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Based on interview and record review, Hospital A failed to stabilize and keep safe one of twenty patients (Patient (Pt) 1) when Pt 1 was brought into the Emergency Department (ED) by ambulance (BIBA) on 11/23/24 on a 5150 hold (a Welfare and Institutions code that allows for the involuntary detention of an adult experiencing a mental health crisis) for suicidal ideations (thoughts, fantasies, or contemplations about ending one's own life) and after being examined by a physician, being placed in a room and monitored by a sitter, Pt 1 ran past staff and left the ED with staff knowledge and staff did not notify security to assist in bringing Pt 1 back to the ED. Pt 1 was hit by a car and transported via emergent medical evacuation to Hospital B where Pt 1 was diagnosed with multiple trauma injuries including a L5 TP fracture (broken back bone) and a femur fracture (broken leg bone) that required surgery.

The cumulative effect of this systemic problem resulted in the hospitals to not ensure the provision of quality healthcare in a safe and responsible manner. (refer to A2407)

Based on interview and record review, Hospital A failed to stabilize and keep safe one of twenty patients (Patient (Pt) 1) when Pt 1 was brought into the Emergency Department (ED) by ambulance (BIBA) on 11/23/24 on a 5150 hold (a Welfare and Institutions code that allows for the involuntary detention of an adult experiencing a mental health crisis) for suicidal ideation's (thoughts, fantasies, or contemplations about ending one's own life) and after being examined by a physician, being placed in a room and monitored by a sitter, Pt 1 ran past staff and left the ED with staff knowledge and staff did not notify security to assist in bringing Pt 1 back to the ED. Pt 1 was hit by a car and transported via emergent medical evacuation to Hospital B where Pt 1 was diagnosed with multiple trauma injuries including a L5 TP fracture (broken back bone) and a femur fracture (broken leg bone) that required surgery.

This failure resulted in Pt 1 not being stabilized for a known mental health emergency medical condition (EMC), permitted to leave the ED without providing security personnel the opportunity to bring Pt 1 back into the facility and subsequently experiencing an avoidable accident with injury. Pt 1 was hit by a car and transported via emergent medical evacuation to Hospital B where Pt 1 was diagnosed with multiple trauma injuries including a L5 TP fracture (broken back bone) and a femur fracture (broken leg bone) that required surgery.

Findings:

During a concurrent interview and record review on 2/25/25 at 2:33 p.m. with the Emergency Department Manager (EDM), Pt 1's Electronic Health records (EHR) for her ED visit on 11/23/24 were reviewed. Pt 1's EHR indicated, she was brought in by ambulance to Hospital A's ED at 1:35 p.m. on a 5150 hold. The EDM stated Pt 1 was seen by medical doctor (MD 1) at 1:39 p.m. to start the medical screening exam (MSE) and place orders. Pt 1 was placed on suicidal precautions (prevention measures). The EDM stated the "ED Physicians Notes" dated 11/23/24 at 7:37 p.m. indicated, "... 18-year-old female presenting for danger to self. Per paramedics and police, she has had history of being placed on hold. She was reportedly walking onto incoming traffic. She stated that she wanted to harm herself. Police witnessed this and placed her on a 5150 hold. She does not give a specific plan at this time as to how she would harm herself. On exam, patient is endorsing SI [suicidal ideation]. Will order labs per protocol. If labs are reassuring, then patient will be cleared for transfer to psychiatric facility ..." The EDM stated at 2:02 p.m. staff in the ED did a safety check on the room Pt 1 was going to be placed in for anything that could be used to harm herself and everything was removed. The EDM stated at 2:10 p.m. Pt 1 was placed in this room, and she changed into the burgundy scrubs and a 1 to 1 sitter (a person that is assigned to observe someone around the clock) was initiated. Pt 1's EHR indicated, Pt 1 was agitated and at 2:21 p.m. received Geodon (an antipsychotic medication used to treat symptoms of schizophrenia [chronic mental health condition characterized by disruptions in thought processes, perceptions, emotions, and social interactions] and bipolar disorder [a chronic mental health condition characterized by extreme mood swings, alternating between periods of mania [elevated mood] and depression [low mood]) which appeared to be helping, from 3 p.m. to 4:30 p.m. Pt 1 was sleeping, at 4:45 p.m. Pt 1 woke up and became more agitated and was pacing. Pt 1's EHR indicated MD 1 spoke with Pt 1 at 4:58 p.m. and planned to place further orders when Pt 1 took off running at 4:59 p.m. through the ambulance bay doors. The EDM stated Pt 1 was followed by the sitter and registered nurse (RN 1), "they ran after her [Pt 1]". The EDM stated staff yelled at Pt 1 encouraging her to return but Pt 1 continued to run and did not come back. The EDM stated the Monitor Tech (MT 1) immediately called the police department at 5:01 p.m. to report Pt 1's elopement. Pt 1's EHR indicated no staff documented any attempts to reach out to the patient or family on 11/23/24 and 11/24/24.

