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Based on interview, record and policy reviews, it was determined that in one of four, Patient (#5), on a court ordered 96 hour hold in the Emergency Department (ED) reviewed, the facility failed to ensure compliance with 42 CFR 489.24. Findings included that the facility failed to protect and prevent elopement of an unstabilized psychiatric patient until an appropriate transfer could be arranged to treat his Emergency Medical Condition (EMC). Please refer to citation A-2407 for further details.

Based on observation, interview, record and policy review, the facility failed to protect an unstabilized psychiatric patient on a court ordered 96 hour hold until an appropriate transfer could be arranged. This occurred for one patient (#5) out of a sample of 30 patients selected from the Emergency Department (ED) Log from December 2013 to May 2014. The facility could not provide a behavior health/psychiatric unit or psychiatrist and needed to transfer the patient to a locked psychiatric facility as ordered by the court.

Findings included:

1. Record review of Patient #5's ED medical record showed that he arrived to the ED on 05/06/14 at 4:00 AM escorted by Law Enforcement with a Chief Complaint of Behavioral Disorder. The record showed an application to Court for a 96 Hour Detention, Evaluation and Treatment/Rehabilitation dated 05/06/14 and showed that the patient admitted he had used drugs for years and had been paranoid (a mental disorder characterized by a pervasive, long-standing suspiciousness and generalized mistrust of others) and unable to focus.

2. Record review of the Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation - Admission for 96 Hours dated 05/06/14 showed that the patient had been found in various areas of the city over the last four hours yelling for help and had been walking in the middle of the main street oblivious to traffic. When the police told him to move out of the street he was unable to understand or follow instructions.

3. Review of the patient's ED Nurse's Notes for Past Health History as documented by Staff E, Registered Nurse (RN), ED Triage/Charge Nurse on 05/06/14 showed Patient #5 was triaged at 4:07 AM when he was brought into the ED. The documentation showed the following:
Pain: unable to assess;
Allergies: unable to assess;
Abuse Screen/Suicide Screen: unable to assess;
Suicidal Evaluation: unable to assess due to age or condition of patient; or
Substance Use: patient declined.

4. Record review of the ED Physician's Assessment showed that the patient was seen by the physician at 3:56 AM presenting with Paranoid Symptoms and poor judgment with worsening progression. The documentation stated that the patient had not been taking his antipsychotic (drugs in a class of medicines used to treat psychosis and other mental and emotional conditions) meds (medications) and exhibited Altered Sensorium (a condition in which a person experiences a change in their perception due to conditions of or changes in the brain or nervous system), delusions (a belief held with strong conviction despite superior evidence to the contrary), confusion and paranoia with a long history of psychiatric illness. The physician documented Diagnoses of psychosis: Off of his meds and patient with bizarre behavior. He was awaiting the rest of laboratory (lab) results and signed out the patients care to Staff K, Medical Doctor (MD), ED Physician.

5. Record review of Staff K's Progress Note dated 05/06/14 at 5:18 AM showed the following: Patient's been given Geodon (an antipsychotic medication--one of a group called "atypical" to distinguish these newer drugs from older medications) with mild improvement in his symptoms. Urinalysis took approximately three hours to convince him to provide and ultimately it was provided with positive findings of methamphetamine (a synthetic stimulant drug which induces a strong feeling of euphoria and is highly addictive), cocaine (an addictive narcotic drug), opiates (any of various narcotic drugs, such as morphine and heroin), and benzodiazepines (any of a family of minor tranquilizers that act against anxiety and convulsions and produce sedation and muscle relaxation).The patient was seen and evaluated by our behavioral health specialist, Staff Q, Registered Nurse (RN) and Staff T, Social Worker (SW), and they discussed the case with the judge who wanted the patient placed in a locked down psychiatric unit. Additional medication including Haldol (Haloperidol is an antipsychotic medication used mostly in the treatment of schizophrenia, acute psychosis, and delirium), Benadryl (an antihistamine with sedative properties) and Ativan (a benzodiazepine medication used to treat anxiety disorders or anxiety associated with depression) to be given due to patient's increased agitation and inability and unwillingness to follow commands.The patient eloped and the police department was contacted.

6. Record review of the facility document titled, "Hourly Rounding Documentation Log" dated 05/06/14 for room #18 (Patient #5) showed the patient's primary nurse, Staff F, documented the following:
- 6:45 AM - Using the phone (telephone located at the nurses' station);
- 7:30 AM - Using the phone;
- 8:15 AM - Using the phone;
- 8:50 AM - Using the phone;
- 12:30 PM - Wanting to leave;
- 4:30 PM - Sitting; and
- 4:45 PM - Patient eloped.

