HospitalInspections.org

Based on medical record review, hospital policy review and staff interviews, the Hospital's administrative staff failed to ensure emergency department (ED) staff:

1) followed hospital policy for patients at risk of elopement; and,

2) had a policy in place that adequately meet the safety needs of patients at risk for elopement, within the hospital's capabilities,while patients were in the process of receiving the appropriate stabilizing treatment.

The surveyors identified the concern for 1 of 20 sample patients (Patient #13) with an emergency medical condition (EMC) that presented to the ED seeking medical care from 6/15/23 to 12/14/23.

Failure to provide the appropriate stabilizing treatment in the ED resulted in Patient #13 eloping from the ED and placed the patient at risk for injury, or death.

Findings include:

1. Review of policy "EMTALA" dated 3/1/23, revealed in part, " ... If the MSE reveals that the individual has an EMC, the Hospital shall provide ...within the capabilities of the staff and facilities available at the Hospital, for further medical examination and treatment as required to stabilize the medical condition ..."

2. Review of policy "Patient Suicide Screening and Precautions" dated 5/1/23, revealed in part, " ...The patient should not leave the room, unescorted ...Based on the Columbia Suicide Screening tool the nurse will initiate the one to one watch. There will be direct visualization of the patient at all times ..." The policy directed nursing staff to initiate the "Patient Safety High Risk Safety Algorithm".

3. Review of the undated "Patient Safety High Risk Algorithm", revealed the RN initated the "Suicide Precaution Team", utilized a Patient Care Technician, person from the Patient Safety Companion Group, Security staff (if available) or other available staff designated by the House Supervisor with training provided if needed.

4. Review of policy "Safety Missing or Wandering Patients" dated 9/2022, revealed in part, " ...Patients are considered at-risk if, at a minimum, they are legally committed ... Patients at risk are placed on precautions...The At Risk Precautions include...Place an "At-Risk: Wandering or Missing" sign outside the patient's room ... The provider will be notified of the patient's At Risk status to determine if additional interventions are necessary..Staff will assess for signs of imminent wandering which includes, but not limited to...needs to use the bathroom... Staff will be aware of anxious patients who may be in the area of a door and should delay in using the door, use another door, or draw the patient away from the door... have the patient change into a hospital gown; paper or blue scrubs should be used for behavioral health patients so all staff can identify a patient who is at risk for wandering...develop a plan of care with the patient to address individual patient needs which prevent wandering or gone missing events... Options: to be initiated as deemed appropriate by the clinical staff based on assessment of the risk, resources and individualized need of the patient... 1:1 observation, bed alarm, chair alarm, door alarm, wandering wrist/ankle band..." The policy directed staff to notify Security of persons after the attempted to elope.

5. During an interview on 3/18/24 at 9:30 AM, the ED Nurse Manager reported the hospital had security guards available 24/7 for the whole hospital . The ED Nurse Manager confirmed the hospital had a policy to utilize one to one sitters for high risk patients. The ED Nurse Manager reported the hospital did not have a policy that required a security presence. The ED Nurse Manager added if the patient was agitated or found to be a flight risk they would call and ask if security was available.

6. Review of Patient #13's medical record revealed:

a. On 10/23/23 at 9:39 AM, ambulance staff brought Patient #13 to the ED. Patient #13 presented to the ED with intentional overdose. Police reported Patient #13 posted on Facebook they were taking pills to kill themselves and police responded to a welfare check. Police brought multiple pill bottles in with the patient.

b. On 10/23/23 at 9:42 AM to 10:00 AM, Triage Registered Nurse (RN) G completed a Columbia Suicide Risk assessment that placed Patient #13 at high risk for suicide. RN G completed a BARS-H (behavioral agitation rating scale) assessment which identified the patient was quiet, awake and without agitation. RN G completed a psychosocial assessment which identified the patient was intermittently agitated and displayed restlessness, hyperactivity, impulsiveness, depression, anxiety, behavior noncompliance with instruction, incoherence with poor judgement and moderate confusion. ED staff moved Patient #13 to ligature free ED Room #4, placed the patient on suicide precautions with 1:1 observation, assigned a sitter, and had the patient change into hospital scrubs.

