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Based on observation, interview and record review, the facility failed to comply with CFR 482.24, the EMTALA requirements.

Findings:

The hospital failed to provide a) appropriate and timely Medical Screening Exams (MSE) to determine the presence of an emergent medical condition (EMC) and b) initial and ongoing assessments, interventions and monitoring to ensure the EMC was stabilized for patients who presented to the Emergency Department (ED) with psychiatric emergencies between 5/19/09 and 4/12/10.

Findings:

1) Patient 1:
a) was not initially assessed and placed at the appropriate level of acuity (Cross Reference A2406),
b) was delayed in receiving an MSE to determine whether an emergent medical condition existed (Cross reference A2406)
c) ensure an additional 10 patients who were logged on the the ED log with the disposition as LWBS/VW (Left Without Being Seen/Voluntary Withdrawal) were provided with an appropriate MSE and when the patient LWBS/VW was provided with information by a licensed staff member of the possible risks of leaving the ED before receiving an MSE, (Cross reference A2406) and
d) did not receive ongoing re-assessments and monitoring to ensure the emergent medical condition was stabilized and Patient 1 was protected from harming herself (Cross reference A2407).

Patient 1 eloped from the ED in a stolen ambulance and died at the scene as a result of bullet wounds in an encounter with law enforcement.

2) Sixteen of 48 sampled patients who presented to the ED with psychiatric emergencies, including suicidal ideations and altered level of consciousness:
a) were not initially assessed and placed at the appropriate level of acuity, (Cross reference A2406) and
b) were delayed in receiving an MSE to determine whether an emergent medical condition existed (Cross reference A2406).

3) Eleven of 48 sampled patients who presented to the ED with psychiatric emergencies, including suicidal ideations and altered level of consciousness:
a) were not provided ongoing re-assessments and monitoring to ensure the condition was stabilized and there was no potential for harm (Cross reference A2407).

Based on interviews and policy review, the facility failed to:

a) ensure 16 of 59 sampled patients (1, 2, 9, 11, 19, 23, 25, 27, 28, 33, 36, 39, 40, 41, 43, 47) who presented to the ED between 5/16/09 and 4/12/10 with a psychiatric emergency or altered mental status received an appropriate and timely MSE. The ED staff failed to appropriately triage (a process for determining the priority of patients to be seen) ED patients as stipulated by the 1) Emergency Services P&P titled ED Triage & Acuity Scale, Addendum dated 11/7/09 and 2) Emergency Services P&P titled Patient Classification Plan, Addendum D1, dated 2/20/08 which defined five levels of Triage Classification.

Immediate Jeopardy (IJ) was called on 4/15/10 at 4:48 p.m. as a direct result of the hospital's failure to ensure systems were in place so all patients presenting to the ED with psychiatric emergencies were a) triaged with an appropriate assessment to determine whether an emergent medical condition existed and b) provided ongoing assessments and monitoring to ensure no further deterioration of the condition which would place patients at the potential for harm. This failure constituted Immediate Jeopardy to patient health and safety.

The IJ was lifted on 4/16/10 at 5:00 p.m. after the hospital submitted and implemented an acceptable Plan of Correction (POC).

Findings:

a)
1. Patient 1, a 39 year old, presented to the ED on 3/27/10 at 7:35 p.m. for a medical clearance prior to admission to a psychiatric facility. Patient 1 had been observed by a law enforcement officer walking into traffic and was placed on a 51-50 (a 72 hour involuntary hold) as a) a danger to herself and b) gravely disabled.

The law enforcement officer took her to the county Psychiatric Health Facility (PHF). A mental health worker (MHW 1), in an admission note at the PHF, described Patient 1 as disoriented, experiencing visual disturbances, pacing and assessed her judgement as poor. MHW 1 was able to reach Patient 1's father, who was out of state, and obtain Patient 1's history, including medications. MHW 1 was told Patient 1 was currently under treatment for psychotic and bi-polar disorders. Patient 1's father told MHW 1 "she just needs to take her meds and she will be ok in a few hours".

Patient 1 was triaged shortly after arrival at the hospital ED on 3/27/10 at 7:31 p.m. In a review of the Triage Nursing Record, the chief complaint was noted as "PHF Eval". The Triage Nurse (TN) documented Patient 1 "denies suicidal ideations" but there was no evidence of an assessment for suicidal risks. Patient 1 was assigned a Level III Urgent Medical Condition (a condition described by ED policy with the potential to progress to an emergency and an expectation to see the physician at or under 60 minutes).

In review of an ED P&P titled ED Triage & Acuity Scale, Addendum, dated 11/7/09, the following definitions were present for a patient with an acute psychosis or related psychiatric emergency, including suicidal ideations and an altered level of consciousness:

Level II. Acute psychosis/extreme agitation: "These patients may be suffering from metabolic disturbances, poisoning or other organic problems. If the acute psychosis/agitation is part of a known ongoing psychiatric illness, the patient will benefit from early intervention with antipsychotics, sedatives or, if necessary, physical restraints. Obtain history from patient or other health care providers."

