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Based on review of the 1/2/22 video recording, review of medical records, review of Medical Staff Bylaws including Rules and Regulations, review of policies and procedures and interviews, it was determined that the facility failed to provide appropriate treatment within its capability and capacity for one (1) out of 20 sampled patients, Patient (P)#1, when P#1 presented to the Emergency Department on 1/2/22 for complaints of suicidal ideations.

Findings were:

Cross refer to A-2406, as it relates to the facility's failure to provide P#1 with an appropriate Medical Screening Examination.

Cross refer A-2407, as it relates to the facility's failure to provide P#1 with stabilizing treatment.

Based on review of the 1/2/22 video recording, review of medical records, review of Medical Staff Bylaws including Rules and Regulations, review of policy and procedures and interviews, it was determined that the facility failed to provide an appropriate and ongoing medical screening exam for one of 20 patients (Patient #1) when Patient (P) #1 presented to the Emergency Department (ED) on 1/2/22 for complaints of suicidal ideations.

Findings included:

A review of the video surveillance recording took place with Public Safety Manager (PSM) MM on 1/24/22 at 2:00 p.m. in the Public Safety office. Video was dated 1/2/22. Observed P#1 was dressed in black shorts and a black shirt. At video timestamp 15:20 (3:20 p.m.), P#1 was observed walking out of the area in the ED where rooms 1, 2, and 3 were located. P#1 walked past the nurse's station, past the male patient sitter that was standing at the door. P#1 walked in the direction of the ED exit doors. At timestamp 17:05 (5:05 p.m.), P#1 was observed in the ED where rooms 1, 2, and 3 were located. A public safety officer was observed speaking to P#1. P#1 walked around the public safety officer toward the ED exit. P#1 walked out of view toward the exit.

A review of P#1's medical record revealed that he arrived at the facility at 1:34 p.m. on 1/2//22 by private vehicle with complaints of psychiatric symptoms. Continued review of P#1's medical record revealed that triage was started at 1:50 p.m. and an acuity level (scale used to determine the seriousness or potential seriousness of a complaint) of 2 was assigned. P#1 was placed in a treatment room until a regular ED patient room became available. Laboratory tests were ordered per the facility's standard protocols and samples were drawn at 2:10 p.m. P#1 was moved to ED patient room 3 at 2:29 p.m. A medical screening examination was started at 2:35 p.m. The provider assessment revealed that P#1 reported suicidal and homicidal ideations with a plan to kill himself with a gun. P#1 reported that he got into an altercation earlier in the day with his best friend. P#1 reported a history of dissociate identity disorder (multiple personalities) and was not on any medication. The physical examination was within defined limits. Continued review of the record revealed that a 1013 (order for transport to an emergency receiving facility mental health) was signed at 2:41 p.m.

At 3:10 p.m., RN AA documented that P#1 was yelling at a patient in the next room. P#1 was observed getting out of bed with the intent to go into the room next door. RN AA instructed him to remain his room. At 3:22 p.m., RN BB documented that P#1 had eloped. The facility's security department and the local police were notified. RN AA documented that P#1 returned to ED room 3 accompanied by the police at 3:38 p.m. Review of the 'Flowsheet' assessment timed 3:38 p.m. revealed that P#1 was depressed, irritable and anxious. He was restless but cooperative and his judgement was impaired. A suicide risk assessment was scored as 'high'. A patient sitter and visitor were in the room with P#1.

At 4:48 p.m., RN AA documented that P#1 became irate about having a COVID test. P#1 left the facility for a second time. RN AA documented the police were called. At 5:52 p.m., RN AA documented that the police notified the facility that contact had been made with P#1 and were not bringing him back to the ED because he would run again. Per police, P#1 was talking to his sister on the phone.

A review of the facility's 'Medical Staff Bylaws including Rules and Regulations', adopted 4/16/19 revealed the Medical Staff was actively involved in the measurement, assessment, and improvement of at least the following:

(a) patient safety, including processes to respond to patient safety alerts, meet patient safety goals, and reduce patient safety risks.
(b) the Hospital's and individual practitioners' performance on Centers for Medicare & Medicaid Services ("CMS") core measures.
(c) medical assessment and treatment of patients.
4.A.9. Telemedicine Privileges:
(a) A qualified individual may be granted telemedicine privileges regardless of whether the individual was appointed to the Medical Staff.
(e) Telemedicine privileges granted in conjunction with a contractual agreement will be incident to and continuous with the agreement.

Active staff members must assume all the responsibilities of membership on the active staff including providing specialty coverage for the Emergency Department (ED) and accepting referrals from the ED for follow up care of patient treated in the ED.

ARTICLE XI EMERGENCY SERVICES
11. A. A continued review revealed that emergency services and care will be provided to any person who comes to the ED and such emergency services and care will be provided without regard to the patient's insurance status, economic status, or ability to pay for medical services.

