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Based on interview and record review, the facility failed to ensure the facility's policy on leaving against medical advice (AMA) was implemented, for one of 20 sampled patients (Patient 8).

This failure had the potential for harm to and delay of care for Patient 8.

Findings

A concurrent interview and review of Patient 8's record were conducted with the Emergency Room Manager (ERM) on August 23, at 3:20 p.m. The facility document titled, "ED [Emergency Department] Physician Record," indicated Patient 8 presented to the emergency department (ED) on August 4, 2024, at 1:40 a.m., for anxiety (a mood disorder), paranoia (a thought process that involves feelings of distrust and suspicion about others), and hallucinations (an experience involving the apparent perception of something not present). The document indicated, "...Observation Note...The patient [Patient 8] was placed under Observation status at 0140 [1:40 a.m.] for ongoing evaluation and risk stratification of their bizarre behavior. Patient has not been medically cleared. Patient is pending evaluation...Disposition...Upon re-evaluation, it is determined that the patient requires ongoing observation and treatment..."

A facility document titled, "Nursing Note-Text," dated August 4, 2024, at 6:55 a.m. indicated, "...Pt [Patient 8] saying incomprehensible words, unable to assess what pt is saying..."

A facility document titled, "ED Physician Record," dated August 4, 2024, at 7:20 a.m., indicated, Patient has not been medically cleared...Patient is pending evaluation...Disposition: Patient AMA'ed at 0650 with [family member] present and agreeable to AMA[leaving against medical advice].... Patient and [family member] made aware of the risks of AMA'ing and decided to proceed...Family and patient wished to leave due to long waiting hour, patient's [family member] wants to take him to another facility. Denies SI [suicidal ideation, thoughts of killing oneself], HI [hallucinations, an experience involving the apparent perception of something not present] at this time. Patient and family AMA..." The document further indicated, "...Addendum by [name of physician] on August 04, 2024 [August 4, 2024], at 7:49 [7:49 a.m.]...Patient and [family member] decided not to leave AMA according to the nurse at 0750 [7:50 a.m.]...upon re-eval [re-evaluation]at 0820 [8:20 a.m.], patient AMA'ed again...Upon re-eval at 0830, patient checked back in to the ED..." The document further indicated, "...Addendum by [name of physician] on August 04, 2024, at 11:20 [11:20 a.m.]...Upon re-eval at 0845 [8:45 a.m.], patient AMA'ed..."

A facility document titled, "Nursing Note-Text," dated August 4, 2024, at 8:13 a.m. indicated, "...pt wants to leave AMA. pt [sic] denies SI and denies HI. Patient a/ox4 [alert and oriented to person, place, time, and event). pt verbalized understanding of leaving AMA up to and including death. pt left with family members]..."

A facility document titled, "Nursing Note-Text," dated August 4, 2024, at 10:31 a.m., indicated, "...Patient called to move to [bed number] for psych eval [psychiatric evaluation]. No answer from patient in WR [waiting room] or outside of ED..."

A facility document titled, "Nursing Note-Text," dated August 4, 2024, at 11 a.m., indicated, "...Patient called for bed assignment...no answer from WR or outside..."

A facility document titled, "Nursing Note-Text," dated August 4, 2024, at 11: 27 a.m., indicated, "...Patient called for 3rd [third] time. Not found in WR or outside area of ER. Patient presumed to have eloped [when a patient leaves a hospital unsupervised and undetected]. Patient was last seen in [an area of the ED] with [family members] accompanying him..."

The ERM stated it appears the Patient 8 came in on August 4, 2024, at 1:40 a.m., left AMA with a family member, returned to the ED again at 8:22 a.m., and left again. The ERM stated there is no documentation Patient 8 signed the AMA form. The ERM stated the patient should have signed an AMA form.

An interview was conducted with Coordinator Infection Prevention (CIP) on August 23, 2024, at 3:40 p.m. The CIP stated Patient 8 should have signed an AMA form. The CIP stated there is no documentation Patient 8 signed the AMA form.

