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Based on document review and staff interviews, the acute care hospital's (ACH) administrative staff failed to ensure the emergency department staff (ED) followed the ACH's policies, provided all stabilizing treatment to 1 of 21 patients (Patient #1) selected for review, who presented to the hospital for emergency care from 5/1/22 through 8/04/22. Failure to provide adequate 1:1 continuous observation to Patient #1 with suicidal ideation resulted in Patient #1 eloping from the ACH's ED in an unstable emergency medical condition which could have resulted in Patient #1 harming themselves or committing suicide. The hospital administrative staff identified an average of 8,923 patients per month who presented to the hospital's dedicated emergency departments and requested emergency medical care.

Findings Include:

Review of the policy "Emergency Medical Screening and Examination and Treatment (EMTALA)", effective 9/2021, revealed in part, "An individual, who is not otherwise a Patient of the Hospital, shall be provided an appropriate MSE within the capabilities of the Emergency Department ...".
An "Emergency Medical Condition (EMC) 1. Medical/Psychiatric: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the women or her unborn child) in serious jeopardy, b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part ...".
"The individual ... requests examination or treatment for a medical condition, or has such a request made on his or her behalf ".
"Further Steps When Emergency Medical Condition is Found: If an individual has an Emergency Medical Condition, further medical examination and treatment within the Capabilities and Capacity of staff and facilities must be provided as required to Stabilize the Emergency Medical Condition ...".
"Stable for discharge: A patient is stable for discharge when, within reasonable clinical confidence, it is determined that the patient has reached the point where their continued care, including diagnostic work-up and/or treatment, could be reasonably performed as an outpatient or later as an inpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions ...".

Review of the policy, "Patient Suicide Screening and Precautions", Appendix E: 1:1 Supervision/Sitter use for Suicidal Patients (Roles and responsibilities), effective 12/20, revealed in part,"...Sitter Responsibilities...Stay in the patient's room, unless as communicated with the RN 1. Remain with the patient at all times 2. Stay between the patient and the door to prevent the patient from A. Trapping you in the room B. Trying to leave...".

On 7/13/22 at 9:02A.M., RN B documented Patient #1 had presented to the acute care hospital ED with complaints of suicidal ideation, with a plan to kill self with a firearm, stated they knew someone that could obtain one.

On 7/13/22 at 9:30 A.M., RN G reported, patient was placed in a trauma family waiting room with a sitter present due to all emergency departments rooms being full. RN G stated over flow patients are placed in small family waiting rooms that are placed in back hallway.

On 7/13/22 at 10:00A.M., Patient #1 evaluation done by emergency department PA A, determined patient had suicidal ideation with a plan, determined to be high risk for suicide, to remain on suicide precautions, 1:1 monitoring, safety interventions, ID band on, visual checks continuous, labs ordered, consult psychiatry, and inpatient bed placement.

On 7/13/22 at 2:00 P.M. Psychiatry with patient, DO D completing evaluation. Evaluation was positive for dysphoric mood and suicidal ideation. Negative for hallucinations and self-injury. Plan to admit to psych and get a 48 hold if attempts to leave.

On 7/13/22 at 2:32 P.M. RN C documented Patient #1 in hall between 2 trauma rooms pacing, ran down hallway, and exited out the ED's emergency exit. Public Safety was notified and responded, did not find. Des Moines Police were called to assist and do a wellness check, and was not found.

On 7/14/22, Patient #1 arrived at the ACH's ED for the second time at 2:30 PM for suicidal ideation, approximately 24 hours after elopement the day prior. DO D diagnosed Patient #1 with unspecified mood disorder, stimulant abuse, suicidal ideation, COPD, unspecified Viral Hepatitis C, Nicotine dependence, and homelessness.

At 4:07 PM, RN C completed the Columbia scale with a being: "High Risk". Patient #1 placed on suicide precautions with 1:1 observation.

At 4:33 PM, PA X stated, Patient #1 arrives for suicidal ideation with plans to obtain a gun from an ex-boyfriend. Patient #1 was here yesterday and left. Patient #1 stated they had to get pets that were taken to Animal Rescue League. Wants to stay, and get treatment. Medical review and exam completed. Unremarkable except positive for amphetamines. PA X noted DO D assessed Patient #1 and agreed with plan to admit inpatient.

Please refer to A2407 for additional information.

Based on document review and staff interviews, the acute care hospital's (ACH) emergency department (ED) staff failed to ensure 1 of 21 patients (Patient #1) selected for review, who presented to the hospital for emergency care from 5/1/22 through 8/04/22, received all stabilizing treatment. Failure to provide adequate 1:1 continuous observation to Patient # 1 with suicidal ideation resulted in Patient #1 eloping from the ED in an unstable emergency medical condition which could have resulted in Patient # 1 causing harm to themselves or committing suicide. The hospital administrative staff identified an average of 8,923 patients per month who presented to the hospital's dedicated emergency departments and requested emergency medical care.

