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Based on interview and record review, the hospital failed to ensure an appropriate medical screening examination (MSE) was provided for one patient (Patient #22), and failed to ensure stabilization of patients who were determined to have an emergency medical condition (EMC), within the capacity and capability of the hospital for one patient (Patient #18), of 22 records reviewed of patients who presented to the hospital Emergency Department (ED) for emergency care.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA), dated 04/17/23, showed that:
- Patients who come to a Dedicated ED requesting examination and treatment will be triaged and receive a MSE by a Qualified Medical Professional (QMP).
- The MSE extends until the point that the QMP determines that an EMC does or does not exist. A patient should continue to be monitored based on the patient's needs, and monitoring should continue until the individual is Stabilized or admitted or appropriately transferred.
- When an individual presents with psychiatric symptoms, the MSE should include an assessment of suicide (ending one's own life) or homicide (ending another's life) attempt or risk, orientation, or assaultive behavior that indicates danger to self or others. When the hospital determines that an individual poses a danger to self or others, this is considered an EMC.
- A minor may request examination or treatment for an EMC. The hospital should not delay an MSE by waiting for parental consent.
- When the MSE reveals that the person has an EMC, the hospital will provide stabilizing treatment as required to stabilize the medical condition or will transfer the patient. Stabilizing treatment is ongoing and must be continued until the patient is stabilized or appropriately transferred.
- Capability of the hospital includes (in part) services available at the hospital as a whole, including ancillary services routinely available.

2. Patient #22, a 15 year old minor, presented to the hospital ED on 03/15/25, after he took six oxycodone (very potent pain medication, normal dose is one or two). The patient reported he obtained the drugs from the street (illegally obtained), which made him feel numb all over, anxious, and like his heart was pounding, and was concerned that the drug he had taken was not oxycodone. When the emergency department physician (EDP) entered the patient's examination room, he requested social work to be contacted, which scared the patient. The patient collected his belongings, exited triage, and walked out of the hospital. Although it was documented that attempts were made to get security involved, security indicated they could not assist, and the patient was allowed to leave without completion of the MSE. There were no documented attempts made by the hospital to encourage the minor patient to stay, no attempts by staff or security to physically prevent the patient from leaving, and no documented informed refusal of examination and treatment before the patient was allowed to walk out of the hospital.

Review of a hospital incident report dated 03/31/25, showed that the hospital had identified and corrected failures that led to the patient's elopement, and subsequent failure to provide an appropriate MSE, by escalating all elopements to leadership per policy and reporting the incident in the event reporting system to allow for full investigation per the Risk Management process.

3. Patient #18 presented to the ED on 02/21/25 at 5:36 PM by ambulance, after ambulance staff had responded to reports of an overdose. The patient complained of a severe headache, a head injury, and a broken nose due to an assault. The patient's mother reported he was non-compliant with his psychiatric medications, paranoid and irrational, had five hospital visits within seven days, and was potentially a harm to himself and others. She feared he was being assaulted on the streets, and stated he was medicating with illegal substances. Upon EDP examination, the patient complained of a headache with noted bruising to the patient's right eye and a scab on his nose. He would not answer questions appropriately or cooperate. He was confirmed to have a broken nose, as well as a skin injury to his fingers which were believed to be burns. He appeared paranoid and psychotic and was not alert, was medically cleared for transfer for inpatient psychiatric care, and was placed on a psychiatric hold (ability to prevent a patient from voluntarily leaving due to risk to self or others). Over the course of four days in the ED, the patient was documented as anxious, uncooperative and unable to be directed. He would escalate and required the assistance of security, the use of restraints, and medication. The patient was placed in a room in a secluded hallway that was between two exit doors, and was allowed to leave his room even though he was placed on continuous observation. On 02/24/25, the psychiatric hold by the ED was ordered by the courts (court ordered psychiatric hold) and the patient continued to wait in the ED to be transferred to an available inpatient psychiatric bed. On that evening, the patient was found standing in front of, and staring at, an "alarmed" exit door. He was redirected back to his room but still allowed to come and go, in and out of his room. Later that same evening, the patient eloped from the same door, which failed to alarm, and the staff observing the patient remotely, failed to immediately notify ED staff until four minutes after the patient had eloped from the hospital.