Overdose: "Intentional overdoses are particularly unreliable when trying to determine which agents have been ingested and the actual quantity. These patients require early physician assessment, or advice, with regard to the need for toxic screening, monitoring or methods of prevention absorption, enhancing elimination or the administration of an antidotes."

Level III. Acute psychosis and/or suicidal: "Psychiatric patients, not really agitated but some uncertainty as to whether a threat to themselves or others. May be very emotional but not violent, reasonably cooperative. Some "bi-polars" require safe caring environment and assessment for risk of overdose."

Level IV. Suicidal/Depressed: "Patients complaining of suicidal thoughts or have made gestures but do not seem agitated. Normal vital signs. Because suicidal risk and the possibility of overdose is frequently difficult to accurately define, these patients should have a responsible person staying with them and periodic reassessment should occur. Patients with depression should also be evaluated for their potential for suicide. All providers should show empathy and try to have the patients placed in a quiet and secure area."

In review of an ED P&P titled Patient Classification Plan, Addendum D1, dated 2/20/08, five levels of Triage Classification were defined.

1) Level I (Resuscitation) required immediate aggressive intervention.
2) Level II (Emergent) identified time to physician assessment/interview <15-20 minutes
3) Level III (Urgent) identified a time to physician assessment/interview as <60 minutes.
4) Level IV(Less urgent) time to physician assessment/interview was <2 hours
5) Level V (Non-urgent) was > 2 hours.

In an interview with MHW 1 on 4/7/10 at 1 p.m., she stated she waited with Patient 1 in the waiting room for 90 minutes and Patient 1 became more anxious. At 8:30 p.m., MHW 1 was relieved by another mental health worker (MHW 2) and in an interview with MHW 2 on 4/7/10 at 3 p.m., she stated Patient 1 was "very anxious, very disorganized, very agitated" and "her symptoms were escalating". At approximately 10 p.m. MHW 2 spoke with Patient 1's ED physician (MD 1) informing her that Patient 1 "was getting worse" and asked if Patient 1 could be medicated. MD 1 stated she could not medicate Patient 1 because the Tox screen (a test to determine the level of medications and opiates in the blood) had not come back yet. In a review of Patient 1's lab reports, it was noted that blood was not drawn until 10 p.m.

In a review of the Crisis Notes of five mental health workers (MHW 1, MHW 2, MHW 3, MHW 4, MHW 5) present in the ED from 3/27/10 at 7:30 p.m. until 3/28/10 at 10:12 a.m., following Patient 1's elopement, there were many references to changes in condition and behaviors, including documentation that "symptoms were escalating", "patient cycling rapidly", "increasing anxiety", "increasingly delusional", "highly agitated", "suspicious" and "quite psychotic". In interviews with the five MHW's on 4/7/10 between 1 p.m. and 4 p.m., they described Patient 1 as "a danger to herself" and "gravely disabled". Several of the MHW's stated Patient 1 had said many times she wanted to or had to leave. Note: The Crisis Notes maintained by the MHW's are not included in patients medical records and are not shared with ED staff.

In a review of the nursing notes for 3/27/10 from 7:35 p.m. until 9:05 p.m. when Patient 1 was taken to a room, there was no evidence of a nursing re-assessment by the TN.

In review of a document in the chart titled Physical Exam with Patient 1's identification, no date, time noted as 11:45 p.m., MD 1 described Patient 1 as "pacing in hallway" and "anxious". In a section titled Neuro/Psych: there was documentation Patient 1's thoughts were "tangential and rambling". MD 1 documented the Clinical Impression as Acute Psychosis with paranoid delusions and history of bi-polar disorder. MD 1 also documented a Differential Diagnosis Considered as suicidal vs psychosis.

In an interview with MD 1 on 4/1/10 at 11:15 a.m., she stated she was not aware of a policy for the MSE, including criteria for the assessment of a patient with a psychiatric emergency requiring a medical clearance. MD 1 revealed patients charts are "placed in the rack" (a chart holder) according to triage level and she was not aware of the presence of Patient 1 in the ED for four hours prior to the MSE. MD 1 stated she was aware patients placed at a Level III triage should be seen in 60 minutes, but it was an exceptionally busy night and therefore there was a delay. When asked what else could have been done, she stated she could have considered medicating the patient but thought Patient 1 would be transferred within an hour of the MSE.

In a review of the medical record, there was no evidence that Patient 1 had been seen again by a physician between 3/27/10 at 11:45 p.m. and 3/28/10 at 10:12 a.m. when she eloped. In a continuation of the interview with MD 1, she stated the "physicians would not necessarily see the patient again unless asked to by nursing". In an interview with three ED physicians (MD 2, MD 3, MD 4) on 4/8/10 at 2 p.m., they stated they would not routinely re-assess patients after one hour unless the nurse notified them of a change in the patients condition.

