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Based on records review and interviews, the hospital failed to protect and promote patient rights to a safe environment in six (6) of twelve (12) patients (Patient #1, #4, #5, #6, #7, #8) in that:

1) Patient #1 required emergency treatment after ingesting cleaning solution and over the counter pain medication on 09/08/14. Patient #1 was under Emergency Detention Without a Warrant (APOWW) at the hospital's Emergency Department (ED). Staff was unaware of the patient's substantial risk of serious self-harm and did not provide safety measures according to hospital policy. The patient left the hospital without staff awareness on the same day he had been taken to the ED (09/08/14) and was classified as "eloped." Patient #1 was located by Police in the community on 09/10/14.

2) Patients #4, #5, #6, #7, and #8 presented for emergency care with psychiatric chief complaints including suicidal and homicidal ideation. The patients left the hospital without completed assessments and/or treatment and without staff awareness the same day that they presented to the ED. Patient #4, #5, #6, #7, and #8 had patient outcomes classified as "eloped."

Cross refer to A0144


Based on interviews and records review, it was determined that the deficient practices found posed an immediate jeopardy to the health and safety of patients that had the likelihood to cause harm.

Based on record review and interview the hospital failed to provide a safe setting in the Emergency Department (ED) for six (6) of twelve (12) patients (Patients #1, #4, #5, #6, #7, #8) in that:

1) Patient #1 required treatment on 09/08/14 after ingesting cleaning solution and was under Emergency Detention Without Warrant (APOWW). Hospital staff was unaware of the substantial risk of serious self-harm and did not provide close observation of the patient. Patient #1 left the ED without staff awareness on 09/08/14 and was found in the community by Police on 09/10/14.

2) Patients #4, #5, #6, #7, and #8 presented to the ED with chief complaints including suicidal and homicidal ideation between 08/01/14 and 09/11/14, and left the ED without staff awareness. Their outcomes were classified as "eloped."

Findings included:

1) Patient #1 was found by EMS [Emergency Medical Services] on 09/08/14, at 19:03, "... laying on the living room floor wretching [attempting to vomit]...admits to drinking approximately half a bottle of Windex [cleaning solution] and taking 8 ibuprofen [pain medication]...acted out for attention..." Patient #1 complained of "extreme stomach pain..."

Patient #1's Admission Registration record dated 09/08/14 noted an admission time of 19:26. The patient was admitted with an overdose of Windex and Ibuprofen.

The Peace Officer Application for Emergency Detention Without Warrant (APOWW) dated 09/08/14, at 20:15, noted that a peace officer had reason to believe that Patient #1 exhibited "substantial risk of serious harm...to himself. The patient "...attempted to take his life or harm himself by overdosing...and drinking Windex." Patient #1 was documented to be "...depressed about recent events with family and loss of job."

Hospital Psychiatric Emergency Policy BHCS.SW.024.P, dated 02/16/12, noted that the Warrantless Apprehension "...is a method to be used by a peace officer...when...a person...poses a risk of serious harm to him/herself ...the risk of harm must be imminent..."

ED Nurses Notes dated 09/08/14, at 19:38, by Hospital Personnel #9 noted EMS informed staff that Patient #1 had been "upset with brother, was not thinking, drank 1/4 bottle of Windex and 8 tabs 200 mg [milligram] each IBP [Ibuprofen]. Pt [Patient #1] does not want to harm self."

ED Triage Assessment dated 09/08/14, at 19:44, by Hospital Personnel #9 noted Patient #1 was "...uncomfortable...actively vomiting bile..." Charcoal suspension (to treat poisonings) was administered at 20:30.

ED Physician Notes dated 09/08/14, at 20:19, by Hospital Personnel #12 reflected Patient #1 was vomiting and had epigastric pain. At 21:10 the patient was noted to be absent from his ED room after he was informed by the police that he was under APOWW.

Patient #1's ED Disposition Summary dated 09/09/14, at 15:31, noted the patient had "eloped."

During an interview on 09/11/14, at 15:30, Hospital Personnel #2 stated Patient #1 had been apprehended without a warrant and transported by EMS to the hospital's ED. The patient was in the process to be assessed when he eloped.

