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Based on interview, record review, policy review, and review of video surveillance footage, it was determined the facility failed to have an effective governing body responsible for the conduct of the facility. On 08/01/18, the facility admitted Patient #1 after being found unresponsive by family members with empty narcotic pain medication and sedative/antidepressant medication bottles at the patient's side. The facility admitted Patient #1 with a syncope diagnosis (loss of consciousness). On 08/03/18, at 2:28 AM, Patient #1 expressed thoughts of suicide to staff, and on 08/03/18, at approximately 11:45 AM, the facility social worker requested a psychiatric evaluation from a local Community Mental Health Center (CMCH) for a possible involuntary psychiatric hospitalization. However, the facility failed to implement policies to assess and supervise the patient and on 08/03/18, the patient left the facility without staff knowledge and drove away in an ambulance at 12:21 PM on 08/03/18, that had been left running and unattended in the facility parking lot.

Review of the facility Board of Director Bylaws, undated, revealed the Governing Body had the ultimate responsibility for assuring the provision of high quality patient care. Continued review revealed the Board of Directors would select and employ a competent president/CEO who would be the direct representative in the management of the facility and be given necessary authority and held responsible for the administration of the facility. The policy revealed the Governing Body met at least monthly and special meetings could be called. Interview with the Chief Nursing Officer (CNO) on 08/13/18 at 2:30 PM and on 08/14/18 at 3:00 PM revealed she was covering for the Chief Executive Officer (CEO). The CNO stated the Governing Body had not met since the incident with Patient #1; however, the facility did not feel they could have done anything to prevent the incident.

Based on interview, record review, policy review, and review of video surveillance footage, it was determined the Chief Executive Officer (CEO), appointed by the governing body to manage the facility, failed to ensure one (1) of ten (10) sampled patients (Patient #1) was supervised by nursing staff and received care in a safe setting.

The findings include:

Review of the facility Board of Director Bylaws, undated, revealed the Board of Directors had the ultimate responsibility for assuring the provision of high quality patient care. Continued review revealed the Board of Directors would select and employ a competent president/CEO who would be the direct representative in the management of the corporation and be given necessary authority and held responsible for the administration of the corporation.

Review of Patient #1's medical record revealed the facility admitted the patient on 08/01/18, after being found by family members unresponsive in his/her apartment with empty bottles of narcotic pain medication and sedative/antidepressant medication by the patient.

Interviews with Registered Nurse (RN) #3 and review of documentation revealed on 08/03/18 at approximately 2:28 AM, Patient #1 reported to the RN that he/she "did not want to be here anymore" and that he/she could not report anything to RN #3 because he/she "did not want to be locked up in the nut house." RN #3 asked the patient about a suicide plan and requested a social services consultation; however, RN #3 failed to contact Physician #1 regarding the patient's suicidal statements and failed to stay with the patient until an assessment was completed by the physician as required by the facility's Suicide Risk Assessment policy. In addition, there was no documented evidence a physician completed a suicide risk assessment or suicide severity rating scale as required by the facility's policy. Patient #1 was evaluated by Social Worker #1 at approximately 10:30 AM on 08/03/18, and was recommended a mental health evaluation. RN #1 who was providing care for Patient #1 during the day shift on 08/03/18, stated she was aware of Patient #1's suicidal ideation and was aware Social Worker #1 had requested an assessment for an involuntary psychiatric admission; however, the RN failed to supervise Patient #1. Patient #1 left the facility without staff knowledge on 08/03/18 (exact time unknown) and at 12:21 PM, Patient #1 stole an ambulance parked in the facility parking lot and drove away in a stolen ambulance.

Interview with the Chief Nursing Officer (CNO) on 08/13/18 at 2:30 PM and on 08/14/18 at 3:00 PM revealed the Chief Executive Officer (CEO) was out of the facility on vacation and unable to be reached. However, the CNO stated that the CEO was present during the time of the incident when Patient #1 eloped from the facility and stole the ambulance. The CNO stated the Governing Body met on a monthly basis and the CEO reported any issues and/or concerns to the governing body at that time. According to the CNO, the Governing Body had not met since the incident with Patient #1 had occurred, and she was not aware whether the CEO had reported the incident to the Governing Body. However, according to the CNO, the facility had reviewed the incident regarding Patient #1, and did not feel there was anything the facility could have done to prevent the patient's "unfortunate circumstances."

