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Based on observation, record review and interview the hospital failed to Meet the Condition of Patient Rights by failing to develop and enforce a policy/procedure to ensure the safety of patients presenting to the Emergency Department with suicidal ideations, homicidal ideations, gravely disabled, under an order for Protective Custody, Physician's Emergency Certificate, or Coroner's Emergency Certificate while located in the waiting room awaiting bed placement in the Emergency Department , prior to being seen by a physician, and after being seen by a physician for 4 of 10 sampled patients (#3, #7, #9, #R1, #R2).

An immediate jeopardy situation was identified on 6/15/2011 at 1335 (1:35 p.m.) and reported to the Hospital's Interim Director of Nursing S2. The immediate jeopardy was a result of the hospital's failure to ensure a policy and procedure was developed and implemented to ensure the safety of patients presenting to the Emergency Department with Suicidal Ideations/Homicidal Ideations and/or Gravely Disabled while being held in the waiting room and/or prior to being seen by a physician.
Patient #7 presented to the Emergency Department on 5/23/2011 at 1721 (5:21 p.m.) with command hallucinations telling him to set himself on fire. Patient #7 was held in the Emergency Department Waiting room, post triage at 1759 (5:59 p.m. on 5/23/2011) until placed in Exam Room A on 5/23/2011 at 2029 (8:29 p.m./3 hours). There was no documented evidence that Security was informed of the patient's risk/status. The patient had no family/friend in attendance. The patient reportedly paced back and forth in the waiting room. The triage station had a window for viewing the waiting room; however, Triage Nurse S5 indicated in an interview on 6/15/2011 at 8:10 a.m. that she (S5) continued to triage new patients and #7 was not continuously monitored (24 hour census for 5/23/2011 was 94). Observation of Video Surveillance revealed Patient #7 went to a Public Restroom unattended for 10 minutes (as revealed by time notations on surveillance video/see findings under A0144) while in the waiting room. Exam Room A (where #7 was placed on 5/23/2011 at 2029 (8:29 p.m.) was around the corner from the nursing station and unable to be viewed from the nursing station. Patient #7 was PECd (Physician Emergency Certificate) on 5/23/2011 at 2355 (11:55 p.m.). Assessments/interventions were documented at 5/23/2011 2030 (8:30 p.m.), 2035 (8:35 p.m.), 2137 (9:37 p.m.), 2215 (10:15 p.m.), 5/24/2011 0700 (7:00 a.m.), 0822 (8:22 a.m.), and 1154 (11:54 a.m.). Record review dated 5/23/2011 at 2035 (8:35 p.m.) revealed "call light in reach" (possible strangulation/hanging hazard). RNS4 indicated in an interview on 6/14/2011 at 1040 (10:40 a.m.) that #7 should have been placed on Strict Visual Contact once the patient was PECd. RNS4 indicated #7 was not placed on Strict Visual Contact (confirmed with record review). Patient #7 was transferred to a psychiatric facility on 5/24/2011 at 1225.
Patient #3 was brought to the Emergency Department under an Order for Protective Custody (OPC) on 6/09/2011 at 1111 (11:11 a.m.). Review of OPC dated 6/09/2011 at 1025 (10:25 a.m.) revealed in part, "seems to have some dementia. . . very paranoid, hostile, and aggressive. . . gravely disabled". Patient #3 and her son were placed in the Emergency Department Waiting Room post triage. Patient #3 was seen in the waiting room briefly by Psychiatrist S6 at 1210. Nursing documentation on 6/09/2011 at 1230 (12:30 p.m.) indicated "eloped other before ER (Emergency Room) Physician, after Psych MD (Medical Doctor)".
The hospital continued to have no documented evidence of a policy to ensure the safety of patient presenting to the Emergency Department with Suicidal/Homicidal Ideations and /or Gravely Disabled while being held in the waiting room and/or prior to being seen by a physician.

A plan of removal was submitted by the hospital on 6/16/2011 at 10:30 a.m. to address the immediate jeopardy situation which revealed the hospital had implemented the following:
"In response to the Immediate Jeopardy findings of 6/15/2011, the following interim patient safety intervention was implemented at 1400 (2:00 p.m.) on 6/15/2011: ED (Emergency Department) Charge Nurse and staff were instructed to notify the CNO (Chief Nursing Officer) of any psychiatric patient brought to the department until the interim plan of removal could be developed.
The following Interim Plan of Removal was developed: implementation of this plan commenced on 6/16/2011 at 12:00 a.m.
1. A comprehensive policy titled, "Providing Care for Psychiatric and Suicidal Patients in the Emergency Department" was developed that outlines the care of PEC'd/CEC'd (Physician's Emergency Certificate/ Coroner's Emergency Certificate), suicidal, or gravely disabled patients in the Emergency Department, including procedures, roles and responsibilities, 1:1 observation role and responsibility, patient safety interventions, documentation and patient elopement interventions. . . The Patient Leaving Against Medical Advice policy was revised to include elopement. . An Education Plan was developed that includes review and discussion of the policy, including clinical and non-clinical post tests to validate understanding of the policy. All staff will receive a copy of the new policy. A score of 100% is required. Staff who receive a score of less than 100% will receive one on one education and will retest. Subsequent inability to demonstrate competency will require temporary reassignment. Education on the new policy began on 6/16/2011 at 12:a.m. for the staff working during the evening/night shift. . . Administrative Supervisors, ED (Emergency Department) RN's (Registered Nurses) , PCTs (Primary Care Technicians) and ED physicians will not be permitted to begin their next shift until they have successfully completed the education and competency. . . Elements of the Performance Improvement Plan include the following: The ED PCM (Emergency Department Patient Care Manager) or Administrative Supervisor will be notified when a psych patient arrived in the ED. . . PI monitoring (Performance Improvement monitoring). . . daily. . ."
New Policy revisions include "All patients presenting to the ED for psychiatric evaluation, including patients with an OPC (Order for Protective Custody) will be assigned an ESI (Emergency Severity Index) II (patients had previously been assigned a Triage ESI III) and will be escorted directly to a treatment room for physician evaluation. . . All patients are screened for suicidal risk by RN (Registered Nurse). . . Admission of patients who are PECd, CECd, Suicidal: Search patient's belongings for harmful objects. . . The RN will assess the room for safety and remove potentially harmful items. . .All PECd, CECd, suicidal, or gravely disabled patients will have 1:1 observation at all times. . . Patient Elopement: when a PECd/CECd, suicidal, or gravely disabled patient leaves the hospital without permission, he/she is considered to have eloped. . Nursing will call the Security Office, report the elopement and description of the patient. . (notify) treating physician, family. . ."

