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Based on interview and record review, the facility failed to ensure stabilizing treatment and the maintenance of safety and security relevant to the psychiatric emergency medical condition (EMC) was provided for 1 out of 21 sampled patients (Patient 11) when he was admitted on a psychiatric hold (5150; when a person is deemed a danger to self, others, or gravely disabled, could be involuntary detained for 72 hours) and eloped (patient leaving the hospital before discharged) from the Emergency Department (ED) twice.

This failure resulted in Patient 11 running out of the the facility to a highway and walking in front of a moving vehicle and subsequently died. This failure has the potential to place other patients at a high risk for harm.

Findings:

On December 21, 2023, an unannounced visit was conducted at the facility for an EMTALA survey.

The facility's document titled, "ED Provider Notes," dated December 18, 2023, at 4:56 p.m. was reviewed. The document indicated, "...Chief Complaint...Suicidal...history of anxiety with presumed recent auditory hallucinations [hearing noises without an external stimulus] returns after eloping the ER [emergency room]. He was brought back by family. The patient stated to both staff and family that he is actively suicidal but will not state a plan. He is placed on 5150..."

A review of the facility's document titled, "Application For Assessment, Evaluation, and Crisis Intervention or Placement For Evaluation and Treatment," dated December 18, 2023, at 4:45 p.m. indicated, "...[Patient 11's name] ...Brought in by family for acute SI [Suicidal Ideation; thinking about or planning suicide]...Patient [Patient 11] with history of depression [medical illness that negatively affects how someone feels] presents for acute SI. Patient seen earlier at [Facility Name] ED for anxiety/paranoia [delusional beliefs about persecution, threat or conspiracy] then eloped. Patient brought back by family and now states actively suicidal...signature: [Name of physician]..."

A review of facility's document titled, "Suicide Screening," dated December 18, 2023, at 5:04 p.m., indicated Patient 11 was suicidal.

A review of the facility's document titled, "ED Pt. care timeline," dated December 18, 2023, at 5:05 p.m., indicated, Patient 11 was admitted in ED as Emergency Severity Index 2 (ESI, a five-level triage tool utilized by ED with two meaning emergent).

A review of the facility's document titled, "ED Notes," dated December 18, 2023, at 9:15 p.m. signed by RN 3 was conducted. The document indicated, "...At around 9:10 p.m., received phone call from Operator that security is outside with this patient that eloped from the ED ...RN reports patient's sitter, [name of assigned sitter], CNA [certified nurse assistant] was with the patient waiting for the restroom in the ED lobby when he suddenly ran out..."

A review of the facility's document titled, "ED Notes," dated December 18, 2023, at 9: 20 p.m. signed by RN 3 was conducted. The documented indicated, "...After phone call from operator to the ER [emergency room] main line, desk tech, [name of desk tech] called [ local police department] and made them aware of the 5150 patient that eloped from our facility..."

A review of the facility's document titled, "...Incident from night 12/18/2023 [December 18, 2023]," signed by sitter/CNA [certified nurse assistant assigned to patient] indicated, "...I was assigned to a patient in the ER...I section of the hospital which was a bed in a hallway...the patient requested to go to the bathroom, so I stood up and took him to the nearest restroom, someone was in the bathroom so I advised him to wait until the person in the bathroom comes out. After a couple of minutes, the patient hurried and escaped through the nearest exit door and started running away...I grabbed him by the gown but he ripped it off and kept running, I started shouting out for security so they can help capture the patient. Security finally caught up to us and try to talk to the patient and convince him to return back to the hospital. but the patient didn't want to listen, he continued walking away until he crossed the road and jumped a barbed wire fence an entered the freeway where he was standing on the shoulder lane, immediately when he saw a speeding vehicle coming down the highway he then used that opportunity to run and jump in front of the vehicle therefore killing himself..."

An interview with the Director of Quality and Patient Safety (DQPS) on December 22, 2023, at 11:00 a.m., was conducted. The DQPS stated there were two videos of Patient 11's elopement. The videos were reviewed with the DQPS. Patient 11 was observed walking to the nearest restroom accompanied by the assigned sitter/CNA. Patient 11 then began walking toward the double doors out to the ED main lobby. The sitter began to yell for assistance and a staff nurse knocked on the security's office window. Another video footage showed security in pursuit, outside toward the parking lot. The DQPS further stated, "If we would have known what his plan was, and we knew that his plan was to run to the freeway, then we would or could have taken more measures such as placing two sitters with him any time he was getting up. He stated he was suicidal but never verbalized his plan."

An interview with the Security Manager (SM) on December 22, 2023, at 11:32 a.m., was conducted. The SM stated, "This is not the first time a 5150 tried to run to the freeway. We have been able to stop them. Once we know their plan then we make sure we do what ever it takes to not let them get to the street."

A review of the policy and procedure (P&P) titled, "Patients Suspected or Determined to be a Danger to Self or Others, or Gravely Disabled," dated March 29, 2022, was conducted. The P&P indicated, "...Provide constant visual observation of patient to ensure safety and prevent access to items that can be used for harm..."