Based on interview, record review, review of the facility video footage, and review of the facility policies, it was determined the facility failed to protect and promote the rights of one (1) of ten (10) sampled patients (Patient #1). Patient #1 presented to the facility's Emergency Department (ED) on 08/01/18, after the patient was found unresponsive in his/her home with empty narcotic and sedative/antianxiety medication bottles. The facility admitted the patient on 08/02/18, with a diagnosis of syncope (loss of consciousness); however, the facility failed to assess the patient and determine whether the empty medication bottles were the result of an accidental versus intentional overdose and failed to implement interventions to protect the patient. On 08/03/18 at approximately 2:28 AM, Patient #1 expressed suicidal ideation to a facility nurse. However, the facility again failed to implement their Patient Rights and Suicide Risk Policies and failed to assess and protect the patient when the patient exhibited suicidal ideation. Further, Patient #1 was evaluated by Social Worker #1 at approximately 10:30 AM on 08/03/18, who recommended a mental health evaluation be completed by the Community Mental Health Center (CMHC) for a possible involuntary psychiatric admission. The facility again failed to protect the patient and implement measures to ensure the patient's safety. On 08/03/18, sometime after 11:30 AM, Patient #1 left the facility without staff knowledge. At 12:21 PM, Patient #1 stole an ambulance from the facility parking lot, and drove it to a local entertainment center 2.2 miles away where the patient was arrested. Patient #1's family member stated Patient #1 was placed on "suicide watch" at the local detention center and was court ordered to be admitted to a Behavioral Health Unit.

Based on interview, record review, review of the facility video, and review of the facility policies, it was determined the facility failed to ensure one (1) of ten (10) patients received care in a safe setting (Patient #1). Record review and interview revealed Patient #1 presented to the facility's Emergency Department (ED) on 08/01/18, after the patient was found unresponsive in his/her home with empty narcotic and sedative/antianxiety medication bottles. The facility admitted the patient on 08/02/18, with a diagnosis of syncope (loss of consciousness), and the admission nursing assessment triggered a social services consultation. However, the facility failed to ensure the consultation was completed and the patient suicidal risk was not assessed. On 08/03/18 at approximately 2:28 AM, Patient #1 reported that he/she "just want to go away" and "I want to go live with my husband [who was expired] in the stars." Patient #1 stated he/she did not want to provide any further details because the patient "did not want to be locked up in the nut house." The facility failed to implement their Patient Rights and Suicide Risk Policies and failed to assess and protect the patient when the patient exhibited suicidal ideation. Further, Patient #1 was evaluated by Social Worker #1 at approximately 10:30 AM on 08/03/18, who recommended a mental health evaluation be completed by the Community Mental Health Center (CMHC) for a possible involuntary psychiatric admission. The facility further failed to protect the patient and implement measures to ensure the patient's safety. On 08/03/18, sometime after 11:30 AM, Patient #1 left the facility without staff knowledge and at 12:21 PM, entered an ambulance that had been left unattended and running in the facility parking lot. Patient #1 drove the ambulance from the facility parking lot approximately 2.2 miles to a local entertainment center, where the patient was arrested. Interview with Patient #1's family member revealed Patient #1 was placed on "suicide watch" at the local detention center and the court had ordered the patient to be admitted to a Behavioral Health Unit.

The findings include:

Review of the facility policy titled, "Patient Rights," revised November 2014, revealed patients had the right to receive care in a safe, respectful, and dignified setting.

Review of the facility policy titled, "Suicide Risk Assessment," revised November 2017, revealed the facility would identify patients at risk for suicide, and would assure that their immediate safety needs were met. The policy stated it was an organizational-wide policy and applied to patients being treated for a chief complaint or primary diagnosis of an emotional or behavioral disorder in any inpatient or outpatient setting. According to the policy, patients presenting with emotional or behavioral disorders would undergo a medical screening examination to determine both medical and behavioral health issues. The policy stated Suicidal Ideation (SI) was defined as thoughts or actions given by one person with the intentions of causing serious bodily damage or death to that person. These can range from a detailed plan to a fleeting consideration. The facility defined Suicidal Precautions as interventions implemented to ensure the safety of patients deemed to be in danger to self. Continued review of the policy revealed nursing staff would screen all patients presenting with emotional or behavioral disorders for suicidal ideation, would notify the physician and alert security of a suicidal patient, and should remain with the patient until a physician evaluated the patient and determined the level of Suicidal Ideation. The policy further stated a physician would complete a suicide risk assessment and a suicide severity rating scale, and based on the assessment, suicidal precautions would be ordered. If the physician determined a behavioral health consultation was warranted, Social Services would be contacted as needed to assist. According to the policy, Security or Nursing staff would be in constant attendance (1:1) with the patient at all times and Nursing staff would document safety checks every fifteen minutes. In the event a suicidal patient exhibited at risk behavior, staff would make every attempt at verbal de-escalation of the patient.