c. On 10/23/23 at 9:48 AM Dr. E medically evaluated Patient #13 and documented the following differential diagnoses: overdose, drug ingestion, suicidal attempt, suicidal ideations, homicidal ideations, psychiatric problem and psychiatric disorder. Dr. E ordered screening lab work including a drug screen, ethanol level, and telehealth psychiatric consult. The drug screen returned positive for amphetamines, methamphetamines, and tricyclics.

d. On 10/23/23 at 10:49 AM, ED nursing staff documented a family member reported the patient's spouse left the patient 2 weeks ago.

e. On 10/23/23 at 10:59 AM, ED nursing staff documented a second family member reported the patient had been voicing suidical ideation for the last couple weeks.

f. On 10/23/23 at 4:26 PM, ED nursing staff documented a psychosocial assessment that included a suicide check. ED nursing staff documented the patient was calm, cooperative and having difficulty staying awake. The patient continued to have 1:1 observation.

g. On 10/23/23 at 6:33 PM, ED nursing staff documented the patient was awake and wanted to go home. ED nursing staff documented they explained to the patient the need for a psychiatric evaluation prior to determining if the patient could leave.

h. On 10/23/23 at 7:47 PM, ED nursing staff documented that they informed the patient of the psychiatric provider's recommendation for inpatient treatment. The patient voiced understanding.

i. On 10/23/23 at 7:52 PM Provider V documented the evaluation of Patient #13 as follows, "HIGH risk (previous attempt- today, substance use, loss of relationship, chronic health issue- hearing impairment, increased anger and anxiety, making suicidal threats and plans, etc.). In light of today's presentation and collateral information expressing ongoing concerns for safety, inpatient psychiatric hospitalization for safety and stabilization is warranted."

j. On 10/24/23 at 7:15 AM, ED nursing staff documented the patient no longer needed a 1:1 sitter and that Dr. S would make a note of this in the patient's chart.

k. On 10/24/23 at 8:06 AM RN D documented Patient #13 stated they slept well and denied any suicidal thoughts.

l. On 10/24/23 at 9:46 AM RN G documented Hospital W called with acceptance of Patient #13.

m. On 10/24/23 at 9:51 AM, Dr S documented the patient's understanding and signature on the Consent to Transfer form.

n. On 10/24/23 at 10:32 AM RN G documented Patient #13 became irritable, Patient #13 did not want to be transferred and wanted to go home. Patient #13 reported the patient was no longer suicidal. Dr. S spoke to Patient #13 and Dr. S determined the need to obtain a court order to hold the patient in the ED for treatment.

o. On 10/24/23 at 10:35 AM ED Dr. S obtained a court order from Magistrate U for Patient #13 to be transferred to Hospital W.

Review of the court order, dated 10/24/23 at 10:35 AM, revealed the judge ordered the patient to be detained in custody at the hospital for examination and care for a period not to exeed 48 hours. The judge found probable cause to believe the patient was seriously mentally impaired, and because of that impairment, the patient was likely to injure him/herself or others.

p. On 10/24/23 at 10:38 AM, ED nursing staff documented they placed the patient on Suicide Interventions, high risk with 1:1 continuous observation. At 10:40 AM, ED nursing staff notified the House Superviser that the patient was back on a 1:1. At 10:53 AM, Dr S documented the patient required a 1:1 sitter, but did not specify why the patient required the sitter.