MEDICAL SCREENING EXAMINATIONS
(1) Medical screening examinations, within the capability of the Hospital, will be performed on all individuals who come to the Hospital requesting examination or treatment to determine the presence of an emergency medical condition. Qualified Medical Personnel ("QMP") who can perform medical screening examinations within applicable Hospital policies and procedures are defined as:
(a) Emergency Department:
(I) members of the Medical Staff with clinical privileges in emergency medicine.
(ii) other Active Staff members; and
(iii) appropriately credentialed Advanced Practice Professionals.

The results of the medical screening examination must be documented before the patient leaves the Emergency Department.

6.D. MENTAL HEALTH CONSULTATIONS
A mental health consultation and treatment was requested and offered to all patients that had engaged in self-destructive behavior (e.g., attempted suicide, chemical overdose) or who were determined to be a potential danger to others. If psychiatric care was recommended, evidence that such had been offered and/or an appropriate referral made.

A review of the facility policy titled "Care of Behavioral Health Patients" policy number 9270310, last revised 2/10/21 revealed that the purpose of this policy is to provide guidance for safe, appropriate, and effective care for patients who demonstrate behaviors suggestive of risk for suicide, risk of harm to others, substance abuse or other behaviors that pose a serious and significant safety risk.

Policy: The facility is an acute care hospital and is not an emergency receiving emergency treatment (ERET) facility. Patients accessing care the facility who require psychiatric treatment will be managed through referral and transfer to a psychiatric receiving facility and/or managed through consultative psychiatric services on a temporary basis. It is the facility's policy to honor and promote a patient's rights of autonomy and self-determination while balancing such rights with the need to keep patients, staff, and visitors safe. The facility will not hold a patient involuntarily or force care upon a patient against his or her will simply because a 1013 or 2013 certificate has been executed. However, if in the physician professional judgement, a patient's recent actions or statements are of such a nature as to evidence imminent suicidal or homicidal intent or otherwise represent an immediate threat of harm to the patient or to others, that patient may be held against his or her will pending transfer to an emergency receiving facility as a safeguard measure, for as long as the immediate threat persists.

Patient rights: The execution of a form 1013/2013 does not extinguish a patient's rights. As set forth previously in this policy, in some instances the patient's right to personal privacy may be curtailed to the extent necessary to prevent immediate harm to self or others.

The execution of a form 1013/2013 does not indicate that the patient is incompetent. If a 1013/2013 patient attempts to leave the hospital while he/she is awaiting transport to an emergency receiving facility, the hospital cannot restrain or hold the patient. Staff should make efforts to deescalate any situation where the patient attempts to leave but should only attempt to prevent the patient from leaving the facility if the patient, in the physician's reasonable opinion is in imminent danger.

A review of the facility's policy titled "Admission to Emergency Services, 50043", policy number 9923008, last reviewed 7/22/21 revealed that any individual can come to the facility's emergency department and request an examination or treatment for a medical condition. The facility's emergency department will provide an appropriate medical screening examination to determine whether an emergency medical condition exists. This screening requirement encompasses the use of ancillary services routinely available to the ED. If a determination is made that no emergency medical condition exists there is no mandate for the hospital to provide further treatment to a patient.

A review of the policy titled "Leaving Against Medical Advice" policy number 7810732 last revised 4/2/20 revealed that the purpose of this policy is to establish guidance and provide a procedure to be followed when a patient elect to leave without notifying staff or elects discharge against medical advice.
Procedures.
1. If patient informs nursing staff that he/she is leaving, the immediate supervisor and/or immediate nursing leader will be notified of the patient's desire to leave.
2. The immediate supervisor and/or immediate nursing leader, a physician or designee will inform the patient of the risks of leaving as defined by the physician.
3. The physician/nurse informing patient of risks will document the conversation with the patient in the medical record.
4. The patient's nurse should have the patient read and sign form entitled "leaving hospital against advice" as posted with this policy
5. If the patient refuses to sign such statement, the form should be completed with patient name and date and witnessed by staff. Staff should "signature refused" on the form and make a notation in the medical record.
6. The clinical manager will be informed of the patient intent to leave the hospital against advice.
7. If a patient on 1013 requests to leave AMA or attempts to leave the facility, staff will make a reasonable effort to maintain the patient using nonrestrictive measures. Security should be immediately called to assist.
8. If the patient is deemed an imminent risk to self or others, or become violent, security or trained staff may institute restraint procedures at the direction of registered nurse / physician.

Elopement of medically compromised or behavioral health patients without decision making capacities. If the adult patient who elopes has altered mental status, lacks decision making capacity or is on 1012 status, additional procedures should be implemented as follows:

1. Nursing staff will notify supervisor and initiate a low-key rapid search of the unit searching room to room, utility rooms, exam rooms, lounges, waiting areas, adjacent stairwells.
2. Nursing supervisor will notify local law enforcement and security that the patient is missing, provide a detailed description and explained safety related concerns.
3. If the patient is returned to the unit, the condition of the patient will be assessed and documented
4. Time patient noted to be missing, response to all search efforts, notifications and times will be documented in the medical record.