A review of the facility's policy and procedure titled, "Against Medical Advice, Elopement and Leaving Without Being Seen- ED 0500," revised February 2022, was conducted. The policy indicated, "...Against Medical Advice (AMA): Adult patient who is oriented to person, place and date, chooses to leave the Emergency Department against the advice of the nurse or provider. This includes patients leaving prior to evaluation, completion of diagnostic testing or prior to discharge by the physician...A Patient [sic] leaving the ED AMA status is documented in the Medical Record...The patient, upon departure, signs the AMA Form for patients wishing to leave against medical advice...Patient leaving the ED AMA...Consult with ED provider immediately ...ED provider shall advise patient of risks and potential complications from leaving ...the patient is asked to sign the AMA form. The AMA form shall state the possible consequences as determined by the provider and is maintained in the medical record...Completed AMA forms are maintained in the medical record...If the patient refuses to sign the AMA form, documentation is completed on the AMA form or in the medial record stating that the patient refused to sign the form..."

A review of the facility's policy and procedure titled, "AMA Leaving Against Medical Advice 1505," revised June 2022, was conducted. The policy indicated, "...the 'Leaving Hospital Against Medical Advise' (AMA) form is to be completed. This form documents that the patient was given information regarding possible risks that may result from the decision to leave, the benefits of continued hospitalization any [sic] alternatives...If the patient refuses to sign the (AMA) form a notation to this effect is to be made on the form and signed by the Licensed Nurse. These facts are also documented in the nurse's notes...Specific statements made by the patient regarding his/her reasons for leave should be quoted in the narrative section of the nursing notes..."

Based on interview and record review, the facility failed to ensure records for a patient transferred to and from the facility was maintained, for one of 21 sampled patients (Patient 19).

This failure had the potential to delay the provision of care for Patient 19.

Findings:

A review of Patient 19's record was conducted with the Emergency Room Manager (ERM) on August 22, 2024, at 11:50 a.m. A facility document titled, "ED [Emergency Department] Physician Record," dated August 15, 2024, at 4:18 p.m., indicated, "...This is a 15-year old patient [Patient 19] with a history of psychomotor seizures (a sudden, uncontrolled burst of electrical activity in the brain)...Patient was witnessed by paramedics losing consciousness and falling onto dirt ground...According to paramedics, patient had 2-3 [two to three] seizures prior to their arrival, then had another 3-4 [three to four] seizures on route [on the way to the facility]...Observation note ...On re-evaluation at 1656 [4:56 p.m.], patient had another...seizure in the ED. On re-evaluation at 1708 [5:08 p.m.], patient breaks in and out of seizures...Plan to transfer for higher level of care which I have discussed with [Name of Facility 4] and arranged transport, however, [family member] provided consent but only for transfer to [Name of Facility 5]...[Family member] arrived and was agreeable to transport. Patient transferred in stable condition..."

A facility document titled, "Orders," dated August 15, 2024, at 5:30 p.m., indicated, "...Discharge Request (Transfer Out of Facility Request)..."

An interview was conducted with the ERM on August 22, 2024, at 11:50 a.m. The ERM stated the RN witnessed the discussion of Patient 19's transfer with the ED Physician and Patient 19's family member, but there is no documentation of the transfer form in Patient 19's record.

An interview was conducted with the Coordinator Infection Prevention (CIP) on August 23, 2024, at 2 p.m. The CIP stated there is no documentation of the transfer consent form in Patient 19's record.

A review of facility policy titled, "Transfer to Another Facility," dated February 2023, was conducted. The policy indicated, "...Purpose...To outline the procedure to ensure the safe and appropriate transfer of an ED patient from this hospital to another facility...The individual or the individual's acknowledgement of such notification should be reflected in appropriate signing the Patient Release Form Emergency Department Patient Treatment or Transfer Consent/Request/Refusal Form...Patient's authorization release information is documented and signed on the Patient Release Form Emergency Department Patient Treatment or Transfer Consent/Request/Refusal Form..."

Based on observation, interview, and record review, the facility failed to ensure stabilizing treatment and maintenance of safety and security relevant to the psychiatric emergency medical condition (EMC) were provided, for four of 21 sampled patients (Patients 1, 2, 3, and 15), when:

1. For Patient 1, the patient was on a 5150 hold (an involuntary hold for 72 hours for an adult experiencing a mental health crisis) and was able to elope (when a patient leaves the facility unsupervised);

2. For Patient 2, the patient was on suicidal ideation (SI, having thoughts of killing oneself) precautions (interventions in place to prevent one from committing suicide) and was able to elope;

3. For Patient 3, the patient was on SI precautions and was able to elope; and

4. For Patient 15, the patient was on SI precautions and was able to elope.

These failures resulted in Patients 1, 2, 3, and 15 being able to elope from the Emergency Department (ED) and had the potential for patients with EMC to be able to harm themselves or others.