The clinical record lacked evidence of the following: ED nursing staff completed an updated BARS-H to assess the patient's level of agitation, assessed the patient's risk for elopement, placed the patient on At Risk Precautions for elopement, discussed with the physician any additional necessary interventions to prevent elopement (such as utilize security personnel) and lacked evidence ED staff developed a plan of care with the patient to address individual patient needs in order to prevent the patient from eloping.

q. On 10/24/23 at 10:45 to 12:00 PM, Staff M, Patient Care Tech (PCT)/1:1 Sitter documented continuous 1:1 supervision of the patient on a flow sheet. The flow sheet included instructions for the staff to circle the type of 1:1 observation they provided including suicide precautions, elopement precautions, aggression precautions and fall precautions. The form lacked any type of indication of what type of precautions Staff M, PCT, monitored. Staff M, PCT, did not document whether or not the patient was upset or displaying any behaviors.

r. On 10/24/23 at 11:24 AM, Staff H, PCT, documented delivering the patient's lunch to the patient's ED room.

s. On 10/24/23 at 12:00 PM RN G documented Patient #13 asked the 1:1 sitter to go to the bathroom. Patient #13 opened the door to ED Room #4, ran past staff and eloped from the ED. Security and police were contacted by nursing.

t. On 10/24/23 at 5:50 PM Dr. S documented that the patient would not sign a contract for safety; the patient remained a danger to him/herself. Dr S documented the following in an addendum note: "Sometime after the involuntary hold was placed [Patient #13] asked staff to use the restroom, after taking a few steps out of the room [Patient #13] eloped from the emergency department. Police were notified, at this time [Patient #13] has not been located."

u. On 10/24/23 at 6:15 PM RN B documented Patient #13 was brought back into the ED by law enforcement. RN B reported Patient #13 was tearful at times but very cooperative with staff.

v. On 10/24/23 at 9:00 PM RN B documented Hospital W stated they were no longer able to accept Patient #13.

w. On 10/24/23 at 10:16 PM ED Dr. C documented Hospital X called with acceptance of Patient #13.

x. On 10/24/23 at 10:40 PM RN B documented a court order was from Magistrate U for Patient #13 to be transferred to Hospital X.

y. On 10/25/23 at 12:30 AM RN B documented law enforcement served Patient #13 committal paperwork.

z. On 10/25 23 at 5:00 AM RN B documented Patient #13 slept through the night without incident and remained on suicide precautions with 1:1 sitter observation and security outside room.

aa. On 10/25/23 at 6:17 AM RN D documented Patient #13 was escorted to the restroom and into the secure car for law enforcement transport to Hospital X. RN D also noted Hospital X was notified that Patient #13 was in transport.

7. The hospital's Department of Public Safety (Hospital Security) incident report completed by the Supervisor of Public Safety, dated 10/24/23 at 12:01 PM, revealed the House Supervisor closed the door to the Patient #13's ED room while assisting another patient. Patient #13 immediately opened the door and broke into a full sprint. The House Supervisor and the patient the House Supervisor was assisting blocked Patient #13's 1:1 Sitter from getting to the patient. The patient ran in front of the ambulance as the ambulance was attempting to leave the ambulance bay. The Supervisor of Public Safety reported being contacted at 12:02 PM about the incident and he responded by going to look for the patient.

8. During an interview on 12/21/23 at 9:40 AM, Patient Care Technician (PCT) M reported Patient #13 requested to go to the bathroom. PCT M stood up to ask ED Nurse Manager if Patient #13 could go to the bathroom. Patient #13 exited Room #4 quickly past PCT M and House Supervisor O who was walking by Room #4 and ran out the ED door. PCT M reported being unable to stop Patient #13 from eloping.

On 4/3/24 at 12:05 PM, during an interview, PCT M reported the patient was calm and eating lunch prior to the patient's elopement. PCT M explained PCT M had just reported to the patient's ED nurse prior to the elopement that the patient's behavior had improved and the patient was calm. PCT M explained that if a patient did become agitated, PCT M would immediately notify the nurse and ask for security. PCT M explained the security office was right next to the ED.

