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Based on medical record review, facility policies and procedures, and interviews with staff, it was determined that the facility failed to provide appropriate treatment within its capacity and capability for three (3) out of 20 patients sampled (P#5, P#18, P#20) who were determined to have an Emergency Medical Condition (EMC).

Findings:

Cross-reference A2406 as it relates to the facility's failure to provide an appropriate and continuous medical screening for three (3) out of 20 patients sampled (P#5, P#18, P#20) who were determined to have an Emergency Medical Condition (EMC).

Cross-reference A2407 as it relates to the facility's failure to provide stabilizing care to three (3) out of 20 patients sampled (P#5, P#18, P#20) who were determined to have an Emergency Medical Condition (EMC) until transfer.

Based on medical record review, facility policies and procedures, Medical Staff Bylaws, and interviews with staff, it was determined that the facility failed to provide a continuous and appropriate medical screening for three (3) out of 20 patients sampled (P#5, P#18, P#20) who were determined to have an Emergency Medical Condition (EMC).

Findings:

A review of the Emergency Department (ED) medical record for P#5 revealed that P#5 was brought to the ED by ambulance on 2/5/22 at 7:21 a.m. for a psychiatric evaluation because P#5 was hallucinating and shooting at snakes with a shotgun at his home. P#5 was triaged and received a medical screening exam at 7:25 a.m., as well as laboratory blood testing, a computerized tomography (CT) (images taken from different angles of the body) of P#5's head, and a psychiatric assessment. P#5 was placed on a 1013 hold by Medical Doctor (MD) OO on 2/5/22 at 7:40 a.m. The diagnosis was acute psychosis, and P#5 was pending a psychiatric transfer. A review of a Nurse Progress Note written by RN PP on 2/5/22 at 4:45 p.m. revealed that P#5 left his room and exited the ED. Security followed behind the patient but could not get P#5 to return to the ED. Security contacted the Sheriff's Department with the patient's information to have P#5 returned to the ED. Further review of the medical record failed to reveal that P#5 returned to the ED. A review of a note by the Behavioral Health Facility Mobile Assessor (QQ) on 2/5/22 at 6:03 p.m. revealed that P#5 had eloped and had not been located.

An ED medical record review revealed that P#18 presented to the ED voluntarily with suicidal ideations on 1/10/22 at 11:13 p.m. P#18 was assessed by the Nurse Practitioner at 11:28 p.m., and a psychiatric consult was ordered. After a psychosocial evaluation by the Registered Nurse on 1/10/22 at 11:45 p.m., P#18 was determined to be a high risk for suicide and placed on suicide precautions. A review of the ED record failed to reveal documentation that P#18 was under constant 1:1 observation with a sitter. On 1/11/22 at 3:16 a.m., P#18 was unable to be found in the triage room or the waiting room, and the disposition was set to eloped. A 1013 had not been executed.

An ED medical record review revealed that P#20 was brought to the ED by a friend on 1/24/22 at 2:20 p.m. because P#20 had been walking in the street and almost got hit by a car. The friend said P#20 had been fighting things that were not visible. Triage occurred on 1/24/22 at 2:48 p.m., and laboratory blood tests were completed. A psychosocial assessment completed on 1/24/22 at 2:47 p.m. revealed no suicide risk. P#20 eloped from the ED on 1/24/22 at 7:14 p.m. prior to a medical screening exam, psychiatric consult, or 1013.

A review of the Medical Staff Bylaws, Rules, and Regulations adopted 4/18/19, Article VI.D., Mental Health Consultations, revealed that mental health consultation and treatment would be requested and offered to all patients engaged in self-destructive behavior or who were determined to be a potential danger to others. If psychiatric care were recommended, evidence that such care had at least been offered and/or an appropriate referral made would be documented in the patient's medical record. Review of Article VII.B.2, Emergencies, revealed that consent to medical or surgical treatment or procedures would be implied where an emergency existed. Review of Article VII.C.1 (b) revealed that if an adult could not consent for himself, the attending physician would document that the patient had been examined and lacked sufficient understanding or capacity to make significant responsible decisions regarding his medical treatment or the ability to communicate such decisions.

