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Based on interview and record review, the facility failed to ensure:

1. A suicidal patient, Patient 1 was kept safe and was stabilized after an initial elopement while a patient in the Emergency Department (ED). This failure potentially resulted in the patient's death after a second elopement.

2. A patient, Patient 2 was transferred to a facility which had available space and personnel to accept and treat the patient. The failure to clarify the facility where the patient was to be transferred resulted in a delay in providing medical care which potentially impacted the outcome and medical stability of the patient.

These failures resulted the potential for harm and death to both patients and others.

Based on interview and record review, the facility failed to ensure Patient 1, a suicidal patient was kept safe and was stabilized after an initial elopement while a patient in the Emergency Department (ED). This failure potentially resulted in the patient's death after his second elopement.

Findings:

A review of Patient 1's record was conducted. Patient 1 was brought to the ED by ambulance on May 16, 2015, at 7:09 p.m., following a suicide attempt. The patient was accompanied by law enforcement, who had placed the patient on a 5150 hold due to the ingestion of two blood pressure medications, Lisinopril and Metoprolol. (5150 - a section of the California Welfare and Institutions Code which allow a qualified person to involuntarily confine a person suspected to have a mental disorder that makes him a danger to self, a danger to others, and/or is gravely disabled).

The ED daily staffing sheet was reviewed for the May 16, 2014, 7 p.m. to 7 a.m. night shift. The staff consisted of one Registered Nurse for triaging patients (screening patient to assign the order of treatment based on degree of urgency), one Registered Nurse for the ED proper, and one Licensed Vocational Nurse.

Further review of nursing documentation dated, May 16, 2014, at 9:58 p.m., indicated Patient 1 was speaking with the physician, became upset, pulled off the blood pressure cuff and oxygen monitor and walked out of the ED. The police were notified. The patient was returned to the facility on May 16, 2014. The documentation indicated the patient subsequently eloped for a second time at 11:15 p.m., and never returned.

The facility policy, "Elopement of Patients, Response and Prevention (Approval 04/2014)," was reviewed.

The scope indicated, "The policy applies to all departments and services licensed by the facility and crosses interdisciplinary lines. The Objectives were, "To identify patients who are at risk for elopement. To define prevention strategies for patients identified as high risk for elopement. To define the facility response to patient elopement. Patients who are at increased risk for elopement...major depression..."

An interview was conducted on January 26, 2015, at 4:30 p.m., with Licensed Vocational Nurse (LVN) 4 who was assigned to the ED and to Patient 1 during the 7 p.m. to 7 a.m. shift on May 16, 2014.

LVN 4 stated when Patient 1 first eloped, "He bolted out the ambulance entrance, I don't remember if he had a sitter." LVN 4 stated he did not know the time when Patient 1 was returned to the ED after his first elopement.

LVN 4 further stated he realized the patient was in the ED the second time, because the noise of the fan located over the ED exit doors alerted him when the patient eloped for the second time.

LVN 4 stated it appeared the police placed the patient on a gurney by the ED exit doors. LVN 4 stated he guessed Patient 1 was only back at the ED for a minute. LVN 4 further stated the police did not notify anyone that Patient 1 was brought back to the facility. LVN 1 stated the patient was not reassessed when he returned to the ED the second time, no vital signs were done, and no information was received in order to conduct a reassessment.

LVN 4 further stated the ED Clerk called the police to notify them of Patient 1's second elopement as the police were no longer in the ED.

LVN 4 stated Patient 1 was never returned to the ED after his second elopement and the police didn't call back to the ED to give an update. He stated the patient's emergency contacts were not notified by the ED staff.

An interview was conducted with the Emergency Department Manager (EDM) on January 27, 2015, at 3:55 p.m. The EDM stated they did not know the time Patient 1 returned to the ED after the first time the patient eloped. The EDM further stated the patient's emergency contacts were not notified and should have been called.