Patient 1 eloped from the ED on 3/28/10 at 10:12 a.m. in a stolen ambulance and died at the scene at approximately 10:25 a.m. as a result of bullet wounds when apprehended by law enforcement. (Time from triage to MSE = 4 hours, 10 minutes)

Immediate Jeopardy (IJ) was called on 4/15/10 at 4:48 p.m. as a direct result of the hospital's failure to ensure systems were in place so all patients presenting to the ED with psychiatric emergencies were a) triaged with an appropriate assessment to determine whether an emergent medical condition existed and b) provided ongoing assessments and monitoring to ensure no further deterioration of the condition which would place patients at the potential for harm. This failure constituted Immediate Jeopardy to patient health and safety.

The IJ was lifted on 4/16/10 at 5:00 p.m. after the hospital submitted and implemented an acceptable Plan of Correction (POC).

2. Fifteen of fifty-nine sampled patients (2, 9, 11, 19, 23, 25, 27, 28, 33, 36, 39, 40, 41, 43, 47) who presented to the ED with a psychiatric emergency between 5/16/09 and 3/27/10 did not receive an appropriate triage and/or timely MSE to determine the presence of an emergent medical condition.

Patient 2 presented to the ED on 4/3/10 after being found unresponsive at home following an overdose of benzodiazepine (a tranquilizer). Patient 2 was triaged as a Level II at 12 a.m. and admitted directly into a room. Patient 2 was responding to painful stimuli only. Lab work was drawn and medications were given at the direction of the physician, however the physician did not perform a MSE until 1:50 a.m., one hour and fifty minutes later. According to the ED triage (level of acuteness) scale, a patient classified as a Level II was to be seen by a physician within 15-20 minutes for early assessment, screening and monitoring.

Patient 9, a 13 year old, presented to the ED on 11/18/09 with complaints of "voices telling her to kill people and to hurt herself". Patient 9 had a history of punching and cutting herself. Patient 9 was triaged as a Level III at 7 p.m. and seen by the physician at 7:50 p.m., 50 minutes later. Patient 9, with a history of agitation, hallucinations and an altered mental status should have been triaged, according to the ED triage scale, as a Level II and seen by the physician within 15-20 minutes.

Patient 11 presented to the ED on 2/27/10 with suicidal ideation. Patient 11 was seen by a triage nurse at 11:47 p.m., triaged at Level III and admitted into a room at 12 a.m. Patient 11 was seen by a physician for the MSE at 2:50 a.m., three hours and three minutes after being triaged. According to the ED triage scale, Patient 11 should have been seen within 60 minutes.

Patient 19 presented to the ED on 4/10/10 with an apparent overdose of Tramadol (a medication for moderate to moderately severe pain) and Ibuprofen (an anti-inflammatory). Patient 19 was triaged at Level III by the triage nurse (TN) although, according to the hospital triage scale, an overdose indicated Patient 19 should have been triaged at Level II for early assessment, treatment and monitoring. It was not possible to ascertain when Patient 19 was seen by the physician due to inaccurate time documentation by either the ED nurse or ED physician in the medical record. The TN noted Patient 19 was placed in a room at 3:24 p.m. but the ED physician noted time seen as 2:55 p.m.

Patient 23 presented to the ED on 8/14/09 with diagnoses of bi-polar disorder, suicidal ideation with depression and alcoholism. Prior to admission, Patient 23 was placed on a 51-50 hold as a danger to herself as she had reported she had not taken her medications and she had stated she was "thinking of killing herself". Patient 23 was triaged at 4:16 p.m. as a Level III. The TN documented Patient 23 was anxious and "tearful". Patient 23 was not seen by the physician for the MSE until 6:50 p.m., two hours and 34 minutes later. According to the ED triage scale, Patient 23 should have been seen within an hour.

Patient 25 presented to the ED on 7/24/09 with a diagnosis of depression. Patient 25 was triaged as a Level III at 4:25 p.m. and the TN noted the blood pressure was 151/118. The TN described the patient's complaint as "crying and suicidal feelings" and revealed that Patient 25 stated she felt like hurting herself by cutting her wrists. The TN checked the box for Psychosocial as calm and cooperative however under the Neuro section she documented Patient 25 was experiencing "mood swings", agitation, irritable, suicidal feeling". Patient 25 remained in the waiting area for two hours and forty minutes and did not receive the MSE until 7:45 p.m., three hours and 20 minutes after triage. Patient 25's blood pressure was not re-taken until she was placed in a room at 7:10 p.m. According to the ED triage scale, Patient 25 should have been triaged as a Level II and seen by the physician in 15-20 minutes.

