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Based on interview and record review the facility failed to ensure a complete and accurate Emergency Department (ED) central log was maintained when four of 20 sample patients (Patient 3, 5, 12, and 19) were incorrectly entered in the central log.

This failure had the potential to cause a delay in treatment and/or deterioration of patients' medical conditions.

Findings:

On August 14, 2024, an unannounced visit was conducted at the facility for an Emergency Medical Treatment And Labor Act (EMTALA, a federal regulation that prevents hospitals from denying or limiting treatment to patients based on their insurance or ability to pay) survey.

A review of a facility document titled, "Central Log," dated July 2024, through August 14, 2024, was conducted. The Central log indicated a disposition status of "AMA" (Against Medical Advice), for Patient's 3, 5,12, and 19.

1. A review of Patient 3's medical record was conducted on August 14, 2024, at 11 a.m., with the Emergency Department Director (EDD). The facility document titled, "Emergency Provider Report," dated, July 7, 2024, indicated, "Chief Complaint...presents to the emergency room needing medical clearance for incarceration...Stated Complaint: ok to book...Disposition Decision: patient eloped..."

2. A review of Patient 5's medical record was conducted on August 14, 2024, at 1 p.m., with Scribe 1. The facility document titled, "Emergency Provider Report," dated July 31, 2024, indicated, "History of Present Illness...Patient was apparently endorsing suicidal ideation. She presents with 5150 (involuntary detainment for patients who are a danger to self, others, or gravely disabled) hold written by [local police department]..."

The facility's document titled, "Emergency Provider Report," dated, August 1, 2024, indicated, "...patient managed to get out of restraints and eloped from the ED..."

The facility's document titled, "Emergency Patient Record," dated August 8, 2024, indicated, "Disposition: Patient Disposition: AMA...comments: patient eloped after getting out of restraints and walked out the department..."

A concurrent interview was conducted on August 14, 2024, at 3 p.m., with the EDD. EDD stated nurses use the AMA option on the Central Log Form and then create a note that states the patient eloped.

3. A review of Patient 12's medical record was conducted on August 14, 2024, at 1:30 p.m., with Scribe 2. The facility's untitled document indicated, "...Reason For Visit/Chief Complaint: Medication Refill...Discharge Date: July 28, 2024...Time: 9:30 p.m....Dispo [Disposition]: AMA..."

A facility document titled, "EMERGENCY PATIENT RECORD," dated July 28, 2024, indicated "RN [WAS] TOLD PT [Patient 12] WAS LEAVING, WITNESSED PT LEAVE... Patient disposition: AMA...Disposition Category: Refused Treatment...Chief Complaint: Behavioral Health Related...Disposition comments: PT [patient] ELOPED AS PSYCH AMA PD [Police Department] CALLED CODE GREY [a code for combative person] CALLED..."

On August 14, 2024, at 1:30 p.m., a concurrent interview was conducted with Scribe 2. Scribe 2 stated Patient 12 eloped on July 28, 2024, while on a psychiatric hold.

4. A review of Patient 19's medical record was conducted on August 14, 2024, at 1:10 p.m., with Scribe 3. The untitled facility document indicated "Reason For Visit/Chief Complaint: Ok To Book...Discharge Date: July 20, 2024,...Time: 8:10 p.m...Dispo: AMA..."

A review of facility document titled, "Emergency Provider Report," dated July 20, 2024, was conducted. The document indicated "...Chief Complaint...Bilateral Eyelid Swelling...brought in by [Local Police Department] for evaluation...[Local Police Department] at the bedside...shortly after [Local Police Department] left the patient, and prior to completion of ED workup, the patient eloped and ambulated out of the emergency room..."

A review of a facility document titled, "Disposition," dated July 20, 2024, indicated, "...Disposition : AMA...disposition category: Refused Treatment...disposition comments: No contact with patient. Charting D/C [discharge] only..."

On August 14, 2024, at 1:10 p.m., a concurrent interview was conducted with Scribe 3. Scribe 3 stated, "Ok To Book" means the patient is in police custody. Scribe 3 stated there was no nursing documentation that the patient [Patient 19] eloped or that attempts to find the patient were made.