1. Review of Patient #1's medical record:

Review of a closed medical record showed Patient #1 presented to the Emergency Department (ED) on 7/13/22 at 9:02 AM for suicidal ideation (SI). RN B documented Patient #1 has suicidal ideation with a plan to kill themselves with a firearm if they had one. PA A evaluated Patient #1 for chief complaint of suicidal ideation with a plan. Patient #1 has history of substance abuse with using methamphetamine just 5 days ago. Patient #1 has taken Seroquel (medication used to treat mood disorders) in the past but reported being off their medications for the last 6-8 months. Patient #1 was noted to have normal behavior, cooperative, with judgment impulsive.

At 9:30 AM, RN G reported, Patient #1 was placed in a trauma family waiting room with a sitter present due to all ED rooms being full. RN G stated over flow patients are placed in small family waiting rooms that are placed in back hallway.

At 10:00 AM, Patient #1 evaluation done by PA A, determined that Patient #1 had suicidal ideation with a plan, determined to be high risk for suicide, to remain on suicide precautions. PA A ordered 1:1 monitoring, safety interventions, ID band on, visual checks continuous, labs ordered, consult psychiatry, and inpatient bed placement.

PA A's plan was to get an inpatient psychiatric consult given active SI with plan. Generic psychiatric bed request placed.

At 10:04 AM, inpatient bed request made and psychiatric consult ordered by PA A.

On review of 15-minute check documentation on 7/13/22, from 11:00 AM to 1:15 PM, Patient #1 had been resting and sleeping with sitter present.

At 2:00 PM, Psychiatry with patient, DO D completing evaluation. Evaluation was positive for dysphoric mood (intense feelings of unhappiness) and suicidal ideation. Patient #1 is negative for hallucinations and self-injury. Plan to admit to inpatient psych and get a 48 hold if attempts to leave.

At 2:32 PM, RN C documented, Patient #1 in hall between 2 trauma rooms pacing, then Patient #1 ran down hallway, and exited out the ED's emergency exit. Public Safety was notified and responded, was unable to locate Patient #1. Des Moines Police were called to assist and do a wellness check, and Patient #1 was not found.

2. During an interview on 8/9/22 at 11:00 AM with RN C, revealed that Patient #1 came to the ED for suicidal ideation. All rooms in the emergency area were full so had to use "yellow" room which is a trauma family room waiting area in back hallway. Patient #1 was originally cooperative and voluntarily accepting assistance for suicidal ideation. Patient Safety Companion (PSC) E, new to the role, was placed at bedside with Patient #1 for continuous 1:1 observation.
In the afternoon, RN C had learned from PSC E that Patient #1 was in the hall. Shortly thereafter Patient #1 left before staff could get to the room. No 48-hour hold in place when Patient #1 left. Patient #1 returned the next day, presented for suicidal ideation voluntarily checked in on 7/14/22.

3. During an interview on 8/9/22 at 3:30 PM with PA A, recalled that day the ED was full, we had patients in family waiting rooms. Patient #1 was very honest and open about the plan to commit suicide, plan was to kill self with a firearm, but didn't have one. PA A felt Patient #1 needed to be admitted for further evaluation and treatment.
Later in the day, the PSC E reported to PA A that Patient #1 just left the unit to the outdoors. They called public safety and DSM police. Told by PSC E, Patient #1 had called someone, became distraught, and ran down the hall out the exit. PA A felt Patient #1 was not stable enough for a discharge, but was voluntary at the time of elopement.

4. During an interview on 8/11/22 at 12:55 PM with DO D, stated Patient #1 was very amiable to receive help and wanted to get treatment. Patient #1 had a history of depression and history of suicide attempt. Patient #1 was polite, cooperative, and very open to admission. DO D did know Patient #1 was worried about pets. DO D felt Patient #1 was suicidal and felt inpatient admission was appropriate. DO D thought Patient #1 depression had improved some since arriving in the morning, but not resolved. DO D was very surprised when notified that Patient #1 left because Patient #1 was logical, thoughtful, and agreeable to getting help. DO D felt safety was a concern and recalled writing orders if Patient #1 attempts to leave to get a 48-hour hold.

5. During an interview on 8/15/22 at 1:35 PM with RN G, recalled working as charge nurse on 7/13/22. The ED was very busy and all rooms were all full. When RN G heard that a patient had left, this was communicated to public safety, they were aware. Patient #1 had already left the premises so the police department (PD) were called. Patient #1 was not court ordered. Our standard practice if patient elopes is to notify the public safety here if they have left property the police are called.

RN G recalled the census was full, when this occurs we start using the waiting rooms, hallways, wherever they can find space. We have 5 behavioral health (BH) rooms in the ED are ligature free and are in a secure locked unit. If these 5 rooms were full, then we place BH patients in our medical rooms and remove what we can from the room. If our medical rooms are full then the next step is the BH patients go to a waiting room or family waiting room with a sitter. The family waiting rooms don't have call lights or phones, so no means of communication back there and are not visual from nurses' station.

