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Based on observation, interview and record review, the facility failed to provide an appropriate ongoing medical screening examination, which would include proper monitoring to prevent patient from eloping on multiple occasions. The patient was able to elope on multiple occasions despite an involuntary hold and stabilization was delayed. The patient did not receive an appropriate ongoing medical screening examination, which would have included appropriate monitoring to prevent him from leaving. The facility also failed to stabilize the patient on those occasion that he eloped multiple times.

Findings:

Observation revealed the patient involved in the complaint was present in the emergency center during the visit on 09/19/2022 at 12:55 p.m. The patient was observed lying in bed in room 5 of the emergency center. A sitter was observed outside the door of the room, monitoring the patient with direct view through a glass window. The patient was in bed with bilateral soft restraint in place. The patient appeared calm while in bed with the restraints in place.


Interviewed Registered Nurse (H)
Interview during the observation with the registered nurse assigned to the patient revealed, she said the patient is alert and oriented to person, place, time and situation. The patient has a history of schizophrenia, bipolar disorder and aggressive behavior. She said the patient was restrained because he was verbally and physically aggressive and is at risk for elopement. She said the patient spat on a registered nurse and broke the door of the emergency room ambulance entrance twice.
The patient also eloped yesterday and was returned to the facility by the police. She said the facility is trying to get the patient transferred to a psychiatric hospital, but for him to be accepted at the hospital, he must be restraint free for 12 hours.

Reviewed a sample of patients' clinical records:
A sample of 20 patients' who visited the facility's emergency center requesting care and services were reviewed. Review of the records revealed documentation which indicated several of the patients sampled had behavior/ psychiatric problems which require one to one monitoring. Patients monitoring sheets indicated patients were monitored based on Columbia assessment tool results, except for a one-hour monitoring documented on 09/17/2022 on patient #1's record instead of half hourly monitoring as required by the assessment tool.

Reviewed Patient #1's Clinical Record
09/15/2022
Review of the patient's clinical record revealed the patient was admitted to the facility on 09/15/2022 at 16.16 p.m. The patient was escorted into the facility by the police. The patient's chief complaint on admission; mental health problem.
Triage notes on 09/15/2022 at 1616: RN documented: " Rec'd patient ambulatory, AAOx3 accompanied by M-- C PD- EDO"

Emergency room notes dated 09/15/2022 at 1636 RN documented " Patient brought in by M--C__ PD for suicidal thoughts. Patient stated he has a plan to either "cut wrist or take pills". Patient changed out of personal clothing and into paper scrubs by A, RN. Personal belongings (small blue backpack, blue sweatshirt, shirt, pants, tennis shoes and socks, baseball cap) labeled and placed in ante room 9. VSS. Room cleared. Patient calm and cooperative. sitter outside room. "
1645: "Patient from group home. N --F-- ( group homeowner) 713------"
1815 :" Dinner tray arrived, delivered by security. Patient sitting on bed eating. Calm and cooperative at this time. Sitter outside room. "
1908 :" Handoff given to D---, RN."

