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Based on record review and interview the hosptial failed to ensure that a patient who was admitted on the order of a Physician's Emergency Certificate (PEC) for suicidal precautions did not elope from the hospital for1of 4 patients records reviewed who were admitted with a PEC order in a total sample of 7 patients.(#2) Findings:

Review of the medical record for Patient #2 revealed that a Physician Emergency Certificate (PEC) was initiated on 7/18/2010 at 11:40 am that indicated the patient was a 23 year old male with a history of illicit drug use that wanted detox. The PEC indicated the patient was currently suicidal and was to be admitted to Unit A.

Review of the nurse's notes dated 7/19/2010 at 7:25 pm by S9 RN revealed that Patient #2 indicated "...His jaw felt tight. He was lowered to the floor with generalized tonic/clonic movements observed. He was positioned on his side and had a patent airway. S8, MD Psychiatrist was notified of the seizure and Ativan 2mg was given as ordered. The seizure stopped at 7:15 PM. There was no incontinence of bladder or bowel. The patient's vital signs were B/P 117/63, Pulse 114 beats per minute, Respirations 34 breaths per minute. The patient was oriented to name, age, and situation. Further review of the documentation revealed Emergency Medical Services were in attendance and the patient was transported to the ED for assessment ... "

Review of the ED Physician orders on 7/19/2010 by S6 MD, when the patient was admitted to the ED following the seizure revealed that Patient #2 had an alcohol level drawn, urine drug screen, Basic Metabolic Profile, CBC, Cardiac Enzymes, PT, PTT, Prolactin level, Troponin Adv Level, UA Microscopic and a CT (computerized tomography) of the head without contrast was ordered.

Review of the Physician Notes by S6, MD Emergency Department on 7/19/2010 revealed " ...presents with seizure while at detox center. Patient is detoxing from heroin and oxycontin. Complaining of diarrhea, nausea and vomiting, and substernal chest pain. Patient has been given 2 mg of Ativan daily at treatment center. The onset was prior to arrival. The occurrence was single and witnessed by bystanders. Exacerbating factors consist of none. Risk factors consist of drug abuse. Associated symptoms: fever, shields, nausea, vomiting, headache, chest pain and dizziness ... " Further review of the documentation revealed that as the patient was on his way back from CT the transporter reported that " ...The patient stated he wanted to leave. He states that he told the patient that he was bringing him back to his room and the patient became aggressive, so he proceeded to get security. As he was doing this the patient left. The deputy was notified and is currently searching for the patient. Per Unit A staff, the patient was PEC'd, however, the PEC form was not that sent over with the patient ... "

Review of the documentation in the nurse's notes by S5, RN, Emergency Department on 7/19/2010 at 9:20 pm revealed that S10, Transporter was on the way back to the ED with Patient #2 after the CT of the head and that the "...patient took off his oxygen, jumped off the stretcher, physically threatened the transporter, and ran out the door. Security notified, Police Department and was given a description of patient. IV still attached ..." Further documentation revealed Unit A was notified and disclosed to the ED that Patient #2 was an active PEC status. No copy of the PEC was sent to the ED with the patient.

Review of the ED record revealed the patient was found by a deputy at a gas station near the hospital. Patient #2 was returned to the ED on 7/19/2010 at 10:05 pm and no longer had his IV in place. The documentation revealed Patient #2 was awake, alert, and oriented X3, his respirations were even and unlabored and he was cooperative at this time and able to move all extremities. Patient #2 complaint of generalized body pain at 10/10 and had no other complaints. Further review of the ED record revealed the patient received Ativan 2 mg and Geodon 40 mg at 10:05 pm and received Valium 10mg intravenously at 11:45 pm.

In interview on 09/28/10 at 11:15 a.m. S9, RN, indicated that she was on duty at Unit A when a patient alerted her that Patient #2 was having a seizure in the hall on 07/19/10. S9 indicated the patient was having tonic-clonic type movements. S9 indicated the patient was lowered to the floor and the EMS (Emergency Medical System) was alerted. S9 indicated she notified the physician and an order for Ativan was given. S9 indicated the Ativan was administered and the seizure activity stopped immediately. S9 indicated that the EMS ambulance arrived within 5 minutes of being called and EMS transported the patient (Patient #2) to the Emergency Department. S9 indicated that report was called to the Emergency Department Nurse (she could not remember who the nurse was). S9 indicated that she told the nurse in report that the patient was admitted under a Physician's Emergency Certificate. S9 indicated that Patient #2 was very irritable, uncooperative, and did not want to follow his treatment plan.