In an interview with Patient 25's triage nurse (TN 2) on 4/16/10 at 11:55 a.m., she was asked how she determined the level of triage for patients presenting with a psychiatric emergency. TN 2 stated "there is not a science to it". TN 2 stated she "tends to put things at a 3 if going fast". She stated she would "go by vital signs, who they are with, how they are making sense" and whether or not it was busy in the ED. When asked why she had described the patient as agitated and irritable when she checked the box for calm and cooperative, she stated "someone else may have charted that as we don't always have time". TN 2 was asked if she re-assessed patients in the waiting area, particularly if the blood pressure was elevated and she stated she knew she was "supposed to" do re-assessments, but did not always have the time or the assessments "do not get written down".

Patient 27 presented to the ED on 7/5/09 with diagnoses of suicidal ideation and alcohol intoxication. Patient 27 was on a 51-50 as a danger to herself as she had attempted to cut her left wrist and she had told police officers she wanted to kill herself. Patient 27 was triaged at 12:50 a.m. as a Level III. There was no evidence of an assessment or monitoring for behavioral symptoms, including suicidal ideations. Patient 27 was not seen by the physician for the MSE until 2:25 a.m., one hour and 25 minutes after triage. According to the ED triage scale Patient 27 should have been seen by the physician within an hour.

Patient 28 presented to the ED on 6/4/09 with complaints of taking 70 Klonopin tablets (an antianxiety anti-seizure/benzodiazepine) and alcohol intoxication. Patient 28 was seen by the TN at 7:43 p.m. and classified a Level III. According to the ED triage scale Patient 28 should have been triaged at a Level II for early assessment, treatment and monitoring of an overdose. Patient 28 was seen by the physician within 20 minutes, but could have been delayed with an inaccurate classification of Level III for an overdose.

Patient 33 presented to the ED via ambulance on 7/24/09 at 5:30 p.m. for ingestion of 15 Cymbalta (antidepressant) tablets in an attempt to harm herself. Prior to admission, Patient 33 was placed on a 51-50 for a possible suicidal gesture. Patient 33 was triaged as a Level III and was seen by the physician at 7:10 p.m., one hour fifty minutes after admission. According to the ED triage scale, Patient 33 should have been triaged as a Level II and seen by the physician within 15-20 minutes for early assessment, treatment and monitoring.

Patient 36 presented to the ED on 7/7/09 requesting an evaluation for depression and possible suicidal ideation of "jumping in front of a big rig" a few days ago. Patient 36 was initially triaged at 12:40 p.m. at a Level III and put in a room at 2:35 p.m. The physician performed the MSE at 3:35 p.m. According to the ED triage scale Patient 36 should have been seen by a physician within one hour, however it was 2 hours and 55 minutes between triage and time to a physician.

Patient 39 presented to the ED on 10/2/09 with complaints of anxiety, suicidal ideation and hearing voices telling her to kill herself. Patient 39 was triaged at Level III at 2:30 p.m. The physician did not examine Patient 39 until 2 hours later at 4:30 p.m. According to the ED triage scale Patient 39 should have been seen by the physician within an hour.

Patient 40 presented to the ED via ambulance on 4/17/09 at 8:35 p.m. with complaints of an "altered level of consciousness" (ALOC) and "difficulty to arouse". Patient 40 was classified as a Level III and not seen by the physician until 1:40 a.m., five hours and five minutes after admission. Patient 40 required three doses of intravenous Narcan (an opioid antagonist) to improve her level of consciousness. The physician documented a diagnosis of narcotic overdose. According to the ED triage policy, Patient 40 should have been triaged at a Level II to be evaluated for an overdose and seen by the physician in 15 to 20 minutes.

Patient 41 presented to the ED on 4/17/09 with a history of psychosis and diagnoses of depression with suicidal ideations. Patient 41 was on a 51-50 hold as a danger to himself following an overdose of Vicodin, a narcotic medication he takes for chronic pain. Patient 41 was triaged at 3:15 a.m. as a Level IV, a triage defined by policy as Less Urgent. Patient 41, with a history of depression and presenting with an overdose, should have been triaged at a Level II for early assessment and intervention according to the ED triage policy.
Between 3:15 a.m. and 7:00 a.m., there was no evidence of an assessment of suicide risk or prevention. Between 4:00 a.m. and 7:00 a.m., when Patient 41 was transferred to the county PHF, there was no documentation of any ongoing nursing assessments (including vital signs or pain re-assessment), interventions or monitoring.

Patient 43 arrived from the jail to the ED via ambulance on 1/17/10 at 12:15 a.m., after attempting suicide by multiple self-inflicted lacerations to his right forearm and hanging himself in his cell. Patient 43 was complaining of neck pain and arrived on a backboard with his neck immobilized. Patient 43 had a history of depression and anxiety and he had stated, "It was a series of things that made me want to hang myself." Patient 43 was triaged as a Level III at 12:15 a.m. Patient 43 was seen by the ED MD at 1:50 a.m., (which was 1 1/2 hours after arrival to the ED) at which time he received an initial evaluation for spinal trauma.
In a review of Level II criteria for "Severe trauma: These patients may have high-risk mechanisms and severe single system symptoms in each". Patient 43 should have been classified a Level II and seen by the MD in 20 minutes for early intervention and treatment.