09/16/2022
0719: 911 "safety food tray was ordered for the patient."
0759:" Pt is not talking at this time. Pt appears asleep but opened his eyes and stared blankly at the nurse."
0906: "Faxed warrant to W- O-- B- H--, waiting for signature of accepting facility administrator."
0935: "C-- C-- called for nurse to nurse.'
0940: "Nurse report given to B----at C-------. AOC at 0939 by JP, Dr P accepting MD."
1055 "Patient was denied W- O-- B-- H--"
1117: "911 safety tray ordered for patient."
1207 "Faxed warrant transfer to C-- C-- B-- H--. Waiting for the signature of accepting facility."
1305:"C-- C--B-- refused to sign the signature of accepting facility administrator paperwork."
1327: "T called to find placement for patient"
1343: " MAT Team called for patient placement."
1443: RN B-V-; "Patient walk out of ED. Bedside sitter and hospital Security following patient to return him back. CN P aware."
1530: "Pt return at bedside accompanied by Hospital Security staff. Pt is calm and cooperative. agreed to stay at bed side while waiting for bed allocation."
1645 : " Pt had aggressive behavior episode as shouted on sitter with abusive words then left ED ambulatory. ED attending followed Pt but unable to return him as PT crossed street. Hospital security and CN P aware."
1645:" Charge Nurse P spoke with Na from Mat Team. She was able to get signature from C- C -H- for the signature of accepting facility. Judge has left for the day. Unable to get signature."
09/16/2022 1715: "PT return back at bedside accompanied by F-B-Police."
1731: "911 safety food tray ordered for patient."
1750 "Pt refused to stay in ED. Walk out of ED ambulatory. Pt's sitter and security attempt to return him back but Pt refused."
2323:" Pt moved to room 11 due to staffing needs at this time. Pt is calm and cooperative at this time."

09/17/2022
0020: "Pt again walked out of room and punched open the EMS entrance to ED. MD notified. House supervisor will be contacted. "
0032: "Contacted SLPD at this time to inform them of patient elopement. MD instructed use of 4-point restraints on this Pt till warrant transfer, if he is brought back to ED due to aggressive behavior and multiple elopements House Supervisor notified. "
1.02 a.m.: " Pt returned to ED with SLPD . Pt will be restrained per MD orders due to SI statements, aggressive behavior and multiple elopement. "
0210: "Restraint not needed as he has fallen asleep at this time after being brought back by SLPD."
0804:"911 breakfast tray ordered"
1424: Pt was offered lunch and was upset with staff calling nurse " how can I eat this; you bitch and ho."
1711: "Pt was brought back by SLPD officer badge #8605. Police refused to help hold pt to be restrained. "Call us if he runs away." The Patient appears to be upset and calling staff expletives. "Bitches."
1715:" Pt not in restraints. Pt requests to use restroom. A bedside commode is provided as well as a urinal."
1750: "Pt given dinner."
1830: "Pt is bed w/ eyes closed without restraints."
2022: "Pt is resting with eyes closed, not in restraints."
2126: "Pt is resting with eyes closed, not in restraints."
2155: "Pt suddenly came out of bed, walked out from room, banged the ambulance door and walked out. SLPD informed."
2215: " Pt brought back to the room by SLPD officers."
2226: "Pt eloped at this time slamming his fists into EMS door. SLPD called and pt brought back at this time. Informed MD about elopement and return. Per Health and Safety Code 322.051 subsection 3b1,2,3 in Texas Health and Safety Code, pt will be restrained for patient safety and high elopement risk until pt can be transitioned to C-C- facility tomorrow in AM after warrant is signed. Requesting order for restraints with ED physician at this time."

09/18/2022
0008: "Sleeping in bed with restraints on. Sitter outside the room."
0401. "Pt continually trying to get out of restraint, being verbally abusive to staff and shouting racial slurs. Pt redirected by reminding him that he will be transported from this ED when his warrant is transferred. PT appeared to calm down at this time."
0531: "Patient is verbally abusive and loud trying to come out of restraints. Taken tab Seroquel."
0627: "Asleep in bed with restraints on. Continued sitter observation."
0700: "Hand off report given to RN Jo--."
0708: "Emailed warrant transfer to the Judge, waiting for judge to sign."
0748: "911 safety tray ordered for patient."
1202: Pt eloped from unit. Pt walked out of room 4 in ED and pressed button to open ambulance bay door. Once outside, pt headed towards the left of the hospital. Code gray initiated. MD P-, Charge RN TR and house supervisor notified. Security officer Ju- responded. Police Dept notified of his elopement and stated they would send an officer to search the surrounding areas. ( Pt restraints were removed at 8.43 today as the patient had to be free of restraints for 4 hours prior to transport to MH facility)."
1218: 911 contacted to report pt elopement from unit. They stated they will have officers searching the area for him and were aware of his several elopement issues throughout ED admission. Pt listed as missing person."