Review of a Prehospital Care Report completed by Emergency Medical Technician (EMT) #1 on 08/01/18 at 10:27 PM, revealed Patient #1 was unresponsive upon arrival to the patient's home and EMS administered 0.5 mg of Narcan (treats narcotic overdose) with no response.

Interview with EMT #1 on 08/13/18 at 4:15 PM revealed EMS responded to an emergency call on 08/01/18 for Patient #1. EMT #1 stated when he arrived at Patient #1's residence, he found Patient #1 lying face down on a bed unresponsive, with empty bottles of Hydrocodone (narcotic pain medication) and Trazadone (sedative/antidepressant) beside the patient. EMT #1 stated they believed the patient had overdosed and administered Narcan (treats narcotic overdose). EMT #1 indicated that Patient #1 began to respond during the ambulance ride to the facility, and when they arrived at the facility the patient spoke with nursing staff. EMT #1 stated Patient #1 obviously had behavioral health concerns.

Review of the Emergency Department (ED) Record for Patient #1 revealed Emergency Medical Services brought Patient #1 to the ED on 08/01/18 at approximately 11:00 PM, and the facility was aware that Patient #1 had a "syncope episode this evening, laid down and passed out...has empty bottle of Hydrocodone filled 07/25/18 and Trazadone on 07/24/18."

Review of the ED nursing assessment revealed Patient #1 had a medical history that included Hypertension, Seizure Disorder, Bipolar Disorder, Attention Deficit Hyper-Activity Disorder, Post Traumatic Stress Disorder, and Motor Vehicle Accident. Patient #1 was medically screened by Physician #2 at 11:14 PM, diagnosed with Syncope, and admitted to the facility for further testing.

Interview with Physician #2 on 08/14/18 at 1:00 PM revealed he treated Patient #1 in the ED on 08/01/18, he stated he was aware Patient #1 had empty pill bottles; however, the patient told him that he/she has "spilled" the medications. There was no documented evidence the facility assessed the patient's safety risk in accordance with the Suicide Risk Assessment policy and implemented interventions to protect the patient.

Review of Patient #1's Nursing Admission Assessment dated 08/02/18 at 1:31 AM revealed the RN documented Patient #1 had been diagnosed with Anxiety (Panic Disorder), Depression and Manic-Depressive Disorder and that Patient #1 indicated that he/she had been the subject of abuse in the last few years, but "does not want to talk about it."

Interview with the Chief Nursing Officer (CNO) on 08/13/18 at 2:30 PM revealed because Patient #1 responded "yes" to the abuse questions on the Nursing Admission Assessment, a Social Services consultation request was automatically triggered.

However, review of the Shift Activity Report for Patient #1 dated 08/02/18 at 11:01 AM, revealed Social Services documented that they, "spoke with [RN #1] regarding order that was submitted by assessment, [RN #1] does not know of any need for [Patient #1] to been seen by Social Services."

Interview with RN #1 on 08/13/18 at 1:33 PM and on 08/14/18 at 12:25 PM, revealed that she was working with Patient #1 on 08/02/18 when Social Services inquired about a consult for Patient #1. RN #1 stated she recalled asking Patient #1 if he/she wanted to speak with a Social Worker, and the patient declined. RN #1 stated she took no further action and declined the consult on behalf of the patient.

Continued review of Patient #1's medical record revealed RN #3 documented on 08/03/18 at 2:28 AM, that Patient #1 stated he/she missed being "outgoing and having determination." Patient stated he/she "just wants to go away." RN #3 documented that she questioned Patient #1 whether the patient was feeling down, sad, or hopeless and Patient #1 stated, "I can't tell you that. I'll be put in a nut house." RN #3 documented that she left a voicemail for Social Services regarding a social services consultation for Patient #1. However, RN #3 failed to recognize that the facility had another number to utilize for Social Services in which a social worker could be contacted 24 hours a day. Interview with RN #3 revealed she left a voice mail on the Social Worker's voicemail, but was not aware that facility social workers were available 24 hours via a special telephone number, and could be contacted at all times. Further interview revealed RN #3 did not contact Patient #1's physician about the statements or supervise the patient as required by the facility's policy. RN #3 stated she believed she was trained on the facility policy regarding Suicidal Assessment, but she could not recall when she had received the training or the requirements of the policy. However, there was no documented evidence RN #3 contacted the patient's physician regarding the patient's statements and RN #3 failed to stay with the patient until an assessment was completed as required by the facility's Suicide Risk Assessment policy. In addition, there was no documented evidence the physician completed a suicide risk assessment or suicide severity rating scale when the patient exhibited suicidal ideation as required by the facility's policy.