9. During an interview on 12/20/23 at 8:30 AM, ED Nurse Manager reported using the BARS-H assessment or a Moderate to High score on Columbia Suicide Screening scale to determine the need for a 1:1 sitter. The ED Nurse Manager confirmed hospital staff had not placed signs noting "At-risk" outside the patient's room. The ED Nurse Manager did not recall the patient being at high risk for elopement. The ED Nurse Manager reported the patient had been placed in fabric scrubs. The ED Nurse Manager reported being at the nurses station just prior to the patient's elopement. The patient wanted to go to the restroom. The ED Nurse Manager reported they had been in the process of telling the sitter to escort Patient #13 to the restroom, and at the same time, the House Supervisor walked past Patient #13's room while walking another patient to their room. Patient #13 asked House Supervisor O if the patient could go to the bathroom at that time and House Supervisor O responded "in a minute" and shut Patient #13's door. The ED Nurse Manager reported Patient #13 quickly opened the door to Room #4 and sprinted past 2 employees out the ED entrance. The ED Nurse Manager reported Patient #13 ran down the ambulance ramp immediately at which point camera footage was lost. The ED Nurse manager reported being unable to stop Patient #13 from eloping. The ED Nurse Manager reported when a court hold was obtained for a patient, hospital staff increased the security presence.

10. On 12/20/23 at 11:30 AM, during an interview, the Public Safety Supervisor reported that hospital staff had 3 ways to contact security to assist with patients that were an elopement risk. Public Safety Supervisor explained security personnel had logged a total of 25,000 minutes so far this year (2023) sitting with court committal patients. Public Safety Supervisor reported Patient #13 was a suicide risk, not a court committal.

The hospital had the capability to utilize security guards in the hospital 24/7. The hospital had an unwritten procedure for contacting security to assist with patients under a court committal or who were agitated. The hospital failed to have a written policy in place that specified when the use of security personnel should be utilized to help maintain the safety of patients at risk for elopement.

Based on medical record review, hospital policy review and staff interviews, the Hospital's administrative staff failed to ensure emergency department (ED) staff provided, within their capabilities, the appropriate stabilizing treatment for 1 of 20 sample patients (Patient #13) for patients that presented to the ED seeking medical care from 6/15/23 to 12/14/23 and had an emergency medical condition (EMC).

Failure to provide all appropriate stabilizing treatment at the ED resulted in Patient #13 eloping from the ED and placed the patient at risk for injury or death.

Findings include:

1. During an interview on 3/18/24 at 9:30 AM, the ED Nurse Manager reported the hospital had security guards available 24/7 for the whole hospital . The ED Nurse Manager confirmed the hospital had a policy to utilize one to one sitters for high risk patients. The ED Nurse Manager reported the hospital did not have a policy that required a security presence. The ED Nurse Manager added if the patient was agitated or found to be a flight risk they would call and ask if security was available.

2. Review of Patient #13's medical record revealed:

a. On 10/23/23 at 9:39 AM, ambulance staff brought Patient #13 to the ED. Patient #13 presented to the ED with intentional overdose. Police reported Patient #13 posted on Facebook they were taking pills to kill themselves and police responded to a welfare check. Police brought multiple pill bottles in with the patient.

b. On 10/23/23 at 9:42 AM to 10:00 AM, Triage Registered Nurse (RN) G completed a Columbia Suicide Risk assessment that placed Patient #13 at high risk for suicide. RN G completed a BARS-H (behavioral agitation rating scale) assessment which identified the patient was quiet, awake and without agitation. RN G completed a psychosocial assessment which identified the patient was intermittently agitated and displayed restlessness, hyperactivity, impulsiveness, depression, anxiety, behavior noncompliance with instruction, incoherence with poor judgement and moderate confusion. ED staff moved Patient #13 to ligature free ED Room #4, placed the patient on suicide precautions with 1:1 observation, assigned a sitter, and had the patient change into hospital scrubs.

