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Based on interview, review of Emergency Department (ED) logs, medical records, policy, and video review, the facility failed to provide a medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) within its capacity and capability for four patients (#3, #22, #5 and #12) of 22 ED records reviewed from December 2016 through June 5, 2017. The facility also failed to stabilize one of one patient (#12) reviewed.

The facility had the ability to provide a MSE for Patients #3, #22, #5 and #12 to determine if they had an EMC.

Please see the citation at A2406 for further details.

Based on record review, policy review, video surveillance, and interview, the facility failed to provide a medical screening examination sufficient to determine the presence of a medical and or psychological emergency, within its capacity and capability, for four patients (#3, #22, #5 and #12) of 22 Emergency Department (ED) records reviewed. These failures had the potential to affect all patients who presented to the ED by risking the possibility of delayed treatment, injury or death for those who required immediate medical or psychiatric care. The ED sees approximately 5996 patients per month.

Findings included:

1. Record review of the undated facility policy titled, "Emergency Medical Screening, Treatment, Transfer and On-Call Roster," showed:
-An individual comes to the emergency department when they present at the hospital's emergency department and request examination or treatment for a medical condition, or has such a request made on the individual's behalf.
-A Medical Screening Exam (MSE) was the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an individual has an Emergency Medical Condition or not.
-An Emergency Medical Condition (EMC) means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to any bodily functions, or serious dysfunction of any bodily organ or part.
-The MSE should be appropriate to the individual's signs and symptoms, as well as the capability and capacity of the hospital.

Record review of the undated facility policy titled, "Suicide-Suicidal Patients-Care," stated:
-The goal was to provide the safest environment possible for such patients and to minimize the potential for harm to patients, staff, and others.
-Indications that a patient was suicidal may be a report from an ambulance crew, other transporters, or observation of a patient's verbal and/or action behavior. Additionally, certain symptoms or disorders may provide indications that a patient was, or may become, suicidal.
-The staff member who first received information regarding a patient's suicidal ideation was responsible for alerting the ED physician, ED charge nurse, and requesting a consult from the Behavioral Health Assessment Counselors (BHAC, group of specially trained staff members that perform behavioral health assessments in the ED). Notify security only if the patient presented an immediate threat of elopement or exhibited current harmful acts to themselves or others.
-While awaiting the arrival of BHAC, staff was to provide medical stabilizing treatment as ordered by the physician and initiate the Suicidal Patients One to One Care Order Set.
-The charge nurse would assign a technician to one-to-one observation with the patient who maintained visual view of the patient at all times.
-The patient was to remove all clothing and use a gown.

2. Review of Patient #3's ED record dated 05/26/17 showed:
-She was a 47 year old female who presented by ambulance at 7:46 AM from a local psychiatric facility where she was an inpatient, and complained of left sided chest pain.
- Review of the 5/26/17 EMS trip report showed that the advanced cardiac life support equipped ambulance transported patient # 3 to the ED from a local psychiatric hospital where the patient was being treated for suicidal thoughts and depression, and subsequently developed left sided chest pain that radiated to the left shoulder. Further documentation showed the ambulance arrived at the ED with patient # 3 at 7:42 a.m.

-ED Physician M, documented that the patient had a past medical history of Bipolar Disorder (a mental disorder marked by alternating periods of elation and sadness), Anxiety, Chronic Pain Syndrome, Diverticulitis (a digestive disease in which pouches within the large bowel wall become inflamed), Dysthymic Disorder (a mood disorder characterized by chronic mildly depressed or irritable mood), Fibromyositis (chronic inflammation of a muscle), Pulmonary Embolism (a blockage in one of the pulmonary arteries in the lungs), Kidney Stones, Migraines, Opioid (a type of narcotic [pain] medication) Abuse, Postphlebetic Syndrome (complications that result from the impaired return of blood through the veins of the lower leg to the heart), Protein S Deficiency (a disorder of blood clotting), Post-Traumatic Stress Disorder (a condition of persistent mental and emotional stress that occurred as a result of injury or severe psychological shock) and Transient Ischemic Attack (TIA, a neurological event due to a temporary lack of adequate blood and oxygen to the brain).

-Further documentation showed patient # 3 had a history of chronic chest pain, and had been off of Coumadin (a medication used to thin the blood and prevent clots from forming) for the last several days while an inpatient in a local psychiatric facility.

-ED physician M documented the patient reported that she had not had any current issues with substance abuse.
-Documentation of the psychiatric assessment performed by ED physician M noted the patient was alert, oriented, and thinking appeared to be normal for the situation.