A review of the facility's policy titled "Admissions to Emergency Services" Policy #9923008, revised 7/22/21, revealed that any individual could come to the ED and request an examination or treatment for a medical condition. The ED would provide an appropriate medical screening examination (MSE) to determine whether an emergency medical condition (EMC) existed. If an individual were determined to have an EMC, the facility would either provide further examination and treatment to stabilize the condition or transfer the individual to another medical facility.

A review of the facility's policy titled "Consent/Refusal of Treatment" Policy #9562092, revised 4/2/21, revealed a consent would not be required if an emergency existed, and it was not possible to obtain consent in the usual manner. In the case of refusal to consent, the physician would explain to the patient the risks associated with the refusal, including death, and document such discussion in the progress notes or on the Consent Refusal Form. In instances where a patient had been determined by a court to be incapable of managing his/her affairs, or when a physician had determined and documented that a patient lacked capacity, and the patient was actively refusing medical intervention in an emergent situation, every effort would be made to secure the patient's willing consent to treatment.

A review of the facility's policy titled "Care of Behavioral Health Patients" policy #9270310, revised 2/10/21, revealed that patients who required psychiatric treatment would be managed through referrals and transferred to a psychiatric receiving facility and/or managed through consultative psychiatric services on a temporary basis. The facility would not hold a patient involuntarily or force care upon a patient against his or her will simply because a 1013 or 2013 certificate had been executed. However, if in the physician's professional judgment, a patient's recent actions or statements were of such a nature as to evidence imminent suicidal or homicidal intent or otherwise represented an immediate threat of harm to the patient or others, that patient may have been held against his or her will as a safeguard measure pending transfer to an emergency receiving facility, for as long as the immediate threat persisted. The policy further revealed that all patients would be screened at the time of intake to determine risk for suicide and harm to self or others. The physician of any patient who was screened as moderate or high risk would be notified. Patients designated as high risk for suicide would have specific safety precautions implemented. The policy stated that high-risk suicide patients would have a psychiatric evaluation and/or a 1013 and 1:1 constant observation. The policy further revealed that a 1013/2013 did not indicate that a patient was incompetent. If a 1013/2013 patient attempted to leave the hospital while he/she was awaiting transport to an emergency receiving facility, the hospital could not restrain or hold the patient. Staff would try to deescalate any situation where the patient attempted to leave but would only attempt to prevent the patient from leaving the facility if the patient, in the physician's reasonable opinion, was in imminent danger.

A review of the facility's policy titled "Leaving Against Medical Advice" Policy #7810732, revised 4/2020, revealed the following definitions:

Against Medical Advice (AMA): When a mentally competent adult patient left the hospital or discharged himself despite being advised of possible adverse medical effects by medical personnel.
Elopement: When an adult patient left the designated area without permission or knowledge of the physician or hospital staff.
Decision-making capacity: The ability to understand the nature and consequences of treatment options and to reach an informed decision regarding treatment options. Every adult would be presumed to have decision-making capacity unless determined otherwise by a physician or designee in writing in the medical record pursuant to a court order.

The facility's policy revealed that an adult patient with decision-making capacity had the right to refuse treatment regardless of whether caregivers agreed with the decision. Patients leaving AMA would be informed of the risks of leaving as defined by the physician. If a patient on a 1013/2013 requested to leave AMA or attempted to leave the facility, staff would make a reasonable effort to maintain the patient using non-restrictive measures. Security would be called immediately to assist. If a patient was deemed an imminent risk to self or others, or if the patient became violent, security or trained staff may have to institute restraint procedures at the direction of an RN or physician. The policy further revealed that when a patient with decision-making capacity was missing from the designated room or unit, staff would notify the immediate supervisor. Staff would check the unit sign-out log to determine if the patient was off the unit for a procedure or testing. Security would be notified immediately and given a description of the patient. Officers would begin searching all areas of the facility. The physician and family would be notified that the patient was missing, and the time, response, and search efforts would be documented in the medical record. The patient would be discharged from the system after determining that the patient was no longer on hospital grounds or if the patient did not return within a reasonable time frame as determined by the nursing supervisor. If an adult patient with altered mental status, lacked decision-making capacity, or were on a 1013/2013 status, additional procedures would include a low-key search room to room, utility rooms, exam rooms, lounges, waiting areas, and adjacent stairwells. The nursing supervisor would notify local law enforcement and security that the patient was missing. The time the patient was missing, response to search efforts and notification times would be documented in the medical record. The policy further revealed that if a patient wished to leave triage before receiving a medical screening, the triage nurse would notify the charge nurse and encourage the patient to stay. The patient would be advised of the risks involved in leaving without an MSE. If a record had been made, the nurse would document the conversation in the medical record.

