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Based on a review of Emergency Department (ED) logs, medical records, a review of policy and procedures, and staff interviews, the facility failed to stabilize a patient within the capabilities of the hospital for further examination and treatment.

Findings were:

Cross-reference A-2407 as it relates the facility's failure to provide stabilizing treatment prior to transfer for one patient out of 21 sampled (P#4).

Based on a review of Emergency Department logs, medical records, a review of policy and procedures, Medical Staff Bylaws, and staff interviews, the facility failed to stabilize a patient within the capabilities of the facility for further examination and treatment. Specifically, the hospital failed to maintain a safe environment for one patient out of 21 patients sampled (P#4), when P#4 was evaluated and determined to be a danger to himself, and others was able to elope from the facility.

Findings were:

A review of the facility's emergency department (ED) EMTALA (Emergency Medical Treatment and Labor Act) Log revealed that P#4 presented on 11/30/21 at 12:11 p.m. for complaints of a mental health problem.

A review of P#4's medical record revealed that he arrived in the ED on 11/30/21 at 12:11 p.m. via local law enforcement after an order was signed by a county judge. A review of the court order revealed that P#4 was to be taken into custody by law enforcement and delivered to the facility for examination. P#4 was placed in ED room 14 at 12:13 p.m. and a medical screening examination was started at 12:15 p.m. A psychiatric assessment was ordered at 12:15 p.m. A review of the Patient Care Timeline revealed that at 12:19 p.m., P#4 refused to talk to anyone.

Triage was started at 12:34 p.m. by RN CC. At 12:34 p.m., RN CC documented that P#4 chief complaint was updated to include a mental health problem and had been brought to the ED by local law enforcement after patients' mother had called them. P#4 did not wish to speak to anyone until his mother was contacted. A note written at 12:36 p.m. by RN CC revealed that P#4 ' s mother was contacted via telephone and stated that P#4 had made threats to his (P#4) parents and himself. Specimens were collected for lab work at 12:44 p.m.

A review of the ED Provider Notes timed at 12:47 p.m. revealed that P#4 behavior was normal and thought content included suicidal ideation. The physician medically cleared P#4, Form 1013 (legal documentation to transport a patient deemed a danger to themselves or others for inpatient psychiatric treatment) remained in place, an order to transfer to a psychiatric facility was documented. The clinical impression was psychosis, unspecified type. A Form 1013 (legal document that authorized transport to a mental health emergency receiving facility) was signed by the ED physician at 1:00 p.m.

Continued review of the Patient Care Timeline revealed at 1:18 p.m. during bedside registration, P#4 became agitated and refused to sign documents. P#4 left the room (ED room 14) and was directed to return by RN CC, registration staff, and security. P#4 then pushed through the ambulance entrance and left the ED. Local law enforcement was called immediately. P#4 was returned via law enforcement and was placed in ED room 32 at 1:38 p.m. Orders were placed for suicide precautions at 2:12 p.m. RN DD documented at 2:15 p.m. and 3:15 p.m. that one on one monitoring continued.

A review of a psychiatry intake assessment dated 11/30/21 at 3:12 p.m. revealed that P#4 refused to speak to the assessor about the circumstances that led to the visit. P#4 appeared to respond to internal stimuli and auditory hallucinations (hearing voices/sounds that did not exist). P#4 laughed and smiled inappropriately to himself. P#4 was confused and disoriented to place. Per statements read in court order, P#4 can benefit from an inpatient psychiatric admission; he was psychotic and unable to care for himself.

At 4:10 p.m., P#4 was escorted to the bathroom and returned to his room. At 4:17 p.m. RN CC documented that P#4 reported knee pain with a pain score of 8 (pain scored on a numeric scale with 0 being no pain and 10 being the worst pain). RN CC informed the provider and received an order for pain medication. At 4:27 p.m. P#4 received one tablet of Percocet (pain medication). At 6:59 p.m. RN EE documented that P#4 was sleeping and one on one observation was in progress by a sitter.