-The Fibrin Dimer level (a lab test that can aid in the diagnosis of deep vein thrombosis [blood clot] and pulmonary embolism) was elevated at 2.17 micrograms/milliliter (units of measurement) with the normal range being 0.00-0.50 micrograms/milliliter.
-ED physician M consulted with a hemotologist (a physician that specializes in disorders of the blood) who determined patient # 3 required inpatient admission to re-establish her anti-coagulation (medications that prevent blood clots from forming) medications and continue to rule out any new blood clots.

-ED Registered Nurse (RN) O, triaged the patient and documented that the patient had no thoughts of death or killing herself.
-The patient had a port (a small medical device located under the skin that directly attaches to a large vein and allows for specially trained staff to access and administer medication and draw blood) in her left chest. The port had been accessed with a needle that connected to a short catheter, and then used by staff.
-ED nurse O documented she last saw patient # 3 at 9:05 AM and that the patient continued to complain of chest pain, but refused her oxygen.
-Further documentation by ED nurse O showed that patient # 3's cardiac monitor was removed at 9:29 a.m. At 9:35 a.m. ED nurse O determined patient # 3 was no longer in her room and could not be found. ED nurse O contacted hospital security.
- At 9:35 a.m. ED nurse O documented that patient # 3 "left the ED through EMS bay and walked off hospital property" on the hospital form titled "Statement of Patient Refusing Treatment Against Advice."

-Further documentation showed Staff F, Security Representative, informed ED nurse O that the patient left the ED through the ambulance bay and walked down the hill off of hospital property. Staff F notified the local police department that the patient still had an accessed port in place (an accessed port contained a needle with a short catheter that could be utilized to inject substances).

-ED physician M documented an addendum note at 10:06 a.m. that stated the patient left with her port accessed (needle and catheter in place) and the police had been notified.

Review of video surveillance dated 05/26/17 showed that at 9:30:12 AM, Patient #3 left her room and walked around the loop that circles the interior of the ED. She made a second loop at 9:30:50 AM. At approximately 9:31:20 AM she left the hospital via the Emergency Medical Services (EMS) exit after observing two security representatives enter through the door.

During an interview on 06/06/17 at 2:20 PM, Staff F, Security, stated that he had not been assigned to monitor Patient #3 nor had any contact with her prior to being notified about her elopement. He was called to the room when staff noticed the patient was no longer there. He was informed he needed to look for her due to the fact that she still had her port accessed.

During a telephone interview on 06/07/17 at 9:45 a.m. ED nurse O stated that:
-In report from EMS they informed her that the patient had a history of suicidal ideations (SI) and depression;
-EMS and Patient #3 reported she was to be discharged from the inpatient facility that day;
-Patient # 3 denied any thoughts of suicide;
-She did not put the patient on any Suicide Precautions because she was screened negative for SI;
-No paperwork came with the patient from the inpatient facility; and
-She never called the inpatient psychiatric facility to let them know the patient had eloped.

During an interview on 06/07/17 at 10:30 AM, ED physician M stated that he was aware patient # 3 came from an inpatient psychiatric facility, but he had no concern for SI based on his assessment. Patient #3 was aware she was going to be admitted and had not had any objections.

During a telephone interview on 06/07/17 at 9:30 AM, Staff K, ED Charge RN, stated that:
-She was in charge on 05/26/17 and took a call from the inpatient psychiatric facility prior to the patient's arrival;
-The facility informed her that the patient did not have any suicidal ideation (SI) and the reason for admission was depression.
-If the patient had SI, she would have placed the patient on one-to-one observation;
-She took the radio call from the EMS unit transporting the patient and there was no mention of SI;
-ED nurse O informed her that the patient had eloped and;
-She asked ED nurse O if she had called the psychiatric hospital to let them know of the patient's elopement was told no.

Review of Patient #3's inpatient psychiatric record from the transferring psychiatric facility showed:
-She was admitted on 05/24/17 at 4:22 p.m.
-The History and Physical completed on 05/25/17 by the psychiatrist, documented her chief complaint was hearing voices and suicidal ideation. She had multiple needle track marks due to prior methamphetamine (a drug used as a stimulant) use and the summary of findings was that the patient had suicidal ideations.
-The patient had no planned discharge, but had mentioned to staff she wanted to leave.
-The psychiatrist on staff had requested staff coordinate a meeting with the patient / family to discuss discharge planning, but there was no order for discharge.