Findings:

1. The video footages for Patient 1, dated August 13, 2024, were reviewed with the Chief Nursing Officer (CNO) on August 21, 2024, at 3:10 p.m. The footages showed the following:

-Video 1: A male patient was walking in a green gown with black anti-skid socks. The patient was seen to turn the corner by Fast Track chair 6 and pushed open the double door and exited the ED and 20 seconds later a male and female staff were observed pushing open the double doors and exited the ED. The female staff was observed to come back through the double doors into the ED; and

-Video 2: A male patient was seen walking in a green gown with black anti-skid socks along the facility hallway outside the ED, then turned left towards the exit doors, continued walking towards the doors, pushed the door open, exited the facility, and turned left once outside. A male staff member was seen exiting the ED, then walked down the hall towards the exit, exited the facility and turned left. The male staff member was observed to use his badge to reenter the facility and back to the ED.

On August 22, 2024, at 2:30 p.m., a concurrent interview and review of Patient1's record were conducted with Clinical Supervisor (CS) 1 and the Infection Prevention (IP) staff.

A facility document titled, "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment," dated August 13, 2024, signed at 1:20 a.m., indicated, "...To...[Name of Facility 1]...A Reporting Party Called Police...[Name of Patient 1] Attempting To Get Into His Backyard @ [at] about 0100 hours [1 a.m.]...He [Patient 1] Was Seen On Camera Going To Multiple Houses. [Name of Patient 1] Was "Looking For A Friend." He did Not Know The Current Year, Date, & [and] Did Not Make Sense. He Is Unable To Safely Care For Himself & Is Putting Others In Danger By Trying To Enter Their Properties..." The document indicated check marks were placed after the following sections: "A danger to others" and "Gravely disabled [unable to provide for their own food, clothing, and shelter] adult..."

A document titled, "1) Patient Care Report," from AMR (an emergency transport service), dated August 13, 2024, at 1:16 a.m., indicated, "...Impediment...ED Overcrowding; Hospital Staff Delay/Transfer of Care Delay...Mental Status...Confused...Complaints...Chief-5150...Behavioral/Psychiatric...Primary Symptom...Abnormal behavior...Other Symptoms...Altered Mental Status [confusion]...Primary Impression...Behavioral/psychiatric disorder (mental disorder)...Narrative...[description of Patient 1] Who Had Been Placed On A 5150 After Being Found On Someone Else's Property Going Through Their Trash, And Being Disoriented To Time And Event...Placed The Patient In Soft Restraints Due To The Patient's 5150 hold...Turned Over To Hospital Staff On Transfer Of Care...08/13/2024 [August 13, 2024] 01:40:51 [1:40 a.m.] Patient Arrived at Destination...8/13/2024...03:04:12 [3:04 a.m.]...Destination Patient Transfer of Care..."

A facility document titled, "ED Physician Record," dated August 13, 2024, at 4:50 a.m., indicated Patient 1 was brought in by an ambulance for a 5150 on August 13, 2024, at 3:05 a.m. The document indicated, "...Patient's [Patient 1] presenting complaint has moderate risk of further deterioration, and disability, and morbidity...The patient was placed under Observation status at 0445 for ongoing evaluation and risk stratification of their bizarre behavior...Disposition...Patient eloped from the ED while on a 5150 hold. Code elope was called and attempted to find the patient without success...Diagnosis...Acute psychosis [mental disorder]...Eloped from emergency department...Homicidal ideation [thoughts of killing]..."

A facility document titled, "Orders" dated August 13, 2024, indicated, "...Notify Precautions...Observation Level...08/13/24 2:58:00 [2:58 a.m.]...Suicidal Risk, 1:1 [one staff assigned to observe one patient continuously] Observation at all times...Precautions...08/13/24 2:58:00...Precautions: Elopement [when a patient leaves a hospital unsupervised and undetected]...Suicide Precautions...08/13/24 2:58:00...NOW..."

A facility document titled, "Involuntary Hold Patient Observation Record," dated August 13, 2024, indicated Patient 1 was in the ED and was monitored by a sitter, whose initial appeared on the document, from 3:45 a.m. to 6:15 a.m., on 15 minute interval of documentation.

