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Based on document review, video surveillance and interview, it was determined that the Hospital failed to prevent psychiatric patients from absconding, and failed to ensure staff followed the response and notification processes for absconded patients. As a result, the Condition of Participation 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to prevent psychiatric patients from absconding. See deficiency A-144-A.

2. The Hospital failed to ensure staff followed the response and notification processes for absconded patients. See A-144-B.

The IJ was identified on 7/13/2023 at 42 CFR 482.13, Patient Rights and began on 7/4/2023, due to the Hospital's failure to ensure appropriate supervision and measures were in place to prevent patients from absconding and failure to follow the response and notification processes for absconded patients. This failure is likely to cause serious harm, injury or death to any psychiatric patient receiving care in the Emergency Department.

The IJ was announced on 7/13/2023 at 3:50 PM, during a meeting with the President, Director of Quality, Chief Operating Officer, Interim Chief Nurse Executive, and ED Nurse Manager. The IJ was not removed by survey exit date of 7/13/2023.

A. Based on document review, and interview it was determined that for 1 of 2 (Pt. #1) patients' clinical records reviewed for elopement, the Hospital failed to prevent psychiatric patients from absconding. This has the likelihood to cause serious harm to any patient admitted to the Hospital.

Findings include:

1. On 7/11/2023, the clinical record of Pt. #1 was reviewed. Pt. #1 was a nursing home (NH) resident that presented to the ED (Emergency Department) via ambulance for a psychiatric evaluation due to aggressive behavior to NH staff. Past medical history included schizophrenia (serious mental condition characterized by disconnection to reality). Pt. #1's medical record did not indicate, that Pt. #1 was at risk for elopement. The clinical record included:

-On 7/03/2023, the "Medical Transportation Patient Care Report" included, "Nature of Call: Psychiatric Evaluation ...Chief Complaint: Psychiatric Problems ...patient was angry and screaming at staff present ... took her (Pt. #1) into intake in the ER (emergency room) to be evaluated ...gave nurse the report ..."

-On 7/04/2023, the 'General Assessment' Report included: " ...Arrival Date/Time: 7/04/2023 at 12:22 AM ...Stated Complaint: Aggressive Behavior ...Chief Complaint: Psychiatric Complaint ...Priority: ESI (Emergency Severity Index) 3 (urgent) ... Per petition (Pt. #1) was aggressive to roommates and nurse ... (E #7/Charge Nurse) at 1:15 AM: ...saw patient (Pt. #1) walking out with another patient (Pt. #2) went after (Pt. #1) informed security and was told that patient went outside (E #7) went outside, patient not there." Pt. #1 was refusing to be touched, have vital signs taken, and laboratory to be drawn.

2. On 7/11/2023 at approximately 12:50 PM, an interview was conducted with E #3 (ED Nurse Manager) stated that psychiatric patients are monitored based on their risks, no additional monitoring is in place for psychiatric patients.

3. On 7/11/2023 at approximately 3:00 PM, an interview was conducted with Emergency Department (ED) Registered Nurse (E #5). E #5 stated that there is no difference or additional monitoring for a patient that presents for a psychiatric evaluation. Patients are not permitted to be walking around in the ED. When patients are brought back to the treatment area, patients will change into a hospital gown, psychiatric patients are to have their blood drawn and wait at there assigned bed to be seen by doctor.

4. On 7/12/2023 at approximately 9:05 AM, an interview was conducted with ED Charge Nurse (E #7). E #7 stated that she called the NH to notify that Pt. #1 had absconded. E #7 stated "the staff from the (NH) laughed at me and said '(Pt. #1)' does that all the time.". E #7 stated that she did not complete an incident report. E #7 stated no additional monitoring is required for a psychiatric patient awaiting psychiatric evaluation.

5. On 7/12/2023 at approximately 10:30 AM, the Director of Quality (E #2) was interviewed. E #2 stated that Hospital does not have a policy/process in place to prevent a patient from absconding.

B. Based on observation, document review and interview, it was determined that for 2 of 2 patients' (Pt. #1, and Pt. #2) records reviewed for elopement, the Hospital failed to ensure care in a safe setting by failing to ensure staff followed the response and notification processes for absconded patients. This has the likelihood to cause serious harm to any patient admitted in the Hospital.