A review of the facility's policy titled "Scope of Care/service: Emergency Department" last revised 6/9/21 revealed that the facility's ED cares for patients who range in age from newborn to geriatric. Care is provided to all patient types without regard to race, religion, ability to patient for services.
Scope and complexity of patient care needs:

The ED provides care 24 hours a day, 7 days a week. The department provided evaluation and treatment or stabilization of injuries and illnesses that have varying degrees of complexity ranging from non-urgent to emergent. All Emergency Department patients are initially assessed by a registered nurse that is trained to perform triage assessment. He/she determines treatment urgency and placement within the department according to written guidelines and protocols. A medical screening exam (MSE) is performed by the Emergency Department physician, mid-level provider or the attending physician. The MSE includes the diagnostic testing, procedures, or treatments appropriate to determine, establish and maintain patient stability. Patients are evaluated for response to these interventions and a disposition is determined by the provider caring for the patient. Dispositions include discharged with written and verbal diagnosis, specific after care and follow up instructions, admission to an inpatient or observation area for further evaluation and management, transfer to another acute care facility that provides the appropriate services necessary for further evaluation and management.

An interview with Emergency Department (ED) Nurse (RN) NN took place on 1/24/22 at 12:30 p.m. during the ED tour. RN NN had worked at the facility for three years. She explained that if a patient had been identified as a behavioral risk and unable to be placed in one of the four behavioral health (BH) rooms, the patient was placed in an available interior (inner) room. RN NN continued to state if a patient was behavioral risk and in a non-behavioral risk room, the room must be stripped of all equipment, cords, linen, and any sharp objects before the patient was placed in the room. She explained that once the patient was in the room, a one-on-one sitter was assigned to watch the patient until admission or discharge. RN NN stated that if a patient wanted to leave the facility, the staff were trained to encourage the patient to stay in the ED and receive treatment. She continued to state that the staff did not put their hands on patients to force them to stay. RN NN stated once the patient leaves the facility as an elopement, the local police department and hospital security were notified.

An interview with Licensed Practical Nurse (LPN) OO took place on 1/24/22 at 12:45 p.m. in the ED. LPN OO explained that she had worked at the facility for six years. She explained that patients identified as behavioral risk were assigned to one of the innermost patient rooms when a BH (Behavioral Health) room was not available. LPN OO explained that regular rooms were stripped of equipment, cords, linen, and sharp objects before BH patients entered. A one-on-one sitter monitored the patient until admission or discharge. LPN OO explained that if a BH patient wanted to leave the facility, staff encouraged the patient to stay in the ED and receive treatment. She stated that staff did not put hands on patients to force them to stay. LPN OO explained that if a BH patient eloped from the facility, local police and hospital safety department were notified.

An interview with Emergency Department Manager (EDM) PP took place on 1/24/22 at 1:00 p.m. in the conference room on the first floor. She had worked in this position for six months. EDM PP explained that patients identified as a behavioral risk were assigned to one of four BH rooms. If a BH room was not available, the patient was put in an available interior (inner) room. EDM PP continued to state that prior to a BH patient being placed a non-behavioral risk room, the room must be stripped of all equipment, cords, linen, and any sharp objects. After the patient was in the room, a sitter was assigned to monitor the patient until admission or discharge. EDM PP explained that the staff were trained to encourage BH patients to remain in the ED for treatment but when they insist on leaving, staff did not physically restrain them. Once a BH patient left without a discharge order, local police and facility security were notified.

An interview with Public Safety Manager (PSM) MM took place on 1/24/22 at 1:45 p.m. in the conference room on the first floor. PSM MM explained that he had worked as the Public Safety Manager for one month. He stated that the ED was a part of his responsibilities as Public Safety Manager to patrol and monitor for safety. Due to staffing shortages, he could not staff an officer in the ED 24 hours, 7 days per week. PSM MM explained that the ED was patrolled by safety officers just as the entire hospital was patrolled. He stated that safety officers were scheduled on one of three shifts which include 7:00 am to 3:00 pm, 3:00 pm to 11:00 pm, and 11:00 pm to 7:00 am daily. PSM MM continued to explain that when security was called to the ED, a safety officer responded immediately to resolve any public safety issues. He explained that when the ED called for a possible elopement and/or 1013, the safety officer responded immediately and spoke with the patient to try and encourage them to stay at the facility. If the patient insisted on leaving the ED, once the patient left the building the safety officer called the local police department by dialing 911. PSM MM stated that officers were trained not to physically restrain anyone that verbally expressed a desire to leave the facility.

During an interview with Charge Nurse (RN) BB on 1/24/22 at 3:15 pm in the conference on the first floor, he explained that he could vaguely remember P#1. He explained that staff attempted to redirect and encourage 1013 patients to stay if they expressed the desire to leave the facility. Especially if it had been determined that the patient was at risk to hurt themselves or others. RN BB explained that the staff did not physically hold or physically try to stop patients from leaving the ED. Once the patient left the facility, staff contacted the police. RN BB continued to explain that it was the hospital policy to remain hands-off toward anyone that requested to leave the facility. If a patient requested to leave the facility, the nurse requested the person to stay and reminded them of the reasons why they need to stay. He stated that once the patient walked towards the exit, security was notified. Security would then try to talk with the patient and persuade them to go back to their room. RN BB could not recall why P#1 was assigned a regular ED room verses a BH room, but it may have been because all four BH rooms (out of 34 ED rooms) were occupied at the time. RN BB stated that when all BH rooms were occupied, they were required to assign BH patients to one of the other rooms in the ED. Before a BH patient was placed in a regular ED room, the staff removed all equipment and anything that could pose a threat to the patient or staff. Usually, the room was left with only a hospital bed.