A facility document titled, "Nursing Note-Text," dated August 13, 2024, at 3:30 a.m., indicated, "...Nursing Note Entered On ...8/13/24 4:36 [4:36 a.m.]...Performed on...8/13/24 3:30 [3:30 a.m.]...Nursing Note: List of items done during initial assessment...complete safety check of room...initiated observation...placed on elopement precautions..."

A facility document titled, "ED Activity Log Elopement" dated August 21, 2024, indicated "...[Name of Patient 1]...Acuity level 3-Urgent...Reason for visit...Altered [confused]...Arrival Date & Time...8/13/24 [August 13, 2024] 01:44 a.m. [1:44 a.m.]...Depart Date & Time...08/13/24 08:23 a.m. [8:23 a.m.]...Discharge Disposition...ED Elopement..."

A facility document titled, "Nursing Note-Text," dated August 13, 2024 at 6:32 a.m, indicated, "....Performed by [Name RN 1]...Nursing Note...while provide [sic] patient report to...[Name of Facility 2]...sitter [a staff who is continuously observing one patient] at bedside advised patient eloped down the hallway. sitter [sic] called operator and announced a code green [hospital code for elopement]. charge [sic] rns [registered nurses] aware...pd [police department] contacted..."

There was no documented evidence Patient 1 was placed on a 1:1 observation from 3 a.m., when the physician ordered it, to 3:44 a.m.

CS 1 stated on August 22, 2024, at 2:40 p.m., the nursing staff must have been busy because they put the patient in under the wrong ESI (emergency severity index, treatment based on the level of urgency and resource needs of the patient, with level 1 being the most critical, level 5 being the least critical) level. CS 1 stated the records indicated Patient 1 was 3-urgent and should have been under ESI level 2 in accordance with the facility policy. CS 1 stated when a patient comes in under 5150 they should be assigned ESI level 2. CS 1 stated the observation ordered by the provider should have been started at 3 a.m. CS 1 stated the staff should not have waited until 3:45 a.m. to start the 1:1 observation (45 minutes after the order was given).

An interview was conducted with the CNO on August 22, 2024, at 3:31 p.m. The CNO stated Patient 1 was listed as altered upon admission to the Emergency department (ED) and documented discharge time as August 13, 2024, at 8:23 am. The CNO stated Patient 1 should not have been able to elope from the facility.

An interview was conducted with Emergency Technician (ERT) 1 on August 23, 2024, at 5:49 a.m. ERT 1 stated he was assigned Patient 1 on a 5150 hold. ERT 1 stated he began his 1:1 observation at 3:45 a.m. ERT 1 stated he left Patient 1 in order to assist another Emergency Room Technician (ERT) and Patient 1 eloped. ERT 1 stated he was told by another staff member that his patient left. He stated he went out after Patient 1 and followed him out and was 30 or more feet away from the patient. He stated he tried to talk the patient into coming back in with no success.

An interview was conducted with RN 1 on August 23, 2024, at 9:08 a.m. He stated he completed the environmental check list (list of items to remove from the room) and then placed Patient 1 in the room. He stated Patient 1 was on a 5150 hold for danger to others and grave danger to self. He stated he was busy and did not feel the need to monitor the sitter to ensure the patient was continuously observed. He stated he did not see the patient elope.

An interview was conducted with Director of Emergency Department (DED) August 23, 2024, at 9:46 a.m. The DED stated ERT 1 was assigned to observe Patient 1 in Room A and a patient on hold in Room B. She stated ERT 1 should have only been watching one patient on a 1:1 observation and not the other patient in Room B. She stated they were trying to clean Room C for the other patient. She stated ERT 1 should not have left Patient 1 without finding coverage to continuously observe the patient on a 1:1. She stated the order should have been started immediately started at 3 a.m. and the staff should not have waited 45 minutes to start.

A review of the facility's video footage dated August 22, 2024, at 3:40 p.m., was conducted with the CNO. The video footage dated August 13, 2024, at 6:19 a.m., showed a male staff was at the corner of Station C in front of Rooms A and C across Room B. The male staff was observed to be at the corner of the nursing station and was observed to be moving in and out of the camera view. A male patient dressed in a green gown was observed walking out of Room A and down the hall passing by Room B. The male staff was not seen in the video at that time.

