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Based on document review, video surveillance review, and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.55, Emergency Services.

Findings include:

1. The hospital failed to ensure that a patient (Pt #1) who presented to the emergency department (ED) with suicidal ideation was triaged and assessed for suicidal ideation, taken directly to the treatment area and monitored to ensure patient safety. (A-1104)

The immediate jeopardy (IJ) began on 10/3/2025, due to the hospital's failure to ensure that a patient (Pt #1) who presented to the emergency department (ED) with suicidal ideation was triaged and assessed for suicidal ideation, taken directly to the treatment area, and monitored to ensure patient safety. Subsequently, Pt #1 had absconded from the ED prior to any assessment and treatment. The IJ was identified on 10/9/2025 at 42 CFR 482.55, Emergency Services. The IJ was announced on 10/9/2025 at 4:25 PM, during a meeting with the Chief Executive Officer, Chief Medical Officer, and Chief Quality and Nursing Officer, and was not removed by the survey exit date of 10/9/2025.

Based on document review, video surveillance review, and interview, for 1 of 3 clinical records (Pt. #1) reviewed for patients who presented to the emergency department (ED) with suicidal ideation, the Hospital failed to ensure that the patient was triaged and assessed for suicidal ideation, taken directly to the treatment area and monitored to ensure patient safety. Subsequently, Pt. #1 had absconded from the ED prior to any assessment and treatment. This lack of assessment and monitoring of patients with suicidal ideation is likely to cause serious harm, injury or death to patients presenting with suicidal ideation, as well as others at large.

Findings include:

1. On 10/9/2025, the Hospital's policy titled, "Triage Protocol (5/2021)" was reviewed on 10/8/2025 and included, "The ED lead RN will evaluate all ambulance runs and law enforcement patients at 'Station A' upon arrival to ED and then notify triage staff of patient arrival. ...The RN assigned to the area will complete the triage procedure. If there are limited bays open, the ED RN will obtain the chief complaint and categorize each patient using the ESI [emergency severity index] levels 1 thru 5 [1 being more severe]. ... The triage staff will initiate interventions as guided by protocol. ... Level 2: Emergent/immediate: Patients are at High-risk: their condition can easily deteriorate, or the condition requires time sensitive treatment. Patients require immediate attention and care and are sent directly to the treatment area. Examples: ... suicidal or homicidal ..."

2. The "Emergency Triage Technician Job Description (8/15/2025)" was reviewed on 10/9/2025 and included, "Essential Functions: Take and record vital signs, assist with other patient assessment and remains as directed. ..."

3. The ED Meeting Minutes, dated 7/18/2025, were reviewed and included, "All members present agreed that the practice of contraband checks on psychiatric, substance abusing, and intoxicated patients should be continued. ... Multiple members noted that at other institutions, all patients are placed in gowns and in that process contraband and weapons are found."

4. On 10/9/2025, Pt. #1's clinical record (dated 10/3/2025) was reviewed and indicated:
On 10/9/2025, the fire department ambulance run sheet (dated 10/3/2025) noted, "In summary, crew was dispatched to residence for a psych[iatric] eval[uation]. Upon arrival, crew was met by [Pt. #1] outside of residence, was alert, oriented x3 and complaint of wanting to hurt himself. Vitals obtained and [Pt. #1] checked for weapons by local police. [Pt. #1] assisted into ambulance for further assessment and transport. Report called into the Hospital ER with no further orders given to EMS. Upon arrival to ER, report given to staff and care transferred without incident. [Pt. #1] placed in triage area per charge nurse due to no beds available. Pt. #1 care was transferred without incident."
-ED Assessment written by E #2 (ED Triage Technician) - "time of arrival 8:19 PM, mode of arrival - ambulance, condition on arrival. Stated complaint - Pt. #1 seeks psych eval due to suicidal ideations. Pt. #1 admits to ETOH (alcohol) abuse prior to arrival to ED. ESI score 2." Vital signs were blood pressure 125/77 (normal blood pressure is considered to be less than 120/80), pulse 86 (normal pulse ranges from 60-100), respirations 16 (normal respiratory rate is between 10-20), temperature 97.5 (normal temperature is between 97 and 99 degrees) and pulse ox 93% (normal pulse oximeter is between 95% and 100%).
-MD #1's (Emergency Physician) orders (dated 10/3/2025 at 8:27 PM) included, "Alcohol stat, EKG, CBC, CMP, Drug Screen urine and urinalysis" There was no documentation of any labs drawn or results in Pt. #1's clinical record.
Pt #1 was placed in the ED waiting room, where Pt #1 was not monitored for safety, and the hospital did not call for Pt #1 from the waiting room for approximately 3 hours.
-E#2's notes (dated 10/3/2025 at 11:11 PM, 11:23 PM and 11:36 PM) indicated, "Pt. # 1 was not seen in waiting room or in the hallway." [This was approximately 3 hours after Pt #1 arrived to the ED.
- MD #1's note, dated 10/3/2025 at 11:22 PM included, "Continuity of Care Note - Pt. #1 apparently presented for alcohol intoxication and psychiatric evaluation. Pt. #1 was visualized on arrival in no distress noted normal vital signs. Psychiatric workup ordered however Pt. #1 absconded from the ED prior to its completion. Pt. #1's location in the ED is listed as "ED hallway."
-Discharge Summary: absconded
Pt. #1's clinical record did not include a suicide assessment or any monitoring of Pt #1 for safety.

5. On 10/8/2025, a policy regarding the care and monitoring of psychiatric patients and suicide risk assessment in the ED was requested. Per the Manager of Risk (E #11), the Hospital does not have a policy related to care/oversight of the psychiatric patients in the ED.