As a result of the hospital's plan of removal, the Immediate Jeopardy situation was removed on 6/16/2011 at 11:25 a.m. due to the hospital's implementation of new policies for patients presenting to the Emergency Department that were Suicidal, Homicidal, or Gravely Disabled were to be triaged at a Level II and taken straight to the Emergency Department; alleviating the former practice of triaging these patients a Level III and placing them in the waiting room while awaiting bed placement in the Emergency Department. Further the new policy required these patients be placed on a 1:1 Observation Level with mandatory documentation on an Observation Flow sheet. Also the hospital implemented new policies to address patients that were under a OPC, PEC, or CEC that eloped. All employees were to be educated and tested regarding new policies at the start of their shift until such a time that all staff had been trained. Monitoring for Performance Improvement was to be done daily. The Plan was to be revised, as needed, based on QAPI (Quality Assessment Performance Improvement) monitoring. The deficiency will remain at a Condition Level and findings can be found at A0144.

Based on observation, record review, and interview the hospital failed to ensure policies and procedures were developed/enforced to ensure the safety of patients presenting to the Emergency Department with suicidal ideations, homicidal ideations, gravely disabled, under an order for Protective Custody, Physician's Emergency Certificate, or Coroner's Emergency Certificate while being placed in the waiting room while awaiting bed placement in the Main Emergency Department, prior to being seen by a physician, and after being seen by a physician for 4 of 10 sampled patients (#3, #7, #9, #R1, #R2). Findings:
Touro Infirmary Hospital has no inpatient Psychiatric Services/Unit. Review of the Emergency Department Transfer Log for Psychiatric Patients transferred to other facilities revealed the following: December 2010- 5 psychiatric transfers, January 2011- 9 psychiatric transfers, February 2011- 4 psychiatric transfers, March 2011- 8 psychiatric transfers, April 2011- 7 psychiatric transfers, May 2011- 7 psychiatric transfers, and June (1 through 15th)- 1 psychiatric transfer.
Patient #3:
The Medical Record for Patient #3 was reviewed. Review revealed Patient #3 arrived at the Emergency Department at 1111 (11:11 a.m.) on 6/09/2011 with presenting complaint of "NOPD (New Orleans Police Department) states ptatients (patient's) son would like her checked out becauses (because) she has been acting differently, not cleaning her house and states she does not know her family. Son in triage, states he does not think she can care for herself, and would like the doctor to see her. Does not know if he needs to put her somewhere. Pt. (patient) has OPC (Order for Protective Custody)." Review of Patient #3's Order for Protective Custody dated 6/09/2011 at 9:45 a.m. revealed in part, "credible person executes a statement under private signature specifying that to the best of their knowledge and belief a person is mentally ill or suffering from substance abuse and is in need of immediate treatment to protect the person or others from physical harm. Description. . . 91 W/F (year old white female) having mental and medical issues which she refusing to seek treatment which is putting her life at risk, pt (patient) seems to have some dementia. She does not know family. she can't see anymore. not able to care for basic needs. hygiene very poor, house very dirty. not wanting any help. very paranoid. hostile and aggressive. taking cabs all over town with out family knowing where she is. they fear something bad will happen to her. Gravely disabled." Further review of Patient #3's electronic medical record revealed in part, "6/09 (2011) at 1157 (11:57 a.m.) (Physician S6/Psychiatrist) went to waiting room to eval patient. Patient's son stated' everything is taking too long, the coroner said ya'll would get us in and out right away'. stated he was leaving and taking his mother home to care for her. (S6) did briefly speak to patient's son and patient prior to leaving. 12:30 (p.m.) Eloped other before ER (Emergency Room) physician after Psych MD. 1232 (p.m.) Patient left ED." Review of Patient #3's entire medical record revealed no documented evidence that Patient #3 who was under an Order for Protective Custody (OPC) had ever been housed in an area other than the open Emergency Department Waiting Room which allowed entrance and exit at will. From arrival time of 11:11 a.m.on 6/09/2011 until the patient left the Emergency Room on 6/09/2011 at 12:32 p.m. was 1 hour and 21 minutes. Review of Patient #3's entire medical record revealed no documented evidence of a physician's order to indicate the Level of Observation required to meet the needs of Patient #3.
During a face to face interview on 6/14/2011 at 10:10 a.m., Registered Nurse S12 indicated she had been the nurse that triaged Patient #3 on 6/09/2011 and remembered the patient. S12 indicated the patient (#3) had presented with a pleasant demeanor. S12 indicated Patient #3 was confused about the identity of her son and identified him as her manfriend/boyfriend. S12 indicated she (S12) detected an odor from Patient #3 and could tell that she (#3) had not been bathing properly. S12 indicated #3 lived alone. S12 indicated Patient #3 was not suicidal/homicidal and S12 had determined it would be safe for Patient #3 to remain in the Waiting Room until a bed was available. S12 indicated she (S12) never thought of Patient #3 as a flight risk. S12 confirmed that she had been aware that Patient #3 was under an Order for Protective Custody. S12 indicated Patient #3's son had stated that he (son) was a Diabetic and needed to go home and eat. S12 indicated Patient #3's son had indicated that he (son) needed to care for himself and did not seem to want to stay in the Waiting Room with the patient (#3). S12 indicated that Patient #3 became a little "feisty" while in the waiting room, stating that she (#3) wanted to go home.
During a face to face interview on 6/14/2011 at 9:15 a.m., Registered Nurse S11 indicated he never had any formal contact with Patient #3; however, he had been working in the back (Main Emergency Department) and was in the process of discharging another patient. S11 indicated the plan had been to clean the room after the other patient left and then place Patient #3 into the room. S11 indicated he had been informed by the Triage Nurse that there was a patient under an Order for Protective Custody that needed to be placed in a room. S11 indicated he had also been aware that Patient #3's son was expressing discontent about not getting her into a room. S11 indicated Psychiatrist S6 had been in the Emergency Department seeing another patient and he (S11) had asked if (S6) would examine Patient #3 in the Waiting Room.
During a face to face interview on 6/14/2011 at 9:55 a.m., Psychiatrist S6 indicated he had seen Patient #3 briefly in the Emergency Department Waiting Room on 6/09/2011. S6 indicated he was unaware of the hospital's practice in regards to holding psychiatric patients in the waiting room. S6 indicated patients were usually in an exam room in the Main Emergency Department by the time Psychiatry was consulted.
During a face to face interview on 6/14/2010 at 1410 (2:10 p.m.), Patient Care Manager of Emergency Department S3 indicated there should be no elopements of patients under an OPC (Order of Protective Custody), PEC (Physician's Emergency Certificate), or CEC (Coroner's Emergency Certificate). S3 indicated these patients should be housed in a manner that would prevent elopement. S3 confirmed that the Waiting Room allowed for free entrance and exit and afforded patients the opportunity for elopement.
Face to face interviews were conducted with Security Officer S13 on 6/14/2011 at 11:14 a.m. and Security Officer S14 on 6/14/2011 at 11:20 a.m. Both officers indicated they manned the Security Desk in the Emergency Department Waiting Room on 6/09/2011 when Patient #3 was seen. Both officers indicated they had no knowledge of Patient #3 being in need of observation for possible flight risk or any other special observation.