On August 23, 2024, at 1:12 p.m., an observation of the ED was conducted with Nursing Supervisor (NS) 1. The placement of the chair where Patien 1 was put on was not observed to be visible from the nursing station.

2. A concurrent interview and review of Patient 2's record were conducted with Clinical Supervisor (CS) 1 on August 22, at 10:40 a.m. Patient 2's record indicated the patient presented at the ED on June 26, 2024, at 5:54 p.m.
A facility document titled, "Triage Note," dated June 26, 2024, at 6:05 p.m. indicated, "...Suicidal Risk Assessment: Presents with suicidal ideation ...C-SSRS [Columbia Suicide Severity Rating Scale, a tool to help determine establish a person's immediate risk of suicide] Suicide Risk Level: Low risk...Suicide Low Risk Interventions: Notify provider of patient risk level for further evaluation..."

A facility document titled, "Emergency Physician Record," dated June 26, 2024, at 7:23 p.m., indicated, ...Chief Complaint...6/26/24 [June 26, 2024] 17:58 [5:58 p.m.]...pt [Patient 2] states he is having thoughts of hurting himself, stated he's been homeless for about a year and a half. plan [sic] is to OD [overdose] with medications...Patient [Patient 2] states he is now having thoughts of SI through OD by fentanyl [a potent narcotic]. States he tried to hurt himself 6 months ago...Physical Examination...Psych [psychological, pertaining to thought processes: Endorses SI...Observation Status...The patient was placed under Observation status at 1808 [6:08 p.m.] on 6/26/2024 for ongoing evaluation...Patient suicide risk assessment is low...During their time in observation they received the following interventions: suicidal precautions, one-to-one monitoring, serial exams, and treatments...Disposition: Prior to DC [discharge], patient eloped from the ED without being further evaluated and treated by ED physician..."

A facility document titled, "Orders," indicated, "...Observation Level 06/26/24 18:24:00 [6:24 p.m.]...Suicidal Risk, 1:1 Observation at all times, constant order...Precautions: Elopement...Suicide Precautions...Now..."

A facility document titled, "Phone Call to Consultants v2," dated June 26, 2024, at 8:13 p.m. indicated, "...Callback #1[number]...Psychiatry...[name of physician contacted]...Time Consult Call Attempt 1 19:25 [7:25 p.m.]...Time Consult Call Returned 19:54 [7:54 p.m.]...Callback #2...Psych Intake Nurse...REACH [a mobile crisis response team) Team...Time Consult Call Attempt 1 19:42 [7:42 p.m.]..." The portion for "Time Consult Call Returned" was blank.

CS1 stated Patient 2 had an order to have a 1:1 sitter. CS1 stated there is no sitter documentation in Patient 2's record. CS1 further stated there are no nursing documentation to give information on what happened or transpired at the time the patient eloped. CS1 stated, when a patient elopes, the staff should notify the charge nurse, look for the patient, and try calling the patient if there is a number on file. CS1 stated if there is no answer after three attempts, the patient is removed from the system as an elopement. CS1 stated Patient 2 was pending a psychiatric [the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] evaluation for his SI. CS1 stated there is no documentation the staff spoke with REACH. CS1 stated if the ED is full and no rooms are available, the patient is put in front of the nurse's station in Station A. CS1 stated the bed where Patient 2 was placed in was a chair in the hallway in front of the nurse's station. CS1 stated, when patients are ordered a 1:1, the patient gets a sitter when the patient has been placed into a room, not when they are in the hallway.

3. A concurrent interview and review of Patient 3's medical record was conducted with CS 1 on August 22, at 10:56 a.m. Patient 3's record indicated the patient presented to the ED on July 22, 2024, at 4:52 p.m.

A facility document titled, "Emergency Department Timeline," indicated, "...Chief Complaint: PATIENT PRESENTS FOR 5150 WITH SUICIDAL THOUGHTS..."

A facility document titled, "Emergency Physician Record," dated July 22, 2024, at 5:33 p.m., indicated, "...presents to the ED with a chief complaint of SI. Patient [Patient 3] states she [sic] "feeling suicidal when she's a black person stalking her". Patient started speaking obscenities and demanded to leave the ED...ED COURSE...The patient was evaluated in the emergency department for presenting issue of psychiatric care...She left the emergency department on her own recognizance. the [sic] patient does not have appropriate insight with respect to my presenting complaint at this time...Initial medical workup was initiated...Patient elected to elope from the emergency department prior to the completion of the workup...Nursing staff and myself did conduct an initial search of the premises to no avail...Disposition: Time 7/22/2024 17:41:00 [5:41 p.m.], Eloped..."

