geodon (medication used to treat acute psychiatric behaviors). At 6:29 AM, the patient eloped for a second time. He ran out of the ED into the parking lot, was located, and was brought back into the ED for treatment and monitoring. At 9:12 PM, the patient eloped for a third time through the Emergency Medical Services (EMS) entrance bay where he ran across the helipad into an adjacent field. The facility staff were unable to locate him. The local police department and a facility security officer attempted to locate the patient, but were unsuccessful. At 10:02 PM, the patient was found at a local concrete company (approximately 3-4 blocks from the facility) where he had climbed a silo and jumped approximately 30-50 feet. EMS responded and found the patient unconscious with multiple traumas. He required intubation (insertion of a breathing tube) and was transported to Hospital B where he expired at 11:40 PM.

During a conference with the Administrator, the Quality Manager, and the Emergency Department Nurse Manager on 9/28/2021 at 1:45 PM, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.13, Conditions of Participation, Patient Rights.

During a conference with the Administrator, the Director of Nursing, the Quality Manger, the Risk Manager, the Corporate Chief Nursing Officer, and the System Quality and Patient Safety Officer on 9/29/2021 at 1:25 PM, in the conference room, the facility presented an Immediate Action Plan, which removed the Immediate Jeopardy. Review of the Immediate Jeopardy Action Plan showed the following actions:

1. Written Risk Assessment on ambulance bay for entrance/exit of patients by the safety officer. The Safety Officer was onsite on 9/29/2021. The onsite Risk Assessment will be completed by the Safety Officer, the ED Nurse Manager, the Quality Manager, and the Administrator. A follow up evaluation will be completed on 10/1/2021.
2. Inactivation of automatic ambulance bay door when suicidal patients present in the ED.
3. Education provided to all ED staff members by the ED Nurse Manager. The training was implemented on 9/28/2021. The education included the following:
a) Review of sitter expectations and guidance for sitters
b) Sitters to be stationed at the end of the bed within arm's length of the patients at all times to include showers and bathroom
c) Review of the facility policy "Patient Care Concerns and Chain of Command"
d) Education on keypad entry installed on the doors at the EMS entrance/exit
e) The education sign-in sheets and attestation forms dated 9/28/2021 and 9/29/2021 showed 27 of the 60 ED staff had completed the training.
f) Installation of keypad on the ED ambulance entrance/exit bay doors. The safety officer and contractor were responsible for installation of the keypad installed on 9/29/2021
4. Observation on 9/29/2021 at 12:20 PM showed the keypad was installed on the entrance/exit door in the ED. There was an electronic lock located at the ED Nurses station. The contracted company was installing the wiring for the door at the time of the observation. The Safety Director was responsible for ensuring regulatory compliance with the keypad and routine maintenance.
5. Educate staff on Escalation of Patient Care Concerns using the Chain of Command policy, suicide prevention policy, and elopement policy which included notification of the nursing staff and the physician for escalating behaviors.
a) Educate staff on policy with specific emphasis on the proper chain of command, suicide prevention, and elopement. Staff will notify the manager immediately upon arrival of a suicidal patient. If the manager is unavailable, staff will notify the administrator on call.
6. The education will be presented to the staff by the ED Nurse Manager. The training was started 9/28/2021 and will be completed by 10/1/2021 with 100% of the ED staff. All new hires will receive the training. Review of the sign-in sheets and attestation forms dated 9/28/2021-9/29/2021 showed 27 of the 60 ED staff members had completed the training.
7. Educate all staff on sitter expectation guidelines
a) The training included the following: a report will be given to the Registered Nurse (RN), the sitter, and security officer for all suicidal patients; the nurse will provide breaks for the sitters; no physical barriers between the patient and the staff member; 1:1 (one on one) observation; sitter must sit between the patient and the doorway; the sitter observes one patient only; sitter will accompany the patient to the shower, baths, toileting; staff will observe the patient while the patient is sleeping; staff will restrict the patient to the unit only; patient may not leave the building at any time.
b) Any staff member who will be functioning as a 1:1 sitter will be required to complete the training
8. The training will be completed by 10/1/2021 for 100% of the ED staff and any team member who may provide sitter services. Review of the sign-in sheets and attestation forms dated 9/28/2021-9/29/2021 showed 27 of the 60 ED staff members had completed the training.
9. Monitoring compliance:
a) 100% of suicide patient charts will be audited on a daily basis by the ED Nurse Manager
b) Use of the Suicide Risk Tracer for observation and documentation tool will be used to assess compliance.
c) 100% of the reviews must meet the requirements on the monitoring tool
d) The chart review and monitoring will start 9/28/2021. This will be an ongoing process.
e) Audit 100% of Suicide charts using the Joint Commission chart tracer and observation audits.
f) Review of the monitoring tools showed the facility had a tracer tool to assess compliance. Sitter will be placed at the end of the stretcher within arm's length at all times for suicidal patients. This was implemented on 9/28/2021. Education was implemented on 9/28/2021 by the ED Nurse Manager
10. Observation in the ED on 9/29/2021 showed the sitters were located at the patients' bedside for 3 patients observed.
11. Nurses to assess for the need for a patient to be moved to a less stimulating environment as staff and resources are available. This would include non-violent patients, patients who may be hyper stimulated by extra stimulus, patients exhibiting escalating behaviors causing agitation/irritation
a) Educate all ER staff and providers to the plan through group meetings, 1:1 with facility leadership and read and sign confirmation.
b) Education was implemented on 9/29/2021 by the ED Nurse Manager and administrative staff.
c) During an interview on 9/29/2021 at 12:45 PM, the Administrator confirmed the ED Medical Director was contacted regarding the use of the Intensive Care Unit (ICU) space for patients who needed a less stimulating environment. The ICU was currently unoccupied and is only accessible by badge entrance and exit by the staff. The ED physicians would be responsible for the care of the ED patients moved to the ICU. The facility's Safety Director had completed an assessment of the ICU rooms and environment to ensure patient safety. Training for the ED Physicians implemented on 9/29/2021 with a completion date of 10/1/2021.
12. Observation on 9/29/2021 at 12:30 PM in the ED, showed 1 patient currently under a 6404 hold. The sitter was sitting at the patient's bedside. A keypad had been installed at the EMS exit door and the wiring was being completed by the contracted company. All other doors upon entrance and exit to the ED were secured and required a badge entry to enter and exit the ED.
13. Observation on 9/29/2021 at 1:00 PM in the ICU, showed 2 patients who were 6404 holds. The patients were currently monitored by sitters who were at the patient's bedside.
14. Flow of oversight
a) Hospital A's Quality Committee
b) Regional Quality Council
c) Medical Executive Committee
d) Hospital A's Board of Directors