Patient #7:
The Medical Record for Patient #7 was reviewed. Record review revealed Patient #7 arrived at the Emergency Department on 5/23/2011 at 1721 (5:21 p.m.) with presenting complaint of "Patient states. Depressed, expresses suicidal ideation. reports hearing voices since last night. Method of arrival: Ambulated without assistance." Review of Patient #7's entire Medical Record revealed no documented evidence indicating whether Patient #7 was alone or accompanied by family/friend. Patient #7 was triaged at 1759 (5:59 p.m.) as "Urgent - 3 (Patient will need more than 2 resources prior to disposition)". Review of electronically documented "Encounter Events" for Patient #7 revealed the patient was moved from the waiting room to Exam Room (A) on 5/23/2011 at 2029 (8:29 p.m./3 hours and eight minutes after the patient presented to the Emergency Department with Command Hallucinations telling him to set himself on fire). Review of Patient #7's entire medical record revealed no documented evidence that the patient was ever re-assessed by the triage nurse or any other healthcare professional during the 3 hours 8 minutes that the patient was housed in the Emergency Department Waiting Room. Review of Patient #7's entire Medical Record revealed no documented evidence that Security had ever been informed of Patient #7's status/risk. Review of electronically documented Nursing Notes for Patient #7 revealed the following, "5/23 (2011) 2030 (8:30 p.m.), Having thoughts of suicide. Plan for suicide is pour gasoline over himself and strike a match. . ." Further review of Patient #7's electronic Nursing Notes documentation revealed in part, "5/23 (2011) 2035 (8:35 p.m.), Placed in gown. Bed in low position. Call light in reach. . ." (possible strangulation/hanging hazard). Review of electronic Physician Documentation regarding Patient #7 dated 5/23/2011 at 2053 (8:53 p.m./3 hours and 32 minutes after Patient #7 arrived at the hospital) revealed in part, "The patient presents to the emergency department with psychosis, suicide ideation, and the patient has a plan to set self on fire. . . Prior diagnosis of Schizophrenia. . . pt. hearing voices telling him to set self on fire. Pt. with previous attempt at suicide where he set self on fire. . ." Review of Patient #7's Physician Emergency Certificate signed by the physician on 5/23/2011 at 2355 (11:55 p.m.) revealed in part, "I am of the opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering from substance abuse so that he/she is gravely disabled, danger to self, unable to seek voluntary admission." Review of Patient #7's entire medical record revealed no documented evidence that the patient was "visited", evaluated, or assessed from 5/24/2011 at 0020 (12:20 a.m.) until 5/24/2011 at 0700 (7:00 a.m./ 7 hours and 40 minutes). Review of Patient #7's entire Medical Record revealed no documented evidence that a physician had ever ordered a Level of Observation for Patient #7. Review of Patient #7's entire Medical Record revealed no documented evidence that an Observation Flow sheet had ever been initiated or that the patient had ever been placed on Strict Visual Contact (1:1). Patient #7 was transferred to a Psychiatric Recipient Hospital on 5/24/2011 at 1154 (11:54 a.m.). Review of Patient #7's entire medical record revealed no documented evidence of a physician's order to indicate the Level of Observation required to meet the needs of Patient #7.
Video Surveillance of the Emergency Department's Waiting Room was viewed with Security Supervisor S22 and Patient Care Manager of the Emergency Department S3 on 6/15/2011 at 1310 (1:10 p.m.). A portion of Patient #7's time in the Waiting Room was viewed. The entire 3 hours and 8 minutes was not viewed. S22 indicated the times on the video surveillance were not accurate, that it was off by several hours; however, there were staff in the Emergency Department that knew Patient #7 and he had been able to have the patient identified in the video. Observation of the Video revealed Patient #7 left the triage desk and seated himself in the Emergency Department Waiting Room. #7 then ambulated from the seating area of the waiting room down the hallway in front of the triage desk and through the first door of the street exit hallway (two door exit). Patient #7 turned around and repeatedly paced back and forth in the same pattern. Patient #7 eventually returned to the Waiting Room seating area and sat down. At 0637 on 5/23/2011 (6:37 a.m./ recall that the times on the video were inaccurate), as revealed on the video screen, Patient #7 got up from his seat and exited into a long hallway moving away from the triage desk. Patient #7, who was alone and unattended by staff, entered a room identified by Security Supervisor S22 as the public bathroom at 6:37:56 (recall that the recorded times on the video were inaccurate) on 5/23/2011 on 5/23/2011. Patient #7 remained in the public bathroom until he was viewed exiting at 6:47:00. This observation was confirmed by S22 and S3. S3 indicated in a face to face interview at 1:10 p.m. on 6/15/2011, after viewing the surveillance video, that it was obvious to her that the safety of suicidal/homicidal/gravely disabled psychiatric patients being held in the Emergency Department Waiting Room could not be ensured with the hospital's current practice.
During a face to face interview on 6/15/2011 at 8:10 a.m., Registered Nurse S5 indicated she remembered triaging Patient #7 on the night of 5/23/2011. S5 indicated Patient #7 had arrived alone and there had been no one accompanying him to include family, friends, Police, or Emergency Medical Personnel. S5 indicated there had been no beds available in the main Emergency Department; therefore Patient #7 had been placed in the Waiting Room. S5 indicated she (S5) could view Patient #7 from the large viewing window located in the Triage Room and remembered seeing Patient #7 pace back and forth. S5 confirmed that she (S5) had never re-assessed Patient #7 during the 3 hours and 8 minutes that #7 remained in the Emergency Department Waiting Room (policy indicates patients being held in the Waiting Room should have documented re-assessments a minimum of every two hours). S5 indicated that she (S5) continued to triage other patients as they arrived and Patient #7 would not have been on Constant Visual Contact. S5 indicated she (S5) had never informed Security of the status or risks for Patient #7.
During a face to face interview on 6/14/2011 at 1410 (2:10 p.m.), Patient Care Manager of Emergency Department S3 indicated the hospital had no policy for monitoring Suicidal, Homicidal, or Gravely disabled patients that were being held in the Waiting Room. S3 indicated if the nurse were to be concerned about a psychiatric patient being placed in the waiting room while awaiting bed placement in the Main Emergency Department, the nurse could place the patient near the triage station; although she would continue to triage incoming patients and would not be able to visualize the psychiatric patients at all times. S3 confirmed the Emergency Department Waiting Room was not a secure area and patients could enter or exit at will. S3 indicated a Security Officer was always located at a desk located near the exit of the Emergency Department waiting room, across from the triage desk; however, the Security Officer would not be aware that a patient was a flight risk or suicide/homicide risk without being informed by the triage nurse.