A facility document titled, "Nursing Note-Text," dated July 22, 2024, at 6:30 p.m., indicated, "...Performed on: 7/22/2024 [July 22, 2024] 17:40 [5:40 p.m.]... Pt [Patient 3] has eloped at this time with no evaluation. MD [medical doctor] was made aware. per MD...'pt has eloped since I have not seen the patient yet.' ..."

CS1 stated Patient 3 eloped after the medical screening exam (MSE) was completed. CS1 stated Patient 3 was placed in a chair in front of the nurse's station for monitoring. CS1 stated if the patient is not in a room, they do not have a sitter. CS1 stated when the patient is placed in a chair in front of the nurse's station, they are being watched by the charge nurse at the station. CS1 stated the safety check and sitter would be done when the patient has a room assigned.

An interview was conducted with the Director of Emergency Department (DED) on August 23, 2024, at 10:15 a.m. The DED stated patients usually come into the ED with a 5150 hold written by police or the REACH team from the county. The DED stated the length of time it takes for a patient with a psychiatric issue to be evaluated for a 5150 depends on how quickly staff can get REACH here to see the patient. The DED stated if a patient walks in and is identified as having SI they will be given an ESI level of two. The DED stated staff then would find a safe space for the patient, either in a room or in general observation and the patient might be in general observation in front of nurses' station until a room is available. The DED stated an MD order is needed for 1:1 observation. The DED stated for patients with suicidal ideations pending a psychiatric evaluation, staff try to keep the patient in a treatment area for observation. The DED stated a patient in general observation will sit in a chair in front of the nurse's station and staff will keep them in sight of the nurses' station while trying to move them into a room. The DED further stated when the patient is in a chair, they don't have a nurse continuously monitoring the patient on 1:1 and they sit the patients in front of clinical nursing supervisors in the nurse's station who monitor the patient. The DED stated, when a patient elopes, the nurses need to document that they notified the MD and PD in the chart.

An interview was conducted with the Director of Quality (DQ) on August 23, 2024, at 11:10 a.m. The DQ stated that after reviewing Patient 3's medical record, Patient 3 does not have a suicide risk assessment completed for their ED visit on July 22, 2024.

An interview was conducted with the DED on August 23, 2024, at 11:20 a.m. The DED stated if the MD ordered a 1:1 sitter for a patient, we should be carrying out the order for 1:1 and the patient is given the sitter when they get to a room. The DED stated the MD tells staff to contact REACH the unit clerk calls, and it is documented when the call is made and returned.

An interview was conducted with Medical Doctor (MD) 1 on August 23,2024, at 1:10 p.m. MD 1 stated when patients come in with psych complaints or SI, they would self-identify why they are here at triage. MD 1 stated, if the patient has SI, the triage nurse will take them back to fast track in a chair at station A with staff monitoring them until they are in a room. MD 1 stated once an order for a 1:1 is placed, the nurses take over and handle the 1:1. MD 1 stated the MD does not call REACH and the unit secretary makes the call to REACH and documents when the call is made and returned.

An interview was conducted with the EDM on August 23, 2024, at 1:15 p.m. The EDM stated ED staff try to get patients with SI into a room as soon as possible to put the patient with a 1:1 sitter and would be under general observation in front of the nurse's station until in a bed is available.

An interview was conducted with Nursing Supervisor (NS) 1 on August 23,2024, at 1:20 p.m. NS 1 stated the patients with SI or 5150 would be an ESI 2. NS 1 stated the charge nurse is notified when a patient has SI or a hold during check in, and the charge nurse clears a room. NS 1 stated if the ED is full, the patient is placed in a chair in front of the nurse's station for the charge nurse to monitor while the room is made ready. NS 1 stated the charge nurse doesn't document monitoring or fill out Q15 sheet (every 15-minute monitoring document) until the patient is in a room.

An interview was conducted with Registered Nurse (RN) 2 on August 23,2024, at 1:28 p.m. RN 2 stated, when a patient comes in with SI or 5150 requiring a 1:1, they go to a bed right away if beds are available and an ED tech sits with the patient. RN 2 stated if there is no bed available, the patient is placed in a chair in front of the charge nurse at the nurse's station until a bed is available. RN2 stated the definition of a 1:1 is that one staff has eyes on the patient for their safety.