A review of the facility's policy and procedure (P&P) titled, "Against Medical Advice- AMA/ Elopement Guidelines", dated January 2023, indicated, "...Definitions...Involuntary Detainment Elopement applies when a patient under some form of custody...Police, 5150/1799/medical hold, CPS (Child Protective Services)...that leaves the hospital without staff knowledge...C. Elopement of Confused Patients and Involuntary Detainment Elopements...f. Public Safety:...8. Public Safety will detain any patients on hold at the direction of staff..."

A review of the facility's P&P titled, "EMTALA - CENTRAL LOG POLICY," dated April 27, 2023, was conducted. The P&P indicated, "...The Central Log, including all additional logs incorporated into the Central Log by reference, shall be maintained in the same manner and with the same central core of information. The logs must contain at a minimum, the name of the individual, the date, time and means of the individual's arrival, the individual's age, the individual's sex, the individual's record number, the nature of the individual's complaint, the individual's disposition, the individual's time of departure, and whether the individual: refused treatment, was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, was discharged, or expired..."

Based on observation, interview, and record review, the facility failed to ensure stabilizing treatment and the maintenance of safety and security relevant to the psychiatric emergency medical condition (EMC), was provided for three of 20 sampled patients (Patient 5,12 and 20), who were admitted on a psychiatric hold (5150 - when a person is deemed a danger to self, others, or gravely disabled, could be involuntary detained for 72 hours) was allowed to walk out of the facility's Emergency Department (ED).

This failure resulted in Patients 5, 12, and 20 to elope (patient leaving the hospital before discharged) from the ED, and had the potential to harm themselves and/or others.

Findings:

On August 15, 2024, an unannounced visit was conducted at the facility for an Emergency Medical Treatment And Active Labor Act (EMTALA, known as the federal Act that prevents hospitals from deny or limiting treatment to patients based on their insurance or ability to pay) survey.

1. A review of Patient 5's medical record was conducted with Scribe 1 on August 14, 2024, at 1 p.m.

A document titled, "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment" dated July 31, 2024, at 12:28 a.m., indicated Patient 5 was placed on a 5150 hold by the local police department, for a danger to self after stating she wanted to kill herself, effective July 31, 2024, at 12:28 a.m.

The facility document titled, "Emergency Provider Report," dated July 31, 2024, at 1:59 a.m., indicated, "...History of present illness...history of seizure [a sudden, uncontrolled burst of electrical activity in the brain] disorder...patient was apparently endorsing suicidal ideation [SI, danger to self]. She presents with a 5150-hold written by [Local Police Department]. Per 5150 report, patient stated she wanted to kill herself by strangling herself with a jacket. Still endorses SI here..."

The facility document titled, "Emergency Provider Report," dated July 31, 2024, at 12:44 p.m., indicated, "...waiting placement at 5150 receiving facility."

A concurrent interview and record review was conducted with Scribe 1 on August 14, 2024, at 1:10 p.m. There was no documented evidence an accepting psychiatric facility was obtained. Scribe 1 stated there was no Social Worker assigned in the ED at night.

The facility document titled, "Restraint Documentation ED," dated July 31, 2024, at 8:25 p.m., indicated, "Restraint status: start. Clinical Justification: Attempt self-harm, combative, destructive, physical aggression, violent...Level of restraint: Violent/Self- destructive. Violent restraint device: quick release synthetic BUE [bilateral upper extremities], Quick release synthetic BLE [bilateral lower extremities]..."

The facility document titled, "Behavioral Health Related," dated July 31, 2024, at 9:21 p.m., indicated, "Ongoing signs/symptoms: Agitated, Auditory hallucinations, suicidal ideation, violent behaviors...Behavior health related reassessment complications comment: patient intermittently screaming when attempting to replace restraints...pt [patient] endorsing auditory hallucinations [hearing voices or sounds that aren't there] and SI w/ [with] a plan and endorses wanting to strangle self..."

The facility document titled, "Suicide Reassessment," dated July 31, 2024, at 9:30 p.m., indicated, "Calculated Risk Level: High Risk."

The facility document titled, "Restraint Documentation ED," dated August 1, 2024, at 3:51 a.m., indicated, "Restraint status: start. Clinical Justification: Attempt self-harm, combative, physical aggression, violent...Level of restraint: Violent/Self- destructive. Violent restraint device: quick release synthetic BUE, soft BLE...Time restraints initiated: 2 a.m..."

