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Based on observation, record review and interview the hospital failed to meet the Condition of Participation for Patient Rights by failing to ensure psychiatric patients with suicidal ideations were provided care in a safe setting while being held in the Emergency Department.

An immediate jeopardy situation was found to exist in this facility on 10/06/2011 and reported to the hospital's Acting Chief Executive Officer S1 at 9:40 a.m.. The immediate jeopardy situation was the hospital's failure to ensure suicidal patients were provided care in a safe setting when being held in the Emergency Department as evidenced by: 1) failing to ensure contracted security guards were trained and deemed competent in observations, behavioral management, and restraint technique prior to being assigned to Continuous Visual Observation of suicidal patients in the Emergency Department, and 2) failing to enforce the hospital policy titled Suicidal Risk Assessment and Precautions which requires the suicidal patient's environment be free of obvious dangerous objects such as loose sharp objects, strings, cords, and wire. Security Guard S13 was assigned to monitor Patient #3 on 8/15/2011 on Continuous Visual Observation. S13 abandoned his (S13) assignment without relief on 8/15/2011 at 7:05 a.m. and Suicidal Patient #3; who had cut her (#3)wrist prior to seeking emergency treatment and had been placed under a Physician's Emergency Certificate declaring she (#3) was in need of immediate psychiatric treatment on 8/14/2011 at 2000 (8:00 p.m.), eloped from the Emergency Department. Further Suicidal Patient #1 was observed on 10/04/2011 at 9:30 a.m. in Room A with Security Guard S7 seated outside the room. Observations on 10/04 at 9:30 a.m. revealed Room A to contain a call light with cord, two empty plastic belonging bags, 10 plastic oxygen tubings, and an unlocked cabinet with 6 Benzakonium Chloride Antiseptic towelettes, 4 bottles of 3% Hydrogen Peroxide (4 ounces each), and 4 bottles of Providone Iodine 10% (4 ounces each). Further Security Guard S7 was observed to be located in the hall with his back to Patient #1; when assigned to Continuous Visual Observation of the patient (#1), with periodic turns of his head to visualize the patient (#1). (See findings cited at A0144)

A plan of removal was submitted by the hospital on 10/07/2011 at 8:00 a.m., revised and submitted with revisions at 10:20 a.m. Review of the hospital's Plan of Removal revealed in part, "A policy has been developed and approved for implementation with staffing procedures of security officers and their responsibilities when assigned to monitor psychiatric/ PEC (Physician Emergency Certificate) patients in the Emergency Department. If any psychiatric /PEC patients are housed prior to this mandatory training (October 11 and 13, all security guards that provide monitoring of PEC/psychiatric patients in the Emergency Department), the charge nurse or nurse manager trained in Non-violent Crisis Prevention will administer training to security personnel prior to any observation of psychiatric/PEC patients and documented (document). This training will be documented on the Emergency Department Security Guard Expectation form and signed by the SMH (Slidell Memorial Hospital) CN/NM (Charge Nurse/Nurse Manager) responsible for performing the training and the security guard being trained. A post test will be administered to the security guard being trained. A post test will be administered to the security guard. If not passed at 100%, the material will be reviewed by the CN/NM and the guard will be allowed to retake the test one time. If he/she fails a second time, the (Security Contracted Service) supervisor will be notified and a replacement guard will (be) requested. If no guard is immediately available, an SMH employee competent to care for psychiatric/PEC patients will be used until a security guard becomes available. CN/NM will observe the security guard after test is passed at intervals starting 30 min (minutes) after observation of a patient begins and documenting these observations. . . . A psychiatric evaluation protocol has been developed and approved for implementation to outline the role of any trained staff or contract personnel monitoring psychiatric/ PEC patients including an every 15 minutes check list for documentation of monitoring and observation. . . Room Preparedness: SMH will begin using the Radio Frequency Identification Device (RFID) system immediately to monitor the location of psychiatric/PEC patients in addition to visual observation. When a psychiatric patient is admitted to the Emergency Department and placed in a room, the room will be cleared of cords, call lights, oxygen, plastic bags, their personal belongings, and other objects that could cause harm to a psychiatric patient, unless required for immediate medical care, and stored outside the room in a locked cart. . . Kits will be made for any patient placed in psychiatric evaluation or demonstrating psychiatric behaviors to include the following items: Purple gown, Arm band for patient identification, RFID tag, Paper bags, Yellow socks, Dummy plug (to prevent call system from alarming when call cord removed from room), heavy duty zip ties for non-locking cabinet drawers, patient belonging bag. All cabinets will be secured with strong zip ties to prevent the patient from obtaining items within the cabinets when a PEC patient is placed in any room in the Emergency Department. Purple gowns have been obtained from a sister facility until gowns which have been ordered are received for all psychiatric/PEC patients. A psychiatric patient room checklist has been developed to prompt and remind staff of the steps to take in preparing a room for the psychiatric/PEC patient. If patient is placed in a room with a door, the security guard will position themselves in the doorway so the door cannot be closed. . ."