6. During an interview on 8/11/22 at 12:22 PM, Patient Safety Companion (PSC) E reported, Patient #1 was cooperative, calm, until having received a call from someone. After the call, Patient #1 became quite agitated and started pacing. Then Patient #1 left the room and walked into the hall. PSC E did not have a call light in the room or a communication device. Patient #1 asked to speak to a nurse, PSC E stepped out to get a nurse since another sitter was nearby for another patient. When PSC E returned, Patient #1 had already ran down the hall to the emergency room exit and left the ED.

7. Review of Patient #1's medical record for second encounter:

Review of a closed medical record showed patient # 1 presented to the ED for the second time on 7/14/22 at 2:30 PM for suicidal ideation (SI), after eloping from the ED on 7/13/22, the day prior, for SI with a plan. Patient #1 stated they found out that their pets were taken to the animal rescue league. Patient #1 returned today and wants to get better and find a place for to live with their pets. Patient #1 reports appetite change, blood in stool, loose stools, and vomiting. Denies abdominal pain. Continues with suicidal ideas and plan continues to focus on using a firearm. Medical examination completed, head to toe assessment was unremarkable. Vital signs stable, urine analysis found positive for methamphetamines. Columbia score was listed as "High Risk" for suicide. DO D evaluated patient and agreed with inpatient admission for suicidal ideation.

Due to no open inpatient bed available in the psychiatric unit at the time, Patient #1 was placed on suicide precautions with 1:1 sitter (PSC) and continuous observation in a medical bed in the ED, close to area where nurses and other team members can observe until placement can be found. Seroquel ordered and started on 7/14/22. Other medical findings loose stools for 6 days, WBC within normal, no anemia. Medically stable and cleared for admission.

On 7/14/22 at 4:33 PM, PA X documented, arrives for suicidal ideation with plans to obtain a gun from an ex. Patient #1 was here yesterday and left. Stated had to get pets that were taken to Animal Rescue League. Wants to stay, and get treatment. Medical review and exam completed. Unremarkable except positive for amphetamines. PA X noted DO H assessed Patient #1 and agreed with plan to admit.
All labs, screens and assessments were completed by 8:00 PM. Patient #1's vitals stable, resting, on suicide precautions, with 1:1 monitoring still in place.

On 7/15/22, documentation on review of day's events showed the day as uneventful. Patient #1 remained on 1:1 continuous observation, suicide precautions, resting intermittently, no concerns. Patient cooperative remains on voluntary status.

On 7/16/22 at 10:24 AM, Patient #1 in the ED evaluated by Psychiatry ARNP A, Patient #1 no longer meets criteria for inpatient, much improved, with only mild suicidal ideation, no plan. Patient #1 reports feels a great deal of the problem was feeling very "tired" as they had been walking for days while homeless. Medically stable, cleared for discharge. Discharge plan and education provided with Patient #1 understanding. Homeless shelter arranged, outpatient appointment for 7/21/22 with behavioral health urgent care facility. Patient #1 to return if symptoms and ideation return.

On 7/16/22 at 10:46 AM, DO K documented, Patient #1 is cleared by psychiatry for discharge, to follow up outpatient with BH Urgent Care on 7/21/22.

8. During an interview on 8/11/22 at 11:52 AM, DO H (psychiatry resident) saw Patient #1 on 2nd encounter. Recalled Patient #1 had left the ED for something about pets, or a situation about the pets. Patient #1 then returned to the ED. Patient #1 still had suicidal ideation on the return visit on 7/14/22. What DO H recalled of Patient #1 was they were cooperative, wanted help, was voluntary, and we could get a hold if Patient #1 attempted to leave.

9. During an interview on 9/6/22 at 9:30 AM, PA K remembered that Patient #1 left the day prior to take care of a situation with pets, and returned the following day. Patient #1 had suicidal ideation with a plan, that type of patient is placed high-risk suicide precautions, include scrubs, 1:1 sitter, and other items. Patient #1 was cooperative, wanted help.

10. During an interview on 8/11/22 at 10:28 AM, ARNP M revealed that ARNP M was Patient #1's behavioral health practitioner when they returned to the ED for second visit. Patient #1 was calm, ready for help. Patient #1 had left on 7/13/22 because of a situation that pets were in danger of losing them. When Patient #1 learned they would be fine and safe, Patient #1 returned to the ED on 7/14/22. Patient #1 responded very well to treatment in the ED, improved right away with Seroquel, food, and sleep. Patient #1 was discharged to homeless shelter.
ARNP M deemed Patient #1 safe to discharge, was voluntary, in a good place emotionally, and not having suicidal ideation. Patient #1 was aware of what led to the problems and had insight. Once on medication, Patient #1 improved quickly.

11. During an interview on 9/6/22 at 9:30 AM, PA J revealed that PA J could not remember many details, however did remember that Patient #1 had left the day prior to take care of a situation with the pets, and returned the following day. Patient #1 had suicidal ideation with a plan, generally the practice is with those patients, PA J places them on "High Risk" suicide precautions, which include scrubs, 1:1 sitter, and other items. PA J remembered Patient #1 was cooperative, and wanted help.