Review of a hospital incident report dated 03/10/25, showed that the hospital had identified and corrected failures that led to the patient's elopement, and subsequent failure to stabilize the patient's EMC through the following actions:
- The ED exit door which failed to alarm when the patient eloped, was repaired.
- All behavioral health patients holding in the ED for greater than 24 hours are reported during a daily "Tiered Safety Huddle" in which the information is escalated to leadership.
- A report titled, "Virtual Safety Monitoring Alerts for Patients out of Camera View" was distributed and reviewed by all telesitter staff with attestation of receipt by 03/24/25.
- Implementation and oversight of the implementation, monitoring and sustainment of the actions was the responsibility of the Chief Nursing Officer.

Based on interview and record review, the hospital failed to ensure an appropriate medical screening examination (MSE) was provided for one patient (Patient #22), of 22 records reviewed of patients who presented to the hospital for emergency care.

Findings included:

Review of the hospital policy titled, "Patients Leaving Against Medical Advice and Elopement," dated 01/15/25 showed:
- For patients with questionable decision making capacity, or a belief that the patient's decision to leave will pose an imminent risk to the health and safety of the patient, the provider should consider efforts to physically detain the patient.
- For patients under the influence of alcohol or drugs, the provider will need will need to make a determination regarding whether the level of intoxication would prohibit the patient from making informed decisions regarding their discharge against medical advice and/or whether it could place the patient at imminent risk of harm to self or others.
- For minors who insist on leaving despite verbal encouragement efforts, If it is determined by the provider that there is an imminent risk of harm, the provider should consider efforts to physically detain the minor patient. Security may be contacted if available to assist, and may assist in the application of restraints.

Review of an emergency department (ED) record for Patient #22, showed the 15-year-old presented to the ED on 03/15/25 at 1:36 PM, with a chief complaint of oxycodone (prescription pain medication that his high risk for addiction and abuse) overdose. Triage Nurse O documented at 2:08 PM, that the patient had been dropped off by a friend after he had taken oxycodone he obtained from the street (illegally) for back pain related to scoliosis (abnormal curvature of the spine). EDP P documented a note at 1:45 PM, that the patient reported the pills he had taken that day made him feel numb all over, anxious, and like his heart was pounding. EDP P documented that he spoke to the nurse to get social work involved, and the patient overheard and understood that it meant a referral to the Division of Child and Family (DCF). The patient became concerned that he would be taken away from his mother, picked up his belongings and left. EDP P documented that security was notified but they were unable to keep the patient in the ED. There was no documentation that the EDP examined the patient or ordered testing, and the patient was documented as left AMA at 1:50 PM.

During an interview on 06/27/25 at 2:00 PM, Triage Nurse O stated that Patient #22 presented to the ED for concerns that he had overdosed after taking six-20 milligram (mg) oxycodone. The patient stated that he didn't feel right and believed that the drug he had taken wasn't oxycodone. The patient appeared anxious and scared, and his heart rate and blood pressure were elevated. Triage Nurse O stated that when the physician entered the room, he commented that social work needed to get involved, and when the patient heard this, he picked up his belongings. Triage Nurse O said to the patient, "Dude, please don't leave," but the patient started walking very rapidly, and before security could get their hands on him, he was out the door. "There was no way to retain the kid. Locking him in the room would be considered imprisonment, and restraints would not have been warranted with his behavior." Triage Nurse O reported that he was unaware if the patient was ever found, or his outcome.

