HospitalInspections.org

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Based on record review and interviews, the facility failed to comply with §489.24(2) when they did not stabilize one of 20 (Patient #1) patients whose records were reviewed.
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Based on record review and interview, Facility A failed to stabilize, protect, and prevent one (Patient #1) of twenty patients from injuring or harming him/herself or others when Facility A allowed Patient #1 to elope from the Emergency Department (ED) and leave against medical advice (AMA) while experiencing a psychiatric emergency.
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Cross reference to Tag A2407 CFR §489.24(d)(1-3).
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Based on record review and interview, Facility A failed to stabilize, protect, and prevent one (Patient #1) of twenty patients from injuring or harming him/herself or others when Facility A allowed Patient #1 to elope from the Emergency Department (ED) and leave against medical advice (AMA) while experiencing a psychiatric emergency.
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Findings included:
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Client Record Review:
Facility A's Emergency Department (ED) Nursing Documentation indicated that on 10/01/2023, at 3:25 AM Patient #1 arrived at the Emergency Department (ED) at Facility A via EMS with Arlington Police Department (APD) Officer due to a sexual assault referral.
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Facility A's ED Nursing Documentation indicated that on 10/01/2023, at 4:48 AM while awaiting a SANE (Sexual Assault Nurse Examiner) exam, Patient #1 exhibited disconnected thinking when the following was documented: "When asking pt (patient) when assault occurred, pt stated "tomorrow." When asked pt what time assault occurred, pt stated "pick a time."
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Facility A's ED Crisis Clinician Assessment Documentation indicated that on 10/01/2023, at 8:21 AM Patient #1 was noted to be at a "Moderate" Suicide Risk Level, and the Plan of Care was for a "Voluntary Inpatient Psych Admission. The Crisis Clinician documented, "Pt is not mentally stable and is agreeable to Inpatient BH (Behavioral Health) for mental health stabilization."
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Facility A's Crisis clinician documented further in the same note that Patient #1 was experiencing Homicidal Ideation precipitated by sexual abuse.
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Facility A's Crisis Clinician documented further in the same note that Patient #1 has a past medical history of Bipolar, Schizoaffective Disorder, and substance abuse and again stated that Patient #1 was not mentally stable.
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Facility A's ED Nursing Documentation showed that on 10/01/2023, at 2:13 PM:
"Pt witnessed walking out of ED. Charge RN walked out to make sure the patient did not have an IV catheter in place. Pt was standing in the ambulance bay outside. When asked the patient about the IV the pt stated she wanted to go smoke. RN informed her that this is a non-smoking facility. Pt proceeded to remove the IV herself. RN informed the patient she was going to help you with the IV removal Pt started yelling and started to follow RN back into the main ED entrance. RN informed security she was leaving, pt proceeded to walk right up to me within inches and stated, "I hope your family is well". The on-duty police officer (Staff #A14) walked up to pt and removed her from the emergency room. Pt proceeded to walk towards Randol Mill. APD notified since pt eloped from ED while waiting for placement for moderate risk suicidal ideation and homicidal ideation."
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Facility A's ED Nursing Documentation indicated that on 10/01/2023, at 2:14 PM Patient #1 eloped, and left against medical advice (AMA) with Police Notification.
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Policy Review:
The facility's policy titled, "Psychiatric Disturbances in the Emergency Department", last reviewed and implemented on 11/03/2021 was reviewed. The policy stated on pages 1 & 2 of 3:

" ... 4.1 When a patient presents to the ED requesting mental health services or is exhibiting a psychiatric disturbance, the patient's medical and psychiatric history including medications, previous admissions and stressors precipitating current event should be obtained. The nurse should complete the Suicide Risk Assessment Tool in CareConnect.
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4.2 The patient should be placed in a safe non-threatening treatment area with visual monitoring capabilities or placed under Visual Observation as defined below.
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4.3 The patient should be placed in paper scrubs, if available, and all personal belongings should be placed in a belongings bag, including clothing, shoes and any implements or objects that may cause patient to injure himself/herself or others. Belongings should be removed from the room and given to an accompanying adult. If patient is unaccompanied, the belongings will be secured until patient's disposition is evaluated and considered stable.
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4.4 Patients considered to be a flight risk should be under Visual Observation at all times ....
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5.1 Visual Observation - Maintaining visual contact of the patient ...."
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Interviews:
In an interview on the morning of 11/14/2023, at 10:15 AM, the ED Charge Nurse (Staff #A3) indicated that she called APD because Patient #1 was not safe to leave and she (Staff #A3) could not follow Patient #1 any further away from the facility for her safety.
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In an interview on the afternoon of 11/15/2023, at 3:08 PM, APD Staff #1 indicated that Staff #A3 had informed him that they (Facility A) did not want Patient #1 back in the ED and said that they (Facility A) were done with her (Patient #1). The interview further indicated that was when APD Staff #1 decided to transport Patient #1 to another facility.
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In the same interview on the afternoon of 11/15/2023, at 3:08 PM, APD Staff #1 indicated that Patient #1 was "talking all wrong" and wanted to hurt the people who assaulted her. APD Staff #1 also stated that Patient #1 threatened his safety when she threatened to hit him.
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