A telephone interview took place with the complainant on 3/2/22 at 1:25 p.m. The complaint stated there were times when the complainant had been called to help talk people into going back to the ED if the person walked out. The complainant said he/she had never encountered any other hospital that let a 1013 patient walk out.

An interview was conducted with ED Director (RN) II on 3/1/22 at 12:59 p.m. in the Conference Room. RN II stated 1013 patients were usually brought to the facility by the police department. If a 1013 patient was going to elope, the patient could not be held against the patient's will. RN II said a 1013 was a transport document, and police was a means of transportation. 1013 patients were not in police custody and did not have a requirement to stay at the ED. A 1013 did not take away a patient's rights. RN II said historically, the ED staff would do whatever was needed to keep a patient at the ED who was a risk to themselves or others. A couple of years ago, the system changed the standard to a patient having a right to refuse care or treatment, and a 1013 did not take away that right. RN II stated that if de-escalation and seclusion techniques were unsuccessful, the physician could order one dose of medication to calm the patient. A second dose would need to be witnessed by a second physician. The provider could order seclusion if the patient were combative. RN II further said when a 1013 patient was on the property, the ED would be the receiving facility and would have to evaluate the patient. The patient could refuse any treatment.

During an interview with the ED Manager (RN) AA on 3/1/22 at 12:10 p.m., RN AA stated that facility staff would not put hands on a patient trying to walk out of the ED if the patient was not hurting themselves or anyone else. In addition, if a patient left the ED, the police department would be notified to bring the patient back. RN AA was aware that P#5 had left the ED, and police were called, but the patient and family agreed that P#5 would not come back to the ED.

An interview was conducted with the Manager of Public Safety (MPS) CC on 3/1/22 at 2:07 p.m. in the Conference Room. MPS CC stated that if a call were received about a patient on a 1013 wanting to leave the ED, security would arrive at the ED and assess the situation. MPS CC would make sure there were no injuries to patients, staff, or visitors. If a patient on a 1013 wanted to leave, MPS CC would encourage the patient to stay and continue treatment. If the patient were advancing toward the door, MPS CC would walk with the patient to continue to encourage the patient to stay. If the patient exited the ED, the patient would be encouraged to come back into the ED. Once the patient left hospital property, the police department would be contacted to bring the patient back to the ED. MPS CC said he would not lay hands on a patient to get them to stay. If a patient exhibited assaultive behavior, MPS CC would utilize the training provided to security in the Use-of-Force Policy to ensure that all patients, visitors, and staff were safe.

An interview was conducted with Licensed Practical Nurse (LPN) FF on 3/1/22 at 2:58 p.m. in the Conference Room. LPN FF stated that if a 1013 patient wanted to leave the ED, LPN FF would try to explain why the patient should not go, and LPN FF would try to deescalate the patient's emotions. Mental health counselors would also intervene. Security would be notified if a 1013 patient wanted to leave. If the patient became violent, the staff would back away from the patient and not lay hands on the patient. The patient would be told that the police would be notified if the patient left the ED. LPN FF said he would inform the charge nurse if a patient were trying to leave. The patient would be told that they had to be evaluated before leaving the ED. LPN FF stated that the staff would not hold back the patient if a patient wanted to leave the ED forcibly.

An interview was conducted with Public Safety Corporal (PS) JJ on 3/1/22 at 3:58 p.m. in the Conference Room. PS JJ stated the ED called and told him that P#5 was running out of the ED. When PS JJ arrived at the ED, PS JJ saw P#5 running toward the access door. When PS JJ got to P#5, P#5 was in the parking lot behind a vehicle. PS JJ tried to persuade P#5 to return to the ED, and it looked like P#5 was going to come back. However, P#5 said, "F-this, y'all are holding me against my will," and P#5 ran away again. PS JJ said he watched as P#5 ran off facility property and called the police department. An officer came to the facility and took a report. PS JJ said that was the last he heard of P#5.