A follow up interview with RN BB took place on 1/25/22 at 10:30 a.m. in the conference room on the first floor. RN BB stated that he had had the opportunity to view the video recording from 1/2/22 and did recall P#1. He recalled that P#1 voiced that he wanted to leave the facility constantly. RN BB recalled that he encountered P#1 in the hallway as he (P#1) walked out of room 3. RN BB asked P#1 to return to his room and explained to him (P#1) that the police would be called if he left. But P#1 continued to walk down the hallway. P#1 was then stopped by the security officer but continued to exit building.

An interview with Patient Care Technician (PCT) FF took place on 1/25/22 at 1:30 p.m. in the conference room on the first floor. PCT FF had worked at the facility for 4 years and verified that he was working in the Emergency Department (ED) on 1/2/22. PCT FF had reviewed the ED surveillance video from 1/2/22 and did recall P#1. He continued to state that what stood out the most about this patient was that he was so agitated (restless) that the staff had to keep trying to calm him down. PCT FF recalled P#1 was in Room 3 and was a 1013 and continuously stated that he wanted to leave. PCT FF explained that if a patient stated that they want to leave the ED, then the staff were not going to stop them because they cannot keep patients against their will. PCT FF verified that he had had EMTALA training in the past and recalled that part of EMTALA was making sure when patients come to the ED that they are stable before being transferred to another facility. He explained that they were trained to keep hands off patients and not to physically force anyone to stay. PCT FF recalled the reason P#1 was not placed in one of the four Behavioral Health (BH) rooms was because they were full. P#1 had been placed in the closest room available, which was room 3. PCT FF continued to explain when this happened, prior to placing a patient with behavioral issues in a non-BH room, the room was stripped of any equipment and all cords to create a safe space for the patient so they cannot hurt themselves. He recalled that this process was done to Room 3 before P#1 was placed in the room.

An interview with Security Officer (SO) GG took place on 1/25/22 at 2:30 p.m. in the conference room on the first floor. SO GG had reviewed the surveillance video involving P#1 on 1/2/22 in the Emergency Department (ED) and vaguely recalled his interactions with P#1. SO GG recalled that P#1 was walking out of the ED, and he tried to convince him to stay because the police will only pick him up and bring him back to the ED. SO GG recalled that P#1 did not seem to care and only wanted to leave and walked past him to exit the building. SO GG explained that once a patient had a 1013, it was the facility's responsibility to keep the patient at the facility for treatment; but, if the patient insisted on leaving, that staff cannot physically force the person to stay. He stated that it was the hospital policy not to physically restrain anyone and if a person could not be convinced to stay, once they left the campus, the police was notified. SO GG did not recall exactly what was said between him and P#1 but he tried to convince him to stay in the ED. SO GG stated he had EMTALA training in the past and recalled that the training included patients who come to the ED should be stable before being discharged or transferred. He continued to explain if patient decided to leave before they are stable, they cannot physically stop them unless the person became violent. SO GG did not recall P#1 posing a threat to himself or others.

A phone interview with Patient Sitter (PS) DD took place on 1/25/22 at 4:00 p.m. PS DD had worked at the facility for six months. PS DD recalled P#1 and the incident that took place on 1/2/22 when he walked out of the Emergency Department (ED). PS DD had been sitting with a patient in Room 1, P#1 was in Room 3 and there was another patient in Room 2. PS DD observed the charge nurse and the doctor go into see P#1. She recalled that the patient in Room 2 received a phone call and began to argue with the person on the phone. P#1 got aggravated and told the patient in Room 2 to "shut up". PS DD recalled that P#1 and the patient in Room 2 argued and shouted at each other. PS DD intervened and told them to stop shouting. PS DD recalled that she gave P#1 a blue gown to change into and he refused to put it on. P#1 then stated that "he can't do this anymore" and stood up from the bed and walked out of Room 3. Once P#1 walked out of the room, she noticed he was walking straight for the exit door, and she called out for security to stop him from leaving. PS DD observed the security guard talking to P#1. P#1 then walked around the security guard and left the building. PS DD stated that in just a few minutes, the police brought P#1 back to the ED and took him to Room 3. P#1 had been back in Room 3 a few minutes when he jumped up again and said, "I'm out of here" and walked out of Room 3 again. She stated that this time he just ran out of the ED. During the time P#1 was in room 3, PS DD did not hear him voice a desire to hurt himself or others, he just appeared to be agitated.