Continued review of Patient #1's nursing notes revealed RN #3 documented on 08/03/18 at 5:56 AM that the patient had removed his/her intravenous (IV) access.

Review of a social services note dated 08/03/18 at 11:44 AM, revealed "Patient [#1] does have sadness and hopeless" but denied suicidal/homicidal ideation or a plan. The note revealed Social Services contacted a Community Mental Health Center (CMHC) and requested a mental health evaluation for the patient and also contacted the on-call Physician Assistant.

Review of a Physician Progress Note dated 08/03/18 at 11:26 AM revealed Physician Assistant (PA) #1 documented that the previous evening Patient #1 had verbalized suicidal ideations and informed nursing staff that he/she did not want to live anymore. The progress note stated Social Services contacted a CMHC who would be assessing Patient #1 "today." The PA documented that in her opinion the patient had no intent to harm himself/herself that morning, but the patient had expressed suicidal ideation's in the past. However, the PA failed to contact a Physician to complete a facility suicide risk assessment and a suicide severity rating scale as directed by the facility's policy and procedure.

Interview with RN #3 on 08/13/18 at 7:00 PM and on 08/14/18 at 12:36 PM revealed she was assigned to provide care for Patient #1 on 08/03/18 when the patient stated he/she did not want to live anymore. According to RN #3, Patient #1 stated, "I want to go live with my husband in the stars." RN #3 stated that Patient #1's husband had expired and the patient wanted to be with him. RN #3 stated she questioned Patient #1 further and the patient did not have an active suicide plan or intent, but stated Patient #1 was "pitiful and sad." Further interview revealed RN #3 took no further action and did not notify the patient's physician of the patient's statements. RN #3 stated she believed she was trained on the facility policy regarding Suicidal Assessment, but she could not recall the details of the policy and was not aware of an assessment tool that was required to utilize when a patient had suicidal ideation. Further interview with RN #3 revealed when Certified Nursing Assistant (CNA) #1 went into Patient #1's room at approximately 5:45 AM, to monitor the patient's vital signs, the CNA reported that he found the patient's IV catheter laying on the patient's bedside table. Continued interview with RN #3 revealed that Patient #1 refused to be placed in a hospital gown and wore his/her own clothing during the admission to the facility.

Interview with Physician #1 on 08/13/18 at 1:55 PM revealed he was the physician on call on 08/03/18. Physician #1 stated RN #3 did not inform her of Patient #1's suicidal statements. Physician #1 stated she could not speculate what she would have done, but had she known about Patient #1's statements, she would have had a further conversation with RN #3.

Interview with Physician Assistant (PA) #1 on 08/13/18 at 2:10 PM revealed she conducted rounds with Physician #3 on the morning of 08/03/18 between 7:30 AM and 8:30 AM and completed the Physician's progress note dated 08/03/13 at 11:26 AM. PA #1 stated the facility contacted her later and asked to delay the discharge for Patient #1 pending CHMC completing a Mental Health Evaluation on Patient #1. PA #1 stated she contacted Physician #3 and informed him of the delay in discharge pending the recommendations made by the CMHC. PA #1 stated she was in the doorway of Patient #1's room during rounds that morning and did not hear the conversation between Physician #3 and Patient #1, and did not personally conduct an assessment of the patient to ensure the patient's safety.

Interview with Physician #3 on 08/14/18 at 1:35 PM revealed that he made rounds and saw Patient #1 on the morning of 08/03/18, and was aware of the patient's suicidal statements earlier that morning, but at no time did the family mention the patient had attempted overdose. Physician #3 stated he did not complete a suicidal assessment/scale per the facility's policy because the patient had no plan for suicide. Physician #3 further stated even though the patient's safety risk was not assessed, he determined that Patient #1 was medically stable and that he planned to discharge the patient. However, Physician #3 stated he received a call from PA #1 stating they were delaying the discharge of Patient #1 until the CMHC evaluated Patient #1 for a possible psychiatric placement.