c. On 10/23/23 at 9:48 AM Dr. E medically evaluated Patient #13 and documented the following differential diagnoses: overdose, drug ingestion, suicidal attempt, suicidal ideations, homicidal ideations, psychiatric problem and psychiatric disorder. Dr. E ordered screening lab work including a drug screen, ethanol level, and telehealth psychiatric consult. The drug screen returned positive for amphetamines, methamphetamines, and tricyclics.

d. On 10/23/23 at 10:49 AM, ED nursing staff documented a family member reported the patient's spouse left the patient 2 weeks ago.

e. On 10/23/23 at 10:59 AM, ED nursing staff documented a second family member reported the patient had been voicing suidical ideation for the last couple weeks.

f. On 10/23/23 at 4:26 PM, ED nursing staff documented a psychosocial assessment that included a suicide check. ED nursing staff documented the patient was calm, cooperative and having difficulty staying awake. The patient continued to have 1:1 observation.

g. On 10/23/23 at 6:33 PM, ED nursing staff documented the patient was awake and wanted to go home. ED nursing staff documented they explained to the patient the need for a psychiatric evaluation prior to determining if the patient could leave.

h. On 10/23/23 at 7:47 PM, ED nursing staff documented that they informed the patient of the psychiatric provider's recommendation for inpatient treatment. The patient voiced understanding.

i. On 10/23/23 at 7:52 PM Provider V documented the evaluation of Patient #13 as follows, "HIGH risk (previous attempt- today, substance use, loss of relationship, chronic health issue- hearing impairment, increased anger and anxiety, making suicidal threats and plans, etc.). In light of today's presentation and collateral information expressing ongoing concerns for safety, inpatient psychiatric hospitalization for safety and stabilization is warranted."

j. On 10/24/23 at 7:15 AM, ED nursing staff documented the patient no longer needed a 1:1 sitter and that Dr. S would make a note of this in the patient's chart.

k. On 10/24/23 at 8:06 AM RN D documented Patient #13 stated they slept well and denied any suicidal thoughts.

l. On 10/24/23 at 9:46 AM RN G documented Hospital W called with acceptance of Patient #13.

m. On 10/24/23 at 9:51 AM, Dr S documented the patient's understanding and signature on the Consent to Transfer form.

n. On 10/24/23 at 10:32 AM RN G documented Patient #13 became irritable, Patient #13 did not want to be transferred and wanted to go home. Patient #13 reported the patient was no longer suicidal. Dr. S spoke to Patient #13 and Dr. S determined the need to obtain a court order to hold the patient in the ED for treatment.

o. On 10/24/23 at 10:35 AM ED Dr. S obtained a court order from Magistrate U for Patient #13 to be transferred to Hospital W.

Review of the court order, dated 10/24/23 at 10:35 AM, revealed the judge ordered the patient to be detained in custody at the hospital for examination and care for a period not to exeed 48 hours. The judge found probable cause to believe the patient was seriously mentally impaired, and because of that impairment, the patient was likely to injure him/herself or others.

p. On 10/24/23 at 10:38 AM, ED nursing staff documented they placed the patient on Suicide Interventions, high risk with 1:1 continuous observation. At 10:40 AM, ED nursing staff notified the House Superviser that the patient was back on a 1:1. At 10:53 AM, Dr S documented the patient required a 1:1 sitter, but did not specify why the patient required the sitter.