The facility document titled, "Suicide Reassessment," dated August 1, 2024, at 3:58 a.m., indicated, "Calculated Risk Level: High Risk."

The facility's document titled, "Suicide Reassessment," dated August 1, 2024, at 4:03 a.m., indicated, "Calculated Risk Level: High Risk."

The facility document titled, "Behavioral Health Related," dated August 1, 2024, at 4:07 a.m., indicated, "Ongoing signs/symptoms: Agitated, Suicidal ideation's, violent behavior...Behavior health related reassessment complications comment: Pt [patient] continuous to become intermittently loud and aggressive, often yelling at staff and frequently getting out of restraints and thrashing around in bed."

The facility document titled, "Restraint Documentation ED," dated August 1, 2024, at 5:07 a.m., indicated, "Restraint status: start. Clinical Justification: Attempt self-harm, combative, physical aggression, violent...Level of restraint: Violent/Self-destructive. Violent restraint device: quick release synthetic BUE, soft BLE..."

The facility's document titled, "Disposition," dated August 1, 2024, at 6:43 a.m., indicated, "Comments: Pt [patient] eloped after getting out of restraints and walked out of the department. Per security, pt [patient] walked into an unknown white vehicle."

An interview was conducted on August 14, 2024, at 1:15 p.m., with Scribe 1. Scribe 1 stated, "The facility has a "No Touch" policy, meaning staff cannot touch patients if they walk out of the facility, and we can't restraint or medicate her to make her stay even on a 5150 hold."

An interview was conducted on August 14, 2024, at 2 p.m., with the Patient Safety Director (PSD). PSD stated, "We are not a psych [psychiatric] facility so we can't hold the patient."

A review of facility document titled, "[Name of Security Agency]," dated August 1, 2024, indicated, "Information...Start time of incident: 4:45 a.m...End time of incident: 5 a.m...Narrative: "I was dispatched to call for a patient assistant to room in the ER when I arrived on seeing the patient...grabbed nurse...I was able to get the patient off the nurse and staff was able to place her in restraints. [Physician1] then instructed us not to stop the patient if she gets loose from the restraints and left. Patient...then broke out of the restraint about 30 to 45 minutes later...[Name of officer], [Patient Safety Observer (PSO3)], and I escorted the patient [Patient 5] off the property until she was off property. The patient then ran across Magnolia Avenue and flagged down a white scion. The patient entered the white vehicle and drove off with them..."

A review of the facility document titled, "[Name of Facility]...Coding Summary," dated August 4, 2024, indicated, "Admit date: July 31, 2024 at 1:17 a.m...Disposition: Psychiatric Elopement...Reason for Visit DX [diagnosis]...Autistic disorder...suicidal ideation's...altered mental status..."

An interview was conducted on August 14, 2024, at 5:20 p.m., with the Vice President of Quality (VPQ). VPQ stated she does not agree that elopements of patients with a psychiatric EMC on a 5150 is an EMTALA violation. VPQ stated [Name of Facility] is not a psych facility and does not do seclusion or chemical restraints. VPQ further stated [Name of Facility] staff do not hold patients if they attempt to leave, even if they are on a 5150 hold for danger to themselves or others.

An interview was conducted on August 15, 2024, at 7:46 a.m., with the Chief Medical Officer (CMO). CMO stated, in the case of EMTALA, being mentally stable is separate from being medically stable. CMO stated patients are seen in the ED and are medically cleared. CMO stated from a mental health perspective the patient on a 5150 would not be stable, but [Name of Facility] is not a mental health facility. CMO stated [Name of Facility] sees a lot of psychiatric patients in the ED. CMO further stated the ED cannot hold the patient in their ED until they get treatment. CMO stated "if a patient is medically stable it is not an EMTALA concern, and the patient can leave at any time. From a mental health perspective if the patient doesn't like their treatment plan, they can leave at any time." CMO further stated "a 5150 is an involuntary hold but if the patient is medically clear it is not EMTALA, and they can leave the hospital even if they are on a 5150 for danger to self or others. A patient with an acute mental health condition, on a 5150 is not covered under EMTALA."