Interview with the facility's Social Worker, Social Worker #1, on 08/13/18 at 1:15 PM and on 08/14/18 at 1:50 PM revealed he received an order for a Social Services evaluation for Patient #1 on 08/03/18, because of statements the patient had made about not wanting to live anymore. The Social Worker stated he was not aware his department had received a consult for the patient on 08/02/18 that was cancelled. Social Worker #1 stated he spoke with the patient at approximately 10:30 AM, on 08/03/18, and after speaking at length with Patient #1 and Patient #1's family, he felt it was in the best interest of everyone to obtain a Behavioral Health Evaluation from the local CMHC to determine the level of psychiatric care that Patient #1 needed at that time. Social Worker #1 stated that Patient #1 did not verbalize any active suicidal thoughts or plans at that time; however, the patient was sad and Patient #1's family was very concerned about Patient #1. Social Worker #1 also stated that Patient #1's family stated that Patient #1 had been misusing his/her medication.

Interview with RN #1 on 08/13/18 at 1:33 PM and on 08/14/18 at 12:25 PM, revealed she was working the day shift on 08/03/18 and was providing care for Patient #1. RN #1 stated she was informed of the statements made by Patient #1 and was aware RN #3 had requested a Social Services evaluation, but did not "think much about it." RN #1 stated Physician #3 and PA #1 made rounds that morning and planned to discharge Patient #1 home. However, after Social Worker #1 spoke with Patient #1 and Patient #1's family, the social worker asked her to call Physician #3 and cancel the patient's discharge until after the CMHC came and completed the mental health evaluation. RN #1 stated that Social Worker #1 also told her they were going to get Patient #1 "some help" and possibly get an order for an involuntary psychiatric admission. Continued interview with RN #1 revealed Social Worker #1 told the RN "if [Patient #1] does not want to go on [his/her] own, we will help [him/her] go." However, interview with the RN revealed even though she was aware a mental health evaluation had been recommended for a possible involuntary psychiatric admission, no action was taken to protect the patient and ensure the patient's safety.

Interview with the Team Supervisor at the CMHC on 08/13/18 at 12:50 PM, revealed the facility contacted her to complete a mental health evaluation on Patient #1 on 08/03/18, due to suicidal ideation. The Team Supervisor of the CMHC stated she received another request for an emergency evaluation and completed that evaluation prior to going to the facility to assess Patient #1 because she felt Patient #1 was in a safe and secure environment at the facility and she did not need to respond immediately to the request for an evaluation.

However, review of video surveillance footage of the facility's entrance to outpatient surgery and the parking lot, revealed on 08/03/18 at 12:18:33 PM, Patient #1 walked up the ramp outside the facility. At 12:18:45 PM, Patient #1 entered the passenger's side of a parked ambulance parked outside the surgery entrance. At 12:18:51 PM, the passenger's door of the ambulance closed. Continued review of the video surveillance footage revealed at 12:19:30 PM, Patient #1 was seen walking from behind the parked ambulance and getting into the driver's side of the ambulance. At 12:19:49 the headlights of the ambulance came on then off. Further review of the video revealed Patient #1 pulled out of the parking lot abruptly at 12:21:10 PM, and exited quickly onto the street in front of the facility at 12:21:23.

Further review of the medical record revealed RN #1 documented on 08/03/18 at 1:00 PM, "Patient [#1] eloped at this time and entered a parked ambulance and drove [himself/herself] to [another location.] Police involved. Will inform MD at this time."

Continued interview with RN #1 on 08/13/18 at 1:33 PM and on 08/14/18 at 12:25 PM, revealed she was not aware when Patient #1 left his/her room or the facility. RN #1 stated the last time she had interaction or recalled seeing Patient #1 was when she assessed Patient #1's level of pain at approximately 10:13 AM after administering pain medication. RN #1 stated that she became aware that Patient #1 was missing when Patient #1's family came to the nurse's station and asked the whereabouts of the patient. RN #1 stated she believed she recalled being trained on the facility's policy regarding Suicidal Assessment, but she could not recall what the policy said.

Continued interview with the Team Supervisor at the CMHC on 08/13/18 at 12:50 PM, revealed she contacted the facility at approximately 1:00 PM to let them know she would be there at approximately 1:30 PM to conduct an evaluation for Patient #1. The CMHC staff stated when she contacted the facility, staff told her the patient had stolen an ambulance and left the facility.