Patient 47 presented to the ED on 10/15/09 with complaints of suicidal ideation, right hand laceration and possibly having eaten glass. Patient 47 was triaged and roomed at 10:54 a.m. and classified at a Level II. By 11:30 a.m. Patient 47 was displaying violent outbursts in the ED and was placed in restraints. The physician noted an exam time of 1 p.m. two hours and six minutes after being triaged and roomed. According to the ED triage scale Patient 47 should have been seen by a physician in 15 to 20 minutes.

Based on interviews and policy review, the facility failed to ensure 10 of 59 sampled patients (1, 9, 14, 15, 16, 23, 25, 33, 41, 46) who presented to the ED between 6/17/09 and 4/12/10 with a psychiatric emergency including suicidal ideations or an altered level of consciousness received treatment as required to stabilize the condition within their capabilities. Patients behavioral symptoms indicative of an emergent conditions were not monitored to ensure safety. The medical symptoms exhibited by patients with emergent psychiatric conditions were not monitored closely or at all.

Patient 1 eloped from the ED on 3/28/10 at 10:12 a.m. in a stolen ambulance and died at the scene at approximately 10:25 a.m. as a result of bullet wounds when apprehended by law enforcement.

Immediate Jeopardy (IJ) was called on 4/15/10 at 4:48 p.m. as a direct result of the hospital's failure to ensure systems were in place so all patients presenting to the ED with psychiatric emergencies were a) triaged with an appropriate assessment to determine whether an emergent medical condition existed and b) provided ongoing assessments and monitoring to ensure no further deterioration of the condition which would place patients at the potential for harm. This failure constituted Immediate Jeopardy to patient health and safety.

The IJ was lifted on 4/16/10 at 5:00 p.m. after the hospital submitted and implemented an acceptable Plan of Correction (POC).

Findings:

1. Patient 1, a 39 year old, was admitted to the ED on 3/27/10 at 7:35 p.m. for a medical clearance prior to admission to a psychiatric facility. Patient 1 had been observed by a law enforcement officer walking into traffic and was placed on a 51-50 involuntary hold as a) a danger to herself and b) gravely disabled.

Patient 1 was then taken to the county PHF by law enforcement. MHW 1's, admission note at the PHF, described Patient 1 as disoriented, and experiencing visual disturbances, pacing and assessed her judgment as poor. According to the note, MHW 1 was able to reach Patient 1's father, who was out of state, and obtain Patient 1's history, including medications. MHW 1 was told Patient 1 was currently under treatment for psychotic and bi-polar disorders. Patient 1's father told MHW 1 "she just needs to take her meds and she will be ok in a few hours".

Patient 1 was then brought to the hospital by a MHW and triaged shortly after arrival at the facility on 3/27/10 at 7:31 p.m. In a review of the triage nursing record, the chief complaint was noted as "PHF Eval (to determine if the patient had any medical conditions prior to transferring to a psychiatric facility)". The designated areas for past medical history and medications on the triage sheet were left blank. In a section titled Psychosocial, Patient 1 was assessed to be calm and cooperative. TN 1 documented Patient 1 "denies suicidal ideations" however, there was no evidence of an assessment for suicidal risks.

Patient 1 was assigned a Level III Urgent Medical Condition (a condition described by facility policy with the potential to progress to an emergency and an expectation to see the physician at or under 60 minutes). Patient 1 waited in the lobby for 90 minutes and was then placed in a room.

In an interview with MHW 1 on 4/7/10 at 1 p.m., she stated she waited with Patient 1 in the waiting room for 90 minutes. MHW 1 stated at 8:30 p.m., Patient 1 became more anxious and stated Patient 1 "had a memory" and recalled being assaulted by a man with long gray hair in a trailer park. MHW 1 stated she informed TN 1 of Patient 1's allegation and was told by TN 1 that if Patient 1 wanted to report a rape, she (Patient 1) should call the police. There was no documentation of this allegation or any re-assessment of Patient 1 in the Triage Nursing Record.

At 8:30 p.m., MHW 1 was relieved by MHW 2 and in an interview with MHW 2 on 4/7/10 at 3 p.m., she stated Patient 1 was "very anxious, very disorganized, very agitated" and "her symptoms were escalating". MHW 2 placed a call to the police department and a police officer interviewed Patient 1 at the bedside. There was no documentation of this interview in the nursing record. At approximately 10 p.m., after Patient 1's interview with the police officer, MHW 2 spoke with Patient 1's physician (MD 1) informing her that Patient 1 "was getting worse" and asked if Patient 1 could be medicated. MD 1 stated she could not medicate Patient 1 because the tox screen (a test to determine the level of medications and opiates in the blood) had not come back yet.