During a face to face interview on 6/15/2011 at 1115 (11:15 a.m.), Security Supervisor S22 indicated any patient that was Suicidal/Homicidal with a flight risk should be held in the back (Main Emergency Department behind locked entrance/exit door) because there would be a liability risk for Security to detain someone without having a PEC/CEC (Physician's Emergency Certificate/Coroner's Emergency Certificate). S22 further indicated holding psychiatric patients in the waiting room could also be a liability in regards to other patients/visitors that might be seated in the Waiting Room in the event of a possible behavior outburst by the psychiatric patient. S22 indicated he would always have his officers assist nursing staff in observing and providing for safety of any patient when requested but he would want any suicidal/homicidal/gravely disabled psychiatric patient to be placed in the back (Main Emergency Department) for safety and liability.
During a face to face interview on 6/14/2011 at 1410 (2:10 p.m.) Patient Care Manager of Emergency Department S3 indicated there had been no Observation Flow Sheet for Strict Visual Contact on Patient #3 during his entire stay in the Emergency Department. S3 indicated it had been the practice at the hospital that all patients with a Physician's or Corner's Emergency Certificate be monitored one on one (one staff to one patient) as Strict Visual Contact. S3 indicated she could find no evidence that Patient #7 had been placed on Strict Visual Contact with documentation on an Observation Flow Sheet during his entire stay from 5/23/2011 through 5/24/2011. S3 further indicated that the room placement for Patient #7 (Exam Room A) was located around the corner from the nursing station and was not in the line of sight of nurses/physicians. S3 indicated due to the location of the room, Patient #3 should have been placed on Strict Visual Contact upon placement in the room. S3 confirmed there was no documented evidence that the environment of Exam Room (A) had been modified to ensure removal of all hazardous items when Patient #7 had been placed in the room. S3 confirmed the call light provided to Patient #7 could have been used as a strangulation/hanging device.
During a face to face interview on 6/14/2011 at 10:40 a.m., Registered Nurse S4 indicated he had been one of the nursing staff assigned to Patient #7 on the date of 5/23/2011 through 5/24/2011. S4 indicated he remembered Patient #7. S4 indicated the Emergency Department had been very busy that night (24 hour census 94). S4 indicated Patient #7 had never been placed on Strict Visual Contact although he (#7) should have been. S4 indicated Patient #7 had been treated as a Standard/Routine Emergency Patient while housed in the Main Emergency Department with the exception of visits to the Bathroom. S4 indicated he had accompanied Patient #7 to the bathroom. S4 confirmed that Patient #7 had been placed in Exam Room A, which was out of the line of sight of nursing staff at the Nursing Station. S4 confirmed that he had provided Patient #7 with a corded call light (possible strangulation/hanging risk).
During a face to face interview on 6/14/2011 at 1530 (3:30 p.m.), Medical Director of Emergency Department S19 indicated he would prefer that no psychiatric patient with suicidal ideation, homicidal ideations, or gravely disabled be housed in the Waiting Room. S19 indicated he preferred these type patients be placed promptly in the Observation Room which is observable from the Nursing Station. S19 indicated it had been the practice of the hospital to call for Strict Visual Contact once a PEC/CEC (Physician's Emergency Certificate) had been planned and/or written. S19 confirmed the absence of physician's orders in Medical Records of Patient #3, #7, #9, #R1, and #R2 indicating what Observation Level the patient should have been under (1:1 or 1:2). S19 indicated any patient at risk for suicide/homicide that could not be placed in the Observation Room, in sight of the nursing station, should have someone sit with them upon placement into the room with documentation.
Patient #9:
The Medical Record of Patient #9 was reviewed. Review revealed Patient #9 arrived at the Emergency Department on 4/16/2011 at 1325 (1:25 p.m.) and was triaged as Urgent-3 at 1337 (1:37 p.m.) with "Presenting Complaint: Patient states "I feel like I want to walk in front of a car or something. Method of arrival: Ambulated without assistance." Review of Patient #9's entire medical record revealed no documented evidence to indicate if the patient was alone or accompanied by family/friend. Review of #9's Encounter Events log revealed the patient was moved into the Observation Room (the one room in Emergency Department designed and designated for Psychiatric Emergencies) at 1340 (1:40 p.m.) Further review revealed Patient #9 had personal belongings searched for hazardous items at 1428 (2:28 p.m.). Review revealed Patient #9 was placed under a Physician's Emergency Certificate that was signed on 4/16/2011 at 1837 (6:37 p.m.). Review of Patient #9's electronic Nurse's Notes dated 4/16 (2011) at 1737 revealed in part "Spoke to nursing supervisor regarding need for SVC (Strict Visual Contact). 1927 (7:27 p.m./ 1 hour and 50 minutes after requested) SVC at bedside. Review revealed Patient #9 was transported to a Recipient Psychiatric Facility on 4/17 (2011) at 11:12. Review of Patient #9's entire medical record revealed no documented evidence to indicate the Level of Observation for Patient #9 from the time of arrival at 1325 until the patient was documented to have a SVC at 1927 (6 hours and 2 minutes). Further review of Patient #9's entire medical record revealed no documented evidence of an Observation Flow Sheet at any time during the patient's Emergency Department stay.
During a face to face interview on 6/14/2011 at 9:15 a.m., Registered Nurse S11 indicated there had probably been no one to one observations for Patient #9 from the point of arrival until a PEC had been written, for that had been the practice in the Emergency Department. S11 indicated that until a physician saw a patient and performed a PEC, there would have been no SVC provided. S11 confirmed there was no Observation Flow Sheet located in Patient #9's Medical Record. S11 indicated all patients on SVC should have an Observation Flow Sheet in the their record to verify that safety checks and observations of the patient had been performed. S11 indicated staff could not call for a SVC tech until a PEC had been obtained on the patient. S11 indicated the times that Patient #9 had been assessed/observed would have been the times documented on the Medical Record (1328, 1337, 1340,1344, 1400, 1428, 1429, 1539, 1736, 1836, 1840, , 1923, 1927, 1928, 2242, (3 hours 14 minutes since the prior observation), , 2100, 0536 (8 hours and 36 minutes since the prior observation), 0632, 0704, 0749, 0848, 0904, 1030, and 1108). S11 indicated it was not documented whether Patient #9 had been alone or accompanied by family/friend.
Patient #R1:
The Medical Record of Patient #R1 was reviewed. Patient #R1 arrived at the Emergency Department on 5/23/2011 at 1034 (10:34 a.m.) with presenting complaint of "threatening to kill police. . . brought in by crisis. . . " Patient #R1 was triaged Urgent -3 at 1036 (10:36 a.m.). Review of Patient #R1's Event Log revealed the patient was placed in the Observation Room at 1050 (10:50 a.m.) and searched for dangerous personal items at 1052 (10:52 a.m.). Review of Patient #R1's Physician Emergency Certificate revealed it was signed by a physician on 5/23/2011 at 1600 (4:00 p.m.). Review of electronic Nursing Notes revealed Patient #R1 had been observed/assessed at 1036, 1050, 1051, 1059, 1100, 1156, 1257, 1600 (3 hours and 3 minutes from the prior assessment/observation), 1601, 1617, 1817 (2 hours from the prior assessment/observation), 1859 (2000 - 0630/ every thirty minutes as per Observation Flow Sheet), 0701, 0702, 0714, 0724, 1052 (3 hours and 28 minutes from the prior assessment/observation), and 1218. Review of Patient #R1's Medical Record revealed an Observation Flow sheet was begun at 2000 (8:00 p.m.) with no documented date. The observation flow sheet contained observations every 30 minutes until 0630 (6:30 a.m.). Patient #R1 was transferred out to a Psychiatric Recipient Hospital on 5/24/2011 at 1221 (12:21 p.m.). Review of Patient #R1's entire medical record revealed no documented evidence of a physician's order to indicate the Level of Observation required to meet the needs of Patient #R1.