During a telephone interview on 06/15/17 at 1:25 p.m, the Chief Nursing Officer (CNO) of the inpatient psychiatric facility, stated that the patient had no planned discharge for the day of her transfer to the ED.

During a telephone interview on 06/16/17 at 10:00 AM, Staff BB, RN of the inpatient psychiatric facility, stated that he cared for Patient #3 the morning of her transfer to the ED. There was no discharge planned for the day of her transfer, and this was never given in report to the ED nor EMS. He remembered the person whom he had given report to at the ED asked about any precautions the patient was on, and he had informed them the patient was on suicide precautions due to her history of depression and suicidal ideations.

During a telephone interview on 06/15/17 at 11:35 AM, Staff S, ED Director, stated that it was uncommon for their facility to receive patients from inpatient psychiatric units. Nursing was expected to review the history and do an assessment, and based on both the current needs and the history make a decision about what was needed for the patient. She had understood from her staff that in regards to Patient #3, the inpatient psychiatric facility relayed to staff that the patient was to be discharged that day and that they were done with her. Therefore, no call was made to the facility when the patient eloped.

The facility failed to provide a thorough medical screening exam to determine the psychiatric needs of the patient who had been transferred to them from an inpatient psychiatric facility.

3. Review of Patient #22's initial visit to the ED on 04/16/17 showed the patient arrived by ambulance at 8:02 AM. Staff U, ED RN, at 8:40 AM documented that the patient:
- Was a 46 year old female brought in by EMS after being called by casino staff;
- Was uncooperative, refused to have vital signs taken, refused to give information about her medical history;
- Urinated on the floor;
- Was not able to be assessed for orientation (who or where she was) or for thoughts about harming herself.

Review of ED Physician Staff E, documentation from 8:20 AM to 9:38 AM showed:
- The patient was brought by EMS with complaints of agitation and altered mental status.
- The patient stated that she passed out at the casino and was brought here against her will.
- The patient stated she was shot by police, she was an ex-marine and her brother was a navy seal.
- The patient argued with the RN's; wanted the RN's paychecks because they were disrespectful and said that they shot her.
- She stated that her blood sugar (measurement of amount of sugar in blood) was over 500 last night and the casino didn't do anything about it.
- The patient stated that she had bed bugs.
- The patient was obviously agitated (irritated, restless) and had flight of ideas (fast speech, abrupt change in topics).
- Multiple blood tests and a psychiatric assessment were ordered.
- Most of the physical examination was not able to be obtained. The patient was agitated with aggressive posturing and argumentative behavior. She was manic (racing thoughts, difficult to maintain attention).
- He was notified by staff that the patient refused treatment, evaluation, blood draws and psychiatric consult.
- He recommended a psychiatric evaluation since this was the patient's second visit to the ED in eight days but the patient refused.
- He stated his only option was to physically restrain and sedate the patient against her will.
- As the patient left the ED, security asked if they should restrain her and he advised them not to, but to alert the police that she was leaving without having received a medical evaluation.
- The patient eloped (left without an order) from the ED and refused medical evaluation and treatment.
- The medical record did not contain documentation that the ED physician explained to patient # 22 the risks of leaving prior to receiving a medical or psychiatric examination or that the patient understood the risks of leaving without receiving an examination.
- The psychiatric evaluation staff arrived as the patient left the ED.

Staff W, Social Worker Psychiatric Assessor, documented that she arrived to the ED at 8:42 AM to complete a mental health evaluation on Patient #22 but was advised by the nursing staff that the patient was being discharged Against Medical Advice (AMA patient did not want any more treatment). The request for assessment was closed.

Staff U, RN, documented at 8:40 AM that:
- Patient demonstrated flight of ideas.
- Patient stated that this RN shot her, that all staff members shot her.
- The patient slapped at her, threatened to throw urine on her, was going to rape her, and if she did not leave the room she would have her attorney kill her.
- Security was called and attempted to calm the patient.
- The patient got up, walked out of the department on her own without any difficulty.
- Security followed her out of the department.

During an interview on 06/07/17 at 9:05 AM Staff U stated that:
- When Patient #22 arrived in the ED she was loud, belligerent, disrespectful, and yelled and cursed at everyone that was in sight, "and that included me".
- The patient would not provide any information.
- The patient urinated on the chair and floor.
- "The patient slapped at me, said she would rape me, and have her lawyer kill me."
- Security was called, arrived quickly and tried to calm patient.
- The patient was scattered and bizarre, and "may never be in the right state of mind to get a psychiatric evaluation."
- The patient was allowed to leave and security followed her out.

