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Based on hospital policy review, closed medical record review, company police log review, video taped footage review, and interviews with company police officers, physicians, and nursing staff, the hospital failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 1 of 30 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patient #3).

The findings include:

Review of the hospital's current policy "E.M.T.A.L.A. Compliance...." Policy Number H-PC-800-01, revised April, 2011 revealed "...LEGAL DUTIES IMPOSED: Hospital must provide an appropriate medical screening exam without delay to persons presenting for care, to determine whether and emergency medical condition exists. If an emergency medical condition does exist, the Hospital must: 1. stabilize the medical condition, or if unable to stabilize, 2. transfer the patient to a hospital that is capable of stabilizing the medical condition. ...BASIC LEGAL REQUIREMENTS: - Any person presenting to the Hospital seeking care for an emergency medical condition must be given appropriate medical screening examination by a qualified medical person to determine whether an emergency medical condition exist. - If an emergency medical condition exists, the patient must either be stabilized, or if unable to be stabilized, the patient must be transferred to a hospital that is capable of stabilizing condition. ...PROCEDURE: ...*Provide for an appropriate medical screening examination; * Provide necessary stabilizing treatment for emergency medical condition and labor within the hospital's capability and capacity; * Provide an appropriate transfer of an unstabilized individual to another medical facility...."