Findings include:

1. On 7/13/2023, the Hospital's policy "Patient Leaving Without Notification and/or Authorization Absconded Patient", (reviewed 7/2023), was reviewed and included, " ...Policy ... a concerted effort to locate the patient and the incident will be documented ...Procedure ...1. If a patient is away ...unexpectedly, the nurse assigned locates the patient by taking the following steps ...2. Make a thorough search of the nursing unit ...3 ...notify hospital security ...Security personnel will conduct a thorough search ...4. Notify Nursing Supervisor ...8. Security will be responsible for further documentation and follow-up until patient is located ...9. If patient has altered mental status or mentally unstable, hospital security will notify police department and report ...10. Document in patient record ...the time the patient was found missing, when the patient was last seen, that a thorough search for the patient was made, ...11. Complete a Hospital Incident Report Form and give to the Nursing Office."

2. On 7/11/2023, the clinical record of Pt. #1 was reviewed . Pt. #1 was a nursing home (NH) resident that presented to the ED (Emergency Department) via ambulance for a psychiatric evaluation due to aggressive behavior to NH staff. Past medical history included schizophrenia (serious mental condition characterized by disconnection to reality). The clinical record included:

-On 7/03/2023, the 'Medical Transportation Patient Care Report included, "patient was angry and screaming at (NH) staff present ...I certify that (Pt. #1) was physically or mentally incapable of signing at the time of transport ..."

- On 7/04/2023, the 'General Assessment' Report included: " ...Arrival Date/Time: 7/04/2023 at 12:22 AM ... Per petition (Pt. #1) was aggressive to roommates and nurse." Pt. #1 was refusing to be touched, to have vital signs and laboratory drawn. ...(E #7/Charge Nurse) at 1:15 AM: ...saw patient (Pt. #1) walking out with another patient (Pt. #2) went after (the patient) informed security and was told that patient went outside (E #7) went outside, patient not there.

3. On 7/12/2023, the clinical record of Pt. #2 clinical record was reviewed and included that on 7/4/2023 Pt. #2 had presented to the ED for medical evaluation for chest pain/blood in stool. Pt. #2's medical history included hypertension. The clinical record included:

-The nurse's notes on 7/4/2023 at 1:57 AM, "(Pt. #2) eloped (absconded) per charge nurse ...with heplock in place ..."

4. On 7/12/2023 at approximately 10:00 AM, the video surveillance of the ED and main entrance on 7/4/2023 from 1:15 AM through 1:35 AM was conducted. The video footage showed:

-At 1:15 AM, Pt. #2 briefly interacted with Pt. #1 then enter her room.
-At 1:19 AM, Pt. #2 exited her room then went to the bathroom across from Pt. #1's cart. Pt. #2 then came out of the bathroom and walked towards a locked door adjacent to the triage room. Pt. #2 attempted to exit through the locked door twice.
-At 1:20 AM, Pt. #1 stood up from the cart. Pt. #2 then gave Pt. #1 a cigarette. Afterwards, Pt. #1 and Pt. #2 walked in front of the nurses' station, exited the ED through the ED door, while E #5 (ED Nurse) and E #7 (ED Charge Nurse) were at the nurses' station.
-At 1:22 AM, E #8 (Security Officer) was at the front desk and saw Pt. #1 and Pt. #2 exiting the Hospital through the main entrance door. No attempts were made by staff to stop Pt. #1 and Pt. #2 from leaving the ED.

During the video review E #3 (ED Nurse manager) stated that Pt. #2 was upset because she wanted to go outside and smoke a cigarette and nursing staff had told her she could not go.

5. On 7/12/2023 at approximately 9:05 AM, an interview was conducted with ED Charge Nurse (E #7). E #7 stated that Pt. #1's petition noted that Pt. #1 had aggressive behavior. E#7 stated that she witnessed Pt. #1 leaving the Hospital with Pt. #2, E #7 stated that she did not complete an incident report. E #7 stated she called the police to notify Pt. #1 and Pt. #2 had absconded. "The police never came.".E #7 stated she did not notify nursing supervisor that the police did not arrive to the hospital to obtain a report.