As a result of the hospital's plan of removal, the Immediate Jeopardy situation was removed on 10/07/2011 at 10:50 a.m. due to the hospital putting measures in place to ensure all psychiatric/PEC patients would be monitored in rooms free from hazardous material with Continuous Visual Observations by Security Guards that passed a post training test with scores of 100%. Further Security Guards were to be monitored for competency by Charge Nurses/Nurse Manager.

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 suicidal patients were provided care in a safe setting when being held in the Emergency Department as evidenced by: 1) failing to ensure contracted security guards were trained and deemed competent in observations, behavioral management, and restraint technique prior to being assigned to Continuous Visual Observation of suicidal patients in the Emergency Department for 8 of 8 Security Officers reviewed for competency (S7, S8, S13, S17, S18, S19, S20, S21). Review of Psychiatric Patients revealed 2 of 7 Psychiatric patients assigned to untrained Security Guards for Continuous Visual Observations failed to have been observed continuously (#1, #3) out of a total sample of 10. Patient #3 eloped from the hospital while assigned to Security for Continuous Observation when the Security Guard S13 abandoned his (S13) post without relief. and 2) failing to enforce the hospital policy titled Suicidal Risk Assessment and Precautions which requires the suicidal patient's environment be free of obvious dangerous objects such as loose sharp objects, strings, cords, and wire for 1 of 1 patients observed in the Emergency Department for security of environment (the only psychiatric patient present at the time of observations/ Patient #1). 3) failing to ensure the hospital policy titled, "Suicide Risk Assessment and Precautions" was reviewed and revised to ensure the intent of the policy was documented for staff's guidance by failing to remove the statement indicating, "Intervention (Patient at risk for Suicide): Continuous observation by a family member or designee will be maintained until such time that suicide precautions have been discontinued by a physician's order stating patient has met criteria to discontinue." for 1 of 2 policies reviewed for Suicidal Interventions (Suicide Risk Assessment and Precautions)Findings:

1) Review of Security Officer Training and Competency revealed no documented evidence that Security Guards S7, S8, S13, S17, S18, S19, S20, and S21 had ever received training in observation of psychiatric patients, behavioral management, and restraint techniques. Further review revealed officers had signed a form titled, "Security/SPD Detail at Slidell Memorial Hospital" which indicated "I have been told about and understand the policies on the following subjects. . . . " Review of listed policies revealed no documented evidence of review of the hospital's policies titled, "Suicide Risk Assessment and Precautions" or "Restraint Policy: Management and Philosophy of Patient Rights."

During a face to face interview on 10/05/2011 at 11:30 a.m., Director of Facility Services S12 indicated he (S12) was responsible for Competency Evaluation of Security Guards at the hospital. S12 indicated he (S12) considered having the form titled, "Security/SPD Detail at Slidell Memorial Hospital" signed by Security Guards as evidence of competency. S12 indicated the form was signed as a self attestation by contracted Security Guards. S12 indicated at no time did he (S12) observe or evaluate the competency of any Security Guard to include the Security Guards' competency in providing Continuous Visual Observations of Suicidal Patients being held in the Emergency Department. S12 confirmed that Self Attestation would not ensure staff were Competent.