6. On 10/8/2025 at 1:05 PM, video surveillance review was conducted with the Chief Quality and Nursing Officer (E #1) and the Director of Security (E #3). The video footage was from the ED's EMS ambulance doorway; the patient walk-in entrance; the exterior ED roundabout; and the patient care interior (back ED). The following was observed from the video on 10/3/2025:
- 8:07:45 PM: Pt #1 arrived through the Hospital's ED ambulance bay, escorted by the (local fire department EMS/Z #1 and Z #2). Pt #1 was taken to the main ED's back hallway, via wheelchair, by the EMS crew (Z #1, Z #2).
- 8:10:21 PM: The Triage technician (E #2) approached Pt #1 in the main ED hallway. Vital signs taken by E #2, with verbal interaction observed between E #2 and Pt #1. Z #1 and Z #2 remain with patient while E #2 interacting with Pt #1. E #2 walks away from Pt #1 at 8:12 PM.
- 8:12:33 PM: Z #1 and Z #2 transported Pt #1 to the ED nurse's station. Z #1 and Z #2 interacting with a staff member at the nurse's station, while Pt #1 remained in the wheelchair, in the hallway.
- 8:17:05 PM: Registration Clerk (E #16) interacting with Pt #1 in the hallway, placing a wristband on the patient. Pt #1 signing papers presented by the registration clerk.
- 8:20:35 PM: Pt #1 transported to the waiting room, from the back ED, via wheelchair by Z #1 and Z #2. Pt #1 stood up from the wheelchair and sat in the waiting room chair.
- From 8:20:35 PM-9:17:14 PM (approximately 57 minutes), Pt #1 remained in the waiting room (unattended by staff). At 9:17:14 PM, Pt #1 walked out of the front "walk-in" doorway. The Greeter (E #15), and the Security Officer (E #14 ), were stationed at the front when Pt #1 walked out the door.
- From 9:17:14 PM-9:41:27 PM (approximately 24 minutes), Pt #1 remained in front of the ED's car roundabout entrance (unaccompanied).
- 9:41:50 PM: A car drives up to the ED's roundabout. Pt #1 enters the car and is driven away.
Pt #1 was not seen returning to the ED.

7. On10/8/2025 at 11:45 AM, an interview was conducted with the Lead ED RN (E #4). E #4 stated that when patients present to the ED, the triage nurse initiates the screening. E #4 stated that the screening includes suicidal screening (SAD).
On 10/9/2025 at 10:30 AM, an interview was conducted with the ED Medical Director (MD #2). MD #2 stated that MD #2 is aware of the incident regarding Pt. #1. MD #2 stated that a psychiatric patient who is suicidal should immediately be brought back into a room with a sitter for 1:1 monitoring. MD #2 stated that triage needs to be completed, and physician evaluation needs to be done.

8. On 10/9/2025 at 10:50 AM, an interview was conducted with the Director of Nursing (E #8). E #8 stated that the ED tech (E #2) should have communicated that Pt. #1 was suicidal to the charge nurse (E #9). E #8 stated that the charge nurse makes the decision where the patient should be placed. E #8 stated that a suicide assessment is completed on each patient in the ED.

9. On 10/9/2025 at 11:00 AM, an interview was conducted with the ED Charge Nurse (E # 9). E # 9 was the ED Charge Nurse on the day of Pt. #1's ED visit. E #9 stated that E #9 was not told by the ED tech (E #2) that Pt. #1 was suicidal. E #9 stated that if E #9 knew that Pt. #1 was suicidal, Pt. #1 would have been moved to a room or hallway with a 1:1 sitter.

10. On 10/9/2025 at 11:25 AM, an interview was conducted with the ED Technician (E #2). E #2 stated that E #2 does not remember Pt. #1. E #2 stated that the ED sees a lot of drunk and suicidal patients so E #2 cannot remember Pt. #1. E #2 stated that if a patient is suicidal, E #2 would communicate this information to the charge nurse. E #2 stated that if a patient is suicidal, the patient is placed on 1:1 monitoring with a sitter.

11. On 10/9/2025 at 10:05 AM, an interview was conducted with the Manager of Risk and Compliance (E#11). E#11 stated that E#11 became aware of the incident involving Pt.#1 on 10/7/2025. E#11 stated that E#11 started the investigation, but it has not yet been completed. E#8 stated that there was no security report filed involving Pt.#1.

12. On 10/9/2025 at 10:51 AM, an interview was conducted with the ED Charge Nurse (E#12). E#12 stated that when patients are brought by ambulance, a report is given at the nurse's station by EMS personnel to the ED Charge Nurse. E#12 stated that a triage technician will perform a basic triage assessment on the patient and assign an ESI (Emergency Severity Index). Patients assigned an ESI of 2 will be immediately brought to the back and placed in a room. E#12 stated that patients with suicidal thoughts will be roomed right away with a sitter assigned and never brought to the waiting area. E#12 stated that if all ED rooms are occupied, a suicidal patient will be placed in the hallway in the ED, never in the waiting area.

13. On 10/9/2025 at 11:05 AM, an interview was conducted with an ED Triage Technician (E#13). E#13 stated that E#13 performs triage assessments for patients presenting to the ED. E#13 stated that E#13 will assign ESI (Emergency Severity Index) for patients triaged. E#13 stated that patients with suicidal thoughts will not be brought to the waiting area. E#13 stated that E#13 will inform the charge nurse so that these patients can be roomed right away.