Reviewed Columbia risk assessment tool result:
Review of the facility's Columbia risk assessment completed on the following days 09/15/2022 revealed the Patient was assessed as "high Risk"
On 09/16/2022 High Risk
09/17/2022 Patient assessed as moderate risk
09/18/2022 : High risk
09/19/2022: Patient assessed as moderate risk.

Review of the Patient's Patient Safety Attendant Observation Form for High risk of Harm to self or others dated 09/17/2022 revealed for the patient assessed as moderate risk, the tool directed staff to " Document every 30 minutes MODERATE risk 09/17/2022, documentation indicated the Patient was monitored at 0630 and again at 07.30. The Patient was not monitored every half hour as required.
Further review of the record revealed documentation which indicated that on 09/17/2022 from 0030 - 0230 the Registered Nurse documented that the patient eloped, however documentation in the nurses' notes were as follows:
0020: "Pt again walked out of room and punched open the EMS entrance to ED. MD notified. House supervisor will be contacted. "

0032: Contacted SLPD at this time to inform them of patient elopement. MD instructed use of 4-point restraints on this Pt till warrant transfer, if he is brought back to ED due to aggressive behavior and multiple elopements House Supervisor notified. "
1.02 a.m.: " Pt returned to ED with SLPD . Pt will be restrained per MD orders due to SI statements, aggressive behavior and multiple elopement. "
0210: "Restraint not needed as he has fallen asleep at this time after being brought back by SLPD."

Review of the Patient's History and Physical
Review of the Patient's clinical record revealed a History and Physical completed on 09/15/2022 at 1607 by the Facility's Medical Director which documented the following:

Chief Complaint: Patient presents with Mental Health Problem
" 45 male with history of Schizophrenia, depression, Suicide attempts, in past via drug overdosed, presents to ED via PD as an EDO for suicidal thoughts with plan to " cut his wrists and take pills." Patient reports living in a group home but eloping from the home three weeks ago. He has been on the streets and feeling depressed ever since. He says today he was sitting and contemplating how he would kill himself when PD were called for a welfare check. The officer states he has had encounters with him in the past and he has previously exhibited suicidality. Patient states he has been without his daily medications for over a month. He reports nasal congestion and chest pressure that he contributes to been outdoors. He denies illicit drug or ETOH use. Reports medical history of asthma, GERD and SZ.
The history is provided by the patient and police.
Past Medical History:
Asthma
Bipolar affective disorder
Depression
GERD (Gastroesophageal reflux disease
Schizophrenia
Seizure
Vital Signs on admission were as follow: Blood pressure 131/92, Temperature 98.3, Respiration 18, Pulse 89 and SPo2 98%.
Neurological: He is alert and oriented to person place and time. Mental status is at baseline.
Mood and affect: Mood is depressed. Affect is flat
Speech: Normal
Behavior: Behavior is withdrawn. Behavior is not aggressive.
Thought content is not paranoid or delusional. Thought content includes suicidal ideation. Thought content does not include homicidal ideation. Thought content includes suicidal plan. Thought content does not include homicidal plan.
Cognition and Memory Normal.
Review of progress notes revealed the following findings:
Review of laboratory report
Review of rapid drug screen conducted on 09/15/2022 revealed the following results: rapid drug screen abnormal:
Cannabinoid Screen : positive.
Ethanol level: abnormal value 173. Reference <=10mgs /dl

READMISSION 09/18/2022
Review of the record revealed the Patient was readmitted to the facility on 9/18/2022 at 2230. Patient was brought in by the police. ( Note Patient eloped on 09/18/2022.
"Pt arrived via police custody at approximately 2230, Aggressive, cursing and combative. MD at bedside along with several officers for support. Pt medicated and restrained."
2230: "Pt fighting police while handcuffed and escorted by three police officers. Pt laid in prone position on stretcher . SLPD sent in call for additional unit to help restrain pt. PT threatening to kill staff and their families, to kill police officers when he finds them on the street. And rape police officers' spouses. Pt had to be given multiple doses of medication to sedate and calm him down. Pt is on monitoring ( cardiac and respiratory."
2259:" SlPD called that they found pt. And he is being aggressive they are on the way to bring patient back to hospital." (Documented by R S after patient actually was returned to facility.