During an interview on 06/06/17 at 3:45 PM, ED Physician E stated that:
- He believed this patient got in trouble at the casino, the police were called, the police called EMS and EMS brought her here;
- He ordered baseline lab tests and a psychiatric evaluation;
- The patient denied suicidal or homicidal (want to harm self or someone else) thoughts;
- He was aware of what the patient said to the nursing staff;
- The patient statements to staff were acting out, not real threats, the patient did not get along with the nurses;
- The patient was very manic;
- If the patient did not agree to a psychiatric examination or treatment it would get dangerous for the patient and staff, she would get more agitated, we have to hold her down, and she or our staff could get injured;
- It's better to use a passive approach and try to convince the patient to be evaluated and treated if necessary;
- He believed that she was oriented and able to make her own decisions;
- He understands the balance between patient safety and patient rights and took it very seriously but if the patient was not a threat to self or others, they have the right to leave;
- If there was a legitimate threat to self or others, the patient would be restrained and a cannot leave (no AMA and elopement precautions) order would be written;
- Security asked if they should restrain this patient and were advised by me not to, but security should notify the police that the patient was leaving without being evaluated;
- The psychiatric evaluator arrived as the patient walked out.

During a telephone interview on 06/14/17 at 1:00 PM, Staff Z, Safety and Security Representative, stated that;
- He was in the ED when Patient #22 was about to be discharged.
- The patient was loud, obnoxious and disrespectful to everyone in the area.
- As she left he followed her down the hall and she stated she was going to kick his white ass and that she had a gun and she was going to shoot him.
- Another Security officer joined him and the patient called the other officer the "N" word.
- "If a patient was being discharged or leaving AMA, we won't usually stop them."

During an interview on 06/07/17 at 2:35 PM Staff B, Chief Nursing Officer (CNO), stated that the facility did not initiate 96 hour holds (hold patients involuntarily against their will) because they cannot follow through on them, because they are not a psychiatric facility. The physicians can write a medical hold order and indicate that the patient cannot leave or sign out AMA. Staff B stated that it would not be appropriate for her to comment on whether the RN's should have forced a medical hold on this patient because it depended on their situation and she was not there. RN's in the ED can get an order to hold a patient quickly because of the availability of the physician in the ED.

During a telephone interview on 06/07/17 at 1:35 PM, Staff Q, ED Medical Director, stated that:
- The extent of a mental health evaluation depends on the severity of the complaint.
- Schizophrenic (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves) patients exhibiting paranoid (suspicious, distrust of others) behavior are difficult because they often won't consent to evaluation or treatment.
- Patients that have repeated visits to the ED, with the same complaint, could be indicative of a need for a full evaluation.
- It is usually best to get a psychiatric evaluation consult.
- If a patient's behavior escalated, the physician can order the patient to be restrained and not be allowed to leave. We do not utilize 96 hour holds because we were not a psychiatric facility.
- Blood sugar can effect patient's behavior but usually only if it very low or very high (under 70 over 500).

During an interview on 06/07/17 at 1:10 PM Staff R, Security and Safety Supervisor, stated that:
- Security officers apply restraints or hold a patient when the physician orders them.
- Security officers train in nonviolent control, restraint application and de-escalation of patients.
- Security officers won't take a verbal order from a nurse to restrain or hold a patient.
- "Typically we would only write a report for a significant event. If an officer responded to the ED to de-escalate a patient that would not usually be a significant event."

During an interview on 06/07/17 at 12:35 PM, Staff S, ED Nursing Director, stated that:
- It is usually very quick to get the ED physician involved in a situation because of their proximity to patient care.
- Nurses can't stop a patient from leaving the ED until a medical hold order is given by the physician.
- Nurses are trained in de-escalation techniques, but not for hands on interventions.
- Nurses can, and do, call security and they respond quickly.
- Patient # 22 was a difficult case because she didn't want the help she needed.

During a telephone interview on 06/07/17 at 2:10 PM Staff P stated that she was the ED charge nurse at the time of Patient #22's visit but she did not remember any specifics of the patients care.

Record review of Patient #22's second visit to the ED dated 04/17/17 showed the patient arrived by ambulance to the ED at 1:47 AM.