Patient #R2:
The Medical Record of Patient #R2 was reviewed. Patient #R2 arrived at the Emergency Department on 5/23/2011 at 0342 (3:42 a.m.). Patient #R2 was triaged a level Urgent-3 at 0352 (3:52 a.m.) with presenting complaint of "Police state, 'she was found running around, screaming Magazine St. (Street)'. Pt (Patient) in t-shirt and underwear only. Bizarre behavior noted. Method of arrival, carried." Review of the Encounter Event Log for Patient #3 revealed the patient was initially placed in the Observation Room in the Emergency Department at 3:50 a.m. and later moved to the Isolation Room at 10:49 a.m. (to make room for Patient #R1 to be placed in the Observation Room). Review of a Physician Emergency Certificate for Patient #R2 revealed the physician signed the document on 5/23/2011 at 1600 (4:00 p.m.). Review of Patient #R2's electronic Nursing Notes revealed the patient was assessed/observed at 5/23/2011 0346, 0350, 0352, 0353, 0354, 0357, 0405, 0408, 0429,0436, 0444, 0446, 0509, 0516, 0521, 0628, 0700, 0703, 0719, 0740, 0917 ( 1 hour and 37 minutes after the prior assessment/observation), 1049, 1603 (5 hours and 14 minutes after the prior assessment/observation), 1649, 1858, 1930 (Observation flow sheet with observations every 30 minutes from 5/23/2011 at 1930 through 5/24/2011 at 1030), Review of Patient #R2's Observation Flow Sheet revealed documentation every 30 minutes as to the patient's location and observations from 5/23/2011 at 1930 (7:30 p.m.) until 5/24/2011 at 1030 (10:30 a.m.). Patient #R2 was transferred out to a Psychiatric Recipient Hospital on 5/24/2011 at 1045 (10:45 a.m.). Review of Patient #R2's entire medical record revealed no documented evidence of a physician's order to indicate the Level of Observation required to meet the needs of Patient #R2.
Review of a typed document titled, "Items consistently found in rooms psych patient might be placed in" presented by the Emergency Department's Patient Care Manager S3 as current, revealed in part, "In drawers: Bandaids, EKG (electrocardiogram) electrodes, 4x4 gauze pads, KY jell packs, Qtips, alcohol wipes, tongue depressors. On counter tops: Boxes of gloves, sharps container, stretcher wipes. On wall: Call button cord, otoscope, ophthalmoscope, BP (blood pressure) cuff, Otoscope covers, suction canisters with hose, oxygen regulator, pulse ox packs, hand soap, towel dispenser, BP monitor with cables. On floor: B/P monitor w (with) cables, chair, overbed tray, plan trash container (with plastic bags), red trash container (with plastic bags). Note: Items no attached to wall such as suction hose removed if not in use when psych patient in room."
During a face to face interview on 6/14/2011 at 1410 (2:10 p.m.), Patient Care Manager of Emergency Department S3 indicated nursing staff should ensure that all dangerous items were removed from exam rooms prior to placing psychiatric patients in the room. S3 indicated the Observation Room was the only room that remained ready for Psychiatric Patients. S3 indicated there were times when Psychiatric patients had to be placed in other rooms. S3 indicated she had never had garbage cans with plastic liners removed from the room and had never thought of it as a suffocation hazard. S3 confirmed that documentation on Patient #7, indicating the patient was provided a call light would not be acceptable because the patient could use the cord to strangulate or hang himself. S3 indicated it had not been the practice of the hospital staff to document that the rooms had been prepared for a psych patient and she could not be sure that the rooms had been properly secured for psych patients without seeing documentation to verify the preparation.
Review of the hospital policy titled, "Assessment of Patients in the ED (Emergency Department), #300.16, last revised 1/11 " presented by the hospital as current revealed in part, " Triage patient upon arrival or as close to arrival as possible using the emergency Severity Index. . . Level I- In need of lifesaving intervention. Level II- Patient needs care immediately but care can begin by nurse. Level III- Patient will need more than 2 resources prior to disposition. Level IV- Patient will need only 1 resource prior to disposition. Level V- Patient will need no resources other than physician and nurse assessment and disposition. . . If a bed is not available in the main ED after triage and it is not possible to move the patient directly to the treatment area, the patient may be placed in the waiting area. Patient with an ESI (Emergency Severity Index) score of 2 or lower will be brought directly to the treatment area. Patients in the waiting room will be re-evaluated for change or deterioration of condition at a minimum of every two hours with documentation. . . "
Review of the hospital policy titled, " ED (Emergency Department) Observation Room, Use of, #100.7, last revised 8/08 " presented by the hospital as their current policy revealed in part, " Purpose: To provide guidelines for use of ED Observation Room for psychiatric emergency patients. Definition: Psychiatric symptoms refer to but are not limited to the following: 1. Suicidal ideation with/without plan. 2. Homicidal ideation with/without plan. 3. Auditory or visual hallucinations. . . Ambulatory patients who are alone and display acute symptoms with risk of danger to themselves or others will be escorted directly from the triage area to the observation room. . . The patient is placed in a hospital gown for examination and all personal property and articles of clothing will be held by Security until discharge or transfer to another facility. Care of the patient in the Observation Room: a) Visitors are not allowed unless approved by the charge nurse or physician. Visitors are not allowed to bring articles into the Observation Room. Vital signs are completed each shift. Patients will be allowed to leave the observation Room only in the attendance of the ED staff or Security. . . Monitoring will be at the observation level ordered by physician (1:1 or 1:2)" Review of the entire policy revealed no documented evidence as to what Observation Level and/or safety measures should be implemented prior to the physician seeing the patient and ordering an Observation Level. Review of the entire policy revealed no documented evidence of the procedure to ensure psychiatric patients that were being held in a room other than the one (psychiatric) Observation Room, to include the waiting room, were to be ensured of safety, no documented evidence of the procedure for handling psychiatric patients when the Observation Room and all other Emergency Department rooms were full, no documented evidence of the procedure for ensuring the safety of patients that were not "alone" for whom the policy did not require that they be escorted directly from the triage area to the observation room, and no documented evidence of the procedure to ensure safety for patients presenting to the Emergency Department with suicidal ideations, homicidal ideations, or gravely disabled patients during the interim between presenting to the hospital and being seen by the Emergency Department Physician who would determine and order the observation level for the patient (1:1 or 1:2).
Review of the hospital policy titled, "Patient Elopement from the Emergency Department, #100.9, last revised 8/08 " presented by the hospital as their current policy revealed in part, " Any patient that has been seen by the triage nurse but left prior to an evaluation by the emergency Department physician or that has been seen by the Emergency Department Physician but left before treatment or disposition, or "left without being seen" (LWBS) is deemed as an elopement. Procedures: The following will be documented: Time of triage, Time if seen by the physician, If observed, time patient left Emergency Department, If patient departed or eloped prior to treatment or disposition, Documentation will include inability to obtain signed AMA (Against Medical Advice)." Review of the entire policy revealed no documented evidence of the procedure to follow for patients that elope with the following conditions: Actively suicidal, Actively Homicidal, Under Order for Protective Custody, Under Physician's Emergency Certificate, or Under Coroner's Emergency Certificate. Review of the entire policy revealed no documented evidence identifying a procedure to ensure suicidal patients, homicidal patients, gravely disabled patients, patients under Order for Protective Custody, patients under Physician's Emergency Certificates, or patients under Coroner's Emergency Certificates did not elope while being placed in the Waiting Room while awaiting bed placement in the Emergency Department.
This finding was confirmed by S3 on 6/14/2011 at 1410 (2:10 p.m.) in a face to face interview. S3, Patient Care Manager of Emergency Department further indicated the hospital had no other policy that addressed elopement of patients that were Actively suicidal, Actively Homicidal, Under Order for Protective Custody, Under Physician's Emergency Certificate, or Under Coroner's Emergency Certificate. S3 further indicated there was no policy that addressed safety measures to prevent elopement for these patients.
Review of the hospit