At 9:51 p.m. P#4 was escorted to the shower by security staff. At 10:33 p.m., P#4 refused to return to his room and left the building. Local law was enforcement notified. At 11:15 p.m. five local law enforcement officers escorted P#4 back into ED and was placed in room 1 with the understanding that he was not allowed to leave. P#4 threatened violence if staff attempted to place him (P#4) back in the locked unit. One on one observation continued. At 11:27 p.m., P#4 was calm and cooperative. Patient Sitter (Sitter) JJ conducted one on one observation.
On 12/1/21 at 6:59 a.m., P#4 left his room and went into the ED lobby. Security responded and returned P#4 to his room at 7:15 a.m. P#4 agreed to transfer to ED room 33. At 5:31 p.m., the provider documented that P#4 had been accepted to a psychiatric facility. At 2:00 a.m. on 12/2/21, P#4 was transferred to a psychiatric facility via local law enforcement.

A Review of the Behavioral Observation Flowsheets revealed that P#4 was observed by a Patient Sitter during the time he was in the ED.

A review of the facility's Medical Staff Bylaws including Rules and Regulations, adopted 4/16/19 revealed the Medical Staff was actively involved in the measurement, assessment, and improvement of at least the following:
(a) patient safety, including processes to respond to patient safety alerts, meet patient safety goals, and reduce patient safety risks.
(c) medical assessment and treatment of patients.
4.A.9. Telemedicine Privileges:
(a) A qualified individual may be granted telemedicine privileges regardless of whether the individual was appointed to the Medical Staff.
(e) Telemedicine privileges granted in conjunction with a contractual agreement will be incident to and continuous with the agreement.
Active medical staff:
Active staff members must assume all the responsibilities of membership on the active staff including providing specialty coverage for the Emergency Department (ED) and accepting referrals from the ED for follow up care of patient treated in the ED.

A review of the facility policy titled "Care of Behavioral Health Patients" policy number 9270310, last revised 2/10/21 revealed that the purpose of this policy is to provide guidance for safe, appropriate, and effective care for patients who demonstrate behaviors suggestive of risk for suicide, risk of harm to others, substance abuse or other behaviors that pose a serious and significant safety risk.

Policy:
The facility is an acute care hospital and is not an emergency receiving emergency treatment (ERET) facility. Patients accessing care the facility who require psychiatric treatment will be managed through referral and transfer to a psychiatric receiving facility and/or managed through consultative psychiatric services on a temporary basis. It is the facility ' s policy to honor and promote a patient ' s rights of autonomy and self-determination while balancing such rights with the need to keep patients, staff, and visitors safe. The facility will not hold a patient involuntarily or force care upon a patient against his or her will simply because a 1013 or 2013 certificate has been executed. However, if in the physician professional judgement, a patient ' s recent actions or statements are of such a nature as to evidence imminent suicidal or homicidal intent or otherwise represent an immediate threat of harm to the patient or to others, that patient may be held against his or her will pending transfer to an emergency receiving facility as a safeguard measure, for as long as the immediate threat persists.
Patient rights:
The execution of a form 1013/2013 does not extinguish a patient ' s rights. As set forth previously in this policy, in some instances the patient ' s right to personal privacy may be curtailed to the extent necessary to prevent immediate harm to self or others.
The execution of a form 1013/2013 does not indicate that the patient is incompetent. In the event that a 1013/2013 patient attempts to leave the hospital while he/she is awaiting transport to an emergency receiving facility, the hospital cannot restrain or hold the patient. Staff should make efforts to deescalate any situation where the patient attempts to leave but should only attempt to prevent the patient from leaving the facility if the patient, in the physician ' s reasonable opinion is in imminent danger.
A review of the facility's policy titled "Admission to Emergency Services,50043", policy number 9923008, last reviewed 7/22/21 revealed that any individual can come to the facility's emergency department and request an examination or treatment for a medical condition. The facility's emergency department will provide an appropriate medical screening examination to determine whether an emergency medical condition exists.

Procedure:
If it is determined that the individual does have an emergency medical condition, the hospital must either provide such further examination and treatment as may be required to stabilize the condition or transfer the individual to another medical facility. Once the patient is stabilized, the patient can be transferred or discharged.