The EMS record showed that the police department stated the patient walked up to them and stated that she needed an ambulance because she had been shot in the abdomen and she lost a baby. When EMS arrived the patient cussed and yelled at them after they told police they had transported her yesterday morning from the casino across the street from where they were.

Staff X, ED RN, documented on 04/17/17 at 01:56 AM that Patient #22:
- Was brought in by EMS.
- Complained of being shot today at another hospital and then she went to another hospital to deliver her baby that was pronounced dead.
- Was cooperative, alert, and not suicidal.
- Had no complaints.

During a telephone interview on 06/07/17 at 8:30 AM Staff X, ED RN, stated that:
- The patient came in by ambulance, it was her second visit within 24 hours.
- The patient stated she had been shot, was pregnant and went to another hospital to deliver her baby.
- Patient spoke very fast, but was not threatening.
- Patient had no specific complaint.
- If the doctor wanted the patient to be held, they can advise security and it would be done.

At 2:13 AM ED Physician Staff D documented that Patient #22:
- Was seen here 12 hours earlier and stated that she was shot by the police in the abdomen and she lost 20 babies. She was obviously psychotic (characterized by an impaired relationship with reality, a symptom of serious mental disorders, may involve either hallucinations or delusions) and was offered medical and psychiatric treatment but she decided to leave. The physician that evaluated her did not feel that she was a harm to herself or others and did not restrain her.
- Now complained that she was shot earlier in the day and she lost her baby.
- Kept rambling and changed her story about where she was staying, how she got here, and why she came to the ED.
- Wanted to go home so she could get away from everyone because the last time she was here a taxi was called and she believed that arrangements were made for the taxi to take her to the police where they could shoot her again.
- Was obviously psychotic.
- Had a story of being shot which caused her to lose her twins yesterday, which was obviously fabricated.
- Had a bedside ultrasound but there was no evidence of a pregnancy.
- Refused any lab work, wanted to leave, didn't want any treatment and that we cannot keep her.
- Denied any suicidal or homicidal thoughts.
- Just wanted to leave before someone came to harm her.
- She left the ED without receiving any discharge instructions.

During a telephone interview on 06/06/17 at 3:05 PM, Staff D, ED physician, stated that:
- He remembered this patient slightly, although he had not had a chance to review the chart.
- He remembered she had a very bizarre presentation about being shot in the abdomen.
- He remembered that another physician had evaluated this patient earlier and determined the patient was not a danger to herself or others.
- He talked to her about ordering lab tests but she said she wanted to go.
- "She must have agreed to let me ultrasound her belly. If she would have refused it would not have been done."
- He makes many decisions on how extensive the examinations needed to be based on the severity of the presentation.
- If there were a need to hold a patient, security would be advised and they were very competent at doing that.
- It was a tough balance to protect patient rights and keep them safe.
- The medical record did not contain any documentation advising the patient of the risks of leaving prior to a mental health evaluation or that the patient had the capabilities to understand the risks of leaving.

Staff T, ED RN, documented that Patient #22 walked out of the room, demanded to leave and stated, "That faggot Tinkerbell touched me and I'm going to leave." Security was called to escort the patient off hospital property.

During a telephone interview on 06/07/17 at 11:00 AM Staff T, ED RN, stated that:
- EMS responded to a parking lot where this patient was making inappropriate comments.
- Patient was anxious, talked very fast.
- Patient stated she was shot by police.
- She was in the room when the ED physician (Staff D) spoke with the patient.
- She was surprised when the ED physician said the patient could leave.
- She really thought the patient needed a psychiatric evaluation.
- Security was called to ensure the patient made it outside.

The ED Physicians failed to ensure that patient # 22 received within the hospital's capabilities and capacity, a medical screening examination sufficient to determine whether an emergency medical condition existed. Patient # 22 displayed psychotic behavior which included threatening and aggressive behavior. Staff allowed patient # 22 to leave the ED without explaining the risks of refusing an examination or determining whether patient # 22 could understand the risks of leaving.

4. Record review of Patient #5's ED record showed:
-He was a 29 year old male who presented via private vehicle in the care of his mother with a chief complaint of alcohol intoxication.
-The patient's mother stated that her son was drunk and spitting up.
-The mother was assisted with getting her son out of the vehicle.
-While the patient was getting checked in to the ED, he became upset and hostile towards staff, got out of a wheelchair and stated he was going outside to smoke.
- The medical record did not contain documentation that staff attempted to encourage patient # 5 to stay in order to receive an examination or explain the risks of leaving prior to being seen.
- Documentation in the medical record showed patient # 5 was seen by security getting into his mother's vehicle before driving away.