09/19/2022
0000 : 'Patient now sedated. Spoke with J- charge RN from Cypress Creek . Informed J- that it will not be possible to physically keep the patient at the hospital long enough to be transferred without restraints. J- stated that he could not approve for transfer of a patient who requires restraints or have been in restraints but that the admission director Jo would have to be called for approval at 0900 in the AM. Day shift ED staff will be notified."
0220: "Pt requested help urinating . Pt was released from 2 points of 4-point restraint while staff were controlling extremities. Pt was able to urinate Pt then turned over to supine position and restraints were re applied. Pt tolerated turning and reapplication of restraint without outburst. Pt immediately fell asleep after clothes were switched to blue scrubs."
0243: "Pt stable and resting with HOB elevated after using urinal and eating a sandwich, chips and drinking apple juice. Pt allowed nursing staff to return restraints to upper extremities without combative behavior or verbal outbursts. No acute distress. Sitter 1:1 and able to visualize pt. Will continue to monitor."
0721: "Handoff report given to Ja RN."
1055 : "Faxed clinicals to S-B-, W- -, H- C-- C-, B- , ST-J and H- B- - C- for acceptance."
1133: "Spoke with R- from St-J- medical center who states nurse can't be done due to elevated CK level. CK level must be below 500."

09/20/2022
0002: "As per sitter patient jump off the bed heading outside told the sitter he will go home, unable to stop patient to stop patient at this time. Patient is cursing us when attempted to stop him from leaving."
0003: "Patient left again, unable to stop patient at this time patient busted the emergency door and cursing us. Code gray and 911 was called by Nursing supervisor."
0005: "Patient left with his IV on."
0020: " Sergeant R R from SL- Police came in made aware patient left again and can't stop the patient from leaving and patient personal belongings given to him."
0045: " M-police brought the patient back to take IV out."
0107: "Patient now in SLPD custody pending T- evaluation as patient based from PD observation is having psychotic episode. J L ( T) calling the EDO and getting details of visit ( EDO timeline. Time warrant of transfer signed by Judge BH, and the number of times patient eloped etc.) advised that patient had eloped several times and could have been transferred if C- C- made a 24 hr restraint clearance on the patient."
0217 : " C- C- calling to advise the " ADMISSION IS NOW" DECLINE" as patient had left SLSH . patient in SLPD custody. Will have to start over new process if patient returns to ED."
0334 : " JL (T) calling to update patient status . patient is now at T- C- C- for eval and treatment . He will not return to SLSLH ED."

RESTRAINT ASSESSMENT
Restraint Assessment by Physician 9/18/2022 at 2300, 09/19/2022 0100, 0200, 0300,0400, 0500:
" TW was severely aggressive combative, self -destructive, threatening and violent. Verbal de- escalation and redirection were unsuccessful. Less restrictive means were ineffective, and it is in my medical opinion that the chemical restraint LORazepam (ATIVAN) and ziprasidone ( GEODON) and physical bilateral soft wrist and ankle and physical hold restraints ordered are the least restrictive intervention for the patient's behavior and condition."
0809 "Violent restraint d/c at 8.00 a.m. awaiting transport resting comfortably."
0900: "Patient with labile mood and agitated threatening to leave . Restraint in process of removal and had to be left in place for patient and staff safety. Weaning as possible. Patient stable . Will continue to try and de-escalate patient's potential for elopement."
10.00 " Face to face eval- patient stable still threatening to leave. Vitals stable. Patient continues to be only re- direct able with removal of any restraints as patient has eloped x 4 and cannot continue to sedate if we are to transfer patient via sheriff secondary to warrant."