6. On 7/12/2023 at approximately 10:11 AM, an interview was conducted with Security Officer (E # 8). E #8 stated a call was received from E #7 asking him if he witnessed two patients (Pt. #1 and Pt. #2), no identifiers provided to him, walking out the door. E #8 stated that he went outside and witnessed Pt. #1 being farther down the road and Pt. #2 got into a black car and left. E #8 stated that no further actions were performed by him as it was the ED's responsibility to follow-up and complete incident report. E #8 stated that Police did not report to the Hospital regarding Pt. #1.

7. On 7/13/2023, at approximately at 9:41 AM, the Nurse Supervisor (E #12) was interviewed. E #12 stated, "I don't know if an incident report should be completed for patients that have absconded or aware that there is a policy to follow for patients that have absconded."

8. No incident report was completed for Pt. #1 and Pt. #2. The Hospital is not aware of Pt. #1 and Pt. #2 status after they absconded.

Based on document review and interview, it was determined that for 1 of 2 patients (Pt. #8) clinical records reviewed for restraints use, the Hospital failed to ensure that use of restraints was in accordance with the physician's order.

Findings include:

1. On 7/12/2023, the clinical record for Pt. #8 was reviewed. On 5/12/2023, Pt. #8 was brought to the ED (Emergency Department) for psychiatric evaluation and abscess on right lower extremity. On 5/16/2023, a physician's order was obtained to place Pt. #8 in violent restraints (leather restraints) for four hours due to harm to others. However, the clinical record indicated that Pt. #8 was in violent restraints from 10:51 PM through 3:51 AM (five hours).

2. On 7/21/2023, the Hospital's policy titled, "Use of Restraint Policy and Procedure" (9/2022) was reviewed and included, "... Guidelines... 8. Restraint Orders for Management of Violent Behavior... a. 4 hours for adult 18 years of age or older... At the end of the time frame, if the continued use of restraint to manage violent or self-destructive behavior is deemed necessary based on an individualized patient assessment, another order is required..."

3. On 7/12/2023 at approximately 11:00 AM, findings were discussed with E #11 (RN/Registered Nurse Informatics Specialist). E #11 stated that Pt. #8 should be in restraints based on the physician's order. E #11 stated that a nurse should have obtained another order for continued use of restraints.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #8) clinical records reviewed regarding use of restraints, the Hospital failed to ensure that a provider conducted a face- to- face assessment within one hour after the initiation of restraints.

Findings include:

1. On 7/12/2023, the Hospital's policy titled, "Use of Restraint Policy and Procedure" (9/2022) was reviewed and included, "... Guidelines... 14. One-Hour Face-to-Face Assessment for Violent Behavior... the patient must be seen face-to-face within (1) hour after the initiation of the intervention by a physician or other licensed independent practitioner..."

2. On 7/12/2023, the clinical record for Pt. #8 was reviewed. On 5/12/2023, Pt. #8 was brought to the ED for psychiatric evaluation and abscess on right lower extremity. On 5/16/2023, the clinical record indicated that Pt. #8 was placed in violent restraints from 10:51 PM through 3:51 AM. The clinical record lacked a provider's face- to- face assessment within one hour of placing Pt. #8 in violent restraints.

3. On 7/12/2023 at approximately 11:00 AM, findings were discussed with E #11 (RN Informatic Specialist). E #11 stated that there was no documentation to indicate that a physician or a licensed independent practitioner conducted a face-to-face assessment one hour after initiation of the violent restraints.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #8) clinical records reviewed regarding use of restraints, the Hospital failed to complete the required face- to- face evaluation within one hour after the initiation of the intervention.

Findings include:

1. On 7/12/2023, the Hospital's policy titled, "Use of Restraint Policy and Procedure" (9/2022) was reviewed and included, "... Guidelines... 15. One-Hour Assessment Components... a. The patient's immediate situation; b. The patients reaction to the intervention... d. The need to continue or terminate the restraints..."