During an interview on 06/07/17 at 12:35 PM, Staff S, ED Director, stated that she could not recall the specific incident. Patient #5's record was provided for her review. When asked what the expectation would have been for this patient, she noted that this type of patient was challenging for staff. She felt that Staff Y was doing an assessment while she was observing the patient and his behavior. She stated she was confident in Staff Y's decision making and her ability to assess whether the patient was appropriate to leave the department without treatment.

Review of the undated facility policy titled, "Restraint Usage - Security and Safety Department," stated:
-"Voluntary" for the purpose of the policy will refer to a patient who was permitted to accept or reject medical and/or mental health care. "Involuntary" referred to a patient who cannot freely accept or reject medical or mental health care.
-A voluntary patient could not be held against his/her will. On the contrary, an involuntary patient can be held against his/her will.
-The procedure was that when responding to an emergency situation, upon arrival, Security and Safety should first ascertain whether or not the patient was voluntary or involuntary.

Review of the undated facility policy titled, "Civil Involuntary Detention," stated:
-The purpose was to identify patients who suffer from a mental disorder or substance abuse, pose a likelihood of harm to themselves or others and refused treatment, and to provide for a process for handling such patients.
-Behavioral Health Assessment Counselors (BHAC) provided the psychiatric evaluation in the ED.
-If the patient's behavior could not be controlled by the care team, security would be contacted and notified that the patient was pending involuntary detention and request their assistance with handling the patient.

5. Review of Patient #12's ED record, dated 02/28/17 showed:
-He was a 33 year old male who presented to the ED via private vehicle at 11:37 AM with a chief complaint of mental health evaluation for suicidal ideation (thoughts of harming self).
-Staff H, ED Physician, documented that the patient had a history of Attention Deficit Hyperactivity Disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness), Bipolar Disorder (a mental disorder marked by alternating periods of elation and sadness), and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
-The history of present illness showed that the patient had been recently released from jail after 15 years incarcerated and that the past few weeks he had been having difficulty adjusting and was depressed and had suicidal thoughts. The patient admitted to having overdosed twice and told his sister he wanted to get a gun and shoot himself.
-The patient was taking no medications at the time of his visit to the ED.

-Staff N, Registered Nurse (RN), documented that the patient had tried to engage in a police chase prior to the visit in an attempt to crash a vehicle and kill himself. He also had recently quit his job, and been kicked out of his sister's home where he had been living.

-The Comprehensive Intake Assessment (an assessment tool for behavioral health patients utilized to obtain a history, and determine the plan of care and disposition) completed by Staff I, Social Worker and Behavioral Health Assessment Counselor, showed that the patient had intense and daily thoughts of suicide. He had plans to "blow his head off", overdose, electrocute himself, and cut his wrist. Patient #12 refused to answer questions about past or present homicidal ideation (thoughts of harming others). He presented with a depressed and anxious mood, tearful, and irritable at times but overall was cooperative and pleasant. Staff I recommended a disposition of Acute Inpatient Treatment due to risk of harm to self or others.

-Staff H, Physician, noted at the time of his reevaluation that the BHAC had recommended inpatient evaluation and had a facility ready to accept the patient. The patient agreed with the plan, was medically stable for psychiatric evaluation, and was in stable condition at the time of transfer.

-Staff H added an addendum to his note at 3:57 PM that reported the patient became agitated when staff told him they were going to take the strings out of his pants. This led him to threaten to kill staff and run out of the emergency department. Security was activated but they were unable to catch the patient. The local police department was notified to search for the patient, and affidavits were then written to be kept with the chart. The patient was on a one-to-one observation (staff members monitor the patient for their entire stay and keep the patient within their line of site at all times) at the time he eloped from the ED.

-Staff N attempted to obtain consent to transfer the patient to the accepting psychiatric facility, when he became angry about the dress code at the facility. Staff N requested the one-to-one sitter (Staff G, Healthcare Technician/Sitter) call security and Staff I, BHAC, back to the room. The patient then turned to her and stated, "You touch me and I will kill you and I have no problem with that." She stepped out of the room and let security take over the situation while she called the physician. Upon return to the room, she was informed the patient had fled the room and left the ED on foot while security chased after him.

-From 12:15 PM to 3:30 PM Patient #12 was documented as assessed every 15 minutes with a one-to-one Suicide Observation Record.

Review of a Security Department Incident Report, dated 02/28/17 showed: