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Based on document reviews and staff interviews, the hospital failed to ensure 1 of 21 patients selected for review from the emergency department (ED) log and patient # 3 reported by the hospital on September 30, 2022; received appropriate medical screening examinations prior to discharge. The hospital's failures placed patients # 1 and 3 at risk for an undiagnosed emergency medical condition at the time they departed the ED.

The hospital also failed to provide within its capabilities and capacity, treatment to stabilize an emergency medical condition for patient # 2 who presented to the ED on November 21, 2021 and July 29, 2022. The hospital's failure placed patient # 2 at risk for deterioration of his emergency medical condition.

The hospital's administrative staff identified an average of 71 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of the policy, "EMTALA Transfer and Emergency Examination ED", last approved 05/2022, revealed in part, "Each individual who seeks examination or treatment on Medical Center premises shall be offered a medical screening examination to determine whether an emergency medical condition exists...A Medical Screening Exam (MSE) is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an Emergency Medical Condition (EMC) or not. A MSE is not an isolated event. It is an ongoing process that begins, but does not end, with triage...A medical screening examination in the hospital's emergency department will be provided by physicians, physician's assistants, or nurse practitioners to all individuals who present to the hospital Emergency Department...".

"If an individual or a person acting on an individual's behalf refuses further examination and treatment, the individual must be informed of the risks and benefits of such examination and treatment".

2. Review of policy, "Patients Leaving Against Medical Advice (AMA) or Left Without Being Seen (LWBS)", approved 01/22, revealed in part, "... Left Without Being Seen (LWBS): is any patient who checks in to be seen in the Emergency Department and leaves prior to evaluation by the Emergency Department provider. When a patient leaves without being seen there is NO discharge order and NO discussion between the provider and the patient....Against Medical Advice (AMA): is determined by the patient ' s decision to leave the facility having been informed of and acknowledge the risks of leaving without completing treatment...Once the patient ' s...intent to leave the Medical Center or withdraw exam/treatment for the patient becomes known, the patient ' s provider is informed as soon as possible. The patient or authorized representative is encouraged to discuss their concerns with physician...".
3. During an interview on 9/7/22 at 7:45 AM, RN A reviewed Patient #1's medical record and confirmed that they had triaged Patient #1 after they presented to the ED with a mental health concern. RN A also confirmed that they had filled out and signed the AMA form.

RN A acknowledged that they were not qualified to do an MSE to determine if Patient #1 had an EMC. RN A confirmed that there was a provider available in the ED to do an MSE for Patient #1 but RN A did not recall notifying the provider or encouraging Patient #1 to be examined by the ED provider. RN A acknowledged that they filled out the AMA form in error, they revealed a provider was supposed to explain the risks and benefits of refusing an examination and/or treatment, but RN A was not clear on the hospital's policy and did not know if they were also qualified to explain those risks and benefits.

4. During an interview on 9/26/22 at 11:15 AM, ARNP X confirmed they were on the schedule on 6/20/22 but they did not recall Patient #1. They explained that an RN is qualified to do triage, but only a provider could determine whether or not a patient had an MSE. ARNP X further explained that if a patient wanted to leave AMA the nurse would notify the provider so they could talk to the patient and explain the risks and benefits of leaving the ED without further examination or treatment.

5. During an interview on 9/26/22 at 12:00 PM, ARNP Y confirmed they were on the schedule on 6/20/22. ARNP Y said a nurse is not qualified to do an MSE, only providers can determine if a patient has an MSE. ARNP Y recalled instances where they had been called to the triage room to talk to a patient who wanted to leave AMA, but did not recall Patient #1. Also confirmed that an RN is not licensed or educated to determine the risks and benefits for any patient who would want to leave the ED AMA.

6. Review of policy, "Behavioral Health Patient in the Inpatient and Outpatient Setting - Nursing Services, approved 01/2022, revealed in part, ... "1:1 Continuous monitoring by a trained team member: there will be direct visualization of the patient at all times including use of the restroom or off the unit for procedures ... all patients with court committal to ACH will remain in 1:1 supervision until court committal is reversed or patient is discharged to another facility ...".

7. Review of policy, "Patient Safety Companion Program", approved 03/2022, revealed in part, Reasons for a Patient Safety Companion would include elopement risk. "...The safety companion should report to the designated nursing unit to receive a patient report...For mental H[h]ealth patients eyes on patient at all times, no additional activities allowed...".

"When sitting 1:1 with a suicidal patient, you MUST be within 3-5 feet of the patient AND you need to have the patient in view at ALL times. You will need to position yourself in the doorway ...You MUST have eyes on the patient at all times. This means ...no working on computers ...".

8. During an interview on 9/6/22 at 9:00 AM, PCT O revealed they were Patient #2's Patient Safety Companion and had been training PCT P when Patient #2 eloped. They were both seated outside Patient #2's room and PCT O was showing PCT P everything in the computer. PCT O stated that a lab person had gone through the double doors and they could hear Patient #2 running through the doors.

9. On 9/12/22 at 10:25 AM. review of video footage revealed:

On 7/29/22 at approximately 2:05 PM two staff members were sitting outside Patient #2's room door looking at a computer screen. Patient #2's room door was flat against the wall and was not visible. Patient #2 could be seen lying under a blanket.

10. During an interview at the time of the video review, Manager of Clinic Performance Improvement and Health Education confirmed that at the time of this video one of the staff members was sitting within a few feet of Patient #2 but neither staff member had direct eyes on Patient #2.

11. During an interview on 9/6/22 at 8:45 AM, RN F verbalized that Patient #2 had a Patient Safety Companion and that was the main intervention to minimize risk of elopement after he returned to the ED.

12. Review of policy, "Missing Patient Policy", approved 04/2021, revealed in part, "...A missing patient is a patient over the age of 18 whose impaired mental status may put them at risk...If the patient is not immediately found, notify the patient's family...".

Based on document reviews and staff interviews, the hospital failed to ensure 1 of 21 patients selected for review from the emergency department (ED) log March to September 2022 and patient # 3 reported by the hospital on September 30, 2022, received an appropriate medical screening examination prior to discharge. The hospital's failures placed patients # 1 and 3 at risk for an undiagnosed emergency medical condition at the time they departed the ED.

The hospital's administrative staff identified an average of 71 patients per month who presented to the dedicated emergency department requesting care.

The hospital's administrative staff identified an average of 71 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #1's medical record revealed:

On 6/20/22 at 4:40 PM, Patient #1 arrived via car to the ED. RN A documented Patient #1 arrived for a psychiatric evaluation. Patient #1 complained of hearing voices, stated the voices just talk amongst themselves in their mind, they didn't tell Patient #1 do anything. Patient #1 denied suicidal or homicidal intent. Patient #1's speech was slow and they were slow to answer questions, their answers to questions were also very vague, they had difficulty explaining why they were there in the ED. Patient #1 was homeless and lived in a shelter.

Patient #1 also complained of pain in their head that they described as an acute in onset, and continuous. Patient #1's heart rate was 113 (greater than 100 is considered abnormal).

Patient #1 signed the hospital's document consenting to medical treatment and health care related services that the caregivers at the hospital considered necessary or were recommending.

On 6/20/22 at 5:41 PM, Patient #1 wanted to leave the ED and rest tonight to see if they felt better in the morning. Patient #1 was with an employee of the shelter and the employee felt comfortable taking Patient #1 back to the shelter. Patient #1 denied any suicidal or homicidal intent. RN A noted that Patient #1 had had Left Without Being Seen after triage.

On 6/20/22 at unknown time, Patient #1 signed the hospital's AMA form. The form lacked any risks or benefits specific to Patient #1's complaints. RN A also signed the form.

Medical record lacked any documentation of an appropriate MSE by a provider despite Patient #1's complaints of clearly abnormal psychiatric symptoms, headache, and slowed speech all of which could indicate an EMC that may have put Patient #1's health at risk.

2. Review of Emergency Medicine schedule, June 2022, revealed ARNP X, ARNP Y, and MD B were scheduled in the ED to perform an MSE for all patients who presented to the ED on 6/20/22.

3. During an interview on 9/7/22 at 7:45 AM, RN A reviewed Patient #1's medical record and confirmed that they had triaged Patient #1 after they presented to the ED with a mental health concern. RN A also confirmed that they had filled out and signed the AMA form.

RN A acknowledged that they were not qualified to do an MSE to determine if Patient #1 had an EMC. RN A confirmed that there was a provider available in the ED to do an MSE for Patient #1 but RN A did not recall notifying the provider or encouraging Patient #1 to be examined by the ED provider. RN A acknowledged that they filled out the AMA form in error, they revealed a provider was supposed to explain the risks and benefits of refusing an examination and/or treatment, but RN A was not clear on the hospital's policy and did not know if they were also qualified to explain those risks and benefits.

4. During an interview on 9/26/22 at 11:15 AM, ARNP X confirmed they were on the schedule on 6/20/22 but they did not recall Patient #1. They explained that an RN is qualified to do triage, but only a provider could determine whether or not a patient had an MSE. ARNP X further explained that if a patient wanted to leave AMA the nurse would notify the provider so they could talk to the patient and explain the risks and benefits of leaving the ED without further examination or treatment.