1. Emergency medical condition is defined to include any condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the health of the individual or an unborn child in serious jeopardy: serious impairment of bodily functions or serious dysfunction of any bodily organ or part.
2. Stabilization: The term means to provide such medical treatment as may be necessary to assure within reasonable medical probability that no material deterioration of the condition is likely to result from transfer or discharge of the individual.

A review of the policy titled " Leaving Against Medical Advice " policy number 7810732 last revised 4/2/20 revealed that the purpose of this policy is to establish guidance and provide a procedure to be followed when a patient elect to leave without notifying staff or elects discharge against medical advice.
Procedures.

1. If patient informs nursing staff that he/she is leaving, the immediate supervisor and/or immediate nursing leader will be notified of the patient ' s desire to leave.
2. The immediate supervisor and/or immediate nursing leader, a physician or designee will inform the patient of the risks of leaving as defined by the physician.
3. The physician/nurse informing patient of risks will document the conversation with the patient in the medical record.
4. The patient ' s nurse should have the patient read and sign form entitled " leaving hospital against advice " as posted with this policy
5. If the patient refuses to sign such statement, the form should be completed with patient name and date and witnessed by staff. Staff should " signature refused " on the form and make a notation in the medical record.
6. The clinical manager will be informed of the patient intent to leave the hospital against advice.
7. In the event that a patient on 1013 requests to leave AMA or attempts to leave the facility, staff will make a reasonable effort to maintain the patient using nonrestrictive measures. Security should be immediately called to assist.
8. If the patient is deemed an imminent risk to self or others, or become violent, security or trained staff may institute restraint procedures at the direction of registered nurse / physician.
Elopement of medically compromised or behavioral health patients without decision making capacities. If the adult patient who elopes has altered mental status, lacks decision making capacity or is on 1012 status, additional procedures should be implemented as follows:

1. Nursing staff will notify supervisor and initiate a lowkey rapid search of the unit searching room to room, utility rooms, exam rooms, lounges, waiting areas, adjacent stairwells.
2. Nursing supervisor will notify local law enforcement and security that the patient is missing, provide a detailed description and explained safety related concerns.
3. If the patient is returned to the unit, the condition of the patient will be assessed and documented
4. Time patient noted to be missing, response to all search efforts, notifications and times will be documented in the medical record.
Leaving the emergency department without being seen.

1. If a patient wishes to leave from triage prior to receiving a medical screening, the triage/ treatment area nurse will notify the charge nurse and try to encourage the patient to stay and be seen
2. The patient will be advised of the risks involved in leaving without having a medical screening performed.
3. If a record has been made, the nurse will document the conversation in the medical record.

A review of the facility's policy titled, policy number 8152591 "Transfer activities in accordance with EMTALA requirements policy" last revised 6/4/20 revealed that the purpose of the policy is to establish guidance for providing appropriate medical screening examinations, stabilizing treatment and appropriate transfer of patients in accordance with the EMTALA, and all regulations thereunder.
Appropriate transfer -

a. The transferring hospital provides medical treatment within its capacity that minimize the risks to an individual ' s health and in the case of a woman in labor, the health of the unborn child;

Involuntary status - The EMTALA policy applies equally to patient with psychiatric conditions. Such patients who present to the ED will receive a medical screening examination and if they are found to have an emergency medical condition, they will receive stabilizing treatment within the capacities and capacity of the hospital. If their condition remains unstable an EMTALA appropriate transfer will be arranged for them. The 1013 form must be utilized and completed in addition to the hospital transfer forms. No consent for transfer for the patient is required.