An interview was conducted with Paramedic (PMD) GG on 3/2/22 at 11:00 a.m. in the Conference Room. PMD GG stated once mental capacity was determined to be normal, the patient could refuse treatment. PMD GG said being able to refuse might be different based on bizarre behavior. PMD GG explained that a 1013 court order stated a patient was a danger to themselves or others, and the ED would have to hold the patient until the 1013 was lifted. At that point, the ED would keep someone against their will because of the danger to themselves. If a 1013 patient wanted to leave the ED, the staff would try to verbally deescalate to keep the person at the ED using coaching techniques. If the 1013 patient left the ED, the charge nurse would contact the police department to bring the patient back to the ED. PMD GG said ED staff could not risk their safety, and there was only so much the ED staff could do to stop a patient. The staff could not put the patient in harm by forcefully jumping on top of the patient to hold them down. PMD GG said de-escalation training only taught how to observe a patient before becoming violent. When a patient became violent, the ED staff would have to call in professionals from the police department. Security would be contacted right away for further expertise, but hospital security was extremely limited in what they could do.

An interview was conducted with Paramedic (PMD) DD on 3/2/22 at 9:55 a.m. in the Conference Room. PMD DD stated a 1013 was a hold for a psychiatric evaluation. PMD DD said she understood that if a patient on a 1013 wanted to leave the ED, the ED would let the patient go. PMD DD explained that the staff would deescalate and try to convince the patient to stay. If the patient were set on leaving, the staff would not lay hands on the patient.

An interview was conducted with the ED Medical Director (MD) LL on 3/2/22 at 12:30 p.m. MD LL stated the providers would examine patients to determine if the patients were a 1013. MD LL said according to policy, a 1013 patient had rights, and the ED could not force the patient to comply with anything the ED staff said. If a patient was acutely or actively violent (they were breaking things), the ED physicians were authorized to do a one-time medication dose for sedation. According to the System, if a patient was not violent toward ED staff, the staff could discuss with the patient the hold and obligation to transfer and hope the patient was cooperative. MD LL said the ED staff could not physically restrain a person from leaving the building. MD LL stated that security would be involved when a patient was on a 1013, but even security was not allowed to physically restrain a patient from leaving. Security would ask the patient to return and ask for assistance from the police department. MD LL further stated that when assessing a patient's mental capacity, the provider could order physical restraints and put the patient in a bed if a patient had an altered mental status. If a patient were on drugs or intoxicated, the physician would not have any power to hold the patient. MD LL said according to policy, a psychotic patient had the right to leave, and the patient could not be restrained. If MD LL determined that a patient needed to stay, MD LL would sign a 1013 and get security involved if the patient tried to leave. Police would be asked to help and bring the patients back to the ED.

Based on medical record review, facility policies and procedures, Medical Staff Bylaws, and interviews with staff, it was determined that the facility failed to stabilize and appropriately transfer three out of 20 patients sampled (P#5, P#18, P#20) who were determined to have an Emergency Medical Condition (EMC).

Findings:

A review of the Emergency Department (ED) medical record for P#5 revealed that P#5 was brought to the ED by ambulance on 2/5/22 at 7:21 a.m. for a psychiatric evaluation because P#5 was hallucinating and shooting at snakes with a shotgun at his home. P#5 was triaged and received a medical screening exam at 7:25 a.m., as well as laboratory blood testing, a computerized tomography (CT) (images taken from different angles of the body) of P#5's head, and a psychiatric assessment. P#5 was placed on a 1013 hold by MD OO on 2/5/22 at 7:40 a.m. The diagnosis was acute psychosis, and P#5 was pending a psychiatric transfer. A review of a Nurse Progress Note written by RN PP on 2/5/22 at 4:45 p.m. revealed that P#5 left his room and exited the ED. Security followed behind the patient but could not get P#5 to return to the ED. Security contacted the Sheriff's Department with the patient's information to have P#5 returned to the ED. Further review of the medical record failed to reveal that P#5 returned to the ED. A review of a note by the Behavioral Health Facility Mobile Assessor (QQ) on 2/5/22 at 6:03 p.m. revealed that P#5 had eloped and had not been located.

An ED medical record review revealed that P#18 presented to the ED voluntarily with suicidal ideations on 1/10/22 at 11:13 p.m. P#18 was assessed by the Nurse Practitioner at 11:28 p.m., and a psychiatric consult was ordered. After a psychosocial evaluation by the Registered Nurse on 1/10/22 at 11:45 p.m., P#18 was determined to be a high risk for suicide and placed on suicide precautions. A review of the ED record failed to reveal documentation that P#18 was under constant 1:1 observation with a sitter. On 1/11/22 at 3:16 a.m., P#18 was unable to be found in the triage room or the waiting room, and the disposition was set to eloped. A 1013 had not been executed.