Based on record review and interview the hospital failed to ensure nursing staff complete incident reports for high risk incidents that occur in the Emergency Department in order that the high risk incidents be reviewed by QAPI (Quality Assurance Performance Improvement) to determine the root cause of the incidents for 2 of 10 sampled patients (#3, #7).
Patient #7: Review of Patient #7's medical record revealed the patient presented to the Emergency Department on 5/23/2011 at 5:21 p.m. with command hallucinations telling him to set himself on fire. Review of electronically documented "Encounter Events" for Patient #7 revealed the patient was moved from the waiting room to Exam Room (A) on 5/23/2011 at 2029 (8:29 p.m./3 hours and eight minutes after the patient presented to the Emergency Department).Review of Patient #7's entire medical record revealed no documented evidence that the patient was ever re-assessed by the triage nurse or any other healthcare professional during the 3 hours 8 minutes that the patient was housed in the Emergency Department Waiting Room. Further review of Patient #7's electronic Nursing Notes documentation revealed in part, "5/23 (2011) 2035 (8:35 p.m.), Placed in gown. Bed in low position. Call light in reach. . ." (possible strangulation/hanging hazard). Review of electronic Physician Documentation regarding Patient #7 dated 5/23/2011 at 2053 (8:53 p.m./3 hours and 32 minutes after Patient #7 arrived at the hospital) revealed in part, "The patient presents to the emergency department with psychosis, suicide ideation, and the patient has a plan to set self on fire. . . Prior diagnosis of Schizophrenia. . . pt. hearing voices telling him to set self on fire. Pt. with previous attempt at suicide where he set self on fire. . ." Review of Patient #7's Physician Emergency Certificate signed by the physician on 5/23/2011 at 2355 (11:55 p.m.) revealed in part, "I am of the opinion that the above person named is in need of immediate psychiatric treatment in a treatment facility because he/she is seriously mentally ill or suffering from substance abuse so that he/she is gravely disabled, danger to self, unable to seek voluntary admission." Review of Patient #7's entire medical record revealed no documented evidence that the patient was "visited", evaluated, or assessed from 5/24/2011 at 0020 (12:20 a.m.) until 5/24/2011 at 0700 (7:00 a.m./ 7 hours and 40 minutes). Review of Patient #7's entire Medical Record revealed no documented evidence that a physician had ever ordered a Level of Observation for Patient #7. Review of Patient #7's entire Medical Record revealed no documented evidence that an Observation Flow sheet had ever been initiated or that the patient had ever been placed on Strict Visual Contact (1:1). Patient #7 was transferred to a Psychiatric Recipient Hospital on 5/24/2011 at 1154 (11:54 a.m.). Review of Patient #7's entire medical record revealed no documented evidence of a physician's order to indicate the Level of Observation required to meet the needs of Patient #7.
Video Surveillance of the Emergency Department's Waiting Room was viewed with Security Supervisor S22 and Patient Care Manager of the Emergency Department S3 on 6/15/2011 at 1310 (1:10 p.m.). This review revealed Patient #7 entered a Public Restroom down the hall from the Emergency Department Waiting Room unattended and remained there for 10 minutes before returning to the Waiting Room (as revealed by timing documentation on the video). This observation was confirmed by S22 and S3. S3 indicated in a face to face interview at 1:10 p.m. on 6/15/2011, after viewing the surveillance video, that it was obvious to her that the safety of suicidal/homicidal/gravely disabled psychiatric patients being placed in the Emergency Department Waiting Room while awaiting bed placement in the Main Emergency Department could not be ensured with the hospital's current practice.
During a face to face interview on 6/15/2011 at 8:10 a.m., Registered Nurse S5 indicated she remembered triaging Patient #7 on the night of 5/23/2011. S5 indicated Patient #7 had remained in the Waiting Room for 3 hours due to a lack of bed availability in the Main Emergency Department. S5 indicated that although she had a window for viewing patients from the triage desk that she would have continued to triage new patients and Patient #7 would not have always been in her line of sight.
During a face to face interview on 6/14/2011 at 10:40 a.m., Registered Nurse S4 indicated he had been one of the nursing staff assigned to Patient #7 on the date of 5/23/2011 through 5/24/2011. S4 indicated he remembered Patient #7. S4 indicated the Emergency Department had been very busy that night (24 hour census 94). S4 indicated Patient #7 had never been placed on Strict Visual Contact on 5/23/2011 or 5/24/2011 although he (#7) should have been. S4 indicated that he (S4) had asked the house supervisor to send a tech to monitor Patient #7 to the Emergency Department. S4 indicated he remembered a tech reported to the Emergency Department to monitor Patient #7 but never began the process because she was immediately pulled back to the unit from which she had arrived. S4 indicated he did not do an incident report on the failure to have Patient #7 monitored with Strict Visual Contact due to staffing shortage.
During a face to face interview on 6/15/2011 at 7:45 a.m., House Supervisor S21 indicated she had plenty of staff available on the night of 5/23/2011-5/24/2011. S21 indicated there was enough staff in the hospital to send a tech to assist the Emergency Department with observing a patient that was on 1:1. S21 indicated she had already sent two techs there for other patients (R1 and R2) but had enough staff to send additional techs to monitor Patient #7. S21 indicated she had no documentation that a third tech had been requested.
Patient #3:
The Medical Record for Patient #3 was reviewed. Review revealed Patient #3 arrived at the Emergency Department at 1111 (11:11 a.m.) on 6/09/2011 with presenting complaint of "NOPD (New Orleans Police Department) states ptatients (patient's) son would like her checked out becauses (because) she has been acting differently, not cleaning her house and states she does not know her family. Son in triage, states he does not think she can care for herself, and would like the doctor to see her. Does not know if he needs to put her somewhere. Pt. (patient) has OPC (Order for Protective Custody)." Review of Patient #3's Order for Protective Custody dated 6/09/2011 at 9:45 a.m. revealed in part, "credible person executes a statement under private signature specifying that to the best of their knowledge and belief a person is mentally ill or suffering from substance abuse and is in need of immediate treatment to protect the person or others from physical harm. Description. . . 91 W/F (year old white female) having mental and medical issues which she refusing to seek treatment which is putting her life at risk, pt (patient) seems to have some dementia. She does not know family. she can't see anymore. not able to care for basic needs. hygiene very poor, house very dirty. not wanting any help. very paranoid. hostile and aggressive. taking cabs all over town with out family knowing where she is. they fear something bad will happen to her. Gravely disabled." Further review of Patient #3's electronic medical record revealed in part, "6/09 (2011) at 1157 (11:57 a.m.) (Physician S6/Psychiatrist) went to waiting room to eval patient. Patient's son stated' everything is taking too long, the coroner said ya'll would get us in and out right away'. stated he was leaving and taking his mother home to care for her. (S6) did briefly speak to patient's son and patient prior to leaving. 12:30 (p.m.) Eloped other before ER (Emergency Room) physician after Psych MD. 1232 (p.m.) Patient left ED." Review of Patient #3's entire medical record revealed no documented evidence that Patient #3 who was under an Order for Protective Custody had ever been housed in an area other than the open Emergency Department Waiting Room which allowed entrance and exit at will. From arrival time of 11:11 a.m. until the patient left the Emergency Room at 12:32 p.m. was 1 hour and 21 minutes. Review of Patient #3's entire medical record revealed no documented evidence of a physician's order to indicate the Level of Observation required to meet the needs of Patient #3.
During a face to face interview on 6/14/2011 at 10:10 a.m., Registered Nurse S12 indicated she had been the nurse that triaged Patient #3 on 6/09/2011 and remembered the patient. S12 indicated the patient (#3) had presented with a pleasant demeanor. S12 indicated Patient #3 was confused about the identity of her son and identified him as her manfriend/boyfriend. S12 indicated she (S12) detected an odor from Patient #3 and could tell that she (#3) had not been bathing properly. S12 indicated #3 lived alone. S12 indicated Patient #3 was not suicidal/homicidal and S12 had determined it would be safe for Patient #3 to remain in the Waiting Room until a bed was available. S12 indicated she (S12) never thought of Patient #3 as a flight risk. S12 confirmed that she had been aware that Patient #3 was under an Order for Protective Custody. S12 indicated Patient #3's son had stated that he (son) was a Diabetic and needed to go home and eat. S12 indicated Patient #3's son had indicated that he (son) needed to care for himself and did not seem to want to stay in the Waiting Room with the patient (#3). S12 indicated that Patient #3 became a little "feisty" while in the waiting room, stating that she (#3) wanted to go home. S12 confirmed that she had never initiated an Incident Report regarding Patient #3's elopement.
During a face to face interview on 6/14/2011 at 1450 (2:50 p.m.), Director of QAPI (Quality Assessment Performance Improvement) S1 indicated an Incident Report should have been generated for Patients #3 and #7. S1 indicated that had she have received an Incident Report there would have been an investigation into the root cause of the Emergency Department's failure to provide Patient #7 with 1:1 observations which would have included an investigation into staffing issues, communication issues, and the lengthy period of time Patient #7 had spent in the Waiting Room. S1 further indicated that the elopement of Patient #3 would have been investigated and the policy and procedure reviewed. S1 indicated without the staff's cooperation with the Incident Report policy, these high risks incidents would not have been discovered by the QAPI department. S1 indicated Incident Reporting is part of the QAPI process and should be generated as per policy.
Review of the hospital policy titled, " Submitting Incident Reports, #51A, last revised 7/2010" presented by the hospital as current revealed in part, "Incident is an unusual event that is outside the normal course of patient care and/or operation of the facility. . . Documentation of Incidents: Incidents that must be documented in the Incident Portal include but are not limited to falls, medication variance, accidents, injuries, equipment malfunctions, breaches of standards of care, reaches of policies and procedures, or other unusual or untoward events. . . "