An interview with RN AA on 1/26/22 at 1:15 p.m. in the conference room on the first floor. RN AA had reviewed the video surveillance from the ED on 1/2/22 and recalled P#1. She recalled that P#1 was brought into the ED by a friend, and it was obvious that there had been a physical altercation between the two men. The friend left when P#1 was in triage. After the friend left, P#1 stated that he was having suicidal thoughts. The doctor signed a 1013 because he was a threat to himself and possibly others. RN AA recalled that the four BH rooms were occupied, and P#1 was placed in Room 3. She stated that since P#1 was a 1013, Room 3 was stripped of all equipment and any sharp objects before he was placed in the room. RN AA recalled that after P#1 was in the room, a patient sitter was assigned to him. RN AA recalled that P#1 was agitated and when she went to get his vitals. When she needed to swab for a COVID test he became increasingly irritated and stated that he wanted to leave. She advised him to stay at the facility, but he jumped off the bed and walked out of the room. RN AA never touched him or tried to force him to stay. After he left the ED, she called the police department and a few minutes later P#1 was brought back to the ED and returned to Room 3. RN AA went back to Room 3 to try and get the COVID swab and P#1 got irritated and left the ED a second time. She called the police department, but P#1 did not return to the ED after the second elopement.

The hospital failed to appropriately monitor Patient #1 enabling him to leave, delaying an appropriate continuing medical screening exam. The risks and benefits of leaving were not discussed, and his decision-making capacity was not assessed. Patient #1 endorsed suicidal ideations with a plan to the physician and the physician signed a form 1013.

Based on review of the 1/2/22 video recording, review of medical records, review of facility policy and procedures and interviews, it was determined that the facility failed to provide stabilizing treatment for one of 20 patients (Patient #1) when Patient #1 presented to the Emergency Department (ED) on 1/2/22 for treatment of suicidal ideations. After initial contact with the provider, a form 1013 (order to transport a person to a mental health emergency receiving facility for evaluation) was signed for P#1. P#1 was placed in an ED patient room with a patient sitter for one-on-one observation. P#1 left the ED despite staff attempting to convince him to remain for treatment. The facility notified local law enforcement, who accompanied P#1 back to the ED. P#1 walked out of the facility a second time and local law enforcement was notified. P#1 did not return to the ED.

Findings included:

A review of the video surveillance recording took place with Public Safety Manager (PSM) MM on 1/24/22 at 2:00 p.m. in the Public Safety office. Video was dated 1/2/22. Observed P#1 was dressed in black shorts and a black shirt. At video timestamp 15:20, P#1 was observed walking out of the area in the ED where rooms 1, 2, and 3 were located. P#1 walked past the nurse's station, past the male patient sitter that was standing at the door. P#1 walked in the direction of the ED exit doors. At timestamp 17:05, P#1 was observed in the ED where rooms 1, 2, and 3 were located. A public safety officer was observed speaking to P#1. P#1 walked around the public safety officer toward the ED exit. P#1 walked out of view toward the exit.

A review of P#1's medical record revealed that he arrived at the facility on 1/2/22 at 1:34 p.m. by private vehicle with complaints of psychiatric symptoms. Continued review of P#1's medical record revealed that triage was started at 1:50 p.m. and an acuity level (scale used to determine the seriousness or potential seriousness of a complaint) of 2 was assigned. P#1 was placed in a treatment room until a regular ED patient room became available. Laboratory tests were ordered per the facility's standard protocols and samples were drawn at 2:10 p.m. P#1 was moved to ED patient room 3 at 2:29 p.m. A medical screening examination was started at 2:35 p.m. The provider assessment revealed that P#1 reported suicidal and homicidal ideations with a plan to kill himself with a gun. P#1 reported that he got into an altercation earlier in the day with his best friend. P#1 reported a history of dissociate identity disorder (multiple personalities) and was not on any medication. The physical examination was within defined limits. Continued review of the record revealed that a 1013 (order for transport to an emergency receiving facility mental health) was signed at 2:41 p.m.

At 3:10 p.m., RN AA documented that P#1 was yelling at a patient in the next room. P#1 was observed getting out of bed with the intent to go into the room next door. RN AA instructed him to remain his room. At 3:22 p.m., RN BB documented that P#1 had eloped. The facility's security department and the local police were notified. RN AA documented that P#1 returned to ED room 3 accompanied by the police at 3:38 p.m. Review of the 'Flowsheet' assessment timed 3:38 p.m. revealed that P#1 was depressed, irritable and anxious. He was restless but cooperative and his judgement was impaired. A suicide risk assessment was scored as 'high'. A patient sitter and visitor were in the room with P#1.

At 4:48 p.m., RN AA documented that P#1 became irate about having a COVID test. The police were called. At 5:52 p.m., RN AA documented that the police notified the facility that contact had been made with P#1 and were not bringing him back to the ED because he would run again. Per police, P#1 was talking to his sister on the phone.