An ED medical record review revealed that P#20 was brought to the ED by a friend on 1/24/22 at 2:20 p.m. because P#20 had been walking in the street and almost got hit by a car. The friend said P#20 had been fighting things that were not visible. Triage occurred on 1/24/22 at 2:48 p.m., and laboratory blood tests were completed. A psychosocial assessment completed on 1/24/22 at 2:47 p.m. revealed no suicide risk. P#20 eloped from the ED on 1/24/22 at 7:14 p.m. prior to a medical screening exam, psychiatric consult, or 1013.

A review of the Medical Staff Bylaws, Rules, and Regulations adopted 4/18/19, Article VI.D., Mental Health Consultations, revealed that mental health consultation and treatment would be requested and offered to all patients engaged in self-destructive behavior or who were determined to be a potential danger to others. If psychiatric care were recommended, evidence that such care had at least been offered and/or an appropriate referral made would be documented in the patient's medical record. Review of Article VII.B.2, Emergencies, revealed that consent to medical or surgical treatment or procedures would be implied where an emergency existed. Review of Article VII.C.1 (b) revealed that if an adult could not consent for himself, the attending physician would document that the patient had been examined and lacked sufficient understanding or capacity to make significant responsible decisions regarding his medical treatment or the ability to communicate such decisions.

A review of the facility's policy titled "Admissions to Emergency Services" Policy #9923008, revised 7/22/21, revealed that any individual could come to the ED and request an examination or treatment for a medical condition. The ED would provide an appropriate medical screening examination (MSE) to determine whether an emergency medical condition (EMC) existed. If an individual were determined to have an EMC, the facility would either provide further examination and treatment to stabilize the condition or transfer the individual to another medical facility.

A review of the facility's policy titled "Care of Behavioral Health Patients" policy #9270310, revised 2/10/21, revealed that patients who required psychiatric treatment would be managed through referrals and transferred to a psychiatric receiving facility and/or managed through consultative psychiatric services on a temporary basis. The facility would not hold a patient involuntarily or force care upon a patient against his or her will simply because a 1013 or 2013 certificate had been executed. However, if in the physician's professional judgment, a patient's recent actions or statements were of such a nature as to evidence imminent suicidal or homicidal intent or otherwise represented an immediate threat of harm to the patient or others, that patient may have been held against his or her will as a safeguard measure pending transfer to an emergency receiving facility, for as long as the immediate threat persisted. The policy further revealed that all patients would be screened at the time of intake to determine risk for suicide and harm to self or others. The physician of any patient who was screened as moderate or high risk would be notified. Patients designated as high risk for suicide would have specific safety precautions implemented. The policy stated that high-risk suicide patients would have a psychiatric evaluation and/or a 1013 and 1:1 constant observation. The policy further revealed that a 1013/2013 did not indicate that a patient was incompetent. If a 1013/2013 patient attempted to leave the hospital while he/she was awaiting transport to an emergency receiving facility, the hospital could not restrain or hold the patient. Staff would try to deescalate any situation where the patient attempted to leave but would only attempt to prevent the patient from leaving the facility if the patient, in the physician's reasonable opinion, was in imminent danger.

A review of the facility's policy titled "Leaving Against Medical Advice" Policy #7810732, revised 4/2020, revealed the following definitions:

Against Medical Advice (AMA): When a mentally competent adult patient left the hospital or discharged himself despite being advised of possible adverse medical effects by medical personnel.
Elopement: When an adult patient left the designated area without permission or knowledge of the physician or hospital staff.
Decision-making capacity: The ability to understand the nature and consequences of treatment options and to reach an informed decision regarding treatment options. Every adult would be presumed to have decision-making capacity unless determined otherwise by a physician or designee in writing in the medical record pursuant to a court order.