During an interview on 2/25/25 at 3:34 p.m. with the House Supervisor (HS 1), HS 1 stated she received a call on 11/23/24 from the monitor tech (MT 1) stating that a patient had eloped around 5 p.m. HS 1 stated MT 1 had called PD, and staff were currently looking for the patient. HS 1 stated the normal process when a patient elopes from the hospital "is to make sure security is out looking for the patient on our campus; next need to make sure the primary nurse fills in the RADAR (electronic report that reports the incident to the hospital risk department), and that staff are looking for the patient as well." HS 1 stated, "we also alert the administration coming on the next shift." HS 1 stated the responsibility of the hospital is to make sure the policy is being followed, PD is called, call the family and escalate to administration to make sure they are aware.

During an interview on 2/25/25, at 3:21 p.m. with Registered Nurse (RN 1), RN 1 stated she came onto her shift at 4 p.m. on 11/23/24 and asked to take over care of Pt 1. RN 1 stated she was sitting at the nurse's station when a girl (Pt 1) came out of room 6 and she was agitated saying she did not feel good, and something was wrong. RN 1 stated MD 1 showed up and saw Pt 1 and went to speak with her about what was wrong and told her he would get her something to relax. RN 1 stated she worked on getting Pt 1 a dinner tray, "... just as [MD 1] turned left to his office to put the orders in, the patient [Pt1] came back out of her room turned left and ran towards the ambulance doors. She ran out of the doors." RN 1 stated the MT 1 called PD right away and RN 1 ran after the patient but by the time she turned the corner the patient was already out by the street and "I did not have time to yell at her to come back." RN 1 stated the sitter was just outside Pt 1 's door monitoring Pt 1 but Pt 1 just ran right past him. RN 1 stated she is not sure if MT 1 called a code green (hospital code called overhead when a patient elopes) nor if security was called, and she did not see security during the elopement.

During an interview on 2/25/25 at 3:40 p.m. with MD 1, MD 1 stated Pt 1 was on a 5150 hold, and she eloped and maybe got hit by a car. MD 1 stated since the incident extra security has been placed in the ED and stationed near the ambulance entrance. MD 1 stated we [the hospital] try not to put patients in restraints, so we try to deescalate the situation with the patient. MD 1 stated we don't want staff to block the patient, we want them to protect themselves as well. MD 1 stated at the time of the incident, he did put in additional orders for Pt 1. MD 1 stated the ED team called the police and did what they were supposed to do for this type of situation.

During an interview on 2/26/25 at 9:03 a.m. with the Ambulance Triage Nurse (RN 2), RN 2 stated Pt 1 was BIBA on 11/23/24 and described Pt 1 as younger and has been here before. RN 2 stated Pt 1 came in very upset. RN 2 stated Pt 1 tends to be aggressive but easily calmed. RN 2 stated Pt 1 is familiar with the ED routine, "Pt 1 can start to yell and get upset but she never gets physical with staff".