During an interview on 06/30/25 at 9:00 AM, EDP P stated that Patient #22 reported he felt weird after ingesting six - 20 mg oxycodone, "which is an excessive amount." The patient was complaining of heart palpitations (the sensation of feeling your heart beating too fast, fluttering, or pounding) and was tachycardic (a heart rate that is faster than normal, specifically over 100 beats per minute at rest). EDP P stated that when he told the nurse to call social work and informed the patient he was a mandated reporter, the patient picked up his belongings and started to walk out of the open triage door, through the ED entrance doors, and out of the hospital within a minute. "It didn't seem to me that he was about to be voluntarily restrained," and when EDP P shouted into the waiting room for security officers to assist, they responded that they couldn't prevent him from leaving because he wasn't on a court ordered psychiatric hold. EDP P explained that if he wanted to prevent a patient from leaving, he would get security involved, and the police if necessary, and get the patient escorted to a safe place where medications could be administered and the patient could be evaluated by psychiatry on-call, if necessary.

During an interview on 07/02/25 at 9:30 AM, Security Officer (SO) Q stated that he did not have any interaction with Patient #22, but while staged in the area, he heard, "Security, come here." By the time he turned around, he didn't have time to respond because the patient was too quick to stop, and ran down the street. SO Q added that a patient does not have to be on a psychiatric hold to "have a hold on them, they just must be deemed to be unsafe to themselves or others." SO Q stated that hospital staff should do everything they can to prevent a patient from eloping, but to physically prevent a patient from leaving would be criminal. "We do whatever we can to keep them from leaving in the first place, but if all else fails, we call the police to bring them back in."

Based on interview and record review, the hospital failed to ensure patients who were determined to have an emergency medical condition (EMC), were stabilized within the capacity and capability of the hospital for one patient (Patient #18), of 22 records reviewed of patients who presented to the hospital for emergency care.

Findings included:

1. Review of the hospital's policy titled, "Behavioral Health Patient Involuntary Admission Policy," dated 02/21/25, showed that staff shall take all reasonable precautions to prevent the elopement of patients deemed a mentally ill person, subject to involuntary commitment for care and treatment.

Review of the hospital policy titled, "Patients Leaving Against Medical Advice and Elopement," dated 01/15/25 showed that factors impacting elopement risk identification include if the patient is a legal hold for risk of harm to self or others or needs to remain in the facility for their safety or the safety of others. If a patient identified as being at risk for elopement has made an active attempt to elope during the current encounter, they will be deemed high risk for elopement, and a 1:1 constant observer should be placed with the patient.

Review of the hospital's policy titled, "Continuous Visual Monitoring for the Adult Patient Safety using TeleSitters," dated 11/07/24 showed:
- The purpose of the telesitter services was to provide continuous visual monitoring of patients to ensure patient safety.
- Continuous visual monitoring was appropriate for patients who were at risk for elopement, those who are potentially violent or self-destructive, and moderate suicide risk.
- It was not recommended to utilize telesitter monitoring outside of the room, in the hall, or across the hall for the flight risk patient.
- Notify the telesitter monitor technician when the patient is removed from the room for walks, etc.
- The telesitter monitor technician places the patient under continuous visual monitoring, calls the nursing staff directly if an issue arises with the patient that needs staff response, activates the alert alarm when a patient being monitored for suicide precautions is not visible, and documents verbal cues to the patient as well as calls to the nursing staff.

2. Review of an emergency medical services (EMS, ambulance and staff) report dated 02/21/25 at 5:17 PM, showed EMS responded to Patient #18, a 27 year old male, for reports of an overdose. The patient had used K2 (synthetic marijuana) and complained of tooth pain in the lower right side of his mouth. The patient informed EMS that he was unable to walk due to "broken bones" in his legs, yet ambulated without difficulties. He appeared in mild distress due to the tooth pain and was transported to Ascension Via Christi St. Francis campus emergency department (ED).