4. A review of Patient 15's record was conducted with the ERM and the CIP on August 22, at 1140 a.m.
A facility document titled, "ED Summary," dated July 12, 2024, indicated, "...Chief Complaint: pt [Patient 15] SI thoughts x 1 [for one week] week with plan...'

A facility document titled, "Triage Note," indicated, "...Result date: July 12, 2024 14:18 (2:18 p.m.)...General/Screenings Adult Suicidal Risk Assessment: Presents with suicidal ideation...Suicide Risk Assessment...C-SSRS Suicide Risk Level: High Risk...Suicide High Risk Interventions...Place on elopement precautions...Place on suicide precautions..."

A review of the facility document titled, "Orders," indicated, "...Notify/Precautions Observation Level 07/12/24 [July 12, 2024] 14:19:00 [2:19 p.m.]...Suicidal Risk, 1:1 Observation at all times, Constant order...Precautions 07/12/24 14:19:00...Stat [immediately], Precautions: Elopement Suicide Precautions 07/12/24 14:19...Stat..."

There was no documented evidence Patient 15 was assigned placed on 1:1 observation.

A concurrent review of Patient 15's record and interview were conducted with the ERM on August 23, 2024, at 11:40 a.m. The ERM stated Patient 15 was assigned to a room at 2:34 p.m. for observation and did not have a sitter. The ERM stated the Unit Coordinator called the REACH Crisis Team to assess Patient 15 for a 5150 hold at 2:35 p.m. The ERM stated the REACH Crisis Team arrived to the ED at 3:30 p.m., the team was unable to locate the patient and the patient had eloped.

A facility document titled, "ED Physician Record," dated July 12, 2024, at 2:19 p.m., indicated, "...Patient [Patient 15] presents to the ED for evaluation of suicidal ideation which has been ongoing for the past week. Patient states that she wants to slit her wrists...Orders...Ongoing Suicide Assessment...ED Course/Medical Decision Making: At 1530 [3:30 p.m.], REACH attempted to find the patient in the ED with no success. Patient likely eloped from the ED...Due to the patient's complaint...PD [police department] was called and they performed a wellness check at the patient's residence but she was not found. The patient eloped prior to completion of emergency department work-up...Impression and Plan...Diagnosis Suicidal Ideation...Condition: Guarded. Disposition: Eloped, Dispositioned by: Time 7/12/24 at 16:55:00 [4:55 p.m]...Patient has eloped from this ED before being given paperwork regarding diagnosis, treatment options, or follow-up options..."

The facility policy and procedure titled, "Triage ESI Level System -ED 4700," dated May 2021, was reviewed and indicated, "...Purpose: To provide a guideline for use of standardized system whereby patients presenting to the Emergency Department (ED) are treated in order of priority based upon acuity [severity of symptoms] utilizing the Emergency Severity Index (ESI) Five Level Triage System...from level 1 (most urgent) to level 5 (least urgent. The ESI provides a method for categorizing ED patients by both acuity and resource needs to move the patient to a final disposition such [sic] admission, transfer or discharge...ESI Level 2: Potentially life or limb threatening and could worsen without intervention. When an ESI level 2 is identified, patient placement is rapidly facilitated to be evaluated as soon as possible...Examples may include...Psychiatric complaints..."

The facility policy and procedure titled, "Guidelines of the Sitter Program -1258," dated January 2018, was reviewed and indicated, "...Definitions: Sitter: an individual either a hospital employee or a contracted worker who remains at a designated patient's bedside with no other dutied to focused [sic] on patient's safety...The sitter will maintain continuous visual contact with the patient that is assigned as 1:1 care..."

The facility policy and procedure titled,"Safety of Patients at Risk for Suicide," dated April 2021, was reviewed and indicated, "...The purpose of this policy is to outline the requirements for ensuring the safety of patients at {Name of facility] with actual or potential thoughts of self-harm or suicide...One-to-One Observation involves one trained and competent staff member to observe one patient only...Elopement: A patient who is aware that they should not leave but does with intent (i.e. [that is] 5150/Psychiatric hold patients in the ED...The patient will be continuously monitored by a staff member trained and competent to observe a patient at risk for suicide..."