During an interview on 9/29/2021 at 1:15 PM, the Administrator and the Quality Manager stated the facility had implemented the action plan and the training had started for the ED staff. The sitters were positioned at the patient's bedside and were within an arm's length of the patient. The staff were provided education regarding suicide precautions, elopement precautions, and the proper chain of command for patients whose behaviors worsened. The training will be completed by 100% of the ED staff by 10/1/2021. A keypad was placed at the exit doors of the EMS entrance bay to ensure suicidal patients were unable to egress through the EMS entrance. The installation met the safety director's approval to ensure regulatory compliance. Patients who needed a less stimulating environment could be moved to the ICU with a staff member serving as a sitter and oversight by the ED licensed staff and the ED Physician. Those patients will be screened by the ED Physician, the ED Nurse Manager, or the Administrator on Call prior to being moved. The ED Nurse Manager or Administrator on Call will be notified by the ED staff of any suicidal patient who was admitted to the ED. The ED Nurse Manager will assess compliance through chart review and direct observations for 100% of all suicidal patients. The findings will be submitted to the facility's Quality Management, the regional Quality Management, the Medical Executive Committee, and the facility's Board of Directors.

Review of the Immediate Action Plan revealed immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 9/29/2021. The facility remains out of compliance at 42 CFR PART 482.13, Conditions of Participation, Patient Rights (Condition).

Refer to A-0131 and A-0144

Based on medical record record review and interviews, the facility failed to ensure a patient's representative was notified of a patient's elopement for 1 patient (#1) with suicidal ideations of 5 patients reviewed for suicidal ideations of 10 patients reviewed.

The findings included:

Medical record review showed Patient #1 was admitted to the Emergency Department (ED) at Facility A on 9/18/2021 for a Psychiatric evaluation.

Medical record review of an ED Nurse's Triage Note dated 9/18/2021 at 3:37 PM showed the patient presented to the ED by Emergency Medical Services (EMS) after he had jumped from a balcony into a river. He was triaged with an Emergency Severity Index (ESI) score of a 2, indicating emergent needs. The Columbia Suicide Severity Rating Scale (tool used to determine suicidal risk) showed the patient was at high risk for suicide.

Medical record review of an ED Nurse's Note dated 9/18/2021 at 5:23 PM showed "...talked with pt.'s [patient's] father, father reports pt. was acting himself this morning and just prior to the incident that brought the pt. to the ED today pt. suddenly changed. Father reports pt. does hear voices and was treated previously for cutting on his arms. Dad states 'he said he was trying to cut a woman out of his arms'..."

Medical record review of a Mobile Crisis Consult dated 9/18/2021 at 5:40 PM, showed a Mobile Crisis Consult was performed via telephone. The patient stated he was suicidal, he had auditory and visual hallucinations, he was depressed, and he had anxiety. He jumped into the river in a suicide attempt. He was placed under a 6404 (behavioral health involuntary commitment).

Medical record review of an ED Physician's Record dated 9/18/2021 at 5:55 PM, showed Patient #1 had a history of Schizophrenia (mental illness) and previous suicide attempts. He presented to the ED by EMS after he jumped off a balcony into a river.

Medical record review of an Involuntary Commitment Form 6404 dated 9/18/2021 at 6:00 PM, showed the ED Physician signed the form for the commitment of Patient #1 for major depression with a suicide attempt. The ED Physician stated the patient had "...depression, anxiety, suicide attempt, had been hearing voices telling him to do things the past several days..."

Medical record review of an ED Nurse's Note dated 9/19/2021 at 9:12 PM (documented on 9/20/2021 at 9:58 AM) showed the patient eloped a third time and the staff "...chased patient...out of the EMS doors and into the parking lot. Pt. ran across the Helipad and towards [named drug store]. Pt. sat down on side of the road. Security Officer came out EMS doors from ER [emergency room] and I told her which way patient ran. Pt. ran in behind [named Drug store] and I could no longer see him. I called 911 [emergency services] on my cell phone to give law enforcement a direction of travel of the patient at 9:18 PM..."

Medical record review showed the patient was admitted to Facility B on 9/19/2021 at 11:13 PM, after eloping from from Facility A and sustaining a fall from 35-40 feet. At Facility B he was intubated and had bilateral leg injuires. The patient suffered a cardiac arrest at 11:39 PM and expired at 11:40 PM.

Medical record review of the ED Disposition Note at Facility A dated 9/20/2021 at 5:28 AM showed "...was on 6404 and eloped out of the trauma bay..."

Medical record review of an ED Nurse's Note at Facility A dated 9/20/2021 at 4:58 PM (7 hours and 18 minutes after the patient eloped) showed "...patient's father arrived in the ED requesting update on his son. I advised him that he would have to contact [Hospital B]. Patient's personal belongings were released to father..."

During an interview on 9/28/2021 at 10:50 AM, Registered Nurse (RN) #2 stated the patient was under a 6404. He had been evaluated by Mobile Crisis and was waiting on medical clearance and acceptance at an inpatient psychiatric facility. On 9/19/2021 at 9:20 PM, the patient eloped from the ED and the ED staff were unable to locate the patient or bring the patient back into the ED. She stated the patient did not have any family with him and confirmed she had not notified the family of the patient's elopement and that the facility was unable to locate the patient.

During an interview on 9/29/2021 at 11:30 AM, the System Regional Quality Manager confirmed the patient's family was not notified of the patient's elopement until the next day (9/20/2021) when the patient's father came in to check on the patient.

Based on review of facility policy, medical record review, review of facility video recording, and interviews, the facility failed to ensure a safe environment for 1 patient with suicidal ideations (Patient #1) of 5 patients reviewed for suicidal ideations of 10 patients reviewed.

The findings included:

Review of the facility's policy titled "Suicide Prevention," last revised on 1/2021, showed "...the hospital conducts an annual assessment of the environment to identify any risks related to the environment that could potentially contribute to a patient's plan to make a physical attempt to commit suicide...if boarding the patient in an acute care setting while awaiting care for behavioral conditions the hospital will take actions to minimize potential harm to self or others..."

Review of the facility's policy titled "Patient Sitters," last revised 1/9/2021, showed "...patient sitter: associate trained by the hospital to protect patients from harming themselves or others...constantly observes the patient and reports behavior...when sitting with suicidal patients: never leave patient unattended...patient must be within arm's length of the sitter...must be in the line of site at all times...sits between the patient and the door for a safe exit..."

Medical record review showed Patient #1 was admitted to the Emergency Department (ED) on 9/18/2021 for a Psychiatric evaluation.