The facility's policy revealed that an adult patient with decision-making capacity had the right to refuse treatment regardless of whether caregivers agreed with the decision. Patients leaving AMA would be informed of the risks of leaving as defined by the physician. If a patient on a 1013/2013 requested to leave AMA or attempted to leave the facility, staff would make a reasonable effort to maintain the patient using non-restrictive measures. Security would be called immediately to assist. If a patient was deemed an imminent risk to self or others, or if the patient became violent, security or trained staff may have to institute restraint procedures at the direction of an RN or physician. The policy further revealed that when a patient with decision-making capacity was missing from the designated room or unit, staff would notify the immediate supervisor. Staff would check the unit sign-out log to determine if the patient was off the unit for a procedure or testing. Security would be notified immediately and given a description of the patient. Officers would begin searching all areas of the facility. The physician and family would be notified that the patient was missing, and the time, response, and search efforts would be documented in the medical record. The patient would be discharged from the system after determining that the patient was no longer on hospital grounds or if the patient did not return within a reasonable time frame as determined by the nursing supervisor. If an adult patient with altered mental status, lacked decision-making capacity, or were on a 1013/2013 status, additional procedures would include a low-key search room to room, utility rooms, exam rooms, lounges, waiting areas, and adjacent stairwells. The nursing supervisor would notify local law enforcement and security that the patient was missing. The time the patient was missing, response to search efforts and notification times would be documented in the medical record. The policy further revealed that if a patient wished to leave triage before receiving a medical screening, the triage nurse would notify the charge nurse and encourage the patient to stay. The patient would be advised of the risks involved in leaving without an MSE. If a record had been made, the nurse would document the conversation in the medical record.

A review of the facility's policy titled "Transfer Activities in Accordance with EMTALA Requirements" Policy #11101630, revised 1/27/22, revealed that the EMTALA policy applied equally to patients with psychiatric, drug, or alcohol-related conditions. Such patients who presented to the ED would receive a medical screening examination. If they were found to have an emergency medical condition, they would receive stabilizing treatment within the capabilities and capacity of the hospital. If the patient's condition remained unstable, an EMTALA appropriate transfer would be arranged for them. The appropriate involuntary transfer forms (1013; 2013) for a general psychiatric referral or a drug or alcohol referral had to be utilized and completed in addition to the hospital transfer forms. No consent for transfer from the patient would be required.

A telephone interview took place with the complainant on 3/2/22 at 1:25 p.m. The complaint stated there were times when the complainant had been called to help talk people into going back to the ED if the person walked out. The complainant said he/she had never encountered any other hospital that let a 1013 patient walk out.

An interview was conducted with ED Director (RN) II on 3/1/22 at 12:59 p.m. in the Conference Room. RN II stated 1013 patients were usually brought to the facility by the police department. If a 1013 patient was going to elope, the patient could not be held against the patient's will. RN II said a 1013 was a transport document, and police was a means of transportation. 1013 patients were not in police custody and did not have a requirement to stay at the ED. A 1013 did not take away a patient's rights. RN II said historically, the ED staff would do whatever was needed to keep a patient at the ED who was a risk to themselves or others. A couple of years ago, the system changed the standard to a patient having a right to refuse care or treatment, and a 1013 did not take away that right. RN II stated that if de-escalation and seclusion techniques were unsuccessful, the physician could order one dose of medication to calm the patient. A second dose would need to be witnessed by a second physician. The provider could order seclusion if the patient were combative. RN II further said when a 1013 patient was on the property, the ED would be the receiving facility and would have to evaluate the patient. The patient could refuse any treatment.

During an interview with the ED Manager (RN) AA on 3/1/22 at 12:10 p.m., RN AA stated that facility staff would not put hands on a patient trying to walk out of the ED if the patient was not hurting themselves or anyone else. In addition, if a patient left the ED, the police department would be notified to bring the patient back. RN AA was aware that P#5 had left the ED, and police were called, but the patient and family agreed that P#5 would not come back to the ED.

An interview was conducted with the Manager of Public Safety (MPS) CC on 3/1/22 at 2:07 p.m. in the Conference Room. MPS CC stated that if a call were received about a patient on a 1013 wanting to leave the ED, security would arrive at the ED and assess the situation. MPS CC would make sure there were no injuries to patients, staff, or visitors. If a patient on a 1013 wanted to leave, MPS CC would encourage the patient to stay and continue treatment. If the patient were advancing toward the door, MPS CC would walk with the patient to continue to encourage the patient to stay. If the patient exited the ED, the patient would be encouraged to come back into the ED. Once the patient left hospital property, the police department would be contacted to bring the patient back to the ED. MPS CC said he would not lay hands on a patient to get them to stay. If a patient exhibited assaultive behavior, MPS CC would utilize the training provided to security in the Use-of-Force Policy to ensure that all patients, visitors, and staff were safe.