In a review of the Crisis Notes of five mental health workers (MHW 1, MHW 2, MHW 3, MHW 4, MHW 5) present in the ED from 3/27/10 at 7:30 p.m. until 3/28/10 at 10:12 a.m., there were many references to changes in condition and behaviors, including documentation that "symptoms were escalating", "patient cycling rapidly", "increasing anxiety", "increasingly delusional", "highly agitated", "suspicious" and "quite psychotic".

In interviews with the five MHW's on 4/7/10 between 1 p.m. and 4 p.m., they described Patient 1 as "a danger to herself" and "gravely disabled". Several of the MHW's stated Patient 1 had said many times she wanted to or had to leave. MHW 2 stated Patient 1 tried to leave shortly after being placed in Bed 1, pushing her to the side and running into the hall. Security was called and Patient 1 was placed in Bed 5, closer to the nursing station. All five MHW's stated their primary responsibility was to obtain placement for Patient 1 in a psychiatric facility and they frequently left Patient 1 unattended to place phone calls in an attempt to find placement.

In an interview with the PHF Program Manager (PM) on 4/1/10 at 9:00 a.m., he stated it was his responsibility to oversee the county Psychiatric Emergency Services (PES) and the PM defined the role of the county regarding the management of patients with psychiatric crises. The PM revealed this was defined in a Memorandum of Understanding with the hospital, the county PES and law enforcement that has been in place for nineteen years with no date of expiration. The PM stated the role of the MHW at the hospital was to facilitate a transport or discharge while providing crisis intervention. The PM stated there was no expectation ("not at all") for the MHW to ensure the safety or well being of the patient.

In a review of the nursing notes for 3/27/10 at 9 p.m. until 3/28/10 at 7 a.m., there was no evidence, with the exception of two hour vital signs, of monitoring of Patient 1 by the nursing staff. There was no documentation Patient 1's condition was escalating with increased anxiety and delusions. There was no evidence of communication between the MHW's and the nursing staff regarding Patient 1's condition.

In an interview with a Security Officer (SO 1) on 4/8/10 at 2:30 p.m., he acknowledged he was aware of the attempted elopement of Patient 1. He stated Patient 1 said "I don't belong here. I don't want to be here". SO 1 also reported that shortly after Patient 1 was placed in Room 5, he observed her standing in the right side corner of the room with her purse in her arms putting a handful of pills in her mouth. SO 1 stated Patient 1 told him she was going to take the pills and he told her she probably shouldn't. SO 1 stated he informed Patient 1's nurse (RN 1) and he was able to talk Patient 1 into spitting them out.

In an interview with a second Security Officer (SO 2) on 4/8/10 at 2:30 p.m., he stated Patient 1 had asked him for a phone to call her father. SO 2 stated Patient 1 told him four times she had to pick up her father at the airport. SO 2 did not recall what time this was. There was no indication that SO 2 informed the nursing staff that Patient 1 wanted to leave the hospital to "pick up her father at the airport". There was no evidence that nursing staff took actions/interventions to prevent Patient 1 from leaving the hospital.

A document titled with Patient 1's name, dated 3/28/10, was identified by the Assistant Administrator (AA) as a personal belongings sheet. The following prescriptive medications were noted to be in Patient 1's purse while in her possession: hydrocodone (a narcotic pain reliever), zolpidem, (Ambien, a sleeping aid) alprazolam, (Xanax an antianxiety medication), lithium (used to treat manic episodes of manic depression) and Benadryl (an antihistamine). There were also three unidentified tablets present in the purse. Patient 1's purse had not been removed from her possession when she was initially moved to Bed 5.

In a review of an undated ED P&P titled Placement of Patients/Bed Assignments, Addendum B, there was direction to place "confused or mental health observation patients" in Beds 4 or 5 for closer observation.

Bed 5 was noted to be approximately 25 feet and in direct line of sight of the staff entrance/exit double doors. The ambulance bay was approximately 20 additional feet outside of the double doors. In an observation during the morning of 3/29/10, there was significant traffic going in and out of the ED through these doors. There was a 30 second delay noted in the closing of the door when opened. The patient restroom was immediately adjacent to the double doors.

In review of a policy titled Suicide Prevention Protocol, Emergency Department, revised 1/10, (which required a physician order for implementation), there were defined measures for Crisis Intervention which included removing patient belongings when a patient was moved to Bed 4 or 5. In a further review of this ED policy, there were defined assessment criteria to identify risk for suicide. This risk assessment applied to patients presenting with many factors including schizophrenia. The ongoing assessment would include the identification of predisposing factors, biological factors and mood changes.