Medical record review of an ED Nurse's Triage Note dated 9/18/2021 at 3:37 PM showed the patient presented to the ED by Emergency Medical Services (EMS) after he had jumped from a balcony into a river. The patient stated "...I feel like I am not good enough and that I am a disappointment to my family..." He was triaged with an Emergency Severity Index (ESI) score of a 2 indicating emergent needs. The Columbia Suicide Severity Rating Scale (tool used to determine suicidal risk) showed the patient was at high risk for suicide.

Medical record review of an ED Nurse's Note dated 9/18/2021 at 5:23 PM showed "...talked with pt.'s [patient's] father, father reports pt. was acting himself this morning and just prior to the incident that brought the pt. to the ED today pt. suddenly changed. Father reports pt. does hear voices and was treated previously for cutting on his arms. Dad states 'he said he was trying to cut a woman out of his arms'..."

Medical record review of a Mobile Crisis Consult dated 9/18/2021 at 5:40 PM, showed a Mobile Crisis Consult was performed via telephone. The patient stated he was suicidal, he had auditory and visual hallucinations, he was depressed, and he had anxiety. He jumped into the river in a suicide attempt. When asked by the counselor if the patient was alright to speak about the events, the patient put the phone down and a Licensed Practical Nurse (LPN) could he heard asking the patient why he was putting a pencil up to his eye. "...Ct [client] was guarded and crying...had suicide attempts and self-harm this year. Ct. recommended 6404 [behavioral health involuntary commitment]. ED Physician is in agreement with 6404...[patient] will be referred for inpatient admission..."

Medical record review of an ED Physician's Record dated 9/18/2021 at 5:55 PM, showed Patient #1 had a history of Schizophrenia (mental illness) and previous suicide attempts. He presented to the ED by EMS after he jumped off a balcony into a river. The patient "...felt like he was a disappointment to his family and was trying to end his pain. Patient had recently been hearing voices but today states that it was the voices that told him to jump..." His physical examination showed no acute findings other than he was depressed. The patient's diagnoses included Schizophrenia, Suicidal Ideations, and Major Depression and he was placed under a 6404 with a plan to transfer the patient to an inpatient psychiatric facility.

Medical record review of an Involuntary Commitment Form 6404 dated 9/18/2021 at 6:00 PM, showed the ED Physician signed the form for the commitment of Patient #1 for major depression with a suicide attempt. The ED Physician stated the patient had "...depression anxiety, suicide attempt, had been hearing voices telling him to do things the past several days..."

Medical record review of an ED Nurse's Note dated 9/18/2021 at 6:03 PM showed "...[mobile] Crisis on phone to talk to pt. Pt. began talking to crisis and became tearful...."

Medical record review of an ED Nurse's Note dated 9/19/2021 at 2:04 AM showed "...pt. got out of bed and ambulated past nursing station looking at nurses, moving toward the ambulance bay, then started running out back bay..."

Medical record review of an ED Physician's Addendum Note dated 9/19/2021 at 2:05 AM showed "...while I was in the doctor's lounge, pt. announced that he was going to leave and despite their [staff] attempts to convince him to stay, he walked out the ambulance bay with security trailing behind him. The police have been notified are reportedly enroute now...[2:11 AM] pt. has returned to his bed in the ED. Will provide sedation at this time and continue to monitor closely..."

Medical record review of the ED Medication Administration Record dated 9/19/2021 at 2:26 AM showed the patient was given Geodon (antipsychotic medication) intramuscular (IM).

Medical record review of an ED Nurse's Note dated 9/19/2021 at 6:29 AM showed "...called security and police department to notify them that pt. eloped [second time]. Pt. in paper scrubs. Nursing staff and MD [medical doctor] tried to reason with pt. regarding fleeing, telling him that police had been called. He continued to run away..."

Medical record review of an ED Nurse's Note dated 9/19/2021 at 6:30 AM showed "...pt. was escorted through front door by security to fast track, police department came through ambulance bay...pt. tried to charge through police officers that were standing in hallway in front of his bed....Police officers had to speak with patient and explain to him the 6404 document and the reasoning he could not leave..."

Medical record review of an ED Nurse's Note dated 9/19/2021 at 9:12 PM (documented on 9/20/2021 at 9:58 AM) showed the patient eloped a third time and the staff "...chased patient...out of the EMS doors and into the parking lot. Pt. ran across the Helipad and towards [named drug store]. Pt. sat down on side of the road. Security Officer came out EMS doors from ER [emergency room] and I told her which way patient ran. Pt. ran in behind [named Drug store] and I could no longer see him. I called 911 [emergency services] on my cell phone to give law enforcement a direction of travel of the patient at 9:18 PM..."

Medical record review of an ED Physician's Addendum note dated 9/19/2021 at 9:21 PM showed "...pt. ran out of the back door while I was in another patient's room. Security is currently pursuing him outside trying to convince him to return and police have been called to assist..."

Medical record review of an EMS record dated 9/19/2021 11:00 PM showed EMS was dispatched to Facility A at 10:04 PM for a patient who had "...fallen from approximately 30-50 feet from atop...concrete silo...Patient had bleeding from the mouth and nose, mangled extremities lower, unresponsive but breathing. He had multiply [multiple] abrasions and lacerations on his body. His lower extremities appeared deformed. He appeared to have blood on his head and possible crepitus on the face and right side of his head. His airway was open but bleeding from the mouth and nose. He was laying on his right side. There were multiple traumatic injuries..." Further review showed "...I have not confirmed this information at the time of writing but I was told on the scene he [Patient #1] had been at [Facility A] and was a 6404 patient and had been treated for suicidal ideations...he had bolted from the hospital and they had been looking for him and this is how he was found..." Further review showed the patient was unresponsive to verbal or tactile stimulation and was combative. The patient was intubated by EMS. He required continuous suctioning of the mouth and nose and his lower extremity was splinted for transport. The decision was made by EMS to transport the patient to Facility B because the patient was intubated and Facility B was the closest facility with an Intensive Care Unit and capabilities to assess and treat the patient for multiple traumas.

Review of the ED video recording dated 9/19/2021 showed the following:
8:28 PM: Patient #1 was in ED Fast Track room 3 with a sitter sitting in a chair across from the patient which was approximately 6 feet from the patient. The patient was not visualized on the video.
8:53 PM: A local police department officer was at the patient's bedside talking to the patient.
8:56 PM: the police officer left the patient's bedside.
9:07 PM: the sitter went to the patient's bedside and spoke with the patient
9:15 PM: the patient was seen in the hallway of the ED and ran out the EMS entrance/exit doors

Medical record review of the ED Disposition Note at Facility A dated 9/20/2021 at 5:28 AM showed "...was on 6404 and eloped out of the trauma bay..."