Reviewed Physicians' Progress notes
Review of Physician N M G progress notes dated 09/20/2022 at 0600 a.m. revealed the following entry:
" I was informed the pt eloped from the ER. He is in police custody and Jo- with T- was contacted. Since the pt was medically cleared he was able to have the pt taken directly to the T- c- c- and he will not return to ER here."

Review of Dr A---C--- P--- progress notes dated; 09/20/2022 at 0845 revealed the following entry.
"Chief complaint. Patient presents with mental health problem.
Pt eloped earlier this afternoon and brought back in at this time Pt extremely aggressive and belligerent . Pt had to be forcefully restrained for staff safety. Pt threatening to kill staff and their families. Pt is intoxicated upon arrival to ED.
45-year-old with history of bipolar depression, schizophrenia and seizures presents in the company of SLPD in handcuffs. Over the pat 72 hours patient has been in our facility 10 times, absconding and being returned by SLPD while he awaits in patient psychiatric evaluation. At this time patient is violently resisting arrest , refusing to comply with SLPD. Patient requires immediate chemical sedation and 4 points restraints. Patient is openly threatening ED staff as well as SLPD with violence."
" Patient with prolonged course across multiple days. In summary patient with psychosis aggressive and threatening behavior over the course of ED visit over multiple days. Pt in summary was able to be transported directly to T- c- c- this morning per dr Ge--'s noted at change of shift."
Transfer to other facility. 09/20/ 2022 Discharged."
Clinical Impressions; Primary Acute psychosis
Paranoid Schizophrenia, suicidal ideation, Suicidal thought.

Reviewed Facility's Policy and Procedure on Safe Care of Suicidal Patient effective July 2022 directed staff as follows:
High risk
"Patients screened /assessed and found to be HIGH risk will be monitored under direct one - to- one(1) :1 observation by a qualified Observer ( a staff member trained to attend to patients at risk for suicide. And observations and safety interventions are documented every 15 minutes or more frequently as needed ( appendix (H) ."
Moderate Risk Patients:
"Patients screened /assessed and found to be MODERATE risk will be monitored by a Qualified Observer using direct line of sight observations, Observations and safety interventions are documented every 30 minutes 9 appendix H) "

INTERVIEWS:
Interviewed Dr G, Medical Director Emergency Center
In an interview on 09/19/2022 at 1:30 p.m. with Dr G, Medical Director Emergency Center revealed she stated that there are challenges managing psychiatric patients. She said the patient was agitated and violent on arrival to the emergency center. She said she tried to work with the process and have the patient out of restraint for 12 hours so that he could be transferred to a psychiatric facility. The patient pushed pass the sitter, broke the door and left. The patient was administered Ativan and Geodon, but he still left the facility. She said on the 18 th the patient was removed from the system because he had eloped for over 6 hours. He was eventually brought back to the facility by the police, and he was readmitted to the facility. She said verbal de-escalation and chemical restraint were tried, then physical restraint was tried. She said facility's staff knows the importance of keeping patients safe, the sitters are the eyes to watch the patient, but they do not put hands on the patients.
She said the facility has security guard on site, but they are not stationed in the emergency room, however, security will respond if a code gray is called.

Interviewed Registered Nurse (A) Director of Critical Care
Interview on 09/19/2022 at 1.51 p.m. with Registered Nurse (A) (Director of Critical Care) revealed, on 09/16/2022 the facility had a code gray, because the patient became aggressive, combative and left the emergency center and was gone for approximately 30 minutes. He was returned to the facility by S_L_Police. He said the patient had a sitter who was monitoring him, but the sitter was at the point where he was not comfortable because the patient was so agitated, he thought the patient would harm him. The sitter was replaced at his request. He said the Director of Radiology and a security guard tried to stop the patient from leaving but the patient was intimidating to staff. He said facility's staff had to apply 4- point restraint on the patient because he was so violent.