Based on record review and interview the hospital's Emergency Department failed to ensure policies and procedures were developed/implemented regarding safety of psychiatric patients that were suicidal, homicidal, gravelly disabled, under an OPC (Order for Protective Custody), PEC (Physician's Emergency Certificate), or CEC (Coroner's Emergency Certificate) to include placing these patients in the waiting room while awaiting bed placement in the Emergency Department and in the event of elopement. This practice effected 2 of 10 sampled patients (#3, #7). Findings:

Review of the hospital's Emergency Department policies revealed no documented evidence of how staff were to address patients that presented to the Emergency Department that were Suicidal, Homicidal, Gravely Disabled, or under an OPC, PEC, or CEC that were being held in the hospital's Waiting Room and/or eloped from the hospital.

Patient #3:
The Medical Record for Patient #3 was reviewed. Review revealed Patient #3 arrived at the Emergency Department at 1111 (11:11 a.m.) on 6/09/2011 with presenting complaint of "NOPD (New Orleans Police Department) states ptatients (patient's) son would like her checked out becauses (because) she has been acting differently, not cleaning her house and states she does not know her family. Son in triage, states he does not think she can care for herself, and would like the doctor to see her. Does not know if he needs to put her somewhere. Pt. (patient) has OPC (Order for Protective Custody)." Review of Patient #3's Order for Protective Custody dated 6/09/2011 at 9:45 a.m. revealed in part, "credible person executes a statement under private signature specifying that to the best of their knowledge and belief a person is mentally ill or suffering from substance abuse and is in need of immediate treatment to protect the person or others from physical harm. Description. . . 91 W/F (year old white female) having mental and medical issues which she refusing to seek treatment which is putting her life at risk, pt (patient) seems to have some dementia. She does not know family. she can't see anymore. not able to care for basic needs. hygiene very poor, house very dirty. not wanting any help. very paranoid. hostile and aggressive. taking cabs all over town with out family knowing where she is. they fear something bad will happen to her. Gravely disabled." Further review of Patient #3's electronic medical record revealed in part, "6/09 (2011) at 1157 (11:57 a.m.) (Physician S6/Psychiatrist) went to waiting room to eval patient. Patient's son stated' everything is taking too long, the coroner said ya'll would get us in and out right away'. stated he was leaving and taking his mother home to care for her. (S6) did briefly speak to patient's son and patient prior to leaving. 12:30 (p.m.) Eloped other before ER (Emergency Room) physician after Psych MD. 1232 (p.m.) Patient left ED." Review of Patient #3's entire medical record revealed no documented evidence that Patient #3 who was under an Order for Protective Custody had ever been housed in an area other than the open Emergency Department Waiting Room which allowed entrance and exit at will. From arrival time of 11:11 a.m. until the patient left the Emergency Room at 12:32 p.m. was 1 hour and 21 minutes. Review of Patient #3's entire medical record revealed no documented evidence of a physician's order to indicate the Level of Observation required to meet the needs of Patient #3.