2. On 7/12/2023, the clinical record for Pt. #8 was reviewed. On 5/12/2023, Pt. #8 was brought to the ED for psychiatric evaluation and abscess on right lower extremity. On 5/16/2023, the clinical record indicated that Pt. #8 was placed in violent restraints restraints from 10:51 PM through 3:51 PM. The clinical record lacked documentation that the following face- to- face evaluation/assessments were completed: Pt. #8's immediate situation, reaction to the intervention, and need to continue or terminate the restraints.

3. On 7/12/2023 at approximately 11:00 AM, findings were discussed with E #11 (RN Educator). E #11 stated that there was no documentation in Pt. #8's record to indicate that the required one hour face- to -face assessments were completed.

Based on document review and interview, it was determined that for 2 of 2 ED (emergency department) patients (Pt. #3 and Pt. #4) boarding in the ED, the Hospital failed to ensure that the procedure governing the medical care of patients in the ED were followed, by failing to ensure that each patient is assessed by a registered nurse, as required, and/or seen on a daily basis by the attending physician or his/her designee.

Findings include:

1. On 7/11/2023, the clinical record of Pt. #3 was reviewed. Pt. #3 was brought to the ED on 7/8/2023 due to aggressive behavior and failure to thrive. On 7/8/2023 at 8:05 PM, the clinical record indicated that Pt. #3 was admitted for failure to thrive. As of 7/11/2023, Pt. #3 has been in the ED waiting for a medical bed:

- Nurses' shift assessments were missing on 7/9/2023, Night Shift; and 7/10/2023, Day and Night Shifts.
- Pt. #3 was not seen by the attending physician or his/her designee on 7/10/2023.

2. On 7/11/2023, the clinical record for Pt. #4 was reviewed. Pt. #4 was brought to the ED on 7/7/2023 due to aggressive behavior and seizure disorder. On 7/8/2023 at 8:07 PM, the clinical record indicated that Pt. #4 was admitted due to failure to thrive and seizure disorder. As of 7/11/2023, Pt. #3 has been in the ED waiting for a medical bed:

- Nurses' shift assessments were missing on 7/9/2023, Day and Nights Shifts; and 7/10/2023, Night Shift.
- Pt. #4 was not seen by the attending physician or his/her designee on 7/10/2023.

3. On 7/11/2023, the Hospital's policy for admitted patients titled, "Patient Daily Assessment" (7/2023) was reviewed and included, "Policy: Physical assessments are done at least once a shift on all patients... Level of Responsibility: RN (Registered Nurse)... 1. The Patient Daily Assessment will be documented once a shift by all nursing staff..."

4. On 7/11/2023, the Hospital's Medical Staff Bylaws in the ED (2023) was reviewed and included, "A... 2. a. The attending physician or his/her designee must see all patients... on a daily basis. All physician visits shall be documented in the EMR (electronic medical record)..."

5. On 7/11/2023 between approximately 1:00 PM and 2:30 PM, findings were discussed with E #2 (Director of Quality) and E #3 (ED RN Manager). E #2 and E #3 stated that patients admitted in the ED should be assessed by an RN every shift. E #2 also stated that all patients should be seen by the attending physician or his/her designee on a daily basis. E #2 and E #3 could not provide documentation that the required patients' assessments were completed.

B. Based on document review and interview, it was determined that for 2 of 2 crash carts (Crash Carts #6 and #10) observed in the ED (emergency department), the Hospital failed to check the crash carts were completed and documented, as required.

Findings include:

1. On 7/11/2023 between approximately 12:30 PM through 1:15 PM, observational tour of the ED was conducted. During the tour, daily check for crash carts were not done on the following dates: Cart #6 (July 3, 4, 5, 6, 7, and 8, 2023); Cart #10 (July 1, 2, 4, 5, and 6, 2023).

2. On 7/11/2023, the Hospital's policy titled, "Crash Cart Check" (7/2023) was reviewed and included, "Policy: Crash carts will be checked daily..."

3. On 7/11/1023 at approximately 12:45 PM, findings were discussed with E #3 (ED Manager). E #3 stated that the Hospital's ED is open 24 hours a day seven days a week. E #3 stated that the crash carts should be checked daily to make sure that emergency equipments for patient care are functional and available at all times.