A review of the facility policy titled "Care of Behavioral Health Patients" policy number 9270310, last revised 2/10/21 revealed that the purpose of this policy is to provide guidance for safe, appropriate, and effective care for patients who demonstrate behaviors suggestive of risk for suicide, risk of harm to others, substance abuse or other behaviors that pose a serious and significant safety risk.
Policy: The facility is an acute care hospital and is not an emergency receiving emergency treatment (ERET) facility. Patients accessing care the facility who require psychiatric treatment will be managed through referral and transfer to a psychiatric receiving facility and/or managed through consultative psychiatric services on a temporary basis. It is the facility's policy to honor and promote a patient's rights of autonomy and self-determination while balancing such rights with the need to keep patients, staff, and visitors safe. The facility will not hold a patient involuntarily or force care upon a patient against his or her will simply because a 1013 or 2013 certificate has been executed. However, if in the physician professional judgement, a patient's recent actions or statements are of such a nature as to evidence imminent suicidal or homicidal intent or otherwise represent an immediate threat of harm to the patient or to others, that patient may be held against his or her will pending transfer to an emergency receiving facility as a safeguard measure, for as long as the immediate threat persists.

Patient rights: The execution of a form 1013/2013 does not extinguish a patient's rights. As set forth previously in this policy, in some instances the patient's right to personal privacy may be curtailed to the extent necessary to prevent immediate harm to self or others.

The execution of a form 1013/2013 does not indicate that the patient is incompetent. If a 1013/2013 patient attempts to leave the hospital while he/she is awaiting transport to an emergency receiving facility, the hospital cannot restrain or hold the patient. Staff should make efforts to deescalate any situation where the patient attempts to leave but should only attempt to prevent the patient from leaving the facility if the patient, in the physician's reasonable opinion is in imminent danger.

A review of the facility's policy titled "Admission to Emergency Services,50043", policy number 9923008, last reviewed 7/22/21 revealed that any individual can come to the facility's emergency department and request an examination or treatment for a medical condition. The facility's emergency department will provide an appropriate medical screening examination to determine whether an emergency medical condition exists. This screening requirement encompasses the use of ancillary services routinely available to the ED. If a determination is made that no emergency medical condition exists there is no mandate for the hospital ton provide further treatment to a patient.
Procedure:
If it is determined that the individual does have an emergency medical condition, the hospital must either provide such further examination and treatment as may be required to stabilize the condition or transfer the individual to another medical facility. Once the patient is stabilized, the patient can be transferred or discharged.

1. Emergency medical condition is defined to include any condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the health of the individual or an unborn child in serious jeopardy: serious impairment of bodily functions or serious dysfunction of any bodily organ or part.
2. Stabilization: The term means to provide such medical treatment as may be necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from transfer or discharge of the individual.

A review of the policy titled "Leaving Against Medical Advice" policy number 7810732 last revised 4/2/20 revealed that the purpose of this policy is to establish guidance and provide a procedure to be followed when a patient elect to leave without notifying staff or elects discharge against medical advice.
Procedures:

1. If patient informs nursing staff that he/she is leaving, the immediate supervisor and/or immediate nursing leader will be notified of the patient's desire to leave.
2.The immediate supervisor and/or immediate nursing leader, a physician or designee will inform the patient of the risks of leaving as defined by the physician.
3.The physician/nurse informing patient of risks will document the conversation with the patient in the medical record.
4.The patient's nurse should have the patient read and sign form entitled "leaving hospital against advice" as posted with this policy
5. If the patient refuses to sign such statement, the form should be completed with patient name and date and witnessed by staff. Staff should "signature refused" on the form and make a notation in the medical record.
6.The clinical manager will be informed of the patient intent to leave the hospital against advice.

If a patient on 1013 requests to leave AMA or attempts to leave the facility, staff will make a reasonable effort to maintain the patient using nonrestrictive measures. Security should be immediately called to assist.
If the patient is deemed an imminent risk to self or others, or become violent, security or trained staff may institute restraint procedures at the direction of registered nurse / physician.

Elopement of medically compromised or behavioral health patients without decision making capacities.
If the adult patient who elopes has altered mental status, lacks decision making capacity or is on 1012 status, additional procedures should be implemented as follows:
1. Nursing staff will notify supervisor and initiate a lowkey rapid search of the unit searching room to room, utility rooms, exam rooms, lounges, waiting areas, adjacent stairwells.
2. Nursing supervisor will notify local law enforcement and security that the patient is missing, provide a detailed description and explained safety related concerns.
3. If the patient is returned to the unit, the condition of the patient will be assessed and documented
4. Time patient noted to be missing, response to all search efforts, notifications and times will be documented in the medical record.

A review of the facility's policy titled "Scope of Care/service: Emergency Department" last revised 6/9/21 revealed that the facility's ED cares for patients who range in age from newborn to geriatric. Care is provided to all patient types without regard to race, religion, ability to patient for services.
Scope and complexity of patient care needs: The ED provides care 24 hours a day, 7 days a week. The department provided evaluation and treatment or stabilization of injuries and illnesses that have varying degrees of complexity ranging from non-urgent to emergent. All Emergency Department patients are initially assessed by a registered nurse that is trained to perform triage assessment. He/she determines treatment urgency and placement within the department according to written guidelines and protocols. A medical screening exam (MSE) is performed by the Emergency Department physician, mid-level provider or the attending physician. The MSE includes the diagnostic testing, procedures, or treatments appropriate to determine, establish and maintain patient stability. Patients are evaluated for response to these interventions and a disposition is determined by the provider caring for the patient. Dispositions include discharged with written and verbal diagnosis, specific after care and follow up instructions, admission to an inpatient or observation area for further evaluation and management, transfer to another acute care facility that provides the appropriate services necessary for further evaluation and management.

