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Based on record reviews and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure all staff members were re-educated to prevent future occurrences after a patient arrived to the Emergency Department (ED) with an Order of Protective Custody (OPC), and subsequently placed under a Physician's Emergency Certificate (PEC) by the ED physician, eloped from the emergency department for 1 of 1 (#1) patient records reviewed for elopement from a total sample of 4.

Findings:

Review of the hospital's policy titled "Behavioral Patients- Management and Care in the Emergency Department (ED)" effective date 05/21, revealed in part, "Policy Statement: 1.) Patients presenting to LCMH [Lake Charles Memorial Hospital] ED for acute crisis of mental health or substance use disorders can expect to receive care in a safe, timely, effective, efficient, and patient-centered manner guided by evidenced-based practices."

Review of Patient #1's emergency department record revealed date and time of arrival was 10/15/2024 at 12:40 p.m. with a chief complaint of OPC. Further review of the record revealed a PEC dated 10/15/2024 and signed by S3MD at 1:50 p.m.

Review of the nurse's note dated 10/15/2024 at 3:33 p.m. by S1EDD revealed attempted to reach patient at phone number given. Spoke with Family Member #1 states as soon as he gets home, she is calling the police to bring him back.

Review of the nurse's note dated 10/15/2024 at 3:52 p.m. by S4RN revealed MD notified at 1:54 p.m.; missing person alert at 1:58 p.m.; Police Department at 2:00 p.m.

Review of the nurse's note dated 10/18/2024 at 12:44 p.m. by S4RN revealed Patient #1 did not come back after 72 hours.

In an interview on 11/25/2024 at 4:08 p.m. S2EDM stated the police brought Patient #1 to the ED under an OPC. S2EDM stated Patient #1 was seen by the provider and placed under a PEC. S2EDM stated the charge nurse did not know Patient #1 had a PEC in place. S2EDM stated the charge nurse went to do something, came back to the desk, and then noticed the PEC documentation was left on the charge nurse desk by the provider. S2EDM stated once the charge nurse noticed the document, the charge nurse assumed Patient #1 had been brought to the psychiatric holding unit inside the ED. S2EDM stated the charge nurse went to bring the PEC documentation to the psychiatric holding unit and then realized Patient #1 was not there. S2EDM stated once the charge nurse realized that Patient #1 was not in the psychiatric holding unit, she notified the provider, the house supervisor, the police department, and initiated a missing person code. S2EDM stated when the police officer left Patient #1 and walked out of the ED, the fire alarm went off and those doors were closed. S2EDM stated Patient #1 then meandered through the ED and exited through the waiting room. S2EDM stated Patient #1 was not found and did not return to the emergency department within 72 hours.

There was no documentation of all staff members being re-educated to prevent future occurrences.

In an interview on 12/02/2024 at 9:01 a.m. S1EDD verified there was no documentation of all staff being educated on the updated policy. S1EDD stated once the updated policy is in place, all staff will be educated. S1EDD stated staff are aware of the updated policy but the policy is still a draft and had not been approved as of this survey.

In an interview on 12/02/2024 at 10:35 a.m. S1EDD verified S5MD had not sent out the education to the ED providers.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the nursing staff to accurately document patient observations for 1 of 1 (#3) patient records reviewed for observations out of a total sample of 4.

Findings:

Review of Patient #3's emergency department record revealed date and time of arrival was 10/26/2024 at 3:24 p.m. with a chief complaint of Order of Protective Custody (OPC). Further review of the record revealed a Physician's Emergency Certificate (PEC) dated 10/26/2024 and signed by S7MD at 3:47 p.m. Further review of the record revealed on 10/26/2024 at 3:51 p.m. Patient #3 was placed in a room in the Emergency Behavioral Unit (EBU). On 10/26/2024 at 9:54 p.m. Patient #3 departed the EBU and was transferred to another hospital. Review of Patient #3's observation sheet dated 10/26/2024 revealed in part, documentation of frequent observations continued until 10:45 p.m.

In a phone interview on 12/04/2024 at 9:05 a.m. S6Tech stated she didn't realize Patient #3 had left. S6Tech stated she had multiple patients. S6Tech stated she didn't realize Patient #3's observation sheet was with the other observation sheets that she was filling out. S6Tech stated when she realized, she wrote a line through the documented observations and wrote the word gone.

In an interview on 12/04/2024 at 10:13 a.m. S1EDD verified Patient #3 departed from the EBU on 10/26/2024 at 9:54 p.m. S1EDD verified the documentation on the observation sheet continued until 10:45 p.m.