During an interview on 2/26/25 at 9:16 a.m. with the Monitor Technician (MT 1), MT 1 stated he was working at the nurse's station when Pt 1 eloped. MT 1 stated he was busy with transfers, but that security and the house supervisor were there. MT 1 stated the hospital had 4 ambulance patients in the hallways, so it was crowded and chaotic. MT 1 stated he remembers Pt 1 coming to her doorway 2 to 3 times, once asking for her phone. MT 1 stated the sitter, and the security guard were right there. MT 1 stated Pt 1 stated she did not want to stay here anymore and asked why we were keeping her here. Staff told her she needed to stay in her room and seconds later she took off. She just ran past the gurneys at the back door, we didn't have time to stop her. MT 1 stated Pt 1 had been to the ED earlier that day but had eloped, this time Pt 1 was BIBA on a 5150 hold. MT 1 stated when Pt 1 eloped, he did not call a code green but that he did call the police department (PD) right away. MT 1 stated PD took quite a while to come to Hospital A. MT 1 stated he heard on the 911 status net that a young lady had been hit by a car later after the elopement. MT 1 stated the driver of the vehicle was brought in by officers and mentioned that she just darted out in front of his vehicle. MT 1 stated he got off work at 7:30 p.m. that night. When asked if anyone followed Pt 1 outside, MT 1 stated the nurse did and he believed security followed the patient outside as well.

During an interview on 2/26/25 at 10:06 a.m. with Security Guard (SG 1), SG 1 stated when a patient elopes staff is supposed to notify security, and we respond. SG1 stated if the patient is still onsite then security will try to talk with the patient, "we do not put hands on the patient and we do not physically block them, we talk to them and try to get them to stay and be safe". SG 1 stated he worked the day of 11/23/24 and remembers doing his normal patrols and when he went into the ED, he noticed the crisis patient was gone. SG 1 stated he spoke with MT 1 and MT 1 informed him the patient had left already about an hour ago. SG 1 stated MT 1 did not mention that Pt 1 had eloped just that she had left so he figured she was discharged normally. SG 1 stated it wasn't until later that night that the police department came and started investigating Pt 1's elopement. SG 1 stated he spoke with ED staff and told them they should have called a code green and let security know that Pt 1 had eloped so security would know to look for the patient.

During an interview on 2/26/25 at 3:05 p.m. with the Sitter (SI 1), SI 1 stated he was the sitter for Pt 1 on 11/23/24. SI 1 stated he is a monitor technician for Hospital A and on 11/23/24 he was educated and given instructions on how to be a sitter for Pt 1. SI 1 stated this was the first time he was a sitter for a patient, but he knew he needed to be no less than 10 feet away from the patient with uninterrupted visibility. SI 1 stated as a sitter he was responsible to watch the patient and fill in the form every 15 minutes indicating what the patient was doing i.e. sleeping and fill in the initial paperwork that shows the room was cleared of any hazards and was safe for a suicidal patient. SI 1 stated Pt 1 was very agitated when she came in and it was hard to get her to settle down, "she was antsy in the room and would pace around". SI 1 stated he is not sure if the nurse gave Pt 1 any medication, but Pt 1 spent most of his shift sleeping. SI 1 stated then Pt 1 jumped out of bed and said her arm, her body hurt. SI 1 stated the nurse and the doctor both spoke with the patient at that time trying to deescalate her, something was said about getting her medication for pain. SI 1 stated we were going to order her a dinner tray when the doctor turned to leave, and Pt 1 literally ran with her yellow socks on out the ambulance bay doors. SI 1 stated he was in front of the nurse's station sitting and Pt 1 ran right past him and the nurse and him ran after Pt 1. SI 1 stated the nurse was yelling that Pt 1 was on a hold and staff could get her medication and a meal, but Pt 1 did not respond to us she just kept running. SI 1 stated we did follow Pt 1 outside there was an ambulance coming in and by the time we saw her she was already out at the sidewalk and Pt 1 never turned around to look at us. SI 1 stated security was not there at the time Pt 1 eloped, security came afterwards once patient was out of sight. SI 1 stated he believed it was SG 1, but he was not sure if MT 1 called security or if security just showed up. SI 1 stated it was a busy night, there was a transfer of a patient going on. SI 1 stated he is not sure if a code green was called.

During an interview on 2/27/25 at 10:45 a.m. with the Security Manager (SM), the SM stated she covers four sites associated with Hospital A. The SM stated the security guards at the hospital patrol the areas outside and inside the hospital, she mentioned there are sensors that security must tap to show they have patrolled all the areas. The SM stated once they tap the sensor, they need to make a comment to what they see. The SM stated the security officer helps with deescalating patients and persuading them to calm down and stay if they are attempting to elope, if not successful the security officer will ask the medical staff what they would like to do next. The SM stated medical staff will either want to give the patient medication or security officer may have to help hold a limb while restraints are being placed on the patient. The SM stated when there is an elopement there is an expectation that the security guard will submit a report to explain what occurred and what was done. The SM stated SG 1 did not submit a report because he stated that he was not informed about the elopement of Pt 1 until later that night.