Hospital Personnel #3 denied on 09/11/14, at 16:00, that a sitter was provided for Patient #1 during his ED stay. The patient was not placed in the ED's "safe room" for psychiatric patients.

Hospital Personnel #9 was interviewed on 09/12/14, at 14:30, and stated she was unaware that Patient #1's was on APOWW which indicated substantial risk of serious harm to himself. Hospital Personnel #9 stated that he "...would have put him [Patient #1] into a bunny suit [as safety precaution] sooner."

Hospital provided ED log dated 09/08/14 reflected 31 patients of 361 patients (or 8.6 percent) "eloped." Hospital Personnel #11 stated on 09/12/14 at 15:00 that number was "high."

A news paper article dated 09/10/14 at 12:53 noted Police found Patient #1 who had been listed as "critical missing person."




2) A hospital provided patient log dated 08/01/14 through 09/11/14 reflected Patients #4, #5, #6, #7, and #8 presented to the ED with psychiatric complaints including suicidal and homicidal ideation and "eloped."

Hospital Policy BUMC.Nurs.ED.17.P, dated 03/2014, and titled ED Suicide Screening, Risk Assessment and Interventions showed, "Nursing staff prepare a safe environment for patients at moderate or higher risk of self harm....all patients assessed...to be at medium or high risk for suicide or self harm will have continuous close observation...at all times."

Patient #4's ED notes dated 08/11/14, at 21:38, reflected the patient planned to "jump in front of traffic." The patient had active thoughts of suicide with a detailed plan and wished he were dead. The patient was assessed to have "moderate/high suicide risk." Patient #4's ED Disposition Summary noted the patient "eloped" at 22:24.

Patient #5 's ED notes dated 08/24/14, at 20:02, reflected the patient had active thoughts of killing self and wished to be dead. At 20:31, Patient #5 "eloped."

Patient #6 told the ED nurse on 09/04/14, at 17:47, he was "...very depressed and would like to see someone who can help him." During triage at 17:50, the patient was "sad." There was no evidence of further patient assessment until 19:27 when staff was "unable to locate patient." Patient #6 s' ED outcome timed at 20:36 noted he "eloped."

Patient #7 was transported by EMS to the hospital ED on 09/07/14, at 11:00, after she had taken "pills of unknown quantity" and lost consciousness in the bathroom of a convenience store. Admitting diagnosis was Depression. The patient had active thoughts of killing self and wished to be dead. The patient was assessed to have "moderate/high suicide risk." At 19:13 nursing staff noted that the patient was not in her room and documented, "May be she [Patient #7] is in the bathroom.. Will continue to await pt [Patient #7's] return." Patient outcome documentation dated 09/07/14 at 19:55 noted the patient "eloped."

Patient #8 presented to the hospital's ED "talking fast and pressured" and was to undergo psychiatric evaluation on 09/11/14 at 12:57. Triage was completed at 13:08 and the patient was moved to the waiting area. The patient left the ED at 14:04. The patient's outcome was classified as "eloped."

Based on record review and interview, the hospital failed to maintain an effective, ongoing, data-driven assessment and performance improvement program in that although the rate of patients leaving the hospital's Emergency Department (ED) with incomplete evaluation and/or treatment was more than twice the rate set by national benchmark and higher than the hospital set goal, data presentation was canceled from the August 2014 quality care meeting.

On 09/08/14, the "elopement" rate of ED patients increased to almost four times the rate set forth by national benchmark data.

Cross refer to A0283

Based on record review and interview, the hospital failed to set priorities for its performance improvement activities in that although the rate of patients leaving the hospital's Emergency Department (ED) with incomplete evaluation and/or treatment was more than twice the rate set by national benchmark and higher than the hospital set goal, data presentation was canceled from the August 2014 quality care meeting.


On 09/08/14 the "elopement" rate of ED patients was close to three times the hospital's desired goal and almost four times the rate set forth by national benchmark data.