Review of the facility's policy entitled "Suicide Precautions", Policy #5714683, last revised 2/5/19, revealed the purpose was to provide consistent guidelines for assessing patients presenting to Piedmont Rockdale Hospital who demonstrates behaviors suggestive of suicide.

A review of the facility's policy titled, policy number 8152591 "Transfer Activities in Accordance with EMTALA Requirements Policy" last revised 6/4/20 revealed that the purpose of the policy is to establish guidance for providing appropriate medical screening examinations, stabilizing treatment and appropriate transfer of patients in accordance with the EMTALA, and all regulations thereunder.
Involuntary status - The EMTALA policy applies equally to patient with psychiatric conditions. Such patients who present to the ED will receive a medical screening examination and if they are found to have an emergency medical condition, they will receive stabilizing treatment within the capacities and capacity of the hospital. If their condition remains unstable an EMTALA appropriate transfer will be arranged for them. The 1013 form must be utilized and completed in addition to the hospital transfer forms. No consent for transfer for the patient is required.

An interview with Public Safety Manager (PSM) MM took place on 1/24/22 at 1:45 p.m. in the conference room on the first floor. PSM MM explained that he had worked as the Public Safety Manager for one month. He stated that the ED was a part of his responsibilities as Public Safety Manager to patrol and monitor for safety. Due to staffing shortages, he could not staff an officer in the ED 24 hours, 7 days per week. PSM MM explained that the ED was patrolled by safety officers just as the entire hospital was patrolled. He stated that safety officers were scheduled on one of three shifts which include 7:00 am to 3:00 pm, 3:00 pm to 11:00 pm, and 11:00 pm to 7:00 am daily. PSM MM continued to explain that when security was called to the ED, a safety officer responded immediately to resolve any public safety issues. He explained that when the ED called for a possible elopement and/or 1013, the safety officer responded immediately and spoke with the patient to try and encourage them to stay at the facility. If the patient insisted on leaving the ED, once the patient left the building the safety officer called the local police department by dialing 911. PSM MM stated that officers were trained not to physically restrain anyone that verbally expressed a desire to leave the facility.

During an interview with Charge Nurse (RN) BB on 1/24/22 at 3:15 pm in the conference on the first floor, he explained that he could vaguely remember P#1. He explained that staff attempted to redirect and encourage 1013 patients to stay if they expressed the desire to leave the facility. Especially if it had been determined that the patient was at risk to hurt themselves or others. RN BB explained that the staff did not physically hold or physically try to stop patients from leaving the ED. Once the patient left the facility, staff contacted the police. RN BB continued to explain that it was the hospital policy to remain hands-off toward anyone that requested to leave the facility. If a patient requested to leave the facility, the nurse requested the person to stay and reminded them of the reasons why they need to stay. He stated that once the patient walked towards the exit, security was notified. Security would then try to talk with the patient and persuade them to go back to their room. RN BB could not recall why P#1 was assigned a regular ED room verses a BH room, but it may have been because all four BH rooms (out of 34 ED rooms) were occupied at the time. RN BB stated that when all BH rooms were occupied, they were required to assign BH patients to one of the other rooms in the ED. Before a BH patient was placed in a regular ED room, the staff removed all equipment and anything that could pose a threat to the patient or staff. Usually, the room was left with only a hospital bed.

A follow up interview with RN BB took place on 1/25/22 at 10:30 a.m. in the conference room on the first floor. RN BB stated that he had had the opportunity to view the video recording from 1/2/22 and did recall P#1. He recalled that P#1 voiced that he wanted to leave the facility constantly. RN BB recalled that he encountered P#1 in the hallway as he (P#1) walked out of room 3. RN BB asked P#1 to return to his room and explained to him (P#1) that the police would be called if he left. But P#1 continued to walk down the hallway. P#1 was then stopped by the security officer but continued to exit building.

A phone interview Police Officer (PO) HH took place on 1/25/22 at 11:15 a.m. PO HH recalled interacting with P#1 on 1/2/22 as the second officer called to the scene when P#1 walked away from the facility as a "1013 walk-out". He continued to state that his interaction with P#1 was non-confrontational (hostile), but he knew that P#1 had his mind set on not going back to the hospital. He recalled that when P#1 was approached, he would immediately go into a fighting stance as if to say he was not going back without a fight. PO HH explained that it was their goal not to use force or taser an individual before taking them back to the hospital only to have them elope (leave) again. PO HH stated that this was P#1's second time leaving the hospital the same day. PO HH explained that the police officers would opt not to use physical force to get a patient back to the hospital if they did not want to go. He continued to state that P#1 was not showing any signs of hurting himself or others. PO HH continued to state that P#1 was adamant (stubborn) about not going back to the hospital.