Medical record review of an ED Nurse's Note at Facility A dated 9/20/2021 at 4:58 PM showed "...patient's father arrived in the ED requesting update on his son. I advised him that he would have to contact [Hospital B]. Patient's personal belongings were released to father..."

Medical record review showed the patient was admitted to Facility B on 9/19/2021 at 11:13 PM.

Medical record review of an ED Nursing Triage record from Facility B dated 9/19/2021 at 11:14 PM showed the patient presented by EMS after a fall from 35-40 feet where he had been intubated and had bilateral leg injuries. Patient #1 was triaged using the Emergency Severity Index with a score of 1, indicating emergent needs.

Medical record review of an ED Physician's Record at Facility B dated 9/19/2021 at 11:12 PM and documented on 9/20/2021 at 12:22 AM showed "...unresponsive, scalp laceration without active bleeding. Pupils dilated and fixed...nasal crepitus [abnormal popping or crackling sound] noted, bilateral nasal bleeding...Left hip externally rotated, left thigh swollen, left tib/fib [tibia/fibula] contusions, left ankle swelling, left foot swollen and cold without pulses, right leg and knee abrasions, foot warm but without pulses..."

Medical record review of the ED Nurse's Notes at Facility B dated 9/19/2021 showed the following:
11:39 PM: the patient suffered a cardiac arrest.
11:40 PM: the patient was pronounced dead by the ED Physician.

During an interview on 9/27/2021 at 1:50 PM, the ED Nurse Manager stated the patient was brought to the ED by EMS after he had jumped from a balcony into the river. He was brought to the ED for evaluation and possible inpatient psychiatric transfer. The patient was alert and oriented but appeared to be depressed. He was evaluated by the ED Physician and Mobile Crisis and placed under a 6404 with a sitter placed with him. The ED Nurse Manager stated "...he had multiple elopement attempts while in the ED. The first attempt was on 9/19/2021 around 2:00 AM where he ran out the ED EMS entrance...the police came and just a few minutes later our security officer brought him through the main entrance and took him to his bed. The ED Physician saw the patient and he was given Geodon IM. The second time the patient got upset and ran out the door but was detained by security and calmed down...the third elopement was around 9:20 on 9/19/2021...the patient jumped off the stretcher and ran out the EMS entrance doors even when the sitter and RN [Registered Nurse] was trying to talk to him. He ran across the Helipad into the field. The RN was watching him and could see him. The RN called 911 and told them the patient had eloped...to see if they could get the patient and bring him back. They lost sight of him and the local police were continuing to search for him..."

During an interview conducted through a video conference on 9/27/2021 at 2:10 PM, the Risk Manager stated the facility was made aware of the patient elopement on 9/20/2021 after the ED RN called the Administrator.

During an interview on 9/27/2021 at 3:00 PM, RN #1 stated the patient presented to the ED with a suicidal attempt and had a history of suicide attempts and Schizophrenia. RN #1 stated "...I was in the nurses station...I heard the sitter yell 'he's running' and when I looked up, the patient was running down the hallway toward the EMS entrance. I ran after him but by that time he had gotten out the doors and was running across the helipad into the adjacent field. I was outside in the EMS entrance and could see the patient sitting down at the edge of the road. It looked like he was taking his socks off, as it was raining and very wet outside. I called 911 from my cell phone and told them the patient had ran out the ED and we could not catch the patient. By this time, our security officer had arrived in the EMS entrance, I showed her where the patient was, but by this time he had ran in behind the local pharmacy and we could not see him..."

During an interview on 9/27/2021 at 3:25 PM, the Administrator stated he received a call early in the morning on 9/20/2021 from the ED Nurse who stated the patient eloped on 9/19/2021 and the patient may have jumped from a silo. The Administrator stated EMS and local police confirmed it was Patient #1 who had jumped. Patient #1 was transported to Facility B on 9/19/2021 after the incident where he expired. The Administrator stated "...I sent an email out the next morning [9/20/2021] to our Administrative Staff, Quality Management, and Risk Management, stating we needed to start an investigation and we planned to meet about the incident..."

During an interview on 9/28/2021 at 10:50 AM, RN #2 stated the patient was under a 6404. He had been evaluated by Mobile Crisis and was waiting on medical clearance and acceptance at an inpatient psychiatric facility. She stated the patient eloped on 9/19/2021 at 2:00 AM and was found by the security officer and brought back into the ED just minutes after his elopement. The patient was given Geodon IM to help him calm down. RN #2 stated the patient got upset around 6:30 AM and had to be talked down after he had attempted to leave. She stated "...on 9/19/2021, the sitter went to his bedside to check on him and thought he might be escalating, so she stepped back to monitor him. I was in another room and heard the sitter yell 'he's running' and by the time I got out the nurse's station, the patient had already bolted out the EMS entrance doors. The other RN was outside watching him...he had called 911 and the sitter had alerted dispatch the patient had eloped. We called our security and she went outside and was looking for him. About 40 minutes later we heard the EMS tones go out for someone who had allegedly jumped from a silo which was very close the hospital...I knew there a good chance this might be our patient..." She stated the local police and EMS came to the ED and were asking questions about the patient and they confirmed the patient had jumped from the silo. He had multiple traumas and was taken to Facility B and he had expired. She stated the patient did not have any family with him and confirmed she had not notified the family of the patient's elopement and the facility was unable to locate the patient. She stated "...later around 4:00 AM [6.5 hours after the patient had eloped] I called the administrator and told him of the incident..."

During an interview on 9/28/2021 at 10:15 AM, the Quality Manager and the ED Nurse Manager stated an investigation was started on 9/20/2021. A Risk Assessment had been completed, which showed the Fast Track (hallway) stretcher beds were in direct sight of the EMS exit doors by patients in the hallway stretchers. The EMS entrance doors opened automatically and no barrier was present to prevent a patient from running out the doors and eloping.

During a telephone interview on 9/28/2021 at 11:59 AM, ED Physician #1 stated the patient was admitted for a Suicidal Attempt and was placed under a 6404 on admission. The patient eloped on 9/19/2021 around 2:00 AM and was brought back into the ED by the security officer. Around 6:30 AM the patient tried to get out of the bed and the local police was trying to hold him in the bed and the facility was able to calm the patient down. On 9/19/2021 around 9:20 PM the patient eloped from the ED and "...bolted out the EMS doors and ran from the staff..." Later the ED staff was notified by the local police and EMS that Patient #1 had jumped from a silo to the ground and his condition looked very bad. EMS told the ED staff the patient had been taken to Facility B and had expired.