A review of the facility's video footage was conducted on August 15, 2024, at 3:15 p.m., with the PSD. The video footage dated August 1, 2024 indicated,

a) Video 1 - At 4:57 a.m., observed PCO3 standing in the doorway of ED 2, room 1. Security is observed approaching the room and standing outside, across from room 2. During a concurrent interview, the PSD stated at this time Patient 5 was inside room 1, removing herself from restraints.

b) Video 2 - At 4:57:50 a.m., observed PCO3 leaving the room, approaches and speaks with security near room 2.

c) Video 3 - At 4:58 a.m., observed PCO3 going back into the doorway of room 1.

d) Video 4 - At 4:58 a.m., observed PCO3 walking into the room, however, was not visible on camera while inside the room.

e) Video 5 - At 4:58:17 a.m., observed PCO3 at the doorway of room 1 again.

f) Video 6 - At 4:58:29 a.m., observed PCO3 walking out of room 1 and walks across the hall to push a button mounted on the wall. ED exit doors open. Observed PCO3 standing with arms crossed near the button and across the hall from room 1. Security approached.

g) Video 7 - At 4:58:38 a.m., observed PCO3 and security standing across the hall from room 1.

h) Video 8 - At 4:58:40 a.m., observed Patient 5 slowly walking out of the room in a green gown, with open back. Patient 5 pauses and then walks slowly out of the open exit doors while PCO3 and security watched. The nurse, CNC (Clinical Nurse Coordinator), nor other staff were seen on the video.

i) Video 9 - At 4:58:45 a.m., observed PCO3 following Patient 5 out of the exit doors while security follows a few feet behind them. PCO3 and security do not attempt to stop the patient from leaving the exit doors.

j) Video 10 - 4:58:52 a.m., observed Patient 5 standing in a hallway holding her wrist, before walking down another hallway to the right towards the external exit doors.

k) Video 11 - At 4:59 a.m., observed Patient 5 and PCO3 begin to leave the view of the camera moving towards the exit. Observed security following behind Patient 5 and PCO3.

l) Video 12- At 4:59:14 a.m., observed another security staff exiting the ED.

m) Video 13 - At 4:59:18 a.m., Patient 5 is observed outside of the hospital, heading towards hospital's main lobby entrance. Patient observed to be walking slowly.

n) Video 14 - At 4:59:41 a.m., observed Patient 5 outside the building, walking towards the hospital's main entrance.

o) Video 15 - At 5:00 a.m., observed Security and PCO3 walking out the main lobby entrance. PCO3 and security standing outside the main entrance. Patient 5 visible walking into the parking lot alone.

p) Video 16 - At 5:01:27 a.m., observed PCO3 and security staff walking down the sidewalk to the left of the lobby entrance, perpendicular to where Patient 5 walked. Patient 5 is no longer visible in the cameras.

An interview was conducted on August 15, 2024, at 8:20 a.m., with the CNC. The CNC stated Patient 5 was admitted in the ED for pseudo seizures (episode that mimics seizures) and behavioral issues. The CNC stated around shift change there was a need for restraints as Patient 5 was attempting to choke herself. The CNC stated Patient 5 was placed in 4-point, hard restraints, and had a sitter. The CNC stated Patient 5 was able to get out of restraints multiple times. The CNC further stated patients on a 5150 hold for psychiatric conditions need to be medically cleared and that Patient 5 was medically cleared prior to eloping. The CNC stated medical conditions and psychiatric conditions are different. The CNC stated a patient on a 5150 cannot leave against medical advice (AMA); this was considered elopement and police department (PD) were notified.

An interview was conducted on August 15, 2024, at 1:55 p.m., with Security 1. Security 1 stated if a patient is on a 5150 hold and is attempting to elope, security can detain the patient as long as they don't do anything that could harm the patient. Security 1 further stated if the patient is aggressive, they do not touch the patient and allow PD to deal with them.

On August 15, 2024, at 3:55 p.m., a concurrent interview and review of facility policy titled "Against Medical Advice- AMA/Elopement Guidelines," was conducted with the CMO. The CMO stated his interpretation of EMTALA is "Psychiatric patients, even those on an involuntary hold for danger to self or others are allowed to leave the hospital if they want to." The CMO further stated, his interpretation of hospital policy for AMA/Elopement section #8 which states that security may detain a patient on a 5150 hold is "Detaining the patient is upon discretion of the MD and staff. In case of potential physical injury to staff security may intervene but they do not stop psychiatric patients from leaving the hospital."

An interview with PSO3 was conducted on August 16, 2024, at 7:40 a.m. PSO3 stated, the ED staff was familiar with Patient 5 because of her frequent visits to the ED. PSO3 stated the ED staff was also familiar of Patient 5's combative behavior and was considered a "flight risk." PSO3 further stated Patient 5 was in restraints, on both her upper and lower extremities, but still managed to get out of them. PSO3 stated she did not attempt to stop Patient 5 because she was informed by the ED charge nurse, supervisor, and the assigned nurse to let the patient leave because the 5150 was not written by their facility. PSO3 further stated, she opened the door for Patient 5 when she was leaving per the instruction of security.

2. A review of Patient 12's medical record was conducted on August 14, 2024, at 1:30 p.m., with Scribe 2.

The facility document titled, "Emergency Provider Report," dated July 28, 2024, indicated Patient 12 presented to the ED after reporting homicidal ideation (thought pattern characterized by the desire to kill another person) earlier in the day and then eloped from the ED prior to being seen by the physician. Patient 12 was brought back to the facility by the police after punching a window with his hand.

A document titled, "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment" dated July 28, 2024, at 8:30 a.m., indicated Patient 12 was placed on a 5150 hold by a Medical Social Worker, for a danger to self after stating he was hearing voices telling him to kill himself, effective July 28, 2024, at 8:30 a.m.

A review of the facility document titled, "Emergency Provider Report," dated July 28, 2024, indicated "...given the evidence of homicidal ideation 5150 hold placed, patient to be held in our ER until able to transfer..."

A concurrent interview and record review was conducted on August 14, 2024, at 1:40 p.m., with Scribe 2. Scribe 2 stated, Patient 12 was allowed to elope from the ED on July 28, 2024, at 1:47 p.m. Scribe 2 stated Patient 12 was always with a safety attendant with direct line of sight and every 15-minute checks.

A review of the facility document titled, "EMERGENCY PATIENT RECORD," dated July 28, 2024, indicated "RN [WAS] TOLD PT [patient] WAS LEAVING, WITNESSED PT LEAVE TOWARDS AMBULANCE BAY...PT CONTINUED TO BECOME MORE AGGRESSIVE AND BEGAN WALKING DOWN RAMP OFF TO CURB 911 CALLED... Patient disposition: AMA...Disposition Category: Refused Treatment...Chief Complaint: Behavioral Health Related...Disposition comments: PT [patient] ELOPED AS PSYCH AMA PD [Police Department] CALLED CODE GREY (a code for combative person) CALLED..."

A concurrent interview and record review was conducted on August 15, 2024, at 9:10 a.m., with RN 4. RN 4 stated Patient 12 was agitated and wanted to leave the hospital on June 28, 2024. RN 4 stated the social worker was working on psychiatric facility placement for Patient 12 but the patient eloped prior to transfer.

3. A review of Patient 20's medical record was conducted on August 14, 2024, at 1:40 p.m., with Scribe 3.

The facility document titled "APPLICATION FOR ASSESSMENT, EVALUATION AND CRISIS INTERVENTION OR PLACEMENT FOR EVALUATION AND TREATMENT," written by [Name of Facility] resident on July 12, 2024, at 11:25 a.m. indicated Patient 20 was "found by police running around naked, yelling, unable to describe mental health history." Document indicated the patient met criteria for 5150 as a danger to self and gravely disabled adult.

The facility document titled "Emergency Provider Report" dated July 12, 2024, indicated, "chief complaint of Altered mental status. Document indicated EMS [Emergency Medical Staff] reports the patient was found running around naked and yelling. Patient was placed on a 5150 hold at 11:25 a.m., for grave disability [legal term that refers to a person's inability to meet their basic needs due to a mental health condition] and danger to self. Denies SI [suicidal ideation's or HI [hallucinations ideation's]. The document further indicated that while in the emergency room, the patient was agitated requiring chemical restraint [medical procedure that uses drugs to restrict a patient's movement or freedom, or to sedate them]. Patient signed out to fellow resident pending tele psych evaluation [practice of providing psychological services using telecommunications]".