7. During an interview on 05/13/14 at 9:28 AM, Staff F stated that she was the primary nurse for Patient #5 in the ED when he eloped. She stated that she needed to obtain a urine sample the doctor had ordered and the patient refused. She stated that the security officer took the patient to the bathroom to obtain a urine sample but the sample she was given was water. She stated that she finally had to catheterize the patient to obtain the sample and that was how they got him to remove his street clothes. She stated that she took his clothes and put them behind the nurses' station. She stated that she had two other patients and didn't see Patient #5 with street clothes on and did not see him leave the ED.

8. Observation on 05/13/14 at 10:25 AM in the security office showed video camera monitors located in strategic places in and around the ED and the hospital. The video films of the incident showed that Patient #5 was not in the safe room #18 (a room equipped with a bed capable of holding a patient in restraints and a chair with two video monitoring cameras on opposite sides of the room) but outside the door. The films also showed that he was given his street clothes by Staff T, Social Worker (SW). There was also a video monitoring camera just outside the room and at the nurses' station opposite of the room where the unit secretary is located.

9. During an interview on 05/13/14 at 10:50 AM, Staff A, RN, Quality and Patient Safety Officer, stated that the patient was left unattended because there was a failure of communication between the ED nursing staff and security. She stated that the patient was extremely paranoid and would not go into the safe room #18 and so the security officers allowed him to sit outside the room in a chair with them in attendance. She stated that the patient's primary nurse, Staff F, came to the patient to give him three physician ordered medication injections when the patient became angry, refused to have the injections and took a defense stance toward the security officers with his fists clenched. At that time, Staff W, RN, Director of ED, and Staff T, SW, asked if they could talk to the patient. When Staff W and Staff T came out of the room with the patient they told the officers they were no longer needed that the patient had been de-escalated and no longer needed the physician ordered medication injections.

10. During an interview on 05/13/14 at 1:00 PM, Staff A, Quality and Patient Safety Officer, stated, that the medical staff nor security called code 5555 when they knew that he was missing, "but they should have".

11. During an interview on 05/13/14 at 2:15 PM, Staff N, Security Officer, stated that he and another security officer were briefed that Patient #5's physician had ordered chemical restraints (medications) two different times but they had never been given to the patient. He stated that Staff M had told them that Staff W said security was no longer needed for the patient. They returned to the Security Office and were monitoring the video cameras and watching the patient. He stated, "We knew he was going to elope, when we saw him talking on the phone and the SW gave him his clothes " .

12. During an interview on 05/13/14 at 2:55 PM, Staff O, Security Officer, stated that he was also watching the patient by video camera monitor in the security office. He stated that they knew the patient was going to leave but did nothing to detain him.

13. During an interview on 05/13/14 at 3:00 PM, Staff W stated that Patient #5 became hostile when everyone showed up to the safe room #18 to hold the patient down for medication injections. She said she was concerned about the safety of the patient and the safety of staff and bargained with the patient to take oral medication instead of having the injections. She stated that when all the male staff and security left the area that the patient de-escalated and she felt he would be cooperative. She stated that she didn't intend for the security officers to leave and not return but she was aware that they were gone and did not call them to return.

14. During a concurrent interview on 05/13/14 at 3:15 PM, Staff W, RN, Director of ED, and Staff A, Quality and Patient Safety Officer, stated, "We all allowed it [patient elopement] to happen".

15. During an interview on 05/13/14 at 3:30 PM, Staff C, Vice President of Hospital Security, stated that there was not a policy on the 96 hour hold but the officers' work with the ED charge nurse to provide oversight until the patient can be transferred or discharged. He stated that security officers were not patient sitters and they work at the direction of the clinical staff but also have other duties.

16. During a telephone interview on 05/14/14 at 9:30 AM, Staff K, ED Physician, stated that he assumed the care for Patient #5 at 7:00 AM on 05/06/14. He stated that there was a signed judge's order for a 96 hour hold for the patient and the ED was mandated to facilitate that judge's order. He stated that the patient was slightly agitated and had been given oral medication for his agitation. At approximately 1:30 - 2:30 PM the patient was very agitated and Security was called. He stated the patient never physically threatened anyone but Security said he got into a "fight stance" and that's when the order for the injection was given. He was asked by a nurse if they could give an oral medication instead of the IM and he consented. He stated that the patient was not suicidal or homicidal and if he hadn't been a 96 hour hold; he would have discharged him. He stated that he was not aware the patient was given his clothes. He believed Security would have been 1:1 with the patient. He stated that as a whole it was not common for a patient to be outside the safe room #18.

Staff K stated that the SW could not find a psychiatric facility to accept the patient because they had no available beds or the patient would have been transferred at 10:00 AM instead of the elopement at 4:30 PM. Staff K stated that security officers were not always called when a patient requires 1:1 observation and that the facility has other resources to draw upon such as available clinical staff or hospital sitters.

18. During an interview on 05/14/14 at 10:05 AM, Staff L, ED Secretary, stated that she was on duty in the nurses' station outside the safe room #18 when Patient #5 eloped. She stated that she did not leave the area at any time but did not see the patient leave the ED.