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Based on review of medical records (MR), review of facility documents, and interview with staff, it was determined the facility failed to implement it's policy and procedure for the care of a suicidal patient, resulting in patient elopement in one of one medical record reviewed of a suicidal patient. This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to patients.

On October 24, 2024, at 2:55 PM, an IJ was identified for the facility's failure to follow it's policy and procedure on the care of a patient identified at high risk for suicide (A-0144). On October 24, 2024, at 3:23 PM, the IJ template was presented to administration and a removal plan was requested. On October 24, 2024, at 1:59 PM, an acceptable removal plan was received. The facility implemented the following to address the IJ: Re-education to all emergency department (ED) staff on the policy, "Suicide- Risk Screen/Assessment Self Harm/Suicide," for the care of a patient in the ED that is identified as at risk for suicide. The IJ was removed on October 25, 2024, at 2:25 PM, after the State Survey Agency verified full implementation of the removal plan. Condition Level non-compliance remains (A0144).

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on Medical Record Review, staff interview, and review of facility documents, it was determined the facility failed to ensure patients that present to the facility's emergency department (ED) are triaged and assessed per facility policy.

Cross reference:
489.55(a): Policies and procedures governing medical care

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to implement it's policy and procedure for the care of a suicidal patient, resulting in patient elopement in one of one medical record reviewed of a suicidal patient.

Findings include:

On 10/24/24 at 11:00 AM, the medical record of Patient (P) 20 was reviewed. P20 presented to the facility emergency department (ED) on 7/4/24 at 8:13 PM with complaints of alcohol withdrawal and wanting detoxification. The patient's chief complaint was updated at 8:35 PM by Staff (S) 14, Triage Nurse, to include "Suicidal." P20 was assessed to be a high risk per the Columbia Scale [a tool used to determine a patient's risk of suicide]. The medical record lacked evidence of the following: interventions, in place, to ensure a safe environment for the patient; a patient observer to monitor the patient; and documentation of patient monitoring at least every 15 minutes. At 11:56 PM, S22, ED Nurse, documented, "Pt [patient] eloped from ER [emergency room]. This RN [registered nurse] call patient phone, went to voicemail. Three phone calls made to pt's [family member], emergency contact. No answer. Charge nurse and MD [medical doctor] aware." At 12:02 AM, S23, ED nurse, documented, "[Town] PD [police department] made aware of patient's elopement."

On 10/24/24 at 11:33 AM, the above findings were shared with S1, Admin Director of Nursing. S1 confirmed the medical record was lacking documentation of interventions, a monitoring flow sheet, and notes from a patient observer. At 1:47 PM, S1 and S5, Manager of Quality and Performance Improvement, stated that P20's medical record should have contained all of this information. S1 and S5 were unable to provide evidence that a patient observer had been assigned to this patient on 7/4/24.

Facility policy, titled, "Suicide- Rick Screen/Assessment Self Harm/Suicide," revised 8/1/2024, stated, "... Results of the suicide risk screen and assessment will address immediate safety needs and incorporate interventions focused on the safety of the patient ... High Risk severity: Patient with suicidal ideation with intent or intent with a plan in the past month or suicidal behavior within the past 3 months ... The patient is maintained on an appropriate level of observation for the identified risk level ...1:1 Observation - High Risk ... Implement suicide prevention strategies: a. The Patient and Room Environmental Safety Checklist ... will be utilized on every patient identified as low, moderate, or high risk for suicide on admission and every shift ... For patients with moderate or high risk the following measures should be implemented: -Have ALL personal items removed and searched by designated staff -Have attire restricted to a hospital gown -Be assigned a room visible to the nurses' station ..."

Based on staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure patients seeking emergency treatment were triaged by a nurse, according to facility policy, in four of 20 medical records reviewed (Patients (P) 1, 4, 6, 13).

Findings include:

On 10/23/24, 10/24/24 and 10/25/24, medical record review was conducted in the presence of Staff (S)1, Administrative Director of Nursing. The following was noted:

P1 presented to the facility's Emergency (ED) via ambulance on 9/24/24 at 1:20 PM, with hand and ankle pain, after being in a motor vehicle accident. P1 was placed in the ED waiting room. At 2:10 PM a note in the medical record stated, "Advised by registration that the patient was outside yelling as well as [patient's spouse]. Security to go to the waiting room. Patient shouted to security and ED tech that [patient] was having shortness of breath. Speaking in full sentences, vital signa [sic] obtained." A nursing note at 2:53 PM stated, "Patient was not found in waiting room."

The medical record of P1 lacked evidence that the patient's vital signs contained an assessment of pain, and lacked evidence of an ED nursing triage or assessment, prior to the patient leaving the facility one hour and 33 minutes after arrival.

P6 presented to the facility ED on 9/22/24 at 3:40 PM with complaints of weakness and low blood pressure. A nurse's note at 5:38 PM stated, "ED registration staff reports pt [patient] has voluntarily departed the ED. Pt. to be dismissed."

The medical record of P6 lacked evidence of an ED nursing triage or an assessment prior to the patient leaving the facility one hour and 58 minutes after arrival.

A tour of the ED Waiting room was conducted on 10/23/24 at 12:00 PM, in the presence of S1, Admin Director of Nursing. At the time of the tour, there was no staff member in the triage room. Upon asking who the triage nurse was, S1 stated the charge nurse could take on the triage nurse's responsibilities if there was no one staff member designated as a triage nurse. An interview with S6 at 12:20 PM, ED Charge Nurse, confirmed the charge nurse's responsibilities when there is no triage nurse. S6 stated he/she would remain in the main ED and would monitor a board that tracks patients once they come to the facility and have seen registration. S6 stated he/she would then assess and triage the patient. S6 stated that registration (present in the ED waiting room), would call S6 if the patient seems to be a higher level of acuity or if a patient has been waiting in the waiting room and needs additional assistance and need to be seen quicker.


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A review of P4's medical record revealed P4 arrived to the ED on 9/22/24 at 4:08 PM, seeking treatment for vomiting and an esophagus issue. P4 was fully registered at 4:30 PM. There was no evidence in P4's medical record of triage or a medical screening exam (MSE). P4 left without treatment. The medical record had a discharge time of 7:26 PM.

P13 had three ED visits during the time period of 10/21/24 and 10/22/24. Two of the three visit records for P13 revealed P13 left the hospital without treatment. P13 presented to the ED on 10/21/24 at 10:14 PM for alcohol withdrawal. P13 was fully registered at 10:58 PM. The medical record, on the 10/21/24 visit, lacked evidence of a triage assessment or any other stabilizing interventions of treatment before the patient left without being seen on 10/22/24 at 12:54 AM. P13 returned to the ED on 10/22/24 at 10:39 AM for alcohol detox. P13 was fully registered at 10:45 AM. At 11:57 AM, P13's medical record indicated the triage nurse called for the patient in the waiting room but could not find him/her. The medical record on this visit lacked evidence of a triage assessment or any other stabilizing interventions of treatment before the patient left without being seen on 10/22/24 at 11:57 AM. On 10/22/24 at 1:35 PM, P13 returned for alcohol detoxification and a Librium prescription. P13 was fully registered at 1:44 PM. P13 waited 1 hour and 40 minutes to be triaged at 3:14 PM.

On 10/24/24 at 11:38 AM, an interview was conducted with S15, Clinical Coordinator. S15 explained that the time goal of triage is to get to patients as soon as possible. According to S15, if there is a delay, it is due to multiple triages in the main ED or multiple ambulance arrivals. S15 reported that patients in the waiting room are reassessed every two hours for any notable changes. S15 further explained that the reassessment was eyes only unless a notable change was found. If there is a notable change, the triage nurse repeats vital signs and finds the patient a bed. S15 explained that the triage nurse is designated to monitor the patients in the waiting room. According to S15, if the triage RN observed a patient attempting to leave without being seen, he/she should have a conversation with the patient to encourage them to stay and be treated.

Facility policy titled, "Assessment: Nursing Protocol" last reviewed on 8/29/23 stated, "Policy Statement: It is the policy of [Facility Name] to assess all patient parameters rapidly but thoroughly to ensure priority needs and to prevent decompensation or death. The process emphasizes the patient's chief complaint and their subjective symptoms. The initial assessment is to be documented by the RN [Registered Nurse] on the nursing assessment form in the electronic medical record [EMR] within 1 hour of patient arrival ..."

Facility policy titled, "Triage in the Emergency Department (ED)" last reviewed on 10/19/22 stated, "Policy: 1. Triage involves a rapid patient evaluation to determine the acuity level for each patient arriving in the Emergency Department ..."


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