During a face to face interview on 6/14/2011 at 9:55 a.m., Psychiatrist S6 indicated he had seen Patient #3 briefly in the Emergency Department Waiting Room on 6/09/2011. S6 indicated he was unaware of the hospital's practice in regards to placing psychiatric patients in the waiting room while awaiting bed placement in the Main Emergency Department.. S6 indicated patients were usually in an exam room in the Main Emergency Department by the time Psychiatry was consulted.

During a face to face interview on 6/14/2010 at 1410 (2:10 p.m.), Patient Care Manager of Emergency Department S3 indicated there should be no elopements of patients under an OPC (Order of Protective Custody), PEC (Physician's Emergency Certificate), or CEC (Coroner's Emergency Certificate). S3 indicated these patients should be housed in a manner that would prevent elopement. S3 confirmed that the Waiting Room allowed for free entrance and exit and afforded patients the opportunity for elopement. S3 confirmed there were no policies/procedures developed or implemented at the hospital regarding elopement of psychiatric patients.

Patient #7:
The Medical Record for Patient #7 was reviewed. Record review revealed Patient #7 arrived at the Emergency Department on 5/23/2011 at 1721 (5:21 p.m.) with presenting complaint of "Patient states. Depressed, expresses suicidal ideation. reports hearing voices since last night. Method of arrival: Ambulated without assistance." Review of Patient #7's entire Medical Record revealed no documented evidence indicating whether Patient #7 was alone or accompanied by family/friend. Patient #7 was triaged at 1759 (5:59 p.m.) as "Urgent - 3 (Patient will need more than 2 resources prior to disposition)". Review of electronically documented "Encounter Events" for Patient #7 revealed the patient was moved from the waiting room to Exam Room (A) on 5/23/2011 at 2029 (8:29 p.m./3 hours and eight minutes after the patient presented to the Emergency Department with Command Hallucinations telling him to set himself on fire). Review of Patient #7's entire medical record revealed no documented evidence that the patient was ever re-assessed by the triage nurse or any other healthcare professional during the 3 hours 8 minutes that the patient was housed in the Emergency Department Waiting Room. Review of Patient #7's entire Medical Record revealed no documented evidence that Security had ever been informed of Patient #7's status/risk. Review of electronically documented Nursing Notes for Patient #7 revealed the following, "5/23 (2011) 2030 (8:30 p.m.), Having thoughts of suicide. Plan for suicide is pour gasoline over himself and strike a match. . ." Review of electronic Physician Documentation regarding Patient #7 dated 5/23/2011 at 2053 (8:53 p.m./3 hours and 32 minutes after Patient #7 arrived at the hospital) revealed in part, "The patient presents to the emergency department with psychosis, suicide ideation, and the patient has a plan to set self on fire. . . Prior diagnosis of Schizophrenia. . . pt. hearing voices telling him to set self on fire. Pt. with previous attempt at suicide where he set self on fire. . ."

Video Surveillance of the Emergency Department's Waiting Room was viewed with Security Supervisor S22 and Patient Care Manager of the Emergency Department S3 on 6/15/2011 at 1310 (1:10 p.m.). A portion of Patient #7's time in the Waiting Room was viewed. The entire 3 hours and 8 minutes was not viewed. S22 indicated the times on the video surveillance were not accurate, that it was off by several hours; however, there were staff in the Emergency Department that knew Patient #7 and he had been able to have the patient identified in the video. Observation of the Video revealed Patient #7 left the triage desk and seated himself in the Emergency Department Waiting Room. #7 then ambulated from the seating area of the waiting room down the hallway in front of the triage desk and through the first door of the street exit hallway (two door exit). Patient #7 turned around and repeatedly paced back and forth in the same pattern. Patient #7 eventually returned to the Waiting Room seating area and sat down. At 0637 (6:37 a.m./ recall that the times on the video were inaccurate), as revealed on the video screen, Patient #7 got up from his seat and exited into a long hallway moving away from the triage desk. Patient #7, who was alone and unattended by staff, entered a room identified by Security Supervisor S22 as the public bathroom at 6:37:56 (recall that the recorded times on the video were inaccurate). Patient #7 remained in the public bathroom until he was viewed exiting at 6:47:00. This observation was confirmed by S22 and S3. S3 indicated in a face to face interview at 1:10 p.m. on 6/15/2011, after viewing the surveillance video, that it was obvious to her that the safety of suicidal/homicidal/gravely disabled psychiatric patients being held in the Emergency Department Waiting Room could not be ensured with the hospital's current practice.

During a face to face interview on 6/14/2011 at 1410 (2:10 p.m.), Patient Care Manager of Emergency Department S3 indicated the hospital had no policy for monitoring Suicidal, Homicidal, or Gravely disabled patients that were being placed in the Waiting Room while awaiting bed placement in the Main Emergency Department. S3 indicated if the nurse were to be concerned about a psychiatric patient being placed in the waiting room, the nurse could place the patient near the triage station; although she would continue to triage incoming patients and would not be able to visualize the psychiatric patients at all times. S3 confirmed the Emergency Department Waiting Room was not a secure area and patients could enter or exit at will. S3 indicated a Security Officer was always located at a desk located near the exit of the Emergency Department waiting room, across from the triage desk; however, the Security Officer would not be aware that a patient was a flight risk or suicide/homicide risk without being informed by the triage nurse.

During a face to face interview on 6/14/2011 at 1530 (3:30 p.m.), Medical Director of Emergency Department S19 indicated he would prefer that no psychiatric patient with suicidal ideation, homicidal ideations, or gravely disabled be housed in the Waiting Room. S19 indicated he preferred these type patients be placed promptly in the Observation Room which is observable from the Nursing Station. S19 indicated policies regarding the care of psychiatric patients had been developed prior to him taking the position of Medical Director. S19 indicated he had not been aware that there were no policies to address elopement of psychiatric patients or the safety of psychiatric patients being held in the waiting room.