In interview on 09/28/10 at 9:25 a.m. with S5, RN, indicated that she was the nurse on duty in the emergency department who received report on Patient #2. S5 indicated that Patient #2 had a seizure at Unit A and was sent to the Emergency Department for evaluation on 07/19/10. S5 indicated that she was not notified by the nurse who called report that Patient #2 was admitted under a Physician's Emergency Certificate. S5 indicated the patient was sent from the emergency room to the radiology department for a CT of his head. S5 indicated that Patient #2 was transferred to the radiology department by the Transport Technician S10. S5 indicated that the Transport Technician S10 returned to the emergency room and reported that Patient #2 had pulled off his oxygen, made verbal threats, and eloped from the hospital. S5 indicated that the Emergency Department supervisor on duty and the police were notified that Patient #2 had eloped from the hospital. S5 indicated that the police apprehended Patient #2 and brought him back to the hospital shortly after he was reported missing. S5 indicated that if she had been informed of Patient #2's admission status (Physician's Emergency Certificate), then the patient would have been sent to the radiology department with a nurse or security.

In interview on 09/28/10 at 11:30 a.m. with S10 Transport Technician indicated that he transported Patient #2 from the Emergency Department to the Radiology Department for a CT scan. S10 stated that when he picked up the patient he was alert and talking to himself. S10 reported that the CT scan took 5 minutes. S10 indicated that as he was transporting the patient back to the Emergency Department and the patient sat straight up on the stretcher and told him "I have to go" . S10 indicated that the patient then slid to the end of the bed and started pulling at his IV (intravenous) tubing. S10 indicated that the patient insisted that he was leaving and began sticking his hands in his pockets and making verbal threats. S10 indicated that he feared the patient may have a weapon in his pockets, so he stood back and allowed the patient to slide off the end of the stretcher. S10 indicated the patient walked down the hospital hall towards the parking lot. S10 indicated that he immediately notified the hospital security and nursing staff in the Emergency Department. S10 indicated that he was never notified that the patient was admitted on a Physician's Emergency Certificate.

In interview on 09/28/10 at 9:40 a.m. with S6, MD, Emergency Department indicated that he was the physician on duty when Patient #2 was sent from Unit A to the Emergency Department. S6 indicated that Patient #2 had a seizure while at Unit A and was sent to the Emergency Department for evaluation on 07/19/10. S6 indicated that patient #2 was sent to the Radiology Department for a CT scan of his head. S6 indicated that he was told that patient #2 had eloped from the Radiology Department. S6 indicated that he was not aware of the patient's admission status (Physician's Emergency Certificate) until after the patient had eloped from the hospital. S6 stated, "It would have been useful to know the patient was admitted under a Physician's Emergency Certificate."

Review of the hospital policy titled Physicians Emergency Certificate (PEC) revealed " ...A copy of the OBRA/COBRA, transfer form, the emergency department records, the original Physician Emergency Certificate form, and a copy of the COPE team evaluation will be sent with a patient at the time of transfer. Patients that are under PEC, OPC, CEC, and Peace Officers hold are to have 1:1 observation observation ... "

Based on record review and interview the hospital failed to ensure a nurse evaluated the care of each patient by failing: 1. assess that a clonidine patch was discontinued as ordered prior discharging a patient home for 1 of 7 patients (#2); 2. conduct a physical assessment of a patient prior to discharging the patient home for 1 of 7 patients (#2).
Findings:

1.
Review of Patient #2's medical record revealed Clonidine (Catapres TTS) 0.3 mg/24 hours, ER Transdermal was applied to the patient on 07/18/2010 at 2:35 pm as ordered by the attending physician. Further review of the medical record revealed an order to discontinue the Clonidine patch on 07/20/10 at 7:15 a.m. There was no documentation in the medical record that indicated that the Clonidine (Catapres TTS) 0.3 mg/24 hours, ER Transdermal patch was removed as ordered by the attending Physician before the patient was discharged from the hospital.

In interview on 09/28/10 at 10:42 a.m. Registered Nurse S7 indicated there was a physician 's order to discontinue the patient's clonidine patch, but could not remember removing the patch from the patient prior to discharge. S7 confirmed that the removal of the clonidine patch was not documented in the patient's medical record. S7 indicated that the patient was discharged from the Tau Center at 1:45 p.m. on 07/20/10.

2.
Review of the last nursing assessments performed on Patient #2 was a documented by S7 RN on 7/20/2010 at 12:00 pm. There was no documentation that revealed that the patient had been reassessed by a registered nurse before his discharge from the unit on 7/20/2010 at 1:45 pm.

In interview on 09/28/10 at 10:42 a.m. with S7 RN she indicated that she was the nurse who discharged Patient #2 to home. S7 indicated her last assessment of Patient #1 was done on 07/20/10 at 12:00 p.m. which revealed the patient was withdrawn, lethargic, affect was blunted, judgement and insight were poor. S7 stated there were no other assessments documented prior to discharge and further indicated that she could not remember what the patient's condition was upon discharge. S7 indicated that she did not remember Patient #2 having any extrapyramidal side effects from his medications.