5. During an interview on 9/26/22 at 12:00 PM, ARNP Y confirmed they were on the schedule on 6/20/22. ARNP Y said a nurse is not qualified to do an MSE, only providers can determine if a patient has an MSE. ARNP Y recalled instances where they had been called to the triage room to talk to a patient who wanted to leave AMA, but did not recall Patient #1.

6. Review of Patient #3's medical record revealed:

Patient #3 presented to the ACH's ED on 9/27/22 at 6:29 PM via ambulance with seizure like activity while in the local jail. On arrival, Patient #3 was not responsive to verbal stimuli, but when Patient #1 became responsive, Patient #1 was confused to date/time. No injuries were noted but Patient #3 complained of a headache. Patient #3 had been seen in another hospital ED the night prior for possible seizure. Previous ED note documented pseudoseizure (resemble a seizure but without electrical discharges noted in the brain). Patient #3 was placed in handcuff and an officer was in the room.

Patient #3 has history of Adjustment disorder with disturbance of conduct (emotional or behavioral reaction to stressful events or a change) and Oppositional defiant disorder (uncooperative, defiant, and hostile towards others). Patient #3 currently admits to using Marijuana. Patient #3 lives at home with their mother and siblings. Patient #3 expresses there is stress at home related to finances being tight.

7. At 6:55 PM, RN A documented, the officer monitoring Patient #3 reported Patient #3 is having a seizure activity and requested a nurse to assess Patient #3. When RN A entered Patient #3's room, Patient #3 had the blood pressure cord wrapped around their neck 3 times. Patient #3, still handcuffed, responded to painful stimuli (pressure applied to a person's fingernail to assess alertness) and stated "I just don't want to live". Patient #3 was then handcuffed to siderails of the bed for safety precautions and was minimally responsive, not answering many questions. Officer remained at Patient #3's bedside.

8. At 9:42 PM, ARNP X documented, Patient #3 presented to ED with concerns of possible seizure. Currently in the local jail. Patient #3 had been in another local ED last night for a possible seizure, ED note was reviewed and Patient #3 was thought to have a pseudoseizure. No medications were started. Patient #3 tried to choke themselves with oxygen tubing and was sent back to jail on suicide watch. Patient #3 says they want to die and does not want to be here. Says they want to hang themselves. Reports tenderness to both sides of the neck but no redness or swelling noted. Thought content includes suicide ideation (SI, suicide thoughts, thoughts of harming yourself) with a plan to hang themselves.

Patient #3 was in handcuffs but wrapped the blood pressure cable around his neck. Patient #3 states he does not feel safe here due to the nurse pushing on their nail to get Patient #3's attention and get the cable off their neck. No injury noted. Officer is watching through the window.

Patient #3's exam is normal. Notes from this hospitalization and lab were reviewed. Patient #3's exam is stable at this time. Impression: Pseudoseizure and suicidal ideations.

9. At 7:44 PM, Patient #3 was discharged back to jail with recommendations for suicide watch. No discharge medications were prescribed. No psychiatric screening was performed on Patient #3 for their SI.

Based on document review and staff interview, the acute care hospital's (ACH) emergency department (ED) staff failed to ensure 1 of 20 patients (Patient #2) selected for review, who presented to the hospital for emergency care from 9/5/21 through 9/5/22, received all appropriate stabilizing treatment. Failure to provide all appropriate stabilizing treatment at the ACH's ED resulted in Patient #2 eloping from the ACH ED on two separate occasions, the second time Patient #2's whereabouts were unknown for two days, which may have resulted in Patient #2 harming themselves or others. The hospital's administrative staff identified an average of 71 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings include:

1. Review of Patient #2's medical record revealed:
On 11/22/21 at 10:21 AM, Magistrate S signed an order verifying that Patient #2 was a person with a substance related disorder and was a fit subject for custody and treatment. Magistrate S' order was based on letters from Patient #2's mother and brother who shared information about Patient #2 that made them believe Patient #2 might hurt themselves or someone else.

On 11/22/21 at 3:15 PM, Patient #2 presented to the ED accompanied by law enforcement for a court ordered psychiatric evaluation. RN C documented Patient #2 used aggressive language when talking to staff and told RN C they were going to urinate on the wall, refused to change into scrubs. Patient #2 was informed that they were being held in the ED due to a court commitment. Patient #2 was assigned a Patient Safety Companion (a staff member who sits with the patient 1:1 and constantly observes them) due to suicide and elopement risks.

On 11/22/21 at 4:17 PM, DO N noted that Patient #2 was refusing to talk or answer questions unless they could have their telephone. Per court papers, Patient #2 had been threatening suicide for an ongoing period of time because Patient #2 believed their spouse was cheating on them. Patient #2 had a history of schizophrenia (a serious mental disorder in which people interpret reality abnormally).and had not gotten their scheduled dose of injectable medication that helped them with their psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.) Patient #2 also has a significant history of substance abuse. Patient #2 currently denied being suicidal and stated that their entire problem was related to substance abuse. On exam Patient #2 was inattentive, had an anxious and depressed mood, was angry. Their thought content was paranoid, their behavioral was agitated and withdrawn. Patient #2 had impulsive and inappropriate judgement. Patient #2 was assigned a Patient Safety Company.

Patient #2's urine was positive for methamphetamines and marijuana. A psychiatric consult was done through tele-medicine and they recommended transfer for inpatient psychiatric hospitalization for safety and stabilization followed by residential treatment to address substance abuse. Maintain suicidal precautions.

On 11/22/21 at 6:00 PM, ARNP D noted Patient #2 came out to the nurse's station and became belligerent with staff, demanding their boots and stated they were going to leave. Public safety was called to get Patient #2 back to their room and Patient #2 was reminded that they were there on a court order. Patient #2 began cussing at staff, calling them derogatory names and making homophobic slurs. Patient #2 did finally change into scrubs and agreed to get an injection of Geodon (medication used to treat schizophrenia). Patient #2 continued to ask for their phone and were told they cannot have their phone as long as they were acting this way.

On 11/23/21 at 7:53 PM Patient #2 was accepted at another facility for inpatient care.

On 11/24/21 at 11:00 AM, PCT E (who was the Patient Safety Company) documented Patient #2 had ran out of the ED after a nurse opened the door. RN F further clarified that they had been asked to come to Patient #2's room and Patient #2 and their Patient Safety Company were not there when they arrived. RN F checked bathrooms, other ED rooms and hallways, made multiple attempts to contact Patient Safety Companion with no answer. ED charge nurse, ED provider, behavioral health nurse, security and police all notified. Patient Safety Companion arrived back in the ED and explained that Patient #2 had made it outside the facility. Hospital security and police were notified and searching for pt.

Medical record lacked any documentation that Patient #2's mother or brother were notified that Patient #2 had eloped from the hospital even though Patient #2 was court ordered based on family concerns that Patient #2 could harm self or others.

On 11/24/21 at 12:50 PM, Patient #2 was returned to the ED accompanied by police. Patient #2 was refusing to cooperate.

On 11/24/21 at 2:35 PM, MD G examined Patient #2 after they were returned to the ED. Patient #2 was refusing to talk or answer questions unless they could have their telephone. Refusing to comply with lab draw but they did provide a urine sample. Patient #2 continued to state that their problem was related to substance abuse. Remained a 1:1 with a Patient Safety Companion due to committal status.
Medical record lacked documentation of any additional interventions to prevent Patient #2 from eloping again.

On 11/25/22 at 8:59 AM, Patient #2 was transferred to another facility for inpatient care.

4. Review of Public Safety log entry dated 11/24/21 revealed in part, Public Safety Officer (PSO) R reviewed video and noted "...The Patient Companion had left the room to get [Patient #2] a blanket. At the same time, ancillary staff had opened the double doors between ER/Radiology to push a cart through. The [Patient #2] took the opportunity to run with no sitter at the door and the entrance doors being open..."

5. During an interview on 9/14/22 at 9:00 AM, RN C could not recall anything specific about this visit. RN C did think the hospital typically had a sign up on the double doors (through which Patient #2 eloped) telling staff to use another door.

6. During an interview on 9/14/22 at 8:30 AM, DO N recalled caring for Patient #2 for two nights in the ED. Hospital had found a facility where Patient #2 could be transferred for care but the transfer got delayed. DO N explained that they assigned Patient #2 a Patient Safety Companion and had Public Safety nearby if needed, but Patient #2 eloped after the second night in the ED.

7. During an interview on 9/14/22 at 11:20 AM, ARNP D did not recall this specific ED visit. ARNP D said sometime before Patient #2's second elopement in July 2022, the hospital had asked staff to refrain from pushing the handicap button which would open both doors. Staff were instructed to just push the door open after they used their badge to unlock the doors.

8. During an interview on 9/14/22 at 8:45 AM, RN F said they knew Patient #2 had been in the ED before and could be verbally aggressive but the day they eloped they did not display any negative behaviors. Recalled they were in another patient's room when they got a call from PCT E who very calmly asked RN F to come to Patient #2's room when they got a minute. RN F told PCT E it would be a few minutes and when RN F got to the room both Patient #2 and PCT E were gone. RN F searched for them, contacted other staff for assistance. PCT E returned to the ED and said Patient #2 had run out of the ED through the locked double doors after a staff member had opened them and then ran out of the hospital RN F explained that these were double doors that go from Radiology to the ED, they are locked but staff can open with their badge and there is also a handicapped button that you can push that opens both doors if you are going through with a bed. Patient #2 was a committal so hospital had notified police.
RN F did not do/has not done anything different to ensure Patient #2 did not elope from the ED again. RN F relayed that staff have just gotten into the routine where they don't push the handicapped button so both doors won't slowly open wide.

9. During an interview on 9/14/22 at 4:00 PM, PSO R recall receiving a call but it was full of static and they later learned it was because the caller was chasing Patient #2 down the hall. PSO R referenced their report and noted that Patient #2's Patient Safety Companion had gone a few feet down the hallway to get a blanket for Patient #2 at the same time someone else was coming through the double doors, and then Patient #2 took off through those open doors. Patient #2 was gone by the time PSO R got there, thought they went to their brother's house who called police to return Patient #2 to the ED. Hospital had been adjusting the timing on the double doors multiple times over the last several years in an attempt to reduce the amount of time the doors were open after hitting the button that automatically opens them. Staff have been instructed not to use the button that opens the doors unless they were bringing a bed through.

10. During an interview on 9/14/22 at 2:30 PM, PSO T recalled limited interaction with Patient #2 when they eloped in November of 2021. PSO T stated Patient #2 had taken off through the double doors and they had followed Patient #2 until they went down the hill at the back of the hospital. PSO T believed Patient #2 had gone to their brother's house and police had picked them up there.
PSO T reported that even before this happened last November hospital had reduced the time the double doors were open to about 10 seconds after hitting the button that automatically opened both doors. Hospital had done some education, there was information posted on the doors that no one was supposed to use the handicapped button, and staff should make sure the doors shut behind them. There were other things the hospital had looked at possibly doing as well.

11. Review of Patient #2's medical record from an additional ED visit revealed:
On 7/26/22 at 3:40 AM, Magistrate H signed an order for immediate custody due to serious mental impairment and found Patient #2 was likely to injure themselves or others if they were allowed to remain at liberty. Order was based on letters from Patient #2's parents who outlined concerns related to substance abuse, delusions, unwillingness to follow up with recommended outpatient care. Patient #2 had a no-contact order against their spouse and Patient #2's parents were concerned that Patient #2 could harm their spouse.

On 7/28/22 at 11:24 AM, RN I documented that Patient #2 presented to the ED accompanied by county sheriffs for a mental health committal. Patient #2 was alert and oriented but uncooperative and argumentative. Patient #2 was unclean and their clothing was unclean. Patient #2 was assigned a Patient Safety Companion to observe them and keep them safe. Elopement risk was not noted in documentation until 7/29/22 at 7:15AM.

On 7/28/22 at 11:31 AM, MD J examined Patient #2, noted court committal for psych evaluation due to allegedly showing aggressive behaviors, suicidal ideations, and having delusions. Patient #2 had a history of substance use however they denied any recent use or consumption of alcohol. Patient #2 denied any current homicidal or suicidal ideation, auditory or visual hallucinations, stated they had not done anything wrong and were upset about being brought to the ED by law enforcement. Described Patient #1 as agitated, angry and uncooperative. Urine was positive for amphetamines and for marijuana

On 7/28/22 at 5:45 PM, MD J wrote Patient #2 was uncooperative with their tele-medicine psychiatric evaluation, psychiatric provider felt Patient #2 was experiencing methamphetamines withdrawal, suggested consideration for antipsychotic and/or benzodiazepine therapy, offered patient reassessment after 8-10 hours for methamphetamine clearance. MD J deferred any medication due to absence of agitation or overt psychosis.

On 7/28/22 at 7:00 PM, psychiatric consult was done through tele-medicine and they recommended transfer for inpatient psychiatric hospitalization for safety and stabilization.
On 7/29/22 at 11: 25 AM, RN K noted Patient #2 was upset that they could not make a phone call, discussed with Patient #2 that they could not make a call because they were an elopement risk. Patient #2 said that if they did not let them make a call, they were [expletive] leaving. RN K advised Patient #2 that they would have to call the police to bring them back if they left. Patient #2 was loud and verbally aggressive in his tone; public safety was outside of the room for staff safety. Patient #2 refused food and medications including Ativan (used for treatment of anxiety).

On 7/29/22 at 1:38 PM Patient #2 was accepted at another facility for inpatient care.

On 7/29/22 at 2:07 PM, RN M wrote that Patient #2 had eloped out radiology doors.

Medical record lacked any documentation that Patient #2's parents were notified that Patient #2 had eloped from the hospital even though Patient #2 was court ordered based on their concerns that Patient #2 could harm self or others.

On 8/1/22 at 9:12 AM, Magistrate S signed an order for immediate custody based on a report the hospital filed on 8/1/22 stating that Patient #2 was not in compliance with the outpatient treatment order that was in effect.

On 8/1/22 at 3:08 PM, Patient #2 was returned to the hospital ED by police (over two days after eloping on 7/29/22). DO N wrote Patient #2 was brought to ED by county sheriff officers. Patient #1 had been seen in the ED previously and was under court committal for psychiatric admission. Inpatient placement had been arranged but shortly before the arrival of secure transportation Patient #2 had eloped from the ED. Patient #2 apparently arrived at District Court today for an unrelated matter and was ordered into protective custody for transport to ED and then "to the first available behavioral health unit". Patient #2 was upset about being brought back to ED, stated that the court order was illegal. Denied suicidal or homicidal ideation, wanted to be left alone. Patient #2 was noted to be at risk for elopement, Patient Safety Companion assigned.

Medical record lacked any documentation of any additional interventions to prevent Patient #2 from eloping again after eloping from the ED twice through the double doors (11/24/21 and 7/29/22.)

On 8/3/22 at 5:40 PM, Patient #2 was transferred to a facility for inpatient psychiatric care.

12. On 9/12/22 at 10:25 AM. review of video footage revealed:

On 7/29/22 at approximately 2:05 PM two staff members were sitting outside Patient #2's room door looking at a computer screen. Patient #2's room door was flat against the wall and was not visible. Patient #2 could be seen lying under a blanket.

Approximately 8 seconds later staff member was seen wheeling a cart through the open double doors near Patient #2's room.

Approximately 8 seconds later Patient #2 stood up and bolted through their room door and out the open double doors. Patient #2 was wearing blue scrubs and was barefoot. Both staff members got up immediately and ran after Patient #2.

Approximately 9 second later Patient #2 is pushing on an outside door and exited the hospital.

13. During an interview at the time of the video review, Manager of Clinic Performance Improvement and Health Education confirmed that at the time of this video one of the staff members was sitting within a few feet of Patient #2 but neither staff member had direct eyes on Patient #2. Manager of Clinic Performance Improvement and Health Education thought that, based on Patient #2's location in the room, it was questionable whether or not they could see the double doors but did acknowledge Patient #2 would have been able to hear the beep from an employee's badge access to the double doors, and hear the mechanics of the double doors opening.

14. During an interview on 9/6/22 at 9:45 AM, RN I stated they were Patient #2's primary nurse when sheriffs brought Patient #2 to the ED due to court committal. RN I recalled Patient #2 was yelling and swearing, screaming that they were not suicidal or homicidal and they shouldn't be in the ED. RN I knew Patient #2 was a high risk for elopement so Patient #2 was assigned a Patient Safety Companion. Patient #2's belongings were removed for the room to deter elopement, and they were placed in hospital scrubs so they could be more easily identified if they eloped.

15. During an interview on 9/8/22 at 11:05 AM, MD J recalled Patient #2 was a court committal, they examined Patient #2 and made a referral to a mental health provider who recommended inpatient treatment. Patient #2 stayed overnight in the ED while hospital found inpatient placement, and then Patient #2 eloped the next day while awaiting secure transportation to the inpatient facility. Patient #2 exited through doors that were locked but open when a hospital member used their badge to unlock and open the doors. Police were notified but they were unable to locate Patient #2 until two days later when Patient #2 arrived at court for a different warrant. Patient #2 was returned to the ED and subsequently transferred to an inpatient facility. MD J confirmed that Patient #2 had a Patient Safety Company due to their risk of elopement, MD J did not think Patient #2 warranted being restrained or sedated based on their behaviors. Patient #2 was verbally uncooperative and objecting to their stay but staff was able to re-direct.

16. During an interview on 9/6/22 at 10:15 AM, RN K recalled caring for Patient #2 the day they eloped. RN K knew they were a flight risk and Patient #2 was verbally aggressive when RN K did their first assessment so RN K called public safety and had them stand by Patient #2's door while staff were in the room. Patient #2 refused medications and food. RN K did not let Patient #2 know they had found placement for them because of their risk of elopement, was actually calling public safety to be in the room when Patient #2 signed the transfer form when RN K heard, "he's running, he's running!" Patient #2 had a Patient Safety Companion and they were trained that if someone elopes you can talk to them calmly but do not stand in their way or put yourself in a position where you could be physically hurt. They called for help and told police where Patient #2 had gone when they left the hospital.
RN K was aware of elopement risk, verbalized the double doors were in a bad place near the behavioral health rooms, but did not identify any interventions related to the doors to minimize the risk.

17. During an interview on 9/6/22 at 2:00 PM, PCT L recalled Patient #2 was lying in the bed when PCT L arrived to serve as their Patient Safety Companion. Patient #2 used the restroom, did not want food, just pretty much laid in their bed. Patient #2 started to get agitated at one point, said they wanted to leave, and a nurse came down and they called security who stayed by the room for awhile. PCT L let the next Patient Safety Companion know that Patient #2 wanted to leave.

18. During an interview on 9/2/22 at 9:30 AM, Social Worker U recalled they were present when Patient #2 was brought to the ED, spoke with them at that time but not much after that. Patient #2 was uncooperative, parents had filed committals in the past, and Patient #2 had committal paperwork again. this time.
The first time Patient #2 eloped, Social Worker U was told Patient #2 would listen for the "beep" when someone would badge the door, they would watch the door, and then kind of time how long it took from the "beep" until the doors would open. The room door swung both ways so Social Worker U moved the door in the room so Patient #2 could hear the exit doors but could not see the exit doors. Social Worker U did not recall this was a specific intervention to minimize elopement risk, rather they were just doing it knowing that Patient #2 had eloped previously.

19. During an interview on 9/6/22 at 9:00 AM, PCT O revealed they were Patient #2's Patient Safety Companion and had been training PCT P when Patient #2 eloped. They were both seated outside Patient #2's room and PCT O was showing PCT P everything in the computer. PCT O stated that a lab person had gone through the double doors and they could hear Patient #2 running through the doors. PCT O went after Patient #2 and PCT P called public safety. PCT O said it almost seemed like it wasn't the first time Patient #2 had done this, seemed like they knew exactly where to go. PCT O followed Patient #2 out the hospital and saw them go down a hill.
PCT O revealed the previous Patient Safety Companion told them Patient #2 was doing good, sleeping, just knew he was a court committal. PCT O did not know at the time that Patient #2 was an elopement risk. PCT O said they could see Patient #2 lying down even when they were looking at the computer.

20. During an interview on 9/6/22 at 9:15 AM, PCT P confirmed it was their first time as a Patient Safety Companion. Recalled the previous companion had said Patient #2 had been calm and cooperative, lying or sleeping in bed. PCT O showed PCT P how to chart in the computer, a lab tech came through the double doors and then Patient #2 bolted out when they heard the doors open. PCT P said they could see Patient #2 while sitting at the computer.
PCT P tried to call public safety but their communication device didn't work so they hit the panic button and then followed Patient #2. PCT P also commented that Patient #2 seemed to know exactly where they were going, it was like a maze -- right, left, another left and then out the door. Patient #2 went out the hospital and ran down a steep hill.

21. During an interview on 9/7/22 at 1:00 PM, Lab Service Technician (LST) Q explained that their entrance to the ED is through big double doors that are locked but there is a place to scan your badge, and then a button to push that opens both doors. LST Q was pushing a big heavy cart with equipment needed to do a blood draw and as they were approaching the doors a radiology staff member was coming out of an office by the outside doors and that person scanned their badge and hit the button to open the doors. LST Q went through the doors and then to the right and just as they rounded the corner they heard two footsteps and two people yelling. LST Q stated that you can see the doors open from the behavioral health rooms.
LST Q said to their knowledge that is still the way the doors operate.

22. During an interview on 9/6/22 at 3:30 PM, PSO R recalled that on the day they eloped Patient #2 had been up and down, agitated. At one point, PSO R had been asked to come over by Patient #2's room. Patient #2 calmed down in the afternoon and was resting when all of the sudden they jumped up and ran out of the ED when another staff member came into the ED through the double doors. PSO R had been watching the hallway camera and had seen Patient #2 run out of the room. PSO R ran from the opposite of the ED, never saw Patient #2, they were gone that quickly. From camera footage PSO R thought it was about 26-27 seconds from the time Patient #2 jumped up out of bed, was out of the hospital, and down the hill. PSO R also recalled that Patient #2 had eloped earlier in the year (November 2021) and had gone out those same doors.

23. During an interview on 9/12/22 at 9:30 AM, RN M stated did not have any contact with Patient #2 but recalled it was busy the day they eloped. RN M knew Patient #2 was under court committal and was not happy to be there. Patient #2 kept wanting to use their phone but was that was not allowed because staff were worried Patient #2 would call someone to pick them up.
RN M called police and talked to a dispatcher after Patient #2 eloped. RN M said the police usually call back and talk to someone, but no one called RN M back personally, and RN M did not know if anyone talked to the police again after dispatch was notified.