A review of the facility policy, "Suicidal Patient (Approval Date 03/12/14)," was conducted. The policy indicates, "The Nurse Manager and/or R.N. in charge of the patient will see that a safe, protective environment is provided, including all aspects of suicide precautions, i.e., close observation, provision of sitter if deemed necessary, be assigned to watch the patient on a shift by shift basis until the patient is seen and or transferred to Behavioral Health Services."

When Patient 1 was returned to the facility after the first elopement, there was no documentation to indicate Patient 1 was admitted to the ED and continued to be under a 5150 hold, due to a suicide attempt. There was no documentation to indicate Patient 1 had been stabilized in the ED, or was provided a sitter prior to eloping from the ED the second time.

A review of the facility policy, "Interfacility Transfer and EMTALA Compliance Policy (Approval Date 3/12/14)," was conducted. The policy indicates, "it is the policy of the (facility) that all patients coming to [facility name] requesting emergency services receive an appropriate Medical Screening Examination and Stabilizing Treatment, if appropriate, as required by the Emergency Medical Treatment and Active Labor Act."

The facility policy and procedure number "623.02" dated March 12, 2014, indicated "The purpose of this policy is to design and define the scope of services for the Emergency department which are organized to deliver safe and effective nursing care for any patient presenting with urgent medical problems..."

A review of a Certificate of Death dated June 2, 2014, at 9:01 a.m., indicated Patient 1 was found dead in the Colorado River. The date of death for Patient 1 was documented as May 17, 2014. The time Patient 1 was found was documented as 12:41 p.m., or 12 1/2 hours after the patient eloped from the ED for the second and final time.

Based on interview and record review, the facility failed to ensure Patient 2 was transferred to a facility which had available space and personnel to accept and treat the patient. The failure to clarify the facility where the patient was to be transferred resulted in a delay in providing medical care which potentially impacted the outcome and medical stability of the patient.

Findings:

A review of Patient 2's record was conducted. Patient 2 was admitted to the facility on January 22, 2015, at 7:42 a.m., with a chief complaint of difficulty standing, a facial droop and difficulty with speech. The patient was subsequently diagnosed with an ischemic cerebrovascular accident (CVA-stroke). The patient had a history of a quadruple bypass and diabetes.

On January 22, 2015, at 10:46 p.m., the treating Physician, Physician 1, indicated on his disposition statement that, "Patient will be transferred to: (Hospital A)."

An interview was conducted with Physician 1 on January 26, 2015, at 10:40 a.m. Physician 1 stated he was happy he was able to have an accepting physician at (Hospital A) accept the patient, as that rarely happens.

A review of the Transfer Summary Form, reviewing the risks and benefits of the patient's transfer and signed by Physician 1, dated January 22, 2015, at 10:45 p.m. was conducted. The form indicated the name of the destination hospital was (Hospital B).

A review of the Transfer Communications Log was conducted. All communication and phone numbers documented were with (Hospital A). At the bottom of the document was indicated an accepting physician at (Hospital A), however, (Hospital B) was listed as the accepting hospital.

An interview was conducted with the Licensed Vocational Nurse (LVN) 5, who arranged for the transfer of Patient 2 on January 22, 2015. LVN 5 stated there was a list of hospitals posted in the Emergency Department (ED) that had the phone numbers and addresses for (Hospital A) and (Hospital B) switched.

An additional nurses note dated January 22, 2015, at 10:11 p.m., indicated, "(Physician 1 stated to transfer pt (patient) to (Hospital B)..."

LVN 5 stated she subsequently made the transfer arrangements for (Hospital B) instead of (Hospital A) and wrote the wrong address. Patient 2 was discharged from the facility at 11:14 p.m. LVN 5 further stated first the air ambulance and then the ground ambulance transported Patient 2 to (Hospital B).

LVN 5 stated then (Hospital B) then called our facility to ask, "Who was this patient?" (Hospital B) subsequently arranged for the patient's transfer to (Hospital A).

The transfer to a facility, (Hospital B), that had not agreed to accept Patient 2, and had not received a report or update regarding the patient's medical status, lengthened the time the patient received medical treatment, and potentially placed an untoward burden on both the patient and the facility.