Face to face interviews were conducted with Psychiatric Security Supervisor S8 on 10/05/2011 at 9:45 a.m., Security Branch Manager S10 on 10/05/2011 at 10:20 a.m., and Security Field Supervisor S9 on 10/05/2011 at 10:20 a.m. S8, S9, and S10 all indicated there was no documented evidence of any psychiatric training and/or competency for any Security Guard that worked at the hospital to include Officers S7, S8, S13, S17, S18, S19, S20, and S21.

Review of Patient #1's medical record revealed the patient was admitted to the hospital on 10/03/2011 at 9:22 a.m. and triaged a Level 3 (Patients requiring 2 or more resources with vital signs not exceeding the danger zone) at 9:37 a.m. with "depression, having thoughts of suicide." Further review revealed Patient #1 had been placed under a Physician's Emergency Certificate on 10/03/2011 at 10:40 a.m. which indicated Patient #1 was in "need of immediate psychiatric treatment" and "Dangerous to Self".

Observations on 10/04/2011 from 9:30 a.m. through 9:50 a.m. revealed Security Guard S7 seated outside Room A where Suicidal Patient #1 was being held in a fully stocked Fast Track exam room. Security Guard S7 had his (S7) back to the patient's room and was looking towards the nursing station. S7 continued to view the nursing station with occasional turns of his (S7) head towards Room A where Patient #1 was located. S7 moved his body around in chair and faced patient room; however, continued to look away from room with occasional glances into room.

Emergency Department Director S3 was present during these observations and indicated in a face to face interview at 9:50 a.m. (10/04/2011) that Security Guard S7 should have been observing Patient #1 continuously.

During a face to face interview on 10/05/2011 at 9:45 a.m., Security Guard S7 indicated he (S7) had been employed by the hospital for 14 months. S7 indicated he (S7) had never received any formal training in the care of Psychiatric Patients. S7 indicated when he (S7) had been assigned to monitor suicidal patients in the Emergency Department he (S7) had made a point not to disturb the patient by staring at them. S7 indicated suicidal patients should be under constant visual. S7 further indicated some patients would get upset if they thought you (Security Guards) were staring at them so his (S7) practice had been to make intermittent observations of patients while seated outside their room. S7 indicated he (S7) wound not keep 100% view of the patients when they were sleeping. S7 indicated he (S7) could often hear sleeping patients snore.

Review of Patient #3's medical record revealed the patient had been admitted to the hospital's Emergency Department on 8/14/2011 at 1819 (6:19 p.m.) and triaged a level 4 (patient requiring one resource only) at 1822 (6:22 p.m.) with nursing narrative note indicating, ". . . superficial lacerations to left hand and wrist" and chief complaint of "cut wrists, feelings of self worthlessness." Further review revealed Patient #3 had been placed under a Physician's Emergency Certificate on 8/14/2011 at 8:00 p.m. with Mental Condition of "depressed, suicidal ideation" and determined to be "in need of immediate psychiatric treatment in a treatment facility . . . dangerous to self." Review of Patient #3's Nurses Notes (no documented date) 0650 (6:50 a.m.) revealed "pt (patient) amb (ambulated) to BR (bathroom), security (at) side. 0705 (7:05 a.m.) pt (patient) not in room, looked in lobby, walked outside, pt (patient) not in sight."

During a face to face interview on 10/05/2011 at 10:50 a.m., Registered Nurse S11 indicated she (S11) had provided care to Suicidal Patient #3 the shift before the patient (#3) had eloped. S11 indicated the Security Guard (could not recall name) on duty during that shift had abandoned his (unidentified Security Guard) post one time during the shift to get coffee without informing her (S11). S11 indicated she (S11) had informed the Security Guard that he (S11) should always inform her (S11) prior to leaving his post so that she (S11) could watch the suicidal patient.

During a face to face interview on 10/05/2011 at 9:15 a.m., Registered Nurse S6 indicated she (S6) had been the nurse assigned to the care of Suicidal Patient #3 on the day (8/15/2011) the suicidal patient (#3) eloped from the Emergency Department. S6 indicated she (S6) had just come on duty and had observed Security Guard S13, who had also just come on duty, walking Patient #3 to the Bathroom. S6 indicated shortly thereafter, Security Guard S13 approached her (S6) asking if she (S6) had seen Patient #3 because he (S13) could not find her (patient #3). S6 indicated the area had been searched and Suicidal Patient #3 had not been found. S6 indicated Security Guard S13 informed her (S6) that he (S13) had gone to the Bathroom and when he (S13) came back Patient #3 had been gone. S6 indicated Security Guard S13 had not informed anyone that he (S13) needed someone (staff) to relieve him (S13) of his (S13) assignment of Continuous Observation of Patient #3 in order for him (S13) to go to the bathroom.