24. During an additional interview on 9/6/22 at 11:15 AM, DO N did not have a lot of interaction with Patient #2 when they were returned to the ED on 8/1/22. Was aware of Patient #2's elopement risk, verbalized Patient Safety Companion and having security close by were the main interventions.

25. During an interview on 9/6/22 at 8:45 AM, RN F verbalized that Patient #2 had a Patient Safety Companion and that was the main intervention to minimize risk of elopement after he returned to the ED.

26. During an interview on 9/6/22 at 11:30 AM, Patient Safety Companion W recalled being told that Patient #2 had eloped so they were to watch them. The behavioral health room doors swung in and out, on arrival Patient Safety Companion W noted that the door was intentionally opened outward so it would block Patient #2's view of the double doors.

27. During an interview on 9/6/22 at 11:00 AM, Patient Safety Companion V relayed that they were not aware of any new interventions to reduce the risk of elopement after Patient #2 was returned to the ED after they had eloped.

28. During an interview on 9/14/22 at 10:00 AM, RN Nurse Manager confirmed that there was no documentation that Patient #2's family had been notified of the elopement in November 2021 or July 2022 as required by policy. Acknowledged that policy also required Patient Safety Companions should have their eyes on the patient at all times except when doing their 15-minute documentation.

RN Nurse Manager stated it would make sense to have the room door open in a way to obstruct Patient #2's view of the double doors, and it would have been up to staff to communicate that intervention during shift report. Patient Safety Companions should have gotten a report from a prior staff member regarding the reason for having a companion, and any precautions or interventions in place. RN Nurse Manager was not aware of any new interventions for Patient #2 to minimize risk of elopement when Patient #2 returned to the ED on 7/28/22, eloped, and then returned to the ED on 8/1/22.

Explained that hospital had done some education with the ancillary areas to make sure that they knew to refrain from opening the double doors unless necessary to get through. If staff had to open both doors then they should make sure they are shut before they proceed. RN Nurse Manager thought it was communicated to lab staff but did not know if

LST Q had received education.

RN Nurse Manager explained they had used paper signage in the past but it didn't stay up, noted hospital probably needed to get new signage.

29. Review of Webster County Telecommunications Center Command Log revealed:

07/29/22, 2:07 PM Patient #2 left the hospital, court committal, left north side of the building, is in hospital scrubs

07/29/22, 2:11 PM Advised Patient #2 was served yesterday, have to wait for new committal papers

30. During an interview on 9/15/22 at 8:10 AM, Webster County Communications Supervisor recalled taking a call from the hospital that Patient #2 had eloped on 7/29/22. The hospital had relayed information about Patient #2 and that information was put into their system and dispatched to police officers. Recalled that a sheriff got on the call and said they needed to refile court committal papers before they could pick up Patient #2. Communications Supervisor did not know if that information was communicated back to the hospital.

31. During an interview on 9/15/22 at 12:55 PM, Webster County Sheriff explained that the order said they were to pick up Patient #2 and transport them to the ED. When Patient #2 eloped from the ED, the sheriff's office had no authority to physically fight Patient #2 and take them back to the ED. They stated that the hospital got the judge's order when they brought Patient #2 to the ED on 7/28/22, the hospital called police when Patient #2 left the ED on 7/29/22, and Webster County Sheriff understood that the hospital would then file with the magistrate. That communication had to come from the hospital and a new order was issued on 8/1/22.

Webster County Sheriff explained that the reason Patient #2 was returned to the ED in November of 2021 was because local police department (not the sheriff's department) picked them up. The sheriff's office won't do that without another order.

32. During an additional interview on 9/15/22 at 8:45 AM, RN Nurse Manager stated they typically call police when they need to after a patient elopes. RN Nurse Manager did not know if they had any further communication with the police department after Patient #2 eloped on 7/29/22, said the charge nurse would tend to call the police after a couple hours if a patient hadn't been picked up and returned to the ED. RN Nurse Manager was not aware of any issue with Patient #2's committal, recalled that when Patient #2 eloped in November of 2021 the police brought them back on the same court order, they did not need a new committal and they have not had any issues in the past

33. During an interview on 9/6/22 at 1:45 PM, Magistrate H could not recall all the specifics of this case but confirmed that they review the petitions and if there was sufficient evidence they would have signed the document on 7/26/22 that required Patient #2 to have an evaluation. Law enforcement was able to detain Patient #2 and return them to the ED based on that authority. During an additional interview on 9/15/22 at 10:45 AM, Magistrate H confirmed that based on their original order law enforcement could have detained Patient #2 and returned them to the ED, did not know if another order was necessary but acknowledged Magistrate S issued a new one on 8/1/22.