The clinical record lacked evidence of the following: ED nursing staff completed an updated BARS-H to assess the patient's level of agitation, assessed the patient's risk for elopement, placed the patient on At Risk Precautions for elopement, discussed with the physician any additional necessary interventions to prevent elopement (such as utilize security personnel) and lacked evidence ED staff developed a plan of care with the patient to address individual patient needs in order to prevent the patient from eloping.

q. On 10/24/23 at 10:45 to 12:00 PM, Staff M, Patient Care Tech (PCT)/1:1 Sitter documented continuous 1:1 supervision of the patient on a flow sheet. The flow sheet included instructions for the staff to circle the type of 1:1 observation they provided including suicide precautions, elopement precautions, aggression precautions and fall precautions. The form lacked any type of indication of what type of precautions Staff M, PCT, monitored. Staff M, PCT, did not document whether or not the patient was upset or displaying any behaviors.

r. On 10/24/23 at 11:24 AM, Staff H, PCT, documented delivering the patient's lunch to the patient's ED room.

s. On 10/24/23 at 12:00 PM RN G documented Patient #13 asked the 1:1 sitter to go to the bathroom. Patient #13 opened the door to ED Room #4, ran past staff and eloped from the ED. Security and police were contacted by nursing.

t. On 10/24/23 at 5:50 PM Dr. S documented that the patient would not sign a contract for safety; the patient remained a danger to him/herself. Dr S documented the following in an addendum note: "Sometime after the involuntary hold was placed [Patient #13] asked staff to use the restroom, after taking a few steps out of the room [Patient #13] eloped from the emergency department. Police were notified, at this time [Patient #13] has not been located."

u. On 10/24/23 at 6:15 PM RN B documented Patient #13 was brought back into the ED by law enforcement. RN B reported Patient #13 was tearful at times but very cooperative with staff.

v. On 10/24/23 at 9:00 PM RN B documented Hospital W stated they were no longer able to accept Patient #13.

w. On 10/24/23 at 10:16 PM ED Dr. C documented Hospital X called with acceptance of Patient #13.

x. On 10/24/23 at 10:40 PM RN B documented a court order was from Magistrate U for Patient #13 to be transferred to Hospital X.

y. On 10/25/23 at 12:30 AM RN B documented law enforcement served Patient #13 committal paperwork.

z. On 10/25 23 at 5:00 AM RN B documented Patient #13 slept through the night without incident and remained on suicide precautions with 1:1 sitter observation and security outside room.

aa. On 10/25/23 at 6:17 AM RN D documented Patient #13 was escorted to the restroom and into the secure car for law enforcement transport to Hospital X. RN D also noted Hospital X was notified that Patient #13 was in transport.

3. The hospital's Department of Public Safety (Hospital Security) incident report completed by the Supervisor of Public Safety, dated 10/24/23 at 12:01 PM, revealed the House Supervisor closed the door to the Patient #13's ED room while assisting another patient. Patient #13 immediately opened the door and broke into a full sprint. The House Supervisor and the patient the House Supervisor was assisting blocked Patient #13's 1:1 Sitter from getting to the patient. The patient ran in front of the ambulance as the ambulance was attempting to leave the ambulance bay. The Supervisor of Public Safety reported being contacted at 12:02 PM about the incident and he responded by going to look for the patient.

4. During an interview on 12/20/23 at 9:28 AM, ED Staff RN G reported Patient #13 was calm and
cooperative the morning of 10/24/23 and then suddenly the patient was not when the patient ran past the one to one
sitter.

5. On 12/20/23 at 9:46 AM, during an interview, Patient Care Technician (PCT) H reported being aware of a patient's risk of elopement through computer documentation of screening the nurses do during the initial triage assessment and every shift. PCT H explained the ED staff communicate verbally when they think has increased agitation. When asked how ED staff ensure court committal patients do not elope, PCT H reported they make sure the patient has a sitter or security if the patient was agitated.

6. During an interview on 12/21/23 at 9:40 AM, PCT M/1:1 Sittier reported Patient #13 requested to go to the bathroom. PCT M stood up to ask ED Nurse Manager if Patient #13 could go to the bathroom. Patient #13 exited Room #4 quickly past PCT M and House Supervisor O who was walking by Room #4 and ran out the ED door. PCT M reported being unable to stop Patient #13 from eloping.