During a face to face interview on 10/06/2011 at 8:15 a.m., Registered Nurse S14 indicated he (S14) had been the Charge Nurse on the day Suicidal Patient #3 had eloped from the Emergency Department (8/15/2011). S14 indicated a search of inside and outside the hospital had proven no success in locating Suicidal Patient #3. S14 indicated several attempts to reach Patient #3 by telephone had also proven unsuccessful. S14 confirmed there had been no documented evidence of any phone attempts to reach Patient #3 and/or her husband. S14 indicated the Security Guard assigned to Continuous Visual Observation of Patient #3 should never have left his post without seeking relief.

Review of the hospital policy titled, "Restraint Policy: Management and Philosophy of Patient Rights, PC-080" presented by the hospital as current revealed in part, "a staff member who is trained and competent assesses the patient at the initiation of restraint or seclusion and every 15 minutes thereafter. In this hospital an RN (Registered Nurse) will perform the initial assessment. A trained staff member, who is assigned to perform uninterrupted observation of the patient, may perform ongoing 15 minute assessment of the patient with RN oversight. . . Patients are continually monitored, but documentation is performed every 15 minutes.. . All staff who have direct patient care responsibilities and who are involved with the application of restraint, implementation of seclusion,; providing care for a patient in restraint or seclusion, or with assessing and monitoring the condition of the restrained or secluded patient must have ongoing education training in proper and safe use of restraints. this includes all staff that have direct patient care responsibilities and any other individuals who may be involved in the application of restraints (e.g. security guards). Staff must have completed the training requirements outlined in this policy prior to their involvement in seclusion or restraint episodes, as part of orientation,a and subsequently retrained annually during the competency fair with return demonstration technique. . ."

2) Review of the hospital policy titled, "Suicide Risk Assessment and Precautions, PC-090" presented by the hospital as current revealed in part, "Patient environment must be free of obvious dangerous objects such as loose sharp objects, strings, cords, and wires. Dinnerware must be plastic/disposable. Medicines and controlled substances will not be accessible to the patient."

Review of Patient #1's medical record revealed the patient was admitted to the hospital on 10/03/2011 with "depression, having thoughts of suicide."

Observations on 10/04/2011 (Day #2 of Patient #1's admission) at 9:30 a.m. revealed Patient #1 (only psychiatric patient located in the Emergency Room at the time of observations) to be located in Fast Track exam Room A. Observations revealed the room to contain a call light with 112 inch cord, two empty plastic belonging bags, 10 plastic oxygen tubings, and an unlocked cabinet with 6 Benzakonium Chloride Antiseptic towelettes, 4 bottles of 3% Hydrogen Peroxide (4 ounces each), and 4 bottles of Providone Iodine 10% (4 ounces each).

During a face to face interview on 10/04/2011 at 9:50 a.m., Emergency Department Director S3 indicated Cords and Tubing were left in rooms with Suicidal Patients. S3 further indicated the practice was not ideal but it was how it had been done. S3 indicated Security Officers were placed outside the Suicidal Patient's rooms for Continuous Visual Observation.
S3 further indicated Call Lights in the Emergency Department could not be disconnected because it caused them to alarm. S3 indicated the cabinet containing Betadine and Peroxide should have been locked.

During a face to face interview on 10/06/2011 at 8:45 a.m., Registered Nurse S16 indicated she (S16) had been the nurse assigned to the care of Patient #1 on the day shift for 10/04/2011. S16 indicated Patient #1 had been in the Emergency Department for over 24 hours awaiting placement in an inpatient psychiatric facility. S16 confirmed the presence of items in Room A, where Patient #1 was housed, that could be used to inflict self harm or used as a weapon. S16 indicated the hospital practice was to leave the call light in place and oxygen tubing in the room. S16 indicated the cabinet with Betadine and Peroxide should have been locked.