Interview with Patient #1's family member on 08/13/18 at 3:45 PM, revealed they believed Patient #1's hospitalization was due to an overdose of pain pills and/or sleeping pills and the patient was receiving help at the facility. Patient #1's family member stated that she was very concerned about Patient #1 and stated the patient needed help. The family member stated the patient was receiving outpatient counseling prior to hospitalization, which had not been successful. She stated she informed Social Worker #1 that Patient #1 should not be discharged home because the patient was hopeless, sad, and needed some "major" help. Patient #1's family member further stated that when Social Worker #1 informed them that staff from the CMHC was going to come and speak with Patient #1 about a psychiatric placement, Patient #1 just "pulled the covers over [his/her] head." Patient #1's family member stated that after the social worker's visit, she left the facility and when she returned at approximately 12:30 PM, she could not find Patient #1. The family member stated Patient #1's meal tray was in the room; however, the patient could not be found. Patient #1's family member stated she went down the hall to ask where the patient was and a nurse said, "Oh no, [he/she] was the one who stole the ambulance." Patient #1's family member then stated she received a telephone call from local law enforcement informing her that Patient #1 had been arrested for theft of the ambulance. The patient was found at a local entertainment center, approximately 2.2 miles from the facility. Further interview with Patient #1's family member revealed Patient #1 was taken to jail, placed on suicide watch, and remained incarcerated awaiting transfer to a Behavioral Health Unit as part of the patient's court order.

Continued interview with Physician #2 on 08/14/18 at 1:00 PM revealed he was also the Medical Director for the Ambulance Service. Physician #2 stated it was routine for EMS staff to leave ambulances running to prevent battery drainage of equipment. He stated before driving away in the ambulance, there was evidence that Patient #1 went through supplies in the back of the ambulance, such as tubing and bandages, but had not touched the EMS staff's purse or any medications.

Interview with the Chief Nursing Officer (CNO) on 08/13/18 at 2:30 PM and on 08/14/18 at 3:00 PM revealed that she became aware of the incident after she returned from vacation. The CNO stated that after reviewing the record, the facility did not feel that anything could have been implemented to prevent the "unfortunate circumstances" surrounding Patient #1's behavior. The CNO stated, in her opinion, Patient #1 verbalizing suicidal ideation was not a change in condition and did not need to be reported to the physician on call. Continued interview with the CNO revealed that she felt the facility followed their policy because Patient #1 was not "actively suicidal and did not have a plan" therefore, there was no reason to implement their Suicide Risk Assessment policy.

Based on interview, record review, review of facility policy, and review of video surveillance footage, it was determined the facility failed to provide 24-hour nursing supervision for one (1) of ten (10) sampled patients (Patient #1). Patient #1 presented to the facility Emergency Department on 08/01/18, after being found with empty narcotic and sedative/antidepressant bottles at his/her bedside. The facility admitted the patient on 08/02/18, with a diagnosis of syncope (loss of consciousness). Patient #1's admission care plan revealed nursing staff identified the patient had ineffective coping, was at risk for poisoning and trauma, and was cognitively impaired. The facility developed interventions. However, review of nursing staff documentation and interview with Registered Nurse (RN) #1 revealed when Patient #1 expressed suicidal ideations on 08/03/18 at approximately 2:28 AM, the facility failed to implement the interventions to protect and supervise the patient. In addition, on 08/03/18, Social Worker #1 assessed Patient #1 and requested a mental health evaluation for possible involuntary admission to a behavioral health unit. The facility again failed to ensure Patient #1 was supervised while awaiting a mental health evaluation. Patient #1 left the facility on 08/03/18, without staff knowledge sometime after 11:30 AM, and at 12:21 PM, Patient #1 drove away in an ambulance that had been left running in the facility parking lot.

Based on interview, record review, review of facility policy, and review of video surveillance footage, it was determined the facility failed to ensure a Registered Nurse (RN) evaluated and supervised the nursing care for one (1) of ten (10) sampled patients (Patient #1). On 08/01/18, Patient #1 presented to the facility's Emergency Department on 08/01/18, after family found the patient unresponsive, with empty narcotic and sedative/antidepressant bottles at his/her side. The facility admitted the patient on 08/02/18, with a diagnosis of syncope (loss of consciousness). Nursing staff identified Patient #1 had ineffective coping, was at risk for poisoning and trauma, and was cognitively impaired and developed a care plan with interventions to ensure the patient's safety. However, revealed when Patient #1 expressed suicidal ideations on 08/03/18, at approximately 2:28 AM, the facility failed to implement interventions to supervise the patient. Further, on 08/03/18, Social Worker #1 assessed Patient #1 and requested a mental health evaluation for possible involuntary admission to a behavioral health unit. The facility again failed to ensure Patient #1 was supervised while awaiting a mental health evaluation. Patient #1 left the facility on 08/03/18, without staff knowledge sometime after 11:30 AM, and at 12:21 PM, Patient #1 drove away in an ambulance that had been left running in the facility parking lot.
The findings include:

Review of the facility policy titled, "Suicide Risk Assessment," revised November 2017, revealed the facility would identify patients at risk for suicide, and to assure that their immediate safety needs are met. The policy stated nursing staff would screen all patients presenting with emotional or behavioral disorders for suicidal ideation, would notify the physician and alert Security of a suicidal patient, and should remain with the patient until a physician evaluated the patient. The policy did not address how/when nursing staff should screen a patient or provide a tool for the process.

Review of the facility policy titled, "Nursing Assessment," revised April 2017, revealed a registered nurse would perform a nursing assessment and document the assessment in the medical record. The policy stated all registered nurses and licensed practical nurses would reassess patients throughout the shift according to the patient's plan of care and based on changes in the patient's condition.

Review of Patient #1's medical record revealed Patient #1 presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 08/01/18 at approximately 11:00 PM due to "syncope [loss of consciousness] episode this evening, laid down and passed out...has empty bottle of hydrocodone filled 07/25/18 and Trazadone on 07/24/18."

Further review revealed the facility admitted Patient #1 on 08/02/18 at 1:12 AM, with a diagnosis of syncope and a medical history that included Bipolar Disorder, Attention Deficit Hyper-Activity Disorder, and Post Traumatic Stress Disorder.

Review of Patient #1's Nursing Admission Assessment dated 08/02/18 at 1:31 AM revealed the patient indicated that he/she had been the subject of abuse in the last few years but "does not want to talk about it." Continued review of the assessment revealed Patient #1's pain level was rated as a "9" out of 10 and the patient stated, "It hurts from the time I get up, to the time I go to bed." The assessment revealed the patient's goal was to be free from pain.

Review of Patient #1's Care Plan dated 08/02/18 revealed the facility identified the patient had Ineffective Coping, Acute Pain, Risk for Poisoning, Impaired Cognition, and risk for Injury or Trauma. Continued review of the Care Plan revealed the goal was for the patient to remain safe and free from harm. The facility developed nursing interventions that included monitoring the patient's mental status, assess degree of impairment, determine level of anxiety in relation to situation, and provide safety measures as needed.

Review of a Nursing Acute Care Shift Assessment dated 08/02/18 at 7:03 AM revealed RN #1 documented Patient #1's neurological description as "alert, awake and responsive" and "confusion noted at times, [patient] rambles to [himself/herself], doesn't always make sense." Continued review of the Shift Assessment revealed on 08/02/18 at 2:14 AM nursing staff documented that Patient #1 was oriented to self, place, and time but unable to have a lengthy conversation ("incomprehensible"). The nurse also documented the patient could answer questions appropriately, but when asked about details, the question had to be repeated and the patient did not answer immediately. Further review of the Nursing Shift Assessment revealed on 08/02/18 at 6:23 AM nursing staff documented again that "[Patient] answers appropriately but rambles while having a conversation."

Review of the nursing progress notes revealed RN #3 documented on 08/03/18 at 2:28 AM, that Patient #1 missed being "outgoing and having determination." The patient stated he/she "just wants to go away." RN #3 documented that she questioned Patient #1 if he/she was feeling down, sad, or hopeless, and Patient #1 stated, "I can't tell you that. I'll be put in a nut house." RN #3 documented that she left a voicemail for Social Services and ordered a social services consultation. However, there was no documented evidence RN #3 contacted the patient's physician to ensure the patient was assessed regarding the patient's statements and no evidence the RN supervised the patient until an assessment was completed as required by the facility's policy.