During a review of document titled, "Tour Details," dated 11/23/24, the document indicated, SG 1 was on duty that night and there was no mention of an elopement nor anything unusual that night.

During an interview on 2/27/25 at 11:06 a.m. with the Manager of Risk Management (MRM) and the Director of Quality (DQ), the root cause analysis (a structured process used to identify and address issues that lead to adverse events in healthcare) for Pt 1's elopement was reviewed. The MRM stated Pt 1's elopement was investigated, and gaps were found. The MRM and DQ stated a code green was not called and there was some confusion when they interviewed staff as to whether Security was present at the time of the elopement or if they were even informed of Pt 1 eloping at the time. The MRM stated it was later determined that Pt 1 was hit by a car after she eloped. The MRM stated since this event security has been increased and increased their rounding, they now have a security guard always stationed at the back ambulance doors to help with issues in the ED. The MRM stated education has gone out to staff on the elopement policy and to have better communication and "close the loop so that staff and security are on the same page".

During a review of Pt 1's Hospital B's electronic health records (EHR) dated 2/27/25, the EHR indicated Pt 1 arrived by air for an inpatient trauma visit on 11/23/24, at 7:27 p.m. Pt 1's ED Pt (patient) care timeline for Hospital B was reviewed and indicated, "... Chief Complaints Updated pedestrian vs vehicle ... ED Notes Addendum ... Patient came in as a STAT (right now) trauma by [name of air transport]. Per EMS [emergency medical services] patient was an elopement from [Hospital A's name] in which they were struck by a vehicle at approximately 55 mph (miles per hour) ... Patient on arrival presents with significant road rash to their back, frontal forehead with an associated hematoma (bruise), and an obvious femur deformity. Per [name of air transport] patient's dorsalis pedis pulse (felt on top of the foot) was absent however after traction patient presents in hare traction (used to reduce patient pain, secure the leg in an appropriate position and restore length to the femur) with a doppler (device used to detect blood flow) pulse. Patient presenting as a Glasgow coma scale 14/15 (GCS- a number between 3 and 15 that measures a person's level of consciousness. A lower score indicates a lower level of consciousness and a more severe injury.) ... Admit to Inpatient ... Ortho consult ... 11/24/2024 04:30 [4:30 a.m.] ED Notes per [City name] PD [police department] pt was placed on 5150 for DTS [danger to self], and taken to [Hospital A], prior to her eloping and being struck by car. Per PD 5150 is still in effect. Attempting to contact [Hospital A] for copy of 5150 ..." Review of Pt 1's Acute Care Surgery Service Discharge Summary from Hospital B, dated 11/30/24, indicated, "... Injuries -left midshaft femur fracture - scattered abrasions - grade 3 splenic lacerations (a significant injury to the spleen (small organ that stores and filters blood)-L5 TP fracture (broken back bone). Patient underwent left femur intramedullary nail placement (a metal rod that's inserted into the femur (thigh bone) to treat fractures) with orthopedic surgery and is medically cleared for discharge. Pending psych recommendations/probable psych placement ..."

During a review of Hospital A's Policy titled, "EMTALA- Medical Screening Examination (MSE) and Stabilization", dated 11/20/2019, indicated, "... POLICY SUMMARY/INTENT: A. To ensure that all individuals who Come to the Hospital (as defined in the Compliance with EMTALA policy) seeking or in need of Emergency Services and Care receive an appropriate Medical Screening Examination and further examination and Stabilizing treatment in accordance with applicable laws and Hospital policies ... 2. Psychiatric Condition. A Psychiatric Emergency Medical Condition is considered Stabilized when the Treating Physician has determined, within reasonable clinical confidence, that the individual is protected or prevented from injuring or harming himself/herself or others ... 7. Elopement. If an individual leaves the Hospital without notifying Hospital personnel (i.e., elopement), the elopement should be documented by Dedicated Emergency Department staff in accordance with the Patient LWBS/Elopement/AMA/LABS; Dedicated Emergency Department (DED) policy ..."