3) Review of the hospital policy titled, "Suicide Risk Assessment and Precautions, PC-090" presented by the hospital as current revealed in part, "Intervention (Patients at Risk for Suicide): Continuous observation by a family member or designee will be maintained until such time that suicide precautions have been discontinued by a physician's order stating patient has met criteria to discontinue."

Face to face interviews were conducted with Director of Emergency Department S3, Quality Assurance Director S5, and Registered Nurse S16 on 10/06/2011 at 9:10 a.m. S3, S5, and S16 indicated there would never be a time when safety monitoring of a suicidal patient would be delegated to the patient's family member. S3, S5, and S16 indicated any family member that wished to visit a psychiatric patient in the Emergency Department would have to be screened for safety first and would not be allowed to bring any items inside the room. S3, S5, and S16 indicated a Security Guard would be located outside the room and would monitor the visit. S5 indicated the policy titled, "Suicide Risk Assessment and Precautions" needed to be updated because it should not imply that a family member would be delegated the responsibility for Continuous Observation of a Suicidal Patient.

Based on record review and interview the hospital failed to ensure renewal of physician's orders for seclusion were based on assessment and/or knowledge of the patient's need for ongoing seclusion as evidenced by a physician's order for seclusion being timed 4 hours after the previous order for seclusion and 55 minutes after the patient (#3) had eloped from the Emergency Department for 1 of 7 psychiatric patients out of a total sample of 10 (Patient #3). Findings:

Review of Patient #3's medical record revealed the patient had been admitted to the hospital's Emergency Department on 8/14/2011 at 1819 (6:19 p.m.) and triaged a level 4 (patient requiring one resource only) at 1822 (6:22 p.m.) with nursing narrative note indicating, ". . . superficial lacerations to left hand and wrist" and chief complaint of "cut wrists, feelings of self worthlessness." Review of Patient #3's "Restraint or Seclusion Order Sheet" dated 8/14/2011 at 2000 (8:00 p.m.) revealed an order for seclusion without mechanical restraint for self destructive behavior. Further review revealed the order was renewed at 2400 (12:00 a.m. on 8/15/2011), 0400 (4:00 a.m. on 8/15/2011), and 0800 (8:00 a.m. on 8/15/2011/ 1 hour after the patient had eloped from the Emergency Department). Review of Patient #3's Nurses Notes (no documented date) 0650 (6:50 a.m.) revealed "pt (patient) amb (ambulated) to BR (bathroom), security (at) side. 0705 (7:05 a.m/ 55 minutes before the physician's 8:00 a.m. order for seclusion) pt (patient) not in room, looked in lobby, walked outside, pt (patient) not in sight."

Review of the hospital policy titled, "Restraint Policy; Management and Philosophy of Patient Rights, PC-080" presented by the hospital as current revealed in part, "PRN (as needed) or standing orders for seclusion or restraint are unacceptable and will not be utilized to authorize the use of seclusion or restraint. Each episode of restraint or seclusion must be initiated in accordance with the order of a physician or Licensed Independent Practitioner. . . Written and verbal orders for seclusion or restraint are time limited. The physician determines the duration of the restraint order. The order can be less than the following lengths of time but can not exceed: 4 hours for adults 18 years or older. . .After the original order expires, the physician or LIP is encouraged to perform a face to face reassessment of the patient.. . The licensed independent practitioner conducts an in person reevaluation at least every 8 hours for patients ages 18 years and older. . . "

During a face to face interview on 10/07/2011 at 8:00 a.m., Quality Assurance Director S5 confirmed the physician's order for Seclusion of Patient #3 dated 8/15/2011 at 8:00 a.m. would have been written 55 minutes after the patient had already eloped from the hospital. S5 further indicated orders for seclusion and restraint should be renewed as per policy in 4 hour increments for patients over 18. S5 indicated at no time should a physician pre- date and pre- time an order for seclusion/restraint.