Interview with RN #3 on 08/13/18 at 7:00 PM and on 08/14/18 at 12:36 PM, revealed she was assigned to care for Patient #1 during the early morning hours of 08/03/18. RN #3 stated the patient reported he/she felt as if he/she did not want to live anymore. According to RN #3, Patient #1 stated, "I want to go live with my husband in the stars." RN #3 stated that Patient #1's husband had expired and the patient wanted to be with him. RN #3 stated she did question Patient #1 regarding the statements and she did not believe the patient had an active suicide plan or intent, but stated that Patient #1 was "pitiful and sad." RN #3 stated she left a voicemail on the Social Worker's voicemail, but was not aware that facility social workers were available 24 hours via a special telephone number, and could be contacted at all times. Further interview revealed RN #3 did not contact Patient #1's physician about the statements or supervise the patient as required by the facility's policy. RN #3 stated she did not feel Patient #1's verbalization of suicidal ideations was a change in condition; therefore, she did not notify the on-call physician. RN #3 stated she documented the conversation because she felt it was "significant." However, she stated that because Patient #1 did not have a plan, she felt like the patient was okay and there was no need to implement an increased level of supervision. RN #3 stated she believed she was trained on the facility policy regarding Suicidal Assessment, but could not recall when she had received the training or the requirements of the policy. RN #3 also stated she was unaware whether the facility had a suicide assessment tool for nursing staff to complete when a patient verbalized suicidal statements.

Interview with RN #1 on 08/13/18 at 1:33 PM and on 08/14/18 at 12:25 PM revealed she was the nurse assigned to provide care for Patient #1 on 08/03/18 during the day shift. RN #1 stated RN #3 notified her during report that a Social Services consultation had been ordered due to suicidal statements that Patient #1 had made during the night. However, RN #1 stated she did not "think much about it." Further interview revealed RN #1 was also aware that Social Worker #1 stated the facility was going to get Patient #1 "some help and possibly get an involuntary hold." Continued interview with RN #1 revealed Social Worker #1 stated, "If [Patient #1] does not want to go on [his/her] own, we will help [him/her] go." RN #1 stated no additional interventions were implemented to supervise the patient until the patient had a mental health evaluation. RN #1 stated she also believed the facility had provided education regarding Suicidal Assessment, but she could not recall the requirements of the policy. RN #1 stated she was unaware if the facility had a suicide assessment tool for nursing staff to complete when a patient verbalized suicidal statements.

Video surveillance footage of the facility's parking lot for 08/03/18 at 12:18:33 PM, revealed Patient #1 was seen walking up the ramp outside the facility in street clothes. At 12:18:45 PM, the patient entered the passenger's side of a parked ambulance in the parking lot of the facility. At 12:18:51 PM, Patient #1 entered the passenger's door to the ambulance and closed the door. Continued review of the video surveillance footage revealed at 12:19:30 PM Patient #1 exited the passenger side and walked around the back of the ambulance and entered the driver's side door. At 12:19:49 the headlights of the ambulance came on, then went off. Further review of the video revealed Patient #1 pulled out of the parking lot abruptly at 12:21:10 PM, and exited quickly onto the street in front of the facility at 12:21:23.

Continued interview with RN #1 on 08/13/18 at 1:33 PM and on 08/14/18 at 12:25 PM, revealed she was not aware Patient #1 had exited the facility until approximately 12:30 to 1:00 PM, when Patient #1's family came to the nurses' station to ask about the whereabouts of the patient. RN #1 stated the last time she had interaction or recalled seeing Patient #1 was when she assessed Patient #1's level of pain at approximately 10:13 AM, after administering pain medication.

Interview with Patient #1's family member on 08/13/18 at 3:45 PM revealed that she informed Social Worker #1 and "some" member of the nursing staff that she felt like Patient #1 was not "thinking" right. Patient #1's family member stated that the patient had been treatment for mental health issues in the past, along with drug abuse issues and she was very concerned for his/her safety because the treatment had not been effective. Continued interview with Patient #1's family member revealed that she felt "[Patient #1] was crying out for help for a long time and people just would not listen to her or her family and now look what happened."

Interview with the Chief Nursing Officer (CNO) on 08/13/18 at 2:30 PM and on 08/14/18 at 3:00 PM, revealed the facility did not feel that anything could have been implemented to prevent the unfortunate circumstances surrounding Patient #1's behavior. The CNO stated she felt RN #3 did a "good job" assessing Patient #1. The CNO stated she felt because Patient #1 did not indicate that he/she was currently suicidal or had a plan, the facility had followed their Suicide Risk Assessment Policy. Continued interview with the CNO revealed that there was not a "nursing suicide assessment tool" to assess suicide, other than what was built into the normal nursing assessment. However, the CNO stated if a concern for suicide was not identified on the admission assessment, then suicide assessment questions did not populate into the shift assessment.