An interview with Patient Care Technician (PCT) FF took place on 1/25/22 at 1:30 p.m. in the conference room on the first floor. PCT FF had worked at the facility for 4 years and verified that he was working in the Emergency Department (ED) on 1/2/22. PCT FF had reviewed the ED surveillance video from 1/2/22 and did recall P#1. He continued to state that what stood out the most about this patient was that he was so agitated (restless) that the staff had to keep trying to calm him down. PCT FF recalled P#1 was in Room 3 and was a 1013 and continuously stated that he wanted to leave. PCT FF explained that if a patient stated that they want to leave the ED, then the staff were not going to stop them because they cannot keep patients against their will. He explained that they were trained to keep hands off patients and not to physically force anyone to stay. PCT FF recalled the reason P#1 was not placed in one of the four Behavioral Health (BH) rooms was because they were full. P#1 had been placed in the closest room available, which was room 3. PCT FF continued to explain when this happened, prior to placing a patient with behavioral issues in a non-BH room, the room was stripped of any equipment and all cords to create a safe space for the patient so they cannot hurt themselves. He recalled that this process was done to Room 3 before P#1 was placed in the room.

An interview with facility Security Officer (SO) GG took place on 1/25/22 at 2:30 p.m. in the conference room on the first floor. SO GG had reviewed the surveillance video involving P#1 on 1/2/22 in the Emergency Department (ED) and vaguely recalled his interactions with P#1. SO GG recalled that P#1 was walking out of the ED, and he tried to convince him to stay because the police will only pick him up and bring him back to the ED. SO GG recalled that P#1 did not seem to care and only wanted to leave and walked past him to exit the building. SO GG explained that once a patient had a 1013, it was the facility's responsibility to keep the patient at the facility for treatment; but, if the patient insisted on leaving, that staff cannot physically force the person to stay. He stated that it was the hospital policy not to physically restrain anyone and if a person could not be convinced to stay, once they left the campus, the police was notified. SO GG did not recall exactly what was said between him and P#1 but he tried to convince him to stay in the ED. SO GG stated he had EMTALA training in the past and recalled that the training included patients who come to the ED should be stable before being discharged or transferred. He continued to explain if patient decided to leave before they are stable, they cannot physically stop them unless the person became violent. SO GG did not recall P#1 posing a threat to himself or others.

A phone interview with Patient Sitter (PS) DD took place on 1/25/22 at 4:00 p.m. PS DD had worked at the facility for six months. PS DD recalled P#1 and the incident that took place on 1/2/22 when he walked out of the Emergency Department (ED). PS DD had been sitting with a patient in Room 1, P#1 was in Room 3 and there was another patient in Room 2. PS DD observed the charge nurse and the doctor go into see P#1. She recalled that the patient in Room 2 received a phone call and began to argue with the person on the phone. P#1 got aggravated and told the patient in Room 2 to "shut up". PS DD recalled that P#1 and the patient in Room 2 argued and shouted at each other. PS DD intervened and told them to stop shouting. PS DD recalled that she gave P#1 a blue gown to change into and he refused to put it on. P#1 then stated that "he can't do this anymore" and stood up from the bed and walked out of Room 3. Once P#1 walked out of the room, she noticed he was walking straight for the exit door, and she called out for security to stop him from leaving. PS DD observed the security guard talking to P#1. P#1 then walked around the security guard and left the building. PS DD stated that in just a few minutes, the police brought P#1 back to the ED and took him to Room 3. P#1 had been back in Room 3 a few minutes when he jumped up again and said, "I'm out of here" and walked out of Room 3 again. She stated that this time he just ran out of the ED. During the time P#1 was in room 3, PS DD did not hear him voice a desire to hurt himself or others, he just appeared to be agitated.

An interview with RN AA on 1/26/22 at 1:15 p.m. in the conference room on the first floor. RN AA had reviewed the video surveillance from the ED on 1/2/22 and recalled P#1. She recalled that P#1 was brought into the ED by a friend, and it was obvious that there had been a physical altercation between the two men. The friend left when P#1 was in triage. After the friend left, P#1 stated that he was having suicidal thoughts. The doctor signed a 1013 because he was a threat to himself and possibly others. RN AA recalled that the four BH rooms were occupied, and P#1 was placed in Room 3. She stated that since P#1 was a 1013, Room 3 was stripped of all equipment and any sharp objects before he was placed in the room. RN AA recalled that after P#1 was in the room, a patient sitter was assigned to him. RN AA recalled that P#1 was agitated and when she went to get his vitals. When she needed to swab for a COVID test he became increasingly irritated and stated that he wanted to leave. She advised him to stay at the facility, but he jumped off the bed and walked out of the room. RN AA never touched him or tried to force him to stay. After he left the ED, she called the police department and a few minutes later P#1 was brought back to the ED and returned to Room 3. RN AA went back to Room 3 to try and get the COVID swab and P#1 got irritated and left the ED a second time. She called the police department, but P#1 did not return to the ED after the second elopement.

P#1 endorsed having suicidal ideations with a plan and the ED provider signed a form 1013. P#1 eloped from the facility two times and did not return after the second time. The facility's failure to ensure that P#1 was in secure environment resulted in an incomplete medical screening examination and stabilization.