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Based on a review of facility documents, medical records (MR), employee interviews (EMP), it was determined that the facility failed to have safety measures in place to reduce the risk of psychiatric patient elopements (A0142), and failed to following the patient sitter policy which resulted in an elopement of a psychiatric patient (A0144).

This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.



Cross reference:
482.13(c)Patient Rights: Privacy and Safety
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on a review of facility documents, medical records (MR), and employee interviews (EMP), it was determined that the facility failed to ensure safety measures were in place to reduce the risk of psychiatric patient elopements for eight of ten medical records reviewed (MR1, MR2, MR5, MR6, MR7, MR8, MR9, and MR10).




Finding include:




On August 8, 2024, a review of the Psychiatric Patients in the Emergency Department Policy revealed, "To ensure the safety and appropriate plan of care of the psychiatric patient presenting to the Emergency Department. 5. Security or a Sitter will be requested to observe any patient that presents as homicidal. suicidal, or exhibiting impaired judgment for personal and or other's safety, or as deemed necessary by the ED nurse, or physician....10. Patients for mental health (MH) evaluation are not permitted to leave the ED. 11. In the event that a situation escalates that cannot be safely managed, security will collaborate with ED staff to determine if assistance is required from the local police department...".



On August 8, 2024, review of the Patient Sitter Policy revealed, "The policy of Excela Health to utilize patient sitters in accordance with established standards to minimize the safety risk to the patient or another individual. This policy applies to all employees or Contractor employees working in a sitter position or capacity within Excela Health. E. Patient sitter responsibilities include but are not limited to: 1. Sitting with patient in view 2. Providing protection to keep a patient from harming themselves or others...5. Patient sitters must remain in the patient room with the patient at all times. ...7. The use of radios, headphones and any other other electrical devices by sitters for personal use is prohibited...".



On August 8, 2024, review of Infant/Child Abduction and Missing Person Policy - Code Amber, Policy 4-11-214, revealed, "the purpose is to establish guidelines for the prevention of infant/child abduction and/or missing person, and prompt recognition and response to any abduction and/or missing person in the Acute Care and Outpatient settings on the Westmoreland premises. ...Missing person may be an infant/child/adult. ...The person who first becomes aware of the abduction or missing person immediately notifies the hospital operator at extension 1111 and then Security at extension 2222, providing all available information to both parties need to ensure a full description is provided...When code Amber Adult is announced via overhead paging, all employees are alerted to observe for any person matching the description. ...The employee should attempt to delay the person by questioning the suspected missing person until a Security of Police respond. Nursing should be available to identify the person if needed. ...Upon receiving a report of a missing person...the Security Officer shall, verify that all closed caption television are being monitored, obtain as much information from the caller as possible, notify all security officers and Greensburg and State Police if warranted....Upon receiving notification of the missing person...the switchboard operator shall page the following, Safety Manager, Patient Safety, Risk Manager, Administrator on Call, Security Supervisor, Nursing Supervisor...".



Review of MR1, on August 8, 2024, revealed that the patient was a 28 year old male with a history of psychiatric disorders, arrived in the Emergency Department for a psychiatric evaluation because patient was off all medication for two weeks with a suicide attempt. On the morning of August 2, 2024, MR1 attempted to slit his wrists at 08:42 AM, MR1 was placed in a patient room and a patient sitter was order due to the Columbia Suicide Severity Rating Scale. MR1 had positive thoughts for suicide and a psychiatric consultation to see the patient. MR1 had a history of psychiatric admissions in the past and the most recent was in July of 2024, at 11:08 AM, the determination was made to admit the patient to the inpatient psych unit as and a COVID test was requested prior to moving the patient to the unit.
At 14:07, MR1 eloped from the Emergency Department. The medical record revealed that the patient eloped from the Emergency Department on August 2, 2024. Further review revealed that the sitter policy and missing person's policy were not followed, per policy.



A review of MR2 on August 8, 2024, revealed the patient presented to the Emergency Department on August 6, 2024, for a psychiatric evaluation and 201, after attempting to cut his arms with a knife when the police arrived. A sitter was ordered by the physician. The medical record revealed that the patient eloped from the Emergency Department on August 8, 2024.