Finding included:

The hospital's quality focus meeting dated 08/11/14 reflected the last agenda item was a report on ED patients who left without being seen. The data presentation was rescheduled "...due to lack of time."

Hospital provided ED logs dated 09/08/14 reflected a total of 361 patients were admitted to the hospital ED. The outcome of 31 patients was classified as "eloped."

Hospital Personnel #11 was asked about 31 of 361 ED patients (or 8.6 percent) who left on 09/08/14 before completion of care and stated that number was "high."

A hospital faxed document dated 09/23/14 reflected a council meeting dated 09/15/14. The document noted that five percent of patients left the ED "without being seen" in 08/2014. The hospital's initial goal was three percent. The document noted a national benchmark of 2.2 percent.

Based on records review and interviews, it was determined that the hospital failed to provide an an effective oversight of the nursing service in that nursing staff failed to follow the hospital policy in 1 of 1 patient (Patient #1) who was brought to the Emergency Department on 09/08/14 with substantial risk of serious harm to self, after ingesting cleaning solution and an overdose of over-the-counter pain medication tablets


The nursing staff was unaware that Patient #1 was on an APOWW and did not follow policies to prevent the likelihood of serious harm. Measures to keep the patient safe, including limiting visitors, were not put in place. The patient followed his visitors out of the hospital on 09/08/14 without nursing staff awareness. On 09/10/14, Police found Patient #1 in the community.

Cross refer to A 0395


Based on interviews and records review, it was determined that the deficient practices found posed an immediate jeopardy to the health and safety of patients that had the likelihood to cause harm.

Based on records review and interviews, ED nursing staff failed to supervise and evaluate the care for one of 1 patient (Patient #1) who was brought to the Emergency Department on 09/08/14, with substantial risk of serious harm to self after ingesting cleaning solution and an overdose of over-the-counter pain medication tablets.

The nursing staff was unaware that Patient #1 was on an APOWW and did not follow policies to prevent the likelihood of serious harm. Measures to keep the patient safe, including limiting visitors, were not put in place. The patient followed his visitors out of the hospital on 09/08/14 without nursing staff awareness. Patient #1 was found in the community by police on 09/10/14.

Hospital Policy titled ED Suicide Screening, Risk Assessment and Interventions BUMC.Nurs.ED.17.P dated 03/2014 noted "...if an Involuntary Detention Order is in place, the patient is not to leave the ED/hospital under any circumstances except as a transfer to an inpatient psychiatric facility." The policy noted that an Involuntary Detention Order was also known as APOWW and was the "...practice of using legal means...to commit a person...for observed behavior constituting a clear and present danger to the individual..." The policy's attachment reflected visitors were restricted to one at a time.


Findings included:

Observation of hospital surveillance camera recordings dated 09/08/12, between 19:57 and 21:17, showed the Patient #1 had multiple visitors in his room, including four male and two female visitors. Recordings showed that at 21:15 all visitors left the patient room followed by Patient #1 at 21:16. A female staff member had her back turned towards the patient room and did not react when Patient #1 left.

The Peace Officer Application for Emergency Detention Without Warrant (APOWW) dated 09/08/14, at 20:15, noted that a peace officer had reason to believe that Patient #1 exhibited "substantial risk of serious harm...to himself. The patient "...attempted to take his life or harm himself by overdosing...and drinking Windex." Patient #1 was documented to be "...depressed about recent events with family and loss of job."

Hospital Personnel #6 stated on 09/12/14, at approximately 12:10, that a "group of visitors" was allowed in Patient #1's room and no more than two visitors were "usually allowed" in the ED.

During a telephone interview on 09/12/14, at 13:40, Hospital Personnel #12 was asked whether he was aware Patient #1 had six visitors in his ED room and stated "yes."

Hospital Personnel #9 stated on 09/12/14, at 14:30, that three people were in Patient #1's room. Hospital Personnel #9 denied knowledge of an APOWW and stated that he "would have put him [Patient #1] in a bunny suit [as safety measure] sooner."

A news paper article dated 09/10/14 at 12:53 noted Police found Patient #1 who had been listed as "critical missing person."