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Based on observation, interview, and record review, the facility failed to comply with CFR 489.24, by failing to ensure Patient 16, a suicidal 5150 patient was kept safe and was stabilized following his presentation to the facility's Emergency Department (ED). Patient 16 was brought to the facility via ambulance after he had cut his wrists, and was considered suicidal. Patient 16 was on a 5150 hold for danger to self. Patient 16 left prior to a psychiatric evaluation, and before facility was able to transfer the patient to a facility that had the capability to provide stabilizing treatment.



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Based on interview and record review, the facility failed to ensure Patient 16 a suicidal 5150 patient was kept safe and was stabilized following his presentation to the facility's Emergency Department (ED). This failure had the potential to result in Patient 16 sustaining further harm or death.

5150- a section of the California Welfare and Institutions Code which allowed a qualified person to involuntarily confine a person suspected to have a mental disorder that makes them a danger to self, a danger to others, and/or was gravely disabled.

Findings:

During an interview with the Emergency Department Director (EDD), on July 7, 2015, at 3:40 p.m., the EDD stated it was the facility's practice to have all 5150 patients' change into a hospital gown, check patient belongings for illegal or harmful items, and to place the patient's clothing/belongings away from patient access. The EDD stated this practice was for the safety of the patient, and to deter patients placed on a 5150 hold from eloping (leaving).

The record for Patient 16 was reviewed on July 7, 2015. The record indicated Patient 16 was brought to the ED on June 28, 2015, at 7:34 p.m., via ambulance.

The nursing triage report dated June 28, 2015, at 7:35 p.m., indicated "PT (patient) states he cut his wrist approximately 6 times with a glass because he felt like killing himself."

The police document titled "Application for 72 hour detention for evaluation and treatment" dated June 28, 2015, at 7:22 p.m., indicated "Subj (subject) observed bleeding from cut on arm...Subj. stated ran out of mental health meds (medication) 3 weeks ago. Stated felt like killing himself so cut arm with broken glass."

The document further indicated Patient 16 was deemed a danger to himself.

The "Emergency Nursing Record" dated June 28, 2015, at 8:15 p.m., indicated Patient 16 was assessed for being a high risk for suicide and required interventions to include emergent psychiatric evaluation by a psychiatrist or consulting psychiatric nurse, observation at least every 15 minutes by a sitter, and the initiation of suicide precautions.

The ED physician documentation dated June 28, 2015, at 8:31 p.m., indicated "32 year old male presents with suicidal thoughts...wrist was cut 6 times by bottle. States "feels like killing himself..."

The ED physician documentation indicated Patient 16's wrist lacerations were repaired, and the patient was medically stable. The documentation further indicated Patient 16's diagnosis was a danger to himself, and was to be transferred for psychiatric care.

The "Emergency Nursing Record" entry for June 28, 2015, at 9:40 p.m., indicated "Sitter at bs (bedside) with patient. Patient forcefully grabbed his bag of belongings and put on his clothes...walked out of the ED..."

During an interview and with the EDD, on July 7, 2015, at 3:45 p.m., the EDD stated she was aware of Patient 16 leaving the ED prior to being transferred for psychiatric care. The EDD stated her investigation of the incident was ongoing, but through interviews it was determined the assigned sitter for Patient 16 was not aware of the facility's practice regarding 5150 patients' clothing/belongings. The EDD stated the sitter brought the patient's belongings to the patient's room.

The EDD stated she had identified the need to train all sitters assigned to the ED on the care of patients' on a 5150 hold.