In an interview with RN 1 on 4/7/10 at 7:35 a.m., he stated he was assigned to Patient 1 between 9 p.m. on 3//27/10 and 7 a.m. on 3/28/10. RN 1 described Patient 1's behavior as "calm and cooperative", although"bizarre". RN 1 stated Patient 1 "cycled" throughout the night. When asked what measures he provided to stabilize Patient 1, he stated he took her vital signs and they were stable. RN 1 stated that it was a very busy night and Patient 1 was calm. RN 1 stated "I was looking in on her when I could" and "I am not a psych person". RN 1 acknowledged the only observation he documented was at 11 p.m. when he noted "incontinent of urine, bizarre affect". RN 1 was unable to explain why he failed to follow facility policy, and did not provide close supervision and ongoing monitoring of Patient 1, did not notify the physician or document Patient 1's changes in behavior when Patient 1 attempted to elope and attempted to take a handful of pills.

In review of a document titled Physical Exam with Patient 1's identification, no date, time noted as 11:45 p.m., MD 1 described Patient 1 as "pacing in hallway" and "anxious". In a section titled Neuro/Psych: there was documentation Patient 1's thoughts were "tangential and rambling". MD 1 documented the Clinical Impression as Acute Psychosis with paranoid delusions and history of bi-polar disorder. MD 1 also documented a Differential Diagnosis Considered as suicidal vs psychosis.

In an interview with MD 1 on 4/1/10 at 11:15 a.m., MD 1 described Patient 1 as "fidgety", "anxious" and "confused" and not oriented to her location. MD 1 was asked if Patient 1 had a suicide assessment and she responded, "She was on a 51-50" and she was not suicidal". MD 1 stated she considered medicating Patient 1 with Ativan to "calm her down" but decided against it as "she didn't necessarily need it". MD 1 stated her expectations for the care Patient 1 needed included constant monitoring and a "quiet place" with minimal distractions. MD 1 stated, "in hindsight, she needed one to one supervision" especially if on a 51-50.

In a concurrent interview with the Director of Nursing for Specialty Services (DON 1), she stated "We're not a 51-50 hospital. They (PHF staff, law enforcement) need to stay with the patient and if they leave they need to take the patient off the 51-50".

Further review of Patient 1's medical record showed that there was no evidence that Patient 1 had been seen again by a physician between 3/27/10 at 11:45 p.m. and 3/28/10 at 10:12 a.m. (almost 12 hours). Patient 1 did not receive stabilizing treatment (antianxiety medication, adequate supervision and/or ongoing monitoring of behaviors) while a patient in the ED. She eloped from the ED on 3/28/10 at 10:12 a.m. in a stolen ambulance and died at the scene at approximately 10:25 a.m. as a result of bullet wounds when apprehended by law enforcement.

Immediate Jeopardy (IJ) was called on 4/15/10 at 4:48 p.m. as a direct result of the hospital's failure to ensure systems were in place so all patients presenting to the ED with psychiatric emergencies were a) triaged with an appropriate assessment to determine whether an emergent medical condition existed and b) provided ongoing assessments and monitoring to ensure no further deterioration of the condition which would place patients at the potential for harm. This failure constituted Immediate Jeopardy to patient health and safety.

The IJ was lifted on 4/16/10 at 5:00 p.m. after the hospital submitted and implemented an acceptable Plan of Correction (POC).

2. Patient 9, a 13 year old, presented to the ED on 11/18/09 at 6:52 p.m., with complaints of, "voices telling her to kill people and to hurt herself." Nursing documentation indicated that Patient 9 had a history of punching and cutting herself and prior to admission she had jumped out of a car, attempting to get access to knives. Patient 9 was classified as a Level III and seen by the physician at 7:50 p.m. an hour later. The ED MD requested a mental health consult at 8:10 p.m. which was conducted at 9:00 p.m. The mental health worker put Patient 9 on a 51-50 hold as a danger to herself and she was transferred to a psychiatric in-patient facility at 2:37 a m. Review of Level II presentations included agitation and hallucinations as part of "Altered mental status". There was no evidence of monitoring the patient's behaviors or interventions for suicide risk or further self harm.

3. Patient 14 presented to the ED on 4/6/10 with a history of schizophrenia and bi-polar disorder. Prior to admission, Patient 14 had been placed on a 51-50 hold for "psychotic behavior" as a danger to himself after being found wandering, confused and "not making sense". During triage at 7:45 p.m. Patient 14 was noted to be slow to respond to questions. At 9:00 p.m., the licensed nurse documented Patient 14 was withdrawn and at 9:50 p.m. an additional note stated "appears more withdrawn". At 10:50 p.m. Patient 14 was transferred to an acute psychiatric facility. Between 7:45 p.m. and 10:50 p.m., there was no evidence of monitoring the patient's behaviors for suicide risk or prevention.