During a review of Hospital A's Policy titled, "Code Green - Patient Elopement", dated 5/15/2024, the policy indicated, "... the purpose of this policy is to provide an appropriate response in the event of a missing/eloping patient who is determined to be a danger to himself/herself, or who is identified as a safety risk ... High Risk Patient for Elopement ... A patient who ... on a legal hold (danger to themselves or others); Having active suicidal/homicidal ideation ... On a "patient watch" or has a safety attendant/sitter ... Key Elements A. All reasonable measures will be taken to prevent the elopement of high-risk patients from the hospital ... take all reasonable steps necessary to safely retrieve/locate an eloped patient as quickly as possible ... The hospital's response will be limited to the hospital campus. The police will be notified for assistance beyond the hospital campus ... Patients have the right to leave the hospital ... against medical advice and the organization must ensure patient safety and therefore a safe discharge ...PROCEDURES: A. Upon Discovery of an Eloped Patient: 1. Staff will notify the PBX operator immediately and provide the following information: a. Patient care unit where the patient eloped from. B. Description of the eloped patient. c. Time and location the patient was last seen. 3. The PBX operator will announce a Code Green via the overhead paging system and ensure notifications are made to the administrator in charge, security and risk management. 4. Staff will notify the charge nurse and security services when a patient who does not meet the criteria is missing from the patient care area to assist with retrieving the patient ... B. Recovery: 1. The Security Officer and police department (if applicable) will determine when the Code Green is concluded and will release the site to resume normal operations. 2. The Security Officer will notify the PBX Operator and page, "Code Green, all clear" three (3) times ... 3. Training and Education: a. Patient care staff should receive appropriate orientation and training relative to working with high-risk elopement patients. B. All staff will be educated about Code Green ..."

During a review of Hospital A's policy titled, "One to One Monitoring, Behavioral Health Patients," dated 9/20/2023, the policy indicated, "Policy Summary/Intent: A. Ensure patient safety by identifying patients that are a danger to self or to others. B. Identify personnel that may provide 1:1 continuous monitoring/attention. C. Provide a safe and a supportive environment ... 2. The Registered Nurse (RN) must assess every shift and reassess as needed to determine continued need for 1:1 monitoring. 3. The Sitter will have access at all times to nursing staff, such as the primary RN or the Lead RN. 4. The sitter must be in eye to eye contact with the patient at all times. a. NEVER leave the patient alone or unattended at any time. b. When the patient uses the restroom, make every effort to provide same sex staff to attend to the patient's personal needs and to make sure the patient stays safe ... 6. The duties of the Sitter may include feeding a patient that does not have swallowing restrictions, sitting with the patient, walking with the patient, reading to the patient, praying with the patient, etc. B. Education ... B. Continuous Monitoring: 1 ... Monitor patient continuously in the patient's room ..."

During a review of Hospital A's policy titled, "Suicide Prevention," not dated, the policy indicated, "Policy Summary/Intent: The purpose of this policy is to provide guidelines for screening patients, to identify those patients at risk for suicide, and to provide interventions that are appropriate to the risk level identified in hospital settings ... Key Elements A. Screening: Early identification of patients at risk for suicide is crucial. Complete the C-SSRS screening tool (The Columbia Suicide Severity Rating Scale - it rates an individual's degree of suicidal ideation on a scale by asking questions) for all patients who are being evaluated or treated for a behavioral health condition as their primary reason for care or who may be at risk as determined by the clinician. For patients who are unable to answer or refused, the patient shall be considered as high risk until the screen can be completed ... C. Interventions for non-behavioral health settings: Risk reduction strategies and safety measures should be initiated by the Registered Nurse based upon screening, clinical judgment, and any additional assessments ... 3. Interventions for High Risk: a. Notify the LIP (Licensed Independent Practitioner). b. Document the plan/actions used to mitigate the risk for suicide for the patient to include at minimum: i. PSA (Patient Safety Attendant) for Constant 1:1 observation of the patient. See Attachment F for an example of the minimum information that should be documented including validation at least every 15 minutes that observation has been continuous. I. Line of sight observation of patient continues in the shower/bathroom ... PSA will use an environmental checklist to document risk items removed ... Patients will be placed in burgundy paper scrubs ... 1. Care planning will be initiated, and interventions included ... C-SSRS Frequent Screener tool every shift ..."