Based on record review and interview the hospital failed to ensure it's Quality Assessment Performance Improvement (QAPI) Department thoroughly analyzed a Quantros Patient Safety Event involving Suicidal Patient #3 who eloped from the Emergency Department when a Security Guard (S13) with no Suicide/Psychiatric Observation training or competency evaluation had been assigned to Constant Visual Observations for the suicidal patient (#3). (Patient #3 eloped while assigned to Security Guard S13 who abandoned his assignment without relief.) This resulted in the QAPI department's failure to identify the problem of having no Security Guard in the entire department trained or evaluated as competent in Constant Visual Observations of the Suicidal/Psychiatric patient when they (Security Guards) were routinely assigned to monitor Suicidal patients in the Emergency Department with Constant Visual Observation for 1 of 1 Department reviewed for training/competency in observing Suicidal/Psychiatric Patients in the Emergency Department (Security). Findings:

Review of the hospital's Electronically documented "Patient Safety Event" report regarding Patient #3 revealed in part, "Elopement: (Patient #3) Emergency Department, Pt (patient) was PEC' d (Physician's Emergency Certificate) for depression, Suicidal Ideations. Security Officer that was watching her informed me at 0722 (7:22 a.m.) that pt (patient) had left the hospital. Summary Finding: ER (Emergency Room) patient was being watched one on one by security officer. Security Officer went to rest room and when he returned discovered patient was gone. Security did not notify any other staff that he was leaving room unattened (unattended). Immediate Action Taken: Conducted search for patient. Was unable to locate pt. Reported the incident to the Security Supr (Supervisor). Contributory factors and Issues leading to the Event (blank). Give us your recommendations on what needs to be done as a result of this event (blank). What is the probability of this event recurring? (blank). I have verified the facts around the event from available documentation and used my best judgement in completing the form: Complete. 8/16/2011 10:25 a.m. (See additional findings cited at A0144)"

The following employees were interviewed: Nurse Emergency Department Director S3 on 10/05/2011 at 8:10 a.m., Psychiatric Supervisor/Security Guard S8 on 10/05/2011 at 9:45 a.m., Field Supervisor/Security Guard S9 on 10/5/2011 at 10:20 a.m., and Branch Manager/Security Guard S10 on 10/05/2011 at 10:20 a.m. Neither S3, S8, S9, and S10 could produce any documented evidence that any Security Guard contracted to work at the hospital had any formal training or competency evaluation in monitoring Suicidal/Psychiatric patients in the Emergency Department. S3, S8, S9, and S10 indicated there had been no training provided to Security Guards regarding observations, behavioral management, or restraint technique prior to being assigned Continuous Visual Observations of Suicidal Patients in the Emergency Department. S3 indicated it was the practice in the Emergency Department to have Security Guards monitor all PEC' d (Physician Emergency Certificate) patients in the Emergency Department. S3 indicated if there were more psychiatric patients in the Emergency Department than Security Guards could staff, she (S3) would then assign monitoring of the patients to Emergency Department Nursing Staff that had been trained in Crisis Prevention Intervention and Restraints. S3 indicated Security Guards had been the first choice in assignments when having 1:1 Constant Visual Observations of Psychiatric Patients in the Emergency Department.

During a face to face interview on 10/06/2011 at 10:10 a.m., Quality Director S5 indicated she (S5) had never been informed of the incident regarding Patient #3's elopement from the Emergency Department when under a Physician's Emergency Certificate. S5 indicated Risk Manager S4 had been the investigating staff. S5 indicated S4 should have reported the incident to her (S5). S5 indicated investigation of the incident should have revealed the need for improvement in training and competency evaluation of Security Guards assigned to monitor psychiatric/suicidal patients in the hospital.

Review of the hospital policy titled, "Adverse/Sentinel Events Response and Reporting, PI-050" presented by the hospital as current revealed in part, "The hospital shall develop a system to identify, assess, and internally report and address all known adverse events including sentinel events. In response to each known adverse event, the hospital" shall conduct a timely, thorough and credible investigation and will develop a root cause analysis when indicated by the clinical quality Department, there shall be developed an action plan designed to implement improvements to reduce risk, shall implement those improvements, shall monitor the effectiveness of those improvements. . ."

Review of the hospital's Quality and Performance Improvement Plan revealed in part, "The purpose of the Slidell Memorial Hospital Quality and Performance Improvement Plan is to provide a systematic process that allows for a coordinated continuous approach to process design, performance measurement and analysis with focus placed on safety, outcomes, and the aspects and dimensions that address the mission, vision, values, and strategic plans of the hospital.. . The Quality Improvement Plan includes the following activities: Behavior management and treatment, Unanticipated events . . . with potential for poor outcomes."