An interview was conducted with Licensed Practical Nurse (LPN) FF on 3/1/22 at 2:58 p.m. in the Conference Room. LPN FF stated that if a 1013 patient wanted to leave the ED, LPN FF would try to explain why the patient should not go, and LPN FF would try to deescalate the patient's emotions. Mental health counselors would also intervene. Security would be notified if a 1013 patient wanted to leave. If the patient became violent, the staff would back away from the patient and not lay hands on the patient. The patient would be told that the police would be notified if the patient left the ED. LPN FF said he would inform the charge nurse if a patient were trying to leave. The patient would be told that they had to be evaluated before leaving the ED. LPN FF stated that the staff would not hold back the patient if a patient wanted to leave the ED forcibly.

An interview was conducted with Public Safety Corporal (PS) JJ on 3/1/22 at 3:58 p.m. in the Conference Room. PS JJ stated the ED called and told him that P#5 was running out of the ED. When PS JJ arrived at the ED, PS JJ saw P#5 running toward the access door. When PS JJ got to P#5, P#5 was in the parking lot behind a vehicle. PS JJ tried to persuade P#5 to return to the ED, and it looked like P#5 was going to come back. However, P#5 said, "F-this, y'all are holding me against my will," and P#5 ran away again. PS JJ said he watched as P#5 ran off facility property and called the police department. An officer came to the facility and took a report. PS JJ said that was the last he heard of P#5.

An interview was conducted with Paramedic (PMD) GG on 3/2/22 at 11:00 a.m. in the Conference Room. PMD GG stated once mental capacity was determined to be normal, the patient could refuse treatment. PMD GG said being able to refuse might be different based on bizarre behavior. PMD GG explained that a 1013 court order stated a patient was a danger to themselves or others, and the ED would have to hold the patient until the 1013 was lifted. At that point, the ED would keep someone against their will because of the danger to themselves. If a 1013 patient wanted to leave the ED, the staff would try to verbally deescalate to keep the person at the ED using coaching techniques. If the 1013 patient left the ED, the charge nurse would contact the police department to bring the patient back to the ED. PMD GG said ED staff could not risk their safety, and there was only so much the ED staff could do to stop a patient. The staff could not put the patient in harm by forcefully jumping on top of the patient to hold them down. PMD GG said de-escalation training only taught how to observe a patient before becoming violent. When a patient became violent, the ED staff would have to call in professionals from the police department. Security would be contacted right away for further expertise, but hospital security was extremely limited in what they could do.

An interview was conducted with Paramedic (PMD) DD on 3/2/22 at 9:55 a.m. in the Conference Room. PMD DD stated a 1013 was a hold for a psychiatric evaluation. PMD DD said she understood that if a patient on a 1013 wanted to leave the ED, the ED would let the patient go. PMD DD explained that the staff would deescalate and try to convince the patient to stay. If the patient were set on leaving, the staff would not lay hands on the patient.

An interview was conducted with the ED Medical Director (MD) LL on 3/2/22 at 12:30 p.m. MD LL stated the providers would examine patients to determine if the patients were a 1013. MD LL said according to policy, a 1013 patient had rights, and the ED could not force the patient to comply with anything the ED staff said. If a patient was acutely or actively violent (they were breaking things), the ED physicians were authorized to do a one-time medication dose for sedation. According to the System, if a patient was not violent toward ED staff, the staff could discuss with the patient the hold and obligation to transfer and hope the patient was cooperative. MD LL said the ED staff could not physically restrain a person from leaving the building. MD LL stated that security would be involved when a patient was on a 1013, but even security was not allowed to physically restrain a patient from leaving. Security would ask the patient to return and ask for assistance from the police department. MD LL further stated that when assessing a patient's mental capacity, the provider could order physical restraints and put the patient in a bed if a patient had an altered mental status. If a patient were on drugs or intoxicated, the physician would not have any power to hold the patient. MD LL said according to policy, a psychotic patient had the right to leave, and the patient could not be restrained. If MD LL determined that a patient needed to stay, MD LL would sign a 1013 and get security involved if the patient tried to leave. Police would be asked to help and bring the patients back to the ED.