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Based on record review and interview the facility failed to ensure that facility staff documented attempts to obtain signatures on AMA (Against Medical Advice) forms as per facility policy in 3 of 13 (Patient #s 5, 6 and 9) medical records reviews out of a total universe of 13 medical records.

Findings include:

The facility policy titled "Consent Policy" #10.12 last revised October 2003 was reviewed. This document revealed "Consent for medical or surgical procedures must be informed consent. Elements of informed consent. To be legally valid, the consent given for a medical or surgical procedure must be informed consent...Obtaining Consents. Signature must be provided knowingly and of free will...Use ink. All signatures must be in black or blue ink, as should the time and date any other information written on the document. Fill in consent completely. All spaces on the consent form must be accurately and concisely filled in and completed consent form must then become part of the medical record. If a line exists that requires nothing, a line shall be drawn through the space and initialed."

The facility policy titled "Against Medical Advice" #50.09 last revised July, 2009. This document revealed "Upon notification that a patient is refusing an examination or recommended treatment or desires to leave the hospital, the following will occur: If after the primary care giver attempts to address the patient's concerns, and the patient continues to refuse care, the primary care giver will notify the House Supervisor (when appropriate) and the patient's attending physician of the patient's concern; If, following discussion with the attending physician (when possible), the patient continues to refuse care, the patient's wishes will be honored and the patient will be asked to sign the Leaving the Hospital Against Medical Advise (AMA) and/or Informed Consent to Refuse Examination or Treatment form; The patients primary caregiver will note the patients concerns and refusal of care in the patient's medical record; and the patient's primary care physician will document any discussion with the patient when discussion was possible and/or other significant items regarding the event in the patients medical record."

Patient #5's medical record was reviewed on 8/27/2020 at 7:00 AM. Patient #5 was seen in the Emergency Department on 7/25/2020 for hematuria (blood in urine) and urinary frequency. A "Refusal of Emergency Medical Screening Examination" consent was signed by the patient prior to leaving but there was no documented date, time or staff wittness signature.

An interview was conducted on 9/9/2020 at 3:25 PM who stated "It is our expectation that the Refusal of Medical Exam be signed by a facility employee and have a documented date and time of signatures. The employee who accepted the form from the patient is aware of the expectation and acknowledged that he did not meet the expectation."

Patient #6's medical record was reviewed on 8/27/2020 at 7:30 AM. Patient #6 was seen in the Emergency Department on 6/26/2020 for accidentally taking morning medications twice. A "Medical Decision Making" note completed by the physician documented "I did offer oral (potassium) replacement however prior to this being able to be administered patient elected to leave the department. I was in a code in another room and therefore unable to talk with patient prior to her leaving. She informed the nursing staff of her intentions and she did sign AMA paperwork." There was no documented AMA form in Patient #6's medical record.

An interview was conducted on 9/10/2020 at 10:00 AM who, when asked if there was a signed AMA form for Patient #6 stated "No we did not find one in the medical record."

Patient #9's medical record was reviewed on 8/27/2020 at 10:30 AM. Patient #9 was seen in the Emergency Department on 8/9/2020 for vomiting and diarrhea. A "Clinical Note" completed by physician documented "This patient has decided to conclude his treatment episode prior to its reasonable conclusion and been informed that concluding this episode of care at this time is AGAINST MEDICAL ADVICE. The patient has been asked to sign the AGAINST MEDICAL ADVICE (AMA) form." There is no documented refusal to sign AMA form or signed AMA form in Patient #9's medical record.

An interview was conducted on 8/31/2020 at 3:46 with Senior Director A who, when asked about a signed AMA form on Patient #9 stated "Upon further review we did not find a signed AMA form."

Based on record review and interview the facility failed to ensure that the suicide assessments and precautions and elopement documentation was completed for patients that were suicidal, or had eloped from the Emergency Department in 2 of 13 (Patient #s 1 and 2) medical records reviewed out of a total universe of 13 medical records reviewed.

Findings include:

The facility document "Suicide Risk Assessment and Intervention Work Flow" was reviewed on 8/27/2020. This document revealed "If the patient answers yes to questions #4, 5 or 6 on the C-SSRS (Columbia Suicide Severity Rating Scale) indicating high risk interventions are: 1:1 observations is required, for those patients who answered yes to questions #4, 5 & 6 to the C-SSRS (yes to these questions indicates suicidal thoughts with a plan). Complete the environmental safety checklist when high suicide risk is identified. Re evaluate the environment using the environmental safety checklist periodically when there is a change in care giver, change in location, after visitor, etc."

The facility document "Skills: Suicide Assessment and Precautions" no # or date was reviewed on 8/27/2020. This document revealed "Do not assume that a patient who denies suicidal ideations is not at risk. Actively listen to the patient because he or she may not be honest with health care team members who appear detached and uncaring...13. Initiate suicide precautions if the patient has suicidal thoughts...Documentation: Suicide risk assessment at admission, during any change in the patient's condition or treatment and before discharge."