An interview with the Director of Emergency Services (DES) AA and Clinical Manager of Emergency Services (CM) BB took place on 1/4/22 at 1:30 p.m. in the conference room. CM BB recalled that Patient (P) #4 presented to the ED via law enforcement with a signed affidavit from a judge. CM BB stated that P#4 had been in ED room 14 and not been placed in a behavioral health room because he required a medical screening examination and had abnormal vital signs. CM BB stated that P#4 was a large adult male of approximately six foot five inches and around 300 pounds. CM BB stated that P#4 had told the staff that he wanted to go outside to smoke and forced his way through the ambulance entrance door. P#4 was detained by law enforcement and brought back into the ED. CM BB explained P#4 left a second time and was redirected into the building by hospital security. DES AA recalled that she had been notified of the elopement by local law enforcement. DES AA explained that patients were not put in the behavior health POD if they still required a medical screening or medical procedures including IV ' s. DES AA explained that the facility ' s security staff were present in the ED but were not responsible for monitoring or observing behavioral health patients. She stated that staff were not to attempt to physically prevent patients from leaving the facility and if a patient with an involuntary hold left the ED, the security staff notified the local law enforcement.

An interview with Chief Nursing Officer (CNO) II took place on 1/5/22 at 9:00 a.m. in the conference room. CNO II explained that the facility reviewed and revised the policy on caring for behavioral health patients about two years ago. The review included the facility ' s legal counsel and consulting legal counsel. She explained that the facility was not a designated emergency receiving facility for psychiatric or behavioral health patients. The behavioral health POD in the ED functioned as a holding area for patients awaiting transfer to behavioral health facilities. CNO II further explained that the facility employees a security staff, but they are not law enforcement. CNO II stated that per policy, staff do not physically prevent patients with a form 1013 from leaving the facility. A form 1013 was for authorization to transport mental health patients to an Emergency Receiving Facility. CNO II stated that in her opinion, some members of the community had the misconception that an ED was the same as an Emergency Receiving Facility. The facility did not have a psychiatrist or behavioral health providers on staff. Behavioral health was a contracted service and conducted via telehealth in emergency situations.

An interview with registered nurse (RN) DD took place on 1/5/22 at 10:00 a.m. in the conference room. RN DD recalled being at the nurses ' station when P#4 left his room and pushed through the ambulance entrance doorway. She explained that the doorway can only be accessed via ID badge. RN DD recalled that the police department was notified, and P#4 was brought back to the facility by police. She did not recall exactly how long P#4 was outside but it was not long. RN DD stated that when P#4 left his room, the unit secretary verbally attempted to have him go back into his room. Once P#4 was brought back inside by the police, she recalled that he (P#4) made verbal threats of violence. RN DD explained that when a patient had a signed Form 1013, a sitter was assigned to monitor. She further explained that security staff were not assigned exclusively to the ED, but they were made aware of patients that had a Form 1013. Patients were not placed in the behavioral health area until they received medical clearance. P#4 had been room 14 which was in front of one of the nurses ' stations. RN DD stated that she was not comfortable physically detaining patients. When patients attempted to or voiced wanting to leave, the charge nurse, security and sometimes the provider were notified, and de-escalation techniques were attempted.

An interview with RN FF took place on 1/5/22 at 10:30 a.m. in the conference room. RN FF recalled that when she arrived for her shift (7:00 a.m.), P#4 was in ED room 1 because the behavioral health POD was full. During report, RN FF was told that P#4 had left the building overnight. RN FF recalled that P#4 voiced that he wanted to leave, and she (RN FF) was able to de-escalate him. P#4 then agreed to go back to a room in the behavioral health POD and remained cooperative the remainder of her shift. RN FF stated that one of P#4 ' s previous sports medicine physicians was consulted because P#4 complained of knee pain from an old ACL tear. With the assistance of the sports medicine physician, a behavioral health provider was contacted who agreed to accept P#4 at a psychiatric facility. RN FF explained that patients who had a 1013 had a sitter assigned and if the patient was medically cleared, they could be moved to one of the behavioral health rooms. The security staff assisted when possible. Patients with 1013 ' s who attempted to elope were not physically restrained by staff including security.

An interview with RN CC took place on 1/5/22 at 11:00 a.m. in the conference room. RN CC recalled P#4 and explained that she completed his initial triage. She stated that P#4 initially refused to answer questions. RN CC phoned P#4 ' s mother at his request and he (P#4) agreed to speak to staff afterwards. RN CC stated that P#4 thought he was at the ED to obtain a medical marijuana card. P#4 was taken to ED room 14 after triage. A sitter was assigned once the Form 1013 was signed. P#4 left the room and forced his way through the EMS doors. He was returned to the facility by the police department. RN CC explained that when a 1013 was signed, staff clear the patient room for safety and a sitter was assigned. Security was called if necessary for assistance and the police department was called if a 1013 patient left the building.