4. Patient 15 presented to the ED on 4/12/10 at 1:55 a.m. stating that she took approximately 15 medication tablets (tripezal, lexapro and niacin) in order to kill herself. Patient 15 was evaluated by the mental health worker at 6:00 a.m. and placed on a 51-50 hold. Patient 15 was transferred to a psychiatric facility at 10:31 a.m. on 4/13/10. Patient 15 was a possible overdose with a history of bi-polar disorder. There was no evidence of monitoring behaviors for suicide risk or prevention. There was no documentation Patient 15 had been placed in a secure area and interventions had been taken to prevent her from hurting herself (i.e. removing personal items).

5. Patient 16, a 14 year old, was admitted to the ED on 4/6/10 and reported he had taken 42 Tylenol over a 3 day period. Patient 16 was triaged at 11:15 a.m. and was described as calm and cooperative. Patient 16 eloped after being placed in Room 1. There was no evidence Patient 16, a suicide risk, was provided monitoring or supervision to ensure his safety.

6. Patient 23 presented to the ED on 8/14/09 with diagnoses of bi-polar disorder, suicidal ideation with depression and alcoholism. Prior to admission, Patient 23 was placed on a 51-50 hold as a danger to herself as she had reported she had not taken her medications and she had stated she was "thinking of killing herself". The triage nurse documented Patient 23 was anxious and "tearful". There no evidence of monitoring of the patient's behaviors or interventions for suicide risk or prevention.

7. Patient 25 presented to the ED on 7/24/09 with a diagnosis of depression. Patient 25 was triaged at 4:25 p.m. and the TN noted the blood pressure was 151/118. The TN described the patient's complaint as "crying and suicidal feelings" and revealed that Patient 25 stated she felt like hurting herself by cutting her wrists. The TN checked the box for Psychosocial as calm and cooperative however under the Neuro section she documented Patient 25 was experiencing "mood swings", agitation, irritable, suicidal feeling". Patient 25 (with a history of depression and exhibiting extreme anxiety) remained in the waiting area for two hours and forty minutes. Patient 25's elevated blood pressure was not re-taken (monitored) until she was placed in a room at 7:10 p.m. There was no monitoring of Patient 25 behaviors between 4:25 p.m. and 7:10 p.m. while she remained in the waiting room. At 7:10 p.m., Patient 25 was placed in Room 10, a room not designated for patients requiring close observation.

In an interview with Patient 25's triage nurse (TN 2) on 4/16/10 at 11:55 a.m., she was asked how she determined the level of triage for patients presenting with a psychiatric emergency. TN 2 stated "there is not a science to it". TN 2 stated she "tends to put things at a 3 if going fast". She stated she would "go by vital signs, who they are with, how they are making sense" and whether or not it was busy in the ED. When asked why she had described the patient as agitated and irritable when she checked the box for calm and cooperative, she stated "someone else may have charted that as we don't always have time". TN 2 was asked if she re-assessed patients in the waiting area, particularly if the blood pressure was elevated and she stated she knew she was "supposed to" do re-assessments, but did not always have the time or the assessments "do not get written down".

8. Patient 33 arrived to the ED via ambulance on 7/24/09 for ingestion of 15 Cymbalta (antidepressant) tablets in an attempt to harm herself. Prior to arrival to the ED, Patient 33 had been placed on a 51-50 hold by the police department due to a possible suicide gesture. Patient 33 was triaged incorrectly as a Level III at 5:30 p.m. and placed on a cardiac monitor. At approximately 6:45 p.m., nursing documentation showed that Patient 33 had pulled her IV out and left the ED. Patient 33 was discovered in the parking lot, smoking. Patient 33 was informed of her 51-50 status and returned to the ED. Patient 33, with a history of depression who presented with an overdose, was not monitored for suicide risks. Patient 33 was not closely supervised and eloped to the parking lot to smoke.

9. Patient 41 presented to the ED on 4/17/09 with a history of psychosis and diagnoses of depression with suicidal ideations. Patient 41 was on a 51-50 hold as a danger to himself following an overdose of Vicodin, a narcotic medication he takes for chronic pain. Patient 41 was triaged at 3:15 a.m. incorrectly as a Level IV (Less Urgent) and was not monitored for suicide risk or prevention. There was no documentation of any monitoring of vital signs, pain levels or behaviors.

10. Patient 46 presented to the ED on 5/16/09 with a history of schizophrenia. In a triage note written at 1:15 p.m., the triage nurse documented Patient 46 had multiple lacerations on his left arm and did not know what happened. Patient 46 returned to the waiting area until 2:38 p.m. and was seen by the physician for the MSE at 3:10 p.m. Patient 46 told the physician he had been hearing voices for two days telling him to hurt himself. There was no evidence of monitoring for behavioral symptoms or interventions for suicide risk.

11. Patient 46 again presented to the ED on 6/17/09 with a history of schizophrenia and bi-polar disorder. Prior to admission Patient 46 had been placed on a 51-50 hold as a danger to himself as he stated he was bumped on the head by a monster and burned his penis and expressed he was going to take all of his meds. There was no evidence of monitoring behaviors or interventions for suicide risk or prevention.