Based on record review and interview the hospital failed to ensure all entries in patient's medical records were complete, dated, and timed for 2 of 10 medical records reviewed (Patients #1, #3). Findings:

Review of Patient #1's medical record revealed the patient had been admitted to the hospital's Emergency Department on 10/03/2011 with Suicidal Ideation. Further review revealed an intervention check list with a section for dating and timing that contained check marks with no documented date or time for the following interventions: "Security notified of patient, Security at bedside for observation, Patient placed in room that allows for close monitoring, Clothing and personal belongings are removed from room. . . Seclusion/Restraint paperwork initiated and signed by MD (Medical Doctor), (Contracted Agency) team notified. . ., Call coroner's Office, Reconcile Home medications, and AM Care, meals, exercise provided." Further review revealed the Suicide Risk Assessment Scale for Patient #1 failed to have the section for Sex assessed, as evidenced by no check mark by either male or female. Patient #1 was male which would have added 2 points to his total Suicide Risk Assessment Score.

Review of Patient #3's medical record revealed the patient had been admitted to the hospital's Emergency Department on 8/14/2011 with chief complaint of "cut wrists, feelings of self worthlessness." Review of Patient #3's Intervention flow sheet revealed a section titled Date and Time that had check marks placed with documented date of 8/14/2011 and no documented time under the areas indicating, "Patient placed in gown" and "Belongings obtained from patient." Review of Patient #3's "Restraint or Seclusion Order Sheet" revealed a physician's order to renew seclusion dated 8/15/2011 at 8:00 a.m. (55 minutes after the patient was no longer in the Emergency Department). Review of Patient #3's Nurses Notes (no documented date) 0650 (6:50 a.m.) revealed "pt (patient) amb (ambulated) to BR (bathroom), security (at) side. 0705 (7:05 a.m/ 55 minutes before the physician's 8:00 a.m. order for seclusion) pt (patient) not in room, looked in lobby, walked outside, pt (patient) not in sight. 0715 (7:15 a.m.) (City) police called (and) notified of pt (patient) leaving ER (Emergency Room). 0730 (7:30 a.m.) (City) police here, pt eloped from ER 1620 (4:20 p.m.) (City Police Department) re-called to verify update. unable to make contact at address listed." Review of Patient #3's entire medical record revealed no documented evidence of the police officers name with whom the report had been made or the Item Number. Review of Patient #3's entire medical record revealed no documented evidence of telephone calls made to the two phone numbers listed on the patient's medical record.

Review of the hospital's Quantros Patient Safety Event Report regarding the elopement of Patient #3 from the Emergency Department revealed the incident date and time as "8/15/2011 at 0720 (7:20 a.m.).

During a face to face interview on 10/06/2011 at 8:15 a.m., Charge Nurse S14 indicated he had been on duty the day Suicidal Patient #3 had eloped from the hospital. S14 indicated he (S14) had made multiple attempts to reach Patient #3 at the two phone numbers listed on the patient's medical record. S14 confirmed there was no documentation in Patient #3's medical record to indicate he (S14) had made any effort to reach Suicidal Patient #3 by telephone after the patient eloped from the Emergency Department.

During a face to face interview on 10/5/2011 at 9:15 a.m., Registered Nurse S6 indicated she (S6) had been the nurse that had been assigned to Suicidal Patient #3 on the date the patient had eloped. S6 confirmed that she (S6) had failed to document the name of the police officer whom she reported the incident to, the item number for the police report, and phone calls made to the patient's home to include who made the calls, the date/time of calls, and result of calls.

During a face to face interview on 10/07/2011 at 8:00 a.m., Quality Assurance Director S5 confirmed the physician's order for Seclusion of Patient #3 dated 8/15/2011 at 8:00 a.m. would have been written 55 minutes after the patient had already eloped from the hospital. S5 indicated at no time should a physician pre- date and pre- time an order for seclusion/restraint. S5 confirmed the failure to have documentation of an assessment of Patient #1's Sex on his Suicide Risk Assessment and that dates/times had been missing on multiple entries in both Patient #1's and Patient #3's medical record.