Review of the ED record for Patient #18 showed he presented to the ED on 02/21/25 at 5:36 PM. The patient was triaged at 6:00 PM and complained of a headache. ED Physician (EDP) F documented an examination at 6:34 PM, with a history of homelessness, multiple psychiatric disorders, polysubstance (drugs and or alcohol) abuse, and kidney failure due to a drug overdose. The patient complained he had a head injury and a broken nose due to an assault, which was confirmed by computerized tomography (CT, detailed computerized x-ray). The patient's skin was noted to have bruising to the patient's right eye, a scab on his nose, and the patient would not answer questions appropriately. He appeared paranoid and psychotic and was not alert. His judgement was impaired by abnormal thoughts, he was delusional (having a false or unrealistic belief that is not based on reality), tangential (unable to connect with what is being asked), and with a flight of ideas (rapid thoughts and speech, with difficulty maintaining focus). Per the patient's request, the patient's mother was contacted, who expressed concern about the patient's psychiatric illness, medication non-compliance and reported he was not safe on his own and a potential harm to himself or others. At 7:23 PM, the EDP determined the patient was medically stable for psychiatric evaluation and transfer. Throughout the evening, the patient would escalate, was unable to be redirected, and required the assistance of security officers, restraint, and medications to help him calm. An application for a court ordered psychiatric hold, was signed by the EDP, and on 02/22/25 at 12:33 AM, an order for admission to behavioral health was placed. Throughout the night, the patient would not follow commands and was verbally abusive towards staff. He was placed on a suicide risk protocol, which required the patient to leave his exam room door open, however, he repeatedly closed the door and attempted to flood the room with sink water. He required security response and medication. At 8:40 AM, a consultation was conducted by Telepsychiatrist G, who documented the patient appeared to be responding to internal stimuli (sensations or perceptions that originate from within one's own mind, rather than from something happening in the outside world), and had limited insight, judgement, and impulse control. He was unable to be assessed for suicide due to the patient's agitation, and a recommendation was made to involuntarily admit the patient to behavioral health. Throughout the remainder of the patient's stay in the ED, he continued to escalate, failed to be redirected, and required medication. The patient was moved to a room where he could watch television, and per documentation, was allowed to sit outside of his examination room. On the evening of 02/24/25, the patient was medicated for agitation. His pulse and blood pressure were elevated, and security was called when the patient began yelling profanities outside of his room and was unable to be redirected. At 11:15 PM, ED Registered Nurse (RN) A documented that nursing staff responded to the telesitter alarm sounding in the patient's room, and the patient was unable to be found. Law enforcement later contacted the ED and reported the patient had been located, was booked on charges, and would not be returned to the hospital.

During an interview on 06/27/25 at 1:15 PM, ED RN C stated Patient #18 was on moderate suicide risk and needed to be within eyesight at all times. ED RN C stated he had no concerns that the patient would elope.

During an interview on 07/02/25 at 1:00 PM, Security Officer H stated " ...there is not enough staff for sitters" so ED staff will watch patients who require constant observation, but when ED staff get up to do something, they don't ask for another staff member to watch the patient. On 02/23/25, the patient was standing in his room entrance, cussing at the nurses and yelling, and he was able to calm the patient down. Security Officer H stated, "I never felt" the patient was going to elope.

During an interview on 06/27/25 at 7:30 AM, ED RN A stated that while Patient #18 remained in the ED under a court ordered psychiatric hold, instead of 1:1 monitoring, he was monitored virtually in his examination room by staff located on the 8th floor. The patient's room was located in a secluded hallway that contained two exit doors. The patient would come out of his room, come to the nurses' desk, and required frequent redirection back to his room, however, she was not concerned he would elope.