Interviewed Staff (E) Newell Director of Radiology
Interview on 09/19/2022 at 2.00 p.m. with Staff (E) Director of Radiology revealed he stated, that on the day the patient tried to leave the facility he came toward the end of the Code Gray. He said a Code Gray was called and he responded, the patient was trying to leave the emergency center. He said Dr Si-- was talking to the patient trying to get the patient to stay in the emergency center. He said the patient walked through the ambulance entrance and went to the back of the hospital. The patient kept walking and crossed the street. He said he did not know where the patient went after crossing the street. The police was called and they brought the patient back to the facility within 30 minutes of him leaving.

Interviewed Dr (C)Emergency Room Physician
Interview on 09/19/2022 via the telephone with Dr (C) emergency room physician revealed he stated, when he arrived on duty the patient was calm in the room. He said the patient became agitated and pushed pass the sitter, but the patient was brought back to the facility by the police. He said on returning the patient was calm, but soon after, the patient threw water in the electrical outlet and started a fire.
He said the patient was given Haldol but every time he came back to the facility, he was calm but had this "burst". He said the facility had everybody trying to keep the patient in the hospital, but he did not respond to verbal de-escalation. He said he followed the patient as far as he could when he was leaving the facility , but he had to stop because he was covering the entire emergency room. He said there was nothing other than psychiatric illness which triggered his condition.

Interviewed Dr (D) Emergency Room Physician
Interview on 09/19/2022 at 3.20 p.m. with Dr (D) revealed he said he worked the entire weekend in the facility's emergency room on the PM shift. He said the patient was admitted to the facility prior to him starting his shift. He was told the patient eloped a couple of times and that he was a flight risk. He said when he first met the patient, he introduced himself to the patient and told him what his line of treatment was. The patient told him he wanted Seroquel. He said 15 minutes later after he was administered Seroquel, the patient bolted from the facility. He said the patient returned to the facility with the police escort. On the patient's return to the facility, the police requested to see the physician on duty in the emergency room. He said the police asked him " Why did you let him leave?" He told the police he was responsible for the patients and staff, and he was not going to put his staff in harms way. The police told him to hold the patient down. He then told the police the Patient did not meet the criteria for restraint The cop told him that this was an EMTALA violation The Physician said he told the police " Thanks for telling me about EMTALA violation."
He said on 06/17/2022 the patient eloped and so he told the staff to give the patient some medication. The patient then eloped again while they were getting him settled. When the patient returned to the facility accompanied by the police, he was placed on 4-point restraint.
He said on 9/18/20222 when he started his shift, the patient was not on the premises. He was returned while restrained by three officers. On his return the patient was violent and agitated. The patient was given Ativan, Geodon and Benadryl.
He said it took 4 policemen and three nurses to give him the medication. He said it took 8 - 9 people to apply physical restraint to the patient. He said there was no staff injury during the process, but the staff were only tired.

Interviewed (B) RN Emergency Room
Interview via telephone on 09/21/2022 at 10:30 a.m. with Registered Nurse (B);Manager emergency center revealed she stated that once a patient elopes or absconded her role is to ensure patients, staff and family members present are safe. She then activates a Code Gray which is a security alert/ safety alert. Once called all available staff responds i.e., security, administration, and staff from various departments. Responded staff are given a brief overview of what safety issue.

The Charge Nurse said Patient #1 had a sitter monitoring him 24X7. She said the patient was angry, aggressive, moody. She said the patient's mood did not change much only when he was asleep. She said if staff tries to do the patient's vital signs, he will call the nurse" Bitches, ho and N---'" The patient would throw the tray after eating on the floor and staff would have to clean up the mess every time he ate. She said she saw the aftermath of the patient throwing water in the electrical outlet and it started to spark. She stated " As a team we did a good job for this patient and all patients. "