On 4/3/24 at 12:05 PM, during an interview, PCT M reported the patient was calm and eating lunch prior to the patient's elopement. PCT M explained PCT M had just reported to the patient's ED nurse prior to the elopement that the patient's behavior was calm. PCT M explained the patient got up during a code blue alert (a code used to alert staff a patient has had had an unexpected cardiac or respiratory arrest) and requested to use the restroom. PCT M explained that if a patient did become agitated, PCT M would immediately notify the nurse and ask for security. PCT M explained the security office was right next to the ED.

7. During an interview on 12/20/23 at 8:30 AM, ED Nurse Manager reported using the BARS-H assessment or a Moderate to High score on Columbia Suicide Screening scale to determine the need for a 1:1 sitter. The ED Nurse Manager confirmed hospital staff had not placed signs noting "At-risk" outside the patient's room. The ED Nurse Manager did not recall the patient being at high risk for elopement. The ED Nurse Manager reported the patient had been placed in fabric scrubs. The ED Nurse Manager reported being at the nurses station just prior to the patient's elopement. The patient wanted to go to the restroom. The ED Nurse Manager reported they had been in the process of telling the sitter to escort Patient #13 to the restroom, and at the same time, the House Supervisor walked past Patient #13's room while walking another patient to their room. Patient #13 asked House Supervisor O if the patient could go to the bathroom at that time and House Supervisor O responded "in a minute" and shut Patient #13's door. The ED Nurse Manager reported Patient #13 quickly opened the door to Room #4 and sprinted past 2 employees out the ED entrance. The ED Nurse Manager reported Patient #13 ran down the ambulance ramp immediately at which point camera footage was lost. The ED Nurse manager reported being unable to stop Patient #13 from eloping. The ED Nurse Manager reported when a court hold was obtained for a patient, hospital staff increased the security presence.

8. On 12/20/23 at 11:30 AM, during an interview, the Public Safety Supervisor reported that hospital staff had 3 ways to contact security to assist with patients that were an elopement risk. Public Safety Supervisor explained security personnel had logged a total of 25,000 minutes so far this year (2023) sitting with court committal patients. Public Safety Supervisor reported Patient #13 was a suicide risk, not a court committal.

9. During an interview on 12/21/23 at 10:30 AM, House Supervisor O reported walking through the ED doors and Patient #13 was standing in Room #4 starting to open the door, so House Supervisor O shut the door to Room #4. At that time Patient #13 pushed the door open and ran out the ED door. House Supervisor O reported being unable to stop Patient #13 from eloping. House Supervisor O reported going after the patient and asked the patient to come back. The ED Nurse Manager and a security guard were running after the patient outside. The patient had been calm and cooperative and the patient's elopement had been a total surprise to all of the staff.

10. During an interview on 12/28/23 at 2:06 PM, Dr. S confirmed after the psychiatric evaluation, hospital staff obtained bed placement and a court order. Staff S reported Patient #13 appeared to be calm and cooperative
and did not appear to be a flight risk prior to the elopement.

11. During an interview 12/21/23 at 10:00 AM, ED Medical Director acknowledged since a court hold had been obtained for Patient #13, security presence should have been utilized.

12. During an interview 12/28/23 at 6:17 PM, Officer T recalled responding to a call notifying law enforcement Patient #13 was at home. Officer T reported finding Patient #13 walking around outside of the home and returned the patient to the ED without incident.


Review of Patient #13's medical record, law enforcement reports and staff interviews showed Patient #13 was a high risk for suicide and elopement. The patient was a safety risk to them self and others due to their illness. The hospital failed to provide Patient #13 appropriate stabilizing treatment while being held in the ED waiting for transport to an inpatient psychiatric facility. The hospital failed to provide interventions, within the hospital's capabilities, to assure Patient #13's safety while in their ED, which allowed Patient #13 to elope from the ED putting them self and others at risk for injury or harm.