During a telephone interview on 9/28/2021 at 3:15 PM, Security Officer #1 stated the patient tried to elope from the ED early in the morning on 9/19/2021 and they were able to get him back into the ED. She stated "...on 9/19/2021 around 9:20-9:30 PM, the staff told me the patient had eloped and the RN was in the EMS entrance bay trying to follow the patient. I went outside and the RN showed me where the patient was and said he had called the local police. I could see the patient at the end of the road and he was not coming back toward us...he was running down toward the pharmacy. I went to the property line and was trying to keep him in my line of sight but I lost him. I could see a shadow around the trash can at the pharmacy, but was not sure if it was him. The local police came down the road at that time and I tried to shine my flashlight toward the area I thought the patient had ran toward. At that time I saw the patient running. He was looking back toward us and kept running. The police went toward the area where he was at. They came by and I told them the patient was in paper scrubs and gave them a description of the patient..." The local police department came to the ED and informed the security officer the patient had jumped from the silo. EMS told the facility staff the patient had jumped or fell from the silo and his condition was "terminal." Security Officer #1 stated "...there is not a lot of space in the ED. The patients were only separated by a curtain and were in direct visualization of the EMS entrance door, which presented a direct line of sight for elopement..."

During a telephone interview on 9/29/2021 at 10:15 AM, Licensed Practical Nurse (LPN) #1 stated the patient eloped on 9/19/2021 early in the morning and the facility was able to return the patient to the ED. She stated "...the second night I was asked to sit with him...two police officers came to talk to him about the incident that happened the night before and his whole demeanor changed after that...he sat upon the side of the bed and got up off the stretcher. At that point, he took off and started running toward the EMS entrance doors. I yelled 'he's running' and the RN came out of the room and ran after the patient. I called dispatch and told them the patient had eloped...the patient starting yelling 'I don't know what to do anymore'..."

Based on medical record review, review of facility documentation, observations, and interviews, the facility failed to provide nursing services to prevent an elopement related to a patient with suicidal ideations for 1 patient (Patient #1) of 5 patients reviewed for suicidal ideations of 10 patients reviewed.

The findings included:

During the investigation it was found Patient #1 was admitted to Facility's A's Emergency Department (ED) on 9/18/2021 with suicidal ideations. The patient had a history of previous suicide attempts and schizophrenia (mental disorder). The patient was brought to the ED after he had jumped from a balcony into a river. A medical screening examination was completed on the patient by a Qualified Medical Provider (QMP). The patient was placed under a 6404 (involuntary psychiatric commitment) and was held in the ED awaiting transfer to an inpatient psychiatric facility. On 9/19/2021 at 2:04 AM, the patient eloped from the ED. He was located and brought back into the ED and given Geodon (medication used to treat acute psychiatric behaviors). At 6:29 AM, the patient eloped for a second time. He ran out of the ED into the parking lot, was located, and was brought back into the ED for treatment and monitoring. At 9:12 PM, the patient eloped for a third time through the Emergency Medical Services (EMS) entrance bay where he ran across the helipad into an adjacent field. The facility staff were unable to locate him. The local police department and a facility security officer attempted to locate the patient but were unsuccessful. At 10:02 PM, the patient was found at a local concrete company (approximately 3-4 blocks from the facility) where he had climbed a silo and jumped approximately 30-50 feet. EMS responded and found the patient unconscious with multiple traumas. He required intubation (insertion of a breathing tube) and was transported to Hospital B where he expired at 11:40 PM.

During a conference with the Administrator, the Quality Manager, and the Emergency Department Nurse Manager on 9/28/2021 at 1:45 PM, the facility was informed of an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation, has caused, or is likely to cause injury, harm, impairment, or death) at 42 CFR PART 482.23, Conditions of Participation, Nursing Services.

During a conference with the Administrator, the Director of Nursing, the Quality Manger, the Risk Manager, the Corporate Chief Nursing Officer, and the System Quality and Patient Safety Officer on 9/29/2021 at 1:25 PM, in the conference room, the facility presented an Immediate Action Plan, which removed the Immediate Jeopardy. Review of the Immediate Jeopardy Action Plan, showed the following actions:

1. Written Risk Assessment on ambulance bay for entrance/exit of patients by the safety officer. The Safety Officer was onsite on 9/29/2021. The onsite Risk Assessment will be completed by the Safety Officer, the ED Nurse Manager, the Quality Manager, and the Administrator. A follow up evaluation will be completed on 10/1/2021.
2. Inactivation of automatic ambulance bay door when suicidal patients present in the ED.
3. Education provided to all ED staff members by the ED Nurse Manager. The training was implemented on 9/28/2021. The education included the following:
a) Review of sitter expectations and guidance for sitters
b) Sitters to be stationed at the end of the bed within arm's length of the patients at all times to include showers and bathroom
c) Review of the facility policy "Patient Care Concerns and Chain of Command"
d) Education on keypad entry installed on the doors at the EMS entrance/exit
e) The education sign-in sheets and attestation forms dated 9/28/2021 and 9/29/2021 showed 27 of the 60 ED staff had completed the training.
f) Installation of keypad on the ED ambulance entrance/exit bay doors. The safety officer and contractor were responsible for installation of the keypad installed on 9/29/2021
4. Observation on 9/29/2021 at 12:20 PM showed the keypad was installed on the entrance/exit door in the ED. There was an electronic lock located at the ED Nurses station. The contracted company was installing the wiring for the door at the time of the observation. The Safety Director was responsible for ensuring regulatory compliance with the keypad and routine maintenance.
5. Educate staff on Escalation of Patient Care Concerns using the Chain of Command policy, suicide prevention policy, and elopement policy which included notification of the nursing staff and the physician for escalating behaviors.
a) Educate staff on policy with specific emphasis on the proper chain of command, suicide prevention, and elopement. Staff will notify the manager immediately upon arrival of a suicidal patient. If the manager is unavailable, staff will notify the administrator on call.
6. The education will be presented to the staff by the ED Nurse Manager. The training was started 9/28/2021 and will be completed by 10/1/2021 with 100% of the ED staff. All new hires will receive the training. Review of the sign-in sheets and attestation forms dated 9/28/2021-9/29/2021 showed 27 of the 60 ED staff members had completed the training.
7. Educate all staff on sitter expectation guidelines
a) The training included the following: a report will be given to the Registered Nurse (RN), the sitter, and security officer for all suicidal patients; the nurse will provide breaks for the sitters; no physical barriers between the patient and the staff member; 1:1 (one on one) observation; sitter must sit between the patient and the doorway; the sitter observes one patient only; sitter will accompany the patient to the shower, baths, toileting; staff will observe the patient while the patient is sleeping; staff will restrict the patient to the unit only; patient may not leave the building at any time.
b) Any staff member who will be functioning as a 1:1 sitter will be required to complete the training
8. The training will be completed by 10/1/2021 for 100% of the ED staff and any team member who may provide sitter services. Review of the sign-in sheets and attestation forms dated 9/28/2021-9/29/2021 showed 27 of the 60 ED staff members had completed the training.
9. Monitoring compliance:
a) 100% of suicide patient charts will be audited on a daily basis by the ED Nurse Manager
b) Use of the Suicide Risk Tracer for observation and documentation tool will be used to assess compliance.
c) 100% of the reviews must meet the requirements on the monitoring tool
d) The chart review and monitoring will start 9/28/2021. This will be an ongoing process.
e) Audit 100% of Suicide charts using the Joint Commission chart tracer and observation audits.
f) Review of the monitoring tools showed the facility had a tracer tool to assess compliance. Sitter will be placed at the end of the stretcher within arm's length at all times for suicidal patients. This was implemented on 9/28/2021. Education was implemented on 9/28/2021 by the ED Nurse Manager
10. Observation in the ED on 9/29/2021 showed the sitters were located at the patients' bedside for 3 patients observed.
11. Nurses to assess for the need for a patient to be moved to a less stimulating environment as staff and resources are available. This would include non-violent patients, patients who may be hyper stimulated by extra stimulus, patients exhibiting escalating behaviors causing agitation/irritation
a) Educate all ER staff and providers to the plan through group meetings, 1:1 with facility leadership and read and sign confirmation.
b) Education was implemented on 9/29/2021 by the ED Nurse Manager and administrative staff.
c) During an interview on 9/29/2021 at 12:45 PM, the Administrator confirmed the ED Medical Director was contacted regarding the use of the Intensive Care Unit (ICU) space for patients who needed a less stimulating environment. The ICU was currently unoccupied. The ED physicians would be responsible for the care of the ED patients moved to the ICU. Training for the ED Physicians implemented on 9/29/2021 with a completion date of 10/1/2021.
12. Observation on 9/29/2021 at 12:30 PM in the ED, showed 1 patient currently under a 6404 hold. The sitter was sitting at the patient's bedside. A keypad had been installed at the EMS exit door and the wiring was being completed by the contracted company. All other doors upon entrance and exit to the ED were secured and required a badge entry to enter and exit the ED.
13. Observation on 9/29/2021 at 1:00 PM in the ICU, showed 2 patients who were 6404 holds. The patients were currently monitored by sitters who were at the patient's bedside.
14. Flow of oversight
a) Hospital A's Quality Committee
b) Regional Quality Council
c) Medical Executive Committee
d) Hospital A's Board of Directors

During an interview on 9/29/2021 at 1:15 PM, the Administrator and the Quality Manager stated the facility had implemented the action plan and the training had started for the ED staff. The sitters were positioned at the patient's bedside and were within an arm's length of the patient. The staff were provided education regarding suicide precautions, elopement precautions, and the proper chain of command for patients whose behaviors worsened. The training will be completed by 100% of the ED staff by 10/1/2021. A keypad was placed at the exit doors of the EMS entrance bay to ensure suicidal patients were unable to egress through the EMS entrance. The installation met the safety director's approval to ensure regulatory compliance. Patients who needed a less stimulating environment could be moved to the ICU with a staff member serving as a sitter and oversight by the ED licensed staff and the ED Physician. Those patients will be screened by the ED Physician, the ED Nurse Manager, or the Administrator on Call prior to being moved. The ED Nurse Manager or Administrator on Call will be notified by the ED staff of any suicidal patient who was admitted to the ED. The ED Nurse Manager will assess compliance through chart review and direct observations for 100% of all suicidal patients. The findings will be submitted to the facility's Quality Management, the regional Quality Management, the Medical Executive Committee, and the facility's Board of Directors.

Review of the Immediate Jeopardy Action Plan revealed immediate actions were implemented by the facility and the Immediate Jeopardy was removed on 9/29/2021. The facility remains out of compliance at 42 CFR PART 482.23, Conditions of Participation, Nursing Services (Condition).

Refer to A-0395

Based on review of facility policy, medical record review, review of facility video recordings, and interviews, the facility failed to provide nursing supervision to prevent an elopement of 1 patient (Patient #1) with suicidal ideations of 5 patients reviewed for suicidal ideations of 10 patients reviewed.

The findings included:

Review of the facility's policy titled "Suicide Prevention," last revised on 1/2021, showed "...the hospital conducts an annual assessment of the environment to identify any risks related to the environment that could potentially contribute to a patient's plan to make a physical attempt to commit suicide...if boarding the patient in an acute care setting while awaiting care for behavioral conditions the hospital will take actions to minimize potential harm to self or others..."

Review of the facility's policy titled "Patient Sitters," last revised 1/9/2021, showed "...patient sitter: associate trained by the hospital to protect patients from harming themselves or others...constantly observes the patient and reports behavior...when sitting with suicidal patients: never leave patient unattended...patient must be within arm's length of the sitter...must be in the line of site at all times...sits between the patient and the door for a safe exit..."

Medical record review showed Patient #1 was admitted to the Emergency Department (ED) at Facility A on 9/18/2021 for a Psychiatric evaluation.

Medical record review of an ED Nurse's Triage Note dated 9/18/2021 at 3:37 PM showed the patient presented to the ED by Emergency Medical Services (EMS) after he had jumped from a balcony into a river. The patient stated "...I feel like I am not good enough and that I am a disappointment to my family..." He was triaged with an Emergency Severity Index (ESI) score of a 2 indicating emergent needs. The Columbia Suicide Severity Rating Scale (tool used to determine suicidal risk) showed the patient was at high risk for suicide.

Medical record review of an ED Nurse's Note dated 9/18/2021 at 5:23 PM showed "...talked with pt.'s [patient's] father, father reports pt. was acting himself this morning and just prior to the incident that brought the pt. to the ED today pt. suddenly changed. Father reports pt. does hear voices and was treated previously for cutting on his arms. Dad states 'he said he was trying to cut a woman out of his arms'..."

Medical record review of a Mobile Crisis Consult dated 9/18/2021 at 5:40 PM, showed a Mobile Crisis Consult was performed via telephone. The patient stated he was suicidal, he had auditory and visual hallucinations, he was depressed, and he had anxiety. He jumped into the river in a suicide attempt. When asked by the counselor if the patient was alright to speak about the events, the patient put the phone down and a Licensed Practical Nurse (LPN) could he heard asking the patient why are you putting the pencil up to your eye. "...Ct [client] was guarded and crying...had suicide attempts and self-harm this year. Ct. recommended 6404 [behavioral health involuntary commitment]. ED Physician is in agreement with 6404...[patient] will be referred for inpatient admission..."

Medical record review of an ED Physician's Record dated 9/18/2021 at 5:55 PM, showed Patient #1 had a history of Schizophrenia (mental illness) and previous suicide attempts. He presented to the ED by EMS after he jumped off a balcony into a river. The patient "...felt like he was a disappointment to his family and was trying to end his pain. Patient had recently been hearing voices but today states that it was the voices that told him to jump..." His physical examination showed no acute findings other than he was depressed. The patient's diagnoses included Schizophrenia, Suicidal Ideations, and Major Depression and he was placed under a 6404 with a plan to transfer the patient to an inpatient psychiatric facility.

Medical record review of an Involuntary Commitment Form 6404 dated 9/18/2021 at 6:00 PM, showed the ED Physician signed the form for the commitment of Patient #1 for major depression with a suicide attempt. The ED Physician stated the patient had "...depression anxiety, suicide attempt, had been hearing voices telling him to do things the past several days..."

Medical record review of an ED Nurse's Note dated 9/18/2021 at 6:03 PM showed "...[mobile] Crisis on phone to talk to pt. Pt. began talking to crisis and became tearful...."

Medical record review of an ED Nurse's Note dated 9/19/2021 at 2:04 AM showed "...pt. got out of bed and ambulated past nursing station looking at nurses, moving toward the ambulance bay, then started running out back bay...tried to talk to the patient..."

Medical record review of an ED Physician's Addendum Note dated 9/19/2021 at 2:05 AM showed "...while I was in the doctor's lounge, pt. announced that he was going to leave and despite their [staff] attempts to convince him to stay, he walked out the ambulance bay with security trailing behind him. The police have been notified are reportedly enroute now...[2:11 AM] pt. has returned to his bed in the ED. Will provide sedation at this time and continue to monitor closely..."

Medical record review of the ED Medication Administration Record dated 9/19/2021 at 2:26 AM showed the patient was given Geodon (antipsychotic medication) intramuscular (IM).

Medical record review of an ED Nurse's Note dated 9/19/2021 at 6:29 AM showed "...called security and police department to notify them that pt. eloped [second time]. Pt. in paper scrubs. Nursing staff and MD [medical doctor] tried to reason with pt. regarding fleeing, telling him that police had been called. He continued to run away..."

Medical record review of an ED Nurse's Note dated 9/19/2021 at 6:30 AM showed "...pt. was escorted through front door by security to fast track, police department came through ambulance bay...pt. tried to charge through police officers that were standing in hallway in front of his bed....Police officers had to speak with patient and explain to him the 6404 document and the reasoning he could not leave..."

Medical record review of an ED Nurse's Note dated 9/19/2021 at 9:12 PM (documented on 9/20/2021 at 9:58 AM) showed the patient eloped a third time and the staff "...chased patient...out of the EMS doors and into the parking lot. Pt. ran across the Helipad and towards [named drug store]. Pt. sat down on side of the road. Security Officer came out EMS doors from ER [emergency room] and I told her which way patient ran. Pt. ran in behind [named Drug store] and I could no longer see him. I called 911 [emergency services] on my cell phone to give law enforcement a direction of travel of the patient at 9:18 PM..."

Medical record review of an EMS record dated 9/19/2021 11:00 PM showed EMS was dispatched to Facility A at 10:04 PM for a patient who had "...fallen from approximately 30-50 feet from atop...concrete silo...Patient had bleeding from the mouth and nose, mangled extremities lower, unresponsive but breathing. He had multiply [multiple] abrasions and lacerations on his body. His lower extremities appeared deformed. He appeared to have blood on his head and possible crepitus on the face and right side of his head. His airway was open but bleeding from the mouth and nose. He was laying on his right side. There were multiple traumatic injuries..." Further review showed "...I have not confirmed this information at the time of writing but I was told on the scene he [Patient #1] had been at [Facility A] and was a 6404 patient and had been treated for suicidal ideations...he had bolted from the hospital and they had been looking for him and this is how he was found..." Further review showed the patient was unresponsive to verbal or tactile stimulation and was combative. The patient was intubated by EMS. He required continuous suctioning of the mouth and nose and his lower extremity was splinted for transport. The decision was made by EMS to transport the patient to Facility B because the patient was intubated and Facility B was the closest facility with an Intensive Care Unit and capabilities to assess and treat the patient for multiple traumas.

Review of the ED video recording dated 9/19/2021 showed the following:
8:28 PM: Patient #1 was in ED Fast Track room 3 with a sitter sitting in a chair across from the patient which was approximately 6 feet from the patient. The patient was not visualized on the video.
8:53 PM: A local police department officer was at the patient's bedside talking to the patient.
8:56 PM: the police officer left the patient's bedside.
9:07 PM: the sitter went to the patient's bedside and spoke with the patient
9:15 PM: the patient was seen in the hallway of the ED and ran out the EMS entrance/exit doors

Medical record review of the ED Disposition Note at Facility A dated 9/20/2021 at 5:28 AM showed "...was on 6404 and eloped out of the trauma bay..."

Medical record review of an ED Nurse's Note at Facility A dated 9/20/2021 at 4:58 PM showed "...patient's father arrived in the ED requesting update on his son. I advised him that he would have to contact [Hospital B]. Patient's personal belongings were released to father..."

Medical record review showed the patient was admitted to Facility B on 9/19/2021 at 11:13 PM.

Medical record review of an ED Nursing Triage record from Facility B dated 9/19/2021 at 11:14 PM showed the patient presented by EMS after a fall from 35-40 feet where he had been intubated and had bilateral leg injuries. Patient #1 was triaged using the Emergency Severity Index with a score of 1, indicating emergent needs.

Medical record review of an ED Physician's Record at Facility B dated 9/19/2021 at 11:12 PM and documented on 9/20/2021 at 12:22 AM showed "...unresponsive, scalp laceration without active bleeding. Pupils dilated and fixed...nasal crepitus [abnormal popping or crackling sound] noted, bilateral nasal bleeding...Left hip externally rotated, left thigh swollen, left tib/fib [tibia/fibula] contusions, left ankle swelling, left foot swollen and cold without pulses, right leg and knee abrasions, foot warm but without pulses..."

Medical record review of the ED Nurse's Notes at Facility B dated 9/19/2021 showed the following:
11:39 PM: the patient suffered a cardiac arrest.
11:40 PM: the patient was pronounced dead by the ED Physician.