On August 23, 2024, at 3:05 p.m., the survey team identified significant concerns in the facility's ED. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the facility's CNO, Chief Operating Officer (COO) and the DQ. The facility's CNO, COO, and DQ were verbally notified regarding the concerns of the facility's failure to ensure patients who have been determined to have suicidal ideation and patients on 5150 (involuntary 72-hour hold) were continuously monitored to prevent the patients from eloping. A copy of the IJ template was provided to the DQ.

On August 23, 2024, at 6:28 p.m., the DQ provided a Corrective Action Plan (CAP).

On August 23, 2024, at 6:57p.m., a meeting was conducted with the CNO, COO, and the DQ to review and provide clarification for the CAP.

On August 26, 2024, at 3:15 p.m., the DQ provided a revised CAP. The CAP indicated the following:

- EDUCATION & Training: Immediate training for all Emergency Depatment (ED) staff regarding policies, procedures, and practices: Distributed August 23, 2024: Read and sign Huddle regarding suicidal ideations identified, 1:1 sitter/observer must always be in constant observation on the patient. All registered nurses will receive suicide risk assessment training and documentation regarding suicide risk patients, including specific actions to take, and prevention strategies while in the ED until 5150 holds cleared or discharged to another facility. Education regarding completion of the Observation Log/Environmental checklist will be completed along with the frequency. All technicians will be educated regarding the completion of the Observation log/ environmental checklist. Escalation of behavior will be communicated to the RN;

- Once patient is identified as a 5150 hold or a suicide risk, then they will be brought Immediately to the treatment area and direct 1:1 observation will be initiated by emergency room technician (ED techs), Certified nurse assistants (CNAs), patient observation attendants, registered nurse, or other competent staff immediately and documented using the Observation Log/Environmental checklist. Patient placement should be room 3 or 4 whenever possible, although any treatment area will suffice provided appropriate environment and observation present;

- Forms: ED Patient observation log/environmental checklist (5150 holds and patients at risk) will be completed by the sitter/observer every 15 minutes for the duration of the ED stay until discharged or 5150 hold cleared. Form will be modified to have environmental assessment completed on the back of the monitoring form. Observation documentation will commence immediately upon identification and placement in the treatment area. Competency documents (initial and annual) will be modified to include the added content focusing on identification, frequency of monitoring, and environmental safety;

- Revise the following policies and procedures: Safety of Patients at Risk for Suicide #9001 - Enhance the Identification of patients at risk for suicide, implementation of monitoring and documentation every 15 minutes by a qualified observer. Code Green #1297, Against medical advice/Elopement #0500, AMA leaving against medical advice 1505, Psychiatry involuntary Holds- ED #3700, All observers/sitters will complete the sitter/observer competency assessment, Guidelines of the Sitter Program #1258 - will be modified to include the environmental assessment and the continuous every 15-minute monitoring. The Inpatient monitoring document will be modified to align with the ED document;

- Monitoring: Behavioral health patients presenting to the ED will be audited to assure compliance with identified suicidal patients or patients at risk: Sample Size: 100 % of patients presenting to the ED with identified suicidal ideation; Measure:Education: The ED Director and Director of Education created a mandatory education for all ED nurses and ED technicians regarding assessment, interventions based upon identified risk, observation expectations including frequency and location, documentation, and environmental safety. Training will be conducted initially by in-person meetings, read and sign, and followed by formal learning management system class. This training began August 23rd and has been subsequently modified to include items identified above. Staff were notified about the training during huddles, and by electronic communications. Content will be added to the ED orientation and competency. Registered nurse/LVN: Numerator: number of ED RN that completed the education/training and Denominator # of RN assigned to the ED. ED Technician: Numerator: # of ED Techs that completed the education/training and Denominator # of Techs assigned to the ED. Clinical Observation: Suicidal ideation/5150 patient monitoring ; Numerator: # ED patient Observation Log/Environmental checklist completed and Denominator # patients with suicidal ideation and/or 5150 hold patient.

On August 26, 2024, at 3:40 p.m., the CAP for the immediate jeopardy at the ED was reviewed and accepted. On August 26, at 3:45 p.m., the CAP was verified onsite to have been fully implemented.

August 26, 2024, at 4:21 p.m., the IJ was removed in the presence of DQ, with the COO and the CNO were also on the phone call.