During a follow up interview with DES AA on 1/5/22 at 11:15 a.m. in the conference room, she explained that the local police department will not come to assist with a 1013 patient until the patient leaves the building. DES AA reviewed a schematic of the ED and labeled the designated behavioral health rooms, ED rooms 31-34. She explained that room 32-34 were in the ' POD ' that was locked and confirmed that the patient restroom and shower were outside of the locked area.

An interview with Security Manager (SM) GG took place via telephone on 1/5/22 at 1:00 p.m. SM GG explained that the standard operating procedures for security included directive that staff were not hold patients against their will or hold down patients for medical procedures. Staff notified security with requests for assistance with de-escalation. If a patient had a signed 1013 and left the building, security called local law enforcement. Attempts were made to convince patients to stay and receive treatment and the providers were included if needed. Security staff were always on duty but not for the ED exclusively. SM GG explained that he reviewed video footage and there was none available from prior to 12/12/21. He was not aware of a video monitoring/recording policy. He explained that video storage was maintained on individual DVRs throughout the facility and the capacity was small.

A telephone interview with Patient Sitter (Sitter) JJ took place via telephone on 1/5/22 at 4:00 p.m. Sitter JJ explained that he had been employed at the facility for about nine months as a patient sitter. He stated that he had had de-escalation training. Sitter JJ recalled that he had been instructed not to attempt to physically detain a patient or put self in harm ' s way but to seek assistance from other staff or security if needed. He recalled that P#4 was aggressive and verbally threatening but he did not recall specifics about events. Sitter JJ explained that P#4 was the only patient that he had felt that he was in physical danger.

A tour of the facility's Emergency Department (ED) took place on 1/4/22 at 11:35 a.m. with the Director of Emergency Services (DES) AA and ED Clinical Manager (CM) BB. The ED consisted of a 34-bed unit which included a 4-bed behavioral health pod. The census at the time of the tour was 68. The nurse-to-patient ratio was 1:4 but was based on acuity. An on-call list was posted at the nursing station, and clinical staff could also access it electronically. A Public Safety Officer was noted to be sitting at the nurse ' s station. An observation of the Behavioral Health Pod revealed that the pod consisted of three patient rooms (32,33 and 34) located behind a locked door. The door was badge-activated for entry by staff. A nursing station was housed in a room that had a window that overlooked the patient rooms. Continued observation revealed that a 24-hour sitter was stationed at a video monitoring desk which revealed a 360-degree view within all four rooms, the hallway in the behavioral health pod, the ambulance bay, and the sidewalk outside the ambulance bay area. The patient rooms did not have a bathroom. DES AA explained that patients would be escorted to a bathroom down the hall, and a staff member would stand outside the door and then escort the patient back to the room when the patient was finished. DES AA further explained that a fourth behavioral health patient care room (31) was located outside the locked behavioral health pod. This room would be used if a patient needed medical treatment such as continuous cardiac monitoring or oxygen supplementation. Each patient room housed only one patient. DES AA stated that if a patient arrived involuntarily, they would enter through the ambulance bay. The patient would be taken to a patient room within the behavioral health unit and triaged at the bedside. DES AA continued to explain that if a behavioral health patient needed a behavioral health room, but none were available, the patient would be placed in a standard care room. DES AA stated that equipment that posed a safety risk to the patient would be removed from the room, and a one-on-one sitter would stay with the patient. If a behavioral health patient arrived through the main entrance and was not combative or did not appear to be harmful to themselves, the patient would get triaged and would wait in the waiting room or a standard patient care room if it was available.

A review of the ED floor schematic revealed that ED room 14 was located across from a nurse's station and next to the EMS door. ED rooms 32, 33, and 34 were designated behavioral health rooms in a locked area. The locked behavioral health area did not contain a restroom or shower.