During an interview on 9/27/2021 at 1:50 PM, the ED Nurse Manager stated the patient was brought to the ED by EMS after he had jumped from a balcony into the river. He was brought to the ED for evaluation and possible inpatient psychiatric transfer. The patient was alert and oriented but appeared to be depressed. He was evaluated by the ED Physician and Mobile Crisis and placed under a 6404 with a sitter placed with him. The ED Nurse Manager stated "...he had multiple elopement attempts while in the ED. The first attempt was on 9/19/2021 around 2:00 AM where he ran out the ED EMS entrance...the police came and just a few minutes later our security officer brought him through the main entrance and took him to his bed. The ED Physician saw the patient and he was given Geodon IM. The second time the patient got upset and ran out the door but was detained by security and calmed down...the third elopement was around 9:20 on 9/19/2021...the patient jumped off the stretcher and ran out the EMS entrance doors even when the sitter and RN [Registered Nurse] was trying to talk to him. He ran across the Helipad into the field. The RN was watching him and could see him. The RN called 911 and told them the patient had eloped...to see if they could get the patient and bring him back. They lost sight of him and the local police were continuing to search for him..."

During an interview conducted through a video conference on 9/27/2021 at 2:10 PM, the Risk Manager stated the facility was made aware of the patient elopement on 9/20/2021 after the ED RN called the Administrator. The Risk Manager was notified by the Administrator of the patient's elopement on 9/20/2021.

During an interview on 9/27/2021 at 3:00 PM, RN #1 stated the patient presented to the ED with a suicidal attempt and had a history of suicide attempts and Schizophrenia. RN #1 stated "...he had tried to elope two times...I was in the nurses station...I heard the sitter yell 'he's running' and when I looked up, the patient was running down the hallway toward the EMS entrance. I ran after him but by that time he had gotten out the doors and was running across the helipad into the adjacent field. I was outside in the EMS entrance and could see the patient sitting down at the edge of the road. It looked like he was taking his socks off, as it was raining and very wet outside. I called 911 from my cell phone and told them the patient had ran out the ED and we could not catch the patient. By this time, our security officer had arrived in the EMS entrance, I showed her where the patient was, but by this time he had ran in behind the local pharmacy and we could not see him..."

During an interview on 9/27/2021 at 3:25 PM, the Administrator stated he received a call early in the morning on 9/20/2021 from the ED Nurse who stated the patient eloped on 9/19/2021 and the patient may have jumped from a silo. The Administrator stated EMS and local police confirmed it was Patient #1 who had jumped. Patient #1 was transported to Facility B on 9/19/2021 after the incident where he expired. The Administrator stated "...I sent an email out the next morning [9/20/2021] to our Administrative Staff, Quality Management, and Risk Management, stating we needed to start an investigation and we planned to meet about the incident..."

During an interview on 9/28/2021 at 10:50 AM, RN #2 stated the patient was under a 6404. He had been evaluated by Mobile Crisis and was waiting on medical clearance and acceptance at an inpatient psychiatric facility. She stated the patient eloped on 9/19/2021 at 2:00 AM and was found by the security officer and brought back into the ED just minutes after his elopement. The patient was given Geodon IM to help him calm down. RN #2 stated the patient got upset around 6:30 AM and had to be talked down after he had attempted to leave. She stated "...on 9/19/2021, the sitter went to his bedside to check on him and thought he might be escalating, so she stepped back to monitor him. I was in another room and heard the sitter yell 'he's running' and by the time I got out the nurse's station, the patient had already bolted out the EMS entrance doors. The other RN was outside watching him...he had called 911 and the sitter had alerted dispatch the patient had eloped. We called our security and she went outside and was looking for him. About 40 minutes later we heard the EMS tones go out for someone who had allegedly jumped from a silo which was very close the hospital...I knew there a good chance this might be our patient..." She stated the local police and EMS came to the ED and were asking questions about the patient and they confirmed the patient had jumped from the silo. He had multiple traumas and was taken to Facility B and he had expired. She stated the patient did not have any family with him and confirmed she had not notified the family of the patient's elopement and the facility was unable to locate the patient. She stated "...later around 4:00 AM [6.5 hours after the patient had eloped] I called the administrator and told him of the incident..."

During an interview on 9/28/2021 at 10:15 AM, the Quality Manager and the ED Nurse Manager stated an investigation was started on 9/20/2021. A Risk Assessment had been completed, which showed the Fast Track (hallway) stretcher beds were in direct sight of the EMS exit doors by patients in the hallway stretchers. The EMS entrance doors opened automatically and no barrier was present to prevent a patient from running out the doors and eloping.

During a telephone interview on 9/28/2021 at 11:59 AM, ED Physician #1 stated the patient was admitted for a Suicidal Attempt and was placed under a 6404 on admission. The patient eloped on 9/19/2021 around 2:00 AM and was brought back into the ED by the security officer. Around 6:30 AM the patient tried to get out of the bed and the local police was trying to hold him in the bed and the facility was able to calm the patient down. On 9/19/2021 around 9:20 PM the patient eloped from the ED and "...bolted out the EMS doors and ran from the staff...I was notified the patient had eloped and the RN was outside looking for the patient..." Later the ED staff was notified by the local police and EMS that Patient #1 had jumped from a silo to the ground and his condition looked very bad. EMS told the ED staff the patient had been taken to Facility B and had expired.

During a telephone interview on 9/28/2021 at 3:15 PM, Security Officer #1 stated the patient tried to elope from the ED early in the morning on 9/19/2021 and they were able to get him back into the ED. She stated "...on 9/19/2021 around 9:20-9:30 PM, the staff told me the patient had eloped and the RN was in the EMS entrance bay trying to follow the patient. I went outside and the RN showed me where the patient was and said he had called the local police. I could see the patient at the end of the road and he was not coming back toward us...he was running down toward the pharmacy. I went to the property line and was trying to keep him in my line of sight but I lost him. I could see a shadow around the trash can at the pharmacy, but was not sure if it was him. The local police came down the road at that time and I tried to shine my flashlight toward the area I thought the patient had ran toward. At that time I saw the patient running. He was looking back toward us and kept running. The police went toward the area where he was at. They came by and I told them the patient was in paper scrubs and gave them a description of the patient..." The local police department came to the ED and informed the security officer the patient had jumped from the silo. EMS told the facility staff the patient had jumped or fell from the silo and his condition was "terminal." Security Officer #1 stated "...there is not a lot of space in the ED. The patients were only separated by a curtain and were in direct visualization of the EMS entrance door, which presented a direct line of sight for elopement..."

During a telephone interview on 9/29/2021 at 10:15 AM, LPN #1 stated the patient eloped on 9/19/2021 early in the morning and the facility was able to return the patient to the ED. She stated "...the second night I was asked to sit with him...two police officers came to talk to him about the incident that happened the night before and his whole demeanor changed after that...he sat upon the side of the bed and got up off the stretcher. At that point, he took off and started running toward the EMS entrance doors. I yelled 'he's running' and the RN came out of the room and ran after the patient. I called dispatch and told them the patient had eloped...the patient starting yelling 'I don't know what to do anymore'...we had heard after that the patient had jumped from a silo and had expired..."