A review of MR5 on August 8, 2024, revealed the patient presented to the Emergency Department on March 14, 2024, for a psychiatric evaluation after threatening suicide after fighting with the mother and sister. The medical record revealed that the patient eloped from the Emergency Department prior to assessment and evaluation on March 14, 2024.



A review of MR6 on August 8, 2024, revealed the patient presented to the Emergency Department on July 15, 2024, for a psychiatric evaluation with the police. Documentation reveals the patient was loud and disruptive while in the Emergency Department and security was requested to assist and the patient eloped from the Emergency Department prior to assessment and evaluation on July 15, 2024.



A review of MR7 on August 8, 2024, revealed the patient presented to the Emergency Department on August 2, 2024, for a psychiatric evaluation with the police. Documentation revealed patient was unkept, loud, had an odor of alcohol and security was requested to assist. The patient eloped from the Emergency Department prior to assessment and evaluation on August 2, 2024.



A review of MR8 on August 8, 2024, revealed the patient presented to the Emergency Department on June 19, 2024, for a psychiatric evaluation with the police. Documentation reveals the patient was angry, loud, demanded to see psych. Security was requested to assist and a sitter was ordered, however the patient eloped.



A review of MR9 on August 8, 2024, revealed the patient presented to the Emergency Department with police on February 8, 2024, for a psychiatric evaluation. Documentation revealed the patient was paranoid and hallucinating upon arrival and requested help. Documentation revealed that the patient was not seen by a provider and eloped.



A review of MR10 on August 8, 2024, revealed the patient presented to the Emergency Department on April 10, 2024, for a psychiatric evaluation with the police. Documentation reveals the patient was found on a local college campus after falling out of a moving car. The patient was rambling and pacing. Documentation reveals the patient was not seen by a provider and eloped.



On August 8, 2024, at 11:55, EMP3 confirmed the above.

Based on a review of facility documents, medical records (MR), a hospital surveillance video and employee interviews (EMP), it was determined that the facility failed to following the patient sitter policy which resulted in an elopement of a psychiatric patient for one of 20 medical records reviewed (MR1).



Finding include:



On August 8, 2024, a review of the facility's Patient Sitter Policy revealed, "The policy of Excela Health to utilize patient sitters in accordance with established standards to minimize the safety risk to the patient or another individual. This policy applies to all employees or Contractor employees working in a sitter position or capacity within Excela Health. E. Patient sitter responsibilities include but are not limited to: 1. Sitting with patient in view 2. Providing protection to keep a patient from harming themselves or others...5. Patient sitters must remain in the patient room with the patient at all times. ...7. The use of radios, headphones and any other other electrical devices by sitters for personal use is prohibited...".



Review of MR1 on August 8, 2024, revealed that the patient was a 28 year old with a history of psychiatric disorders and arrived in the facility's Emergency Department (ED) for a psychiatric evaluation. The patient had been off all medication for two weeks and attempted suicide. MR1 had a history of psychiatric admissions in the past and the most recent in July of 2024. Further review of the medical record revealed that the patient was placed in a patient room and a patient sitter was order due to the Columbia Suicide Severity Rating Scale. MR1 had positive thoughts for suicide and after a psychiatric consultation a determination was made to admit the patient to the inpatient psych unit as a Covid test was requested prior to moving the patient to the unit. On August 2, 2024, at 14:07, MR1 eloped from the Emergency Department.



On August 7, 2024, a review of a surveillance video in the ED and and interview with EMP1 at 12:15 PM, provided the following chronological summary of the events that occurred on August 2, 2024.

· 2:06:17: MR1 was seen stepping out of room 18. A security guard in the hall was looking at their phone while reportedly directly observing a patient in room 20. MR1's sitter was sitting in the hallway across from room 18, looking to the right (away from room 18) and appeared not to notice MR1. There did not appear to be any interaction at this time between the security guard, sitter, and patient.
· 2:06:28 the patient's sitter continues looking in the opposite direction of the patient and room 18.
· 2:06:47 MR1 exits through the the non-restricted doorway into the hall. Security guard turns but does not respond and removes radio from his back pocket and returns it without use.
· 2:07:09 MR1 exits at a fast pace through the ambulance bay doors.
· 2:07:24 MR1 observed in parking lot walking at a normal pace and crosses the street and no longer able to be viewed by video surveillance.


On August 8, 2024, at 9:11 AM, EMP3 confirmed the above.