The facility document "Skills: Elopement" was reviewed. This document revealed "Elopement occurs when a patient intentionally leaves an assigned area of care without permission...Elopement takes place without team members knowledge...If a patient elopes all unit healthcare team members are to conduct a thorough systematic search of the unit. If the patient is not found in the unit, notify security and provide information about any legal hold status, temporary detention order, or mandated treatment order. Notify the practitioner, unit manager, administrator, and the risk management personnel. Notify the patients designated family member. The family needs to be aware of the patients elopement. Family members can help by reporting if the patient returns home and by assisting with the patients return to the facility. Family members may also assist the police in identifying places the patient is likely to go. If the patient can not be located by healthcare team members or family members, provide the police and other agencies with appropriate information; date and time of elopement, patients age, the patients physical description, usual address, legal status, potential for violence or safety risk, designated family members name and contact information. Document the strategies in the patients chart...DOCUMENTATION: Any forms required by the organization to be included in the patient's record. Patient flow sheet or specific documentation that identifies last observation of the patient. Discovery of elopement. Interventions in response to elopement. Persons notified of elopement. Incident report. "

Patient #1's medical record was reviewed on 8/26/2020 at 11:00 AM. Patient #1 was seen in the Emergency Department on 7/27/2020 for complaints of increased anxiety and suicidal ideation. Admitting C-SSRS was documented as having answered yes to questions #5 & 6 which puts her at "high risk". Patient #1 eloped from the Emergency Department at 10:46 PM was later found by a relative ambulating down the interstate in dark clothing. There was no documented 1:1 observations, no documented search of facility completed by healthcare team, no completed incident report by healthcare team, notification of security, family notification or notification of police department.

An interview was conducted with the Senior Director A on 9/10/2020 at 10:00 AM who, when asked stated "We can't argue with that, those things are not documented in the medical record."

Patient #2's medical record was reviewed on 8/26/2020 at 11:40 AM. Patient #2 was seen in the Emergency Department on 8/23/2020 for a chief complaint of suicidal ideation. Admitting C-SSRS was documented as having answered yes to questions #4 & 5 which put him at "high risk". Patient #2 eloped from the Emergency Department at 9:15 PM after refusing to pay for ambulance transportation to an inpatient behavioral health facility. There was no documented 1:1 observations, no incident report or environmental safety checklist completed by healthcare team, notification of security or family notification.

An interview was conducted with the Senior Director A on 9/10/2020 at 10:00 AM who, when asked stated "We can't argue with that, those things are not documented in the medical record."

Based on record review and interview the facility failed to ensure that there was completed documentation in medical record of times of reassessment in the waiting area in Emergency Department in 3 of 13 (Patient #s 1, 5 & 6) Emergency Department medical records reviewed in a total universe of 13 medical records reviewed.

Findings include:

The facility policy titled "EMTALA: Medical Screening and stabilizing Treatment" #10.30 last reviewed in October 2013 was reviewed on 9/2/2020 at 3:15 PM. This document revealed "The patient's medical record must reflect: Times of reassessment in the waiting area;"

The facility policy titled "Triage and Assessment of an Emergency Severity Index (ESI) Level" #406.10 last reviewed August 2020 was reviewed on 9/2/2020 at 3:00 PM. This document revealed "Triage: Refers to an essential process performed by an emergency registered nurse to classify ill and injured patients into categories of acuity and prioritization for care based on the nature of a patient's illness or injury and the apparent severity of the same. If not deemed to be a level 1 or 2 acuity, the nurse also assesses the resources required to transition the patient to the appropriate disposition, i.e. discharge, admission or transfer from the Emergency Department...Each person triaged will be assigned an ESI score. The triage registered nurse will complete a limited but targeted and focused assessment based on the patient's complaint. The triage registered nurse will then assign an ESI level and direct the patient accordingly, such as to a room for care, to the waiting area, or to an area for care such as the CT scanner in the case of a stroke. The triage ESI level relfects the determination of whether it is perceived that the patient can safely wait for a medical screening examination and treatment...At times when patients are unable to be directed to a patient treatment room for triage and treatment and must wait in a waiting area, patients are informed to contact the staff at the reception area if their symptoms change while waiting at which time the patient will be reassessed to determine if the initaal triage ESI level remains appropriate for the patient's condition...Rounding on patients in the waiting area to identify unanticipated needs and to assure direct contact with patients is also a routine practice when the transition of patients from the waiting area to the ED treatment rooms is unusually delayed. Documentation of the outcome of those rounds is completed, as appropriate, should a change in condition of any patient be identified.

Patient #1's medical record was reviewed on 8/26/2020 at 11:00 AM. Patient #1 was seen in the Emergency Department on 7/27/2020 for increased anxiety and suicidal ideations. Patient #1 arrived at 6:22 PM had a CSSR (Columbia Suicide Severity Rating Scale) completed at 6:45 PM which scored "high risk" and patient was returned to the waiting room until 8:02 PM (77 minutes later) when she was roomed in Emergency Department. From 8:45 PM until 9:55 PM there was no documented reassessment during that time (70 minutes). There was no documented reassessment of Patient #1 while in the waiting area.

Patient #5's medical record was reviewed on 8/27/2020 at 7:00 AM Patient #5 was seen in the Emergency Department on 7/25/2020 for hematuria (blood in urine) and urinary frequency. Patient #5 arrived at 4:44 PM and patient was "dismissed" at 11:41 PM. There was no documented triage, assessment or re assessment while in the waiting room.

Patient #6's medical record was reviewed on 8/27/2020 at 7:30 AM. Patient #6 was seen in the Emergency Department on 6/26/2020 for accidentally taking morning medications twice. Patient #6 arrived at 2:48 PM was triaged at 2:54 PM, had vitals taken at 4:00 PM (66 minutes later), at 7:37 PM was roomed in the Emergency Department (217 minutes later), at 8:00 PM had vitals taken and at 9:21 PM (81 minutes later) requested to leave against medical advice. There was no documented reassessment of Patient #6 while in waiting room or Emergency Department patient room.

An interview was conducted with Senior Director on 9/10/2020 at 10:00 AM who, when asked about no times of reassessment in medical record stated "We can see the staff going thru the waiting room and talking to the patient's waiting and the patient's are visible to the Emergency Department staff but there is no record of it in the medical records. We can't argue with that."