The facility document titled "Emergency Provider Report" dated July 12, 2024, indicated, "...patient was given multiple rounds of antipsychotic medications [a class of drugs that treat symptoms of psychosis] and was unable to participate so we reached out to the tele psych doctor again. Patient still pending formal evaluation."

The facility document titled "Case Management Report" dated July 12, 2024, indicated, "SW [Social Worker] attempted to meet with patient to complete a Psychosocial Assessment (PSA). Patient unable to participate due to erratic behavior, appears to be responding to internal stimuli [changes, experiences, or feelings that occur within a person]."

Review of a document titled "Case Management Report" dated July 13, 2024, for Patient 20, indicated, " SW is covering ER, observed that patient is discharged and reviewed ER RN notes. Per ER patient left AMA [Against Medical Advice] today and [Local Police Department] was contacted by ER."

Review of Patient 20's "Emergency Notes" dated July 12, 2024, through July 13, 2024, indicated Patient 20 had a safety sitter at the bedside.

Review of Patient 20's record "Emergency Notes" dated July 13, 2024, indicated "Pt [patient] left witnessed by staff to be in regular clothes, scrub pants and grey top, stating "mission inn". Report made with [local police department] for 5150 not yet rescinded, pending SW [social worker] consult."

An interview was conducted on August 14, 2024, at 1:10 p.m., with Scribe 3. Scribe 3 stated sitter documentation should be scanned and entered into the patient's medical record. Scribe 3 stated there was no documented evidence a sitter was with Patient 20 in the ED. Scribe 3 further stated the record indicated Patient 20 eloped before she was seen by the SW and before the 5150 hold was rescinded.

An interview was conducted on August 15, 2024, at 8:50 a.m., with RN 4. RN 4 stated tele psych gives recommendations, but the recommendation is not a formal order. RN 4 stated if tele psych recommends rescinding a hold, the social worker (SW) would come in and see the patient and then rescind the hold if they don't meet criteria. RN 4 stated psych patients are kept in green gowns and given their clothes and valuables back on discharge. RN 4 stated she is not sure why Patient 20 was in regular clothes and not a patient gown at the time she eloped. RN 4 stated she or another staff must have given her the clothes. RN 4 stated Patient 20 did not have a discharge order and eloped. RN 4 stated they do not force the patient to stay and can't hold them down to make them stay.

A review of the facility's policy and procedure (P & P) titled, "Against Medical Advice- AMA/ Elopement Guidelines", dated January 2023, was conducted. The policy indicated, "Definitions...Involuntary Detainment Elopement applies when a patient under some form of custody, i.e., Police, 5150/1799/medical hold, CPS (Child Protective Services)...that leaves the hospital without staff knowledge...Elopement of Confused Patients and Involuntary Detainment Elopements...Public Safety...Public Safety will detain any patients on hold at the direction of staff."

On August 14, 2024 at 5:20 p.m., the survey team identified significant concerns in the hospital's Emergency Department (ED). Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the facility's Chief Nursing Officer (CNO), Chief Operating Officer (COO), Assistant Chief Nursing Officer (ACNO), Vice President for Business Development (VPBD), Vice President for Quality (VPQ) and Patient Safety Director (PSD). The facility's Administrators were verbally notified regarding the concerns of the hospital's failure to ensure an active system was in place to prevent 5150 patients from leaving the hospital before stabilization had been completed.

On August 15, 2024, at 8:15 am, the facility provided a Corrective Action Plan (CAP).

On August 15, 2024, at 1:08 p.m., the CAP for the immediate jeopardy at the ED was reviewed and accepted.

On August 15, 2024, at 5:07 p.m., the immediate jeopardy at the ED was removed in the presence of the PSD, after the CAP implementation was verified through observation, interviews, and record reviews. The CAP included the following components:

1. On August 14, 2024, the leadership team met and reviewed and amended the facility's RI.119 policy.

2. The Director of Security and the Emergency Department were updated on the policy changes.

3. All Emergency Department and Security staff were educated on the updated policy during shift change huddles and prior to assuming a patient assignment.