During an interview on 07/01/25 at 7:30 AM, ED RN B stated the patient was in a hallway bed when he first presented to the ED, and "it was reported that he had tried to walk out, which was why he was made a court ordered psychiatric hold." He would be calm and then become very antsy and it was reported that he had required restraints at some point. By the time ED RN B took over care of the patient, he had been medically cleared and was awaiting a bed in the psychiatric unit at the St. Joseph campus. He had a court ordered hold and was located in a psychiatric safe room (all items in the room are secured to prevent patient access, for safety) with a telesitter. The telesitter was able to watch him and they are able to call and alert ED staff if needed, however, the patient wouldn't stay in his room, and the room was not visible at the nurses' station. Additionally, the patient's room was located near the emergency medical services (EMS, ambulance staff) doors, and in a zone that was not staffed that night. The patient required redirection several times. He was standing outside of his room door, he was yelling at everyone who tried to talk to him, and he was antsy and wouldn't sit still. He repeatedly walked up to the nurses' station desk, but never indicated he was going to leave. He informed us that he was anxious, his heart rate and blood pressure were elevated, and he requested medication. Ativan (medication used to calm patients) was ordered because he was yelling profanities, and security was required to come to the patient's bedside. ED staff unsuccessfully attempted to verbally redirect the patient, and security was on standby for safety in the patient's room, and once we administered the Ativan, he laid down quickly. Between the medication administration at 8:59 PM, and 9:50 PM, the patient began to come out of his room again, and security voluntarily indicated that they would stay with the patient while he was allowed to walk around in the hall. The Ativan had worn off by that time, and the patient would get "very, very antsy," but there was no concern that the patient would leave because he did not indicate he was going to leave. There were a few times that the telesitter monitor staff could not see the patient in his room and would either sound the alarm on the telesitter camera, call the ED, or do both, and ED staff would confirm that the patient was out of his room and that staff had eyes on him. At some point (time unknown), security waved to us, indicating an unofficial handoff of the patient. At 9:50 PM, while walking down the patient's hallway (area that was not staffed), the patient was found at the end of the hall, staring at an alarmed exit door (door the patient later eloped from). The patient was easily redirected back to his room and remained in his room except for a couple times that he walked out to use the bathroom. While assisting staff in a critical patient's room, ED RN B's hospital phone (personal work phone that allows for quick communication between staff) rang and the alarm went off in the patient's room simultaneously, notifying us that the patient could not be seen by the telesitter. No one could find the patient. ED staff reviewed the video footage, and it showed that he had stepped out of his ED room and saw there was no one at the nurses' station, walked back into his ED room, and then left his room and ran out of the ED at 11:11 PM. He was wearing a gown assigned to psychiatric patients, an armband that indicated he was a psychiatric patient, and hospital socks. He then ran across the street and jumped the fence and ran onto the roadway. Police were contacted, and later reported they had located him, and she was unsure what happened to the patient after that. The hospital followed all policies and did everything possible to prevent the patient's elopement. The patient just happened to be in a location for an extensive amount of time where it was not the safest for him, and he should have been in a locked unit.

During an interview on 07/03/25 at 7:00 AM, Telesitter T stated that on 02/24/25, the patient was allowed to stand in his doorway while he was observed by telesitter staff. The telesitter staff were short staffed with only two core staff that night, and the person who was sent to assist with telesitter staffing was not well trained, and there were too many patients to monitor when a staff member went to lunch. This led to a delay in notification of the patient's elopement.

Review of the hospital's internal investigation showed that the patient was last seen at 11:10 PM by the remote telesitter, and the telesitter alarm was not activated until 11:15 PM, which she heard coming from the patient's room. Security determined the patient had exited through door 10.

Review of an event report systems report showed four narratives dated 02/24/25. According to the narratives, Patient #18 eloped through "Door #10" which was "supposed to be alarmed."

Patient #18, a patient who was under a court ordered psychiatric hold and awaiting transfer for inpatient psychiatric care, was placed in a room that was not visible to the nurses and in an area that was not staffed. The patient, who was reported to have attempted to elope during his stay, was not "deemed high risk for elopement" or placed with "a 1:1 constant observer," per policy. The patient was allowed to repeatedly stand in the doorway of his room, and leave his room, at times without staff awareness, and subsequently eloped without stabilization of his EMC.