Closed medical record review for Patient #3 revealed a 47 year-old male whose recent admission to Hospital A (prior to the admission named in the complaint) was from June 17-21, 2011, during which time he was treated for depression and alcohol dependence on the inpatient behavioral health unit. Record review revealed on June 21, 2011 he was discharged to home with follow up outpatient appointments scheduled at the community mental health center and plans to attend Alcoholics Anonymous meeting. Further closed medical record review for Patient #3 revealed the patient presented to Hospital A's DED on 07/27/2011 at 1536 accompanied by a city police officer under an involuntary commitment (IVC) order. Review of the Affidavit and Petition for Involuntary Commitment papers, signed by the city police officer and Magistrate on 07/27/2011, revealed, "Responded to a call in which respondent was in the woods with a gun. Respondent has the gun pointed at his eye and stated that he wanted to kill himself." Record review revealed nursing staff in the DED triaged the patient at 1622. Review of the triage assessment revealed, "...had gun to his head in woods today. SI (suicidal ideations) ....patient has had thoughts of harming self ....Acuity: 2 (on a scale of 1 to 5, with 1 being most acute/urgent). Chief Complaint: Suicidal Thoughts. "Record review revealed the patient was placed in a hallway bed on the behavioral health hall in the DED. Record review revealed the Behavioral Medicine Intake Referral Specialist (RN #1) evaluated the patient at 1808. Review of the Behavioral Intake Referral/Assessment Information form completed by RN #1 revealed, "...client with a history of depression and alcohol dependence, brought by police on petition after putting gun to head, relapsed on alcohol on day of d/c (discharge) from (Hospital A) ....Suicide Risk Assessment: ....plan to shoot self with gun, had gun in hand, removed by police ....History of Suicide Attempts: Yes ....june 2011 ...overdosed ....Hospitalized ...(Hospital A) ....Alcohol and Drug Use: ...ALCOHOL: ...Amount Used: ? gallon vodka Avg. # of Days Used/Week: 7 ....History of Seizures: Yes History of Blackouts: Yes ...PILLS: Name: percocets ....Date Last Used: unsure Amount Used: 15 Avg. # of Days Used/Week: 7 .... Have you ever been in detox or rehab? Yes ....Disposition: Nursing Diagnosis ...:Actively Suicidal Depression Alcohol Withdrawal. Based on the suicide assessment the Behavioral Medicine Intake Referral Specialist has determined the patient to be actively suicidal and has consulted with the on call Psychiatrist: (Physician #2) Date Notified: 27-Jul-11 Time Notified: 06:00 (p.m.) The Psychiatrist recommended the following: to be determined pending med(ical) clearance ....ED Physician: (Physician #1) notified of the recommended disposition ....Clinical Findings: suicidal with plan and intent/relapsed on alcohol/ivc ...." Record review revealed documentation the DED physician (Physician #1) evaluated the patient on 07/27/2011 at 1845. Review of Physician #1's notes (as read to surveyor by the physician) revealed, "HPI (history of present illness): chief complaint: suicidal thoughts ....onset/duration: today ....associated symptoms: suicidal thoughts ...loaded gun at home ....LIST OF SUBSTANCES INGESTED ....vodka ? gallon qd (each day) x 2 months ....PAST HX (history) ...COPD (chronic obstructive pulmonary disease) ....Medications ...pain pills ....) Further review of Physician #1's notes revealed the physician also completed a physical examination of the patient, at which time he found all systems to be within normal limits, with the exception of "wheezes" being noted during evaluation of the patient's breath sounds. Record review revealed at 1626 Physician #1 ordered the following lab tests: serum acetaminophen level, comprehensive metabolic panel, serum salicylate level, thyroid stimulating hormone level, urinalysis, and urine drug screen. Further record review revealed at 1626 Physician #1 ordered and nursing staff administered an intravenous bolus of 1-liter of normal saline. Record review revealed at 1802 Physician #1 ordered a serum ethanol level. Record review revealed the lab tests were completed and resulted at 1818. Review of Physician #1's notes revealed the physician reviewed the lab results and found the urine drug screen was positive for cocaine and opiods, the serum creatinine level was 2.12 (high), and the serum ethanol level was 212 (0.212% - high). Further record review revealed at 1842 Physician #1 ordered for the patient to intravenously receive 1 bag of normal saline with multivitamins, folate, thiamine, and magnesium sulfate added to the bag daily. Record review revealed nursing staff intravenously administered 1 bag of normal saline with multivitamins, folate, thiamine, and magnesium sulfate added to the bag at 2240. Record review revealed at 1850 Physician #1 ordered a one time respiratory inhalation treatment of Atrovent (bronchodilator) and Xopenex (bronchodilator). Record review revealed the respiratory inhalation treatment was administered to the patient by the respiratory care provider at 1944. Review of orders at 1908 revealed an order for a second 1-liter bolus of normal saline to be given intravenously, which the nursing staff administered at 1908. Record review revealed at 2120 Physician #1 ordered for a basic metabolic panel (BMP) with total calcium to be done. Record review revealed the BMP was completed and resulted at 2318. Review of Physician #1's notes (as read to surveyor by the physician) revealed the patient's serum creatinine level decreased to 1.43 and the patient was receiving his third liter of intravenous fluid. Review of Physician #1's notes revealed, "CLINICAL IMPRESSION Ethanol Intoxication ...Suicide Attempt ...dehydration/hypotension/renal failure - resolved w/ fluids. Time (illegible) (checked) admitted ...Condition- (checked) fair)." Review of nursing notes on 07/27/2011 at 2336 revealed, "Pt (patient) has no complaints of pain at present states feeling slightly shaky, MD aware. Denies any homicidal or suicidal ideation at present, (contracted company police officer) at bedside." Record review revealed the patient remained alert, oriented, and cooperative throughout the night of 07/27/2011. Record review revealed the patient was moved into room P3 at about 0500 on 07/28/2011. Review of RN #1's (Behavioral Medicine Intake Referral Specialist) notes on 07/28/2011 at 1018 revealed, "all clinical received by Mental Health, authorization for ADATC (Alcohol and Drug Abuse Treatment Center) pending." Review of RN #1's notes at 1236 revealed, "client has documented felony convictions for assault with a deadly weapon/indecent liberty w/child/conspiracy to escape from prison, multiple breaking and entering and larceny convictions/felony convictions for drug possession and conspiracy to sell scheduled drugs, has spent time incarcerated a total of 11 years/3mos, has been involuntarily committed twice and is facing charges for possession of firearm, which as a convicted felon he was no supposed to have in his possession ....pending acceptance to (Hospital B)/ADATC." Review of Physician #3's progress notes dated 07/28/2011 at 2234 revealed, "Pt c (with) mild tremulousness during shift. CIWA (Clinical Institute Withdrawal Assessment) ordered. Awaiting ADATC bed." Further record review revealed medications ordered by DED physicians and given by nursing staff as ordered while the patient was in the DED awaiting transfer to an ADATC bed included Ativan, Folic Acid, Haldol, Magnesium Oxide, Multivitamin, and Thiamine. Record review revealed the patient remained alert, oriented, and cooperative throughout the day and evening of 07/28/2011. Review of RN #2's notes on 07/28/2011 revealed, "(at 2300) report received, care assumed, family at bedside ....(at 2320) family member leaving, pt conversing goodnights ....at 2324 (Company Police Officer [CPO] #1) noticed pt not in room, other doorway was found to be unlocked, search was made of grounds, unable to find pt, 20 gauge (intravenous) catheter found on floor."

Review of the Company Police Department's Respondent Acceptance Log dated 07/27/2011 - 07/28/2011 revealed documentation by CPO staff of the Patient #3's location and behavior every 30 minutes from 07/27/2011 at 1530 through 07/28/2011 at 2300. Review of the Log revealed no documentation the patient showed indications of planning to elope from the hospital prior to his elopement on 07/28/2011 at 2324.

Review of video taped footage revealed the following events on 07/28/2011:
?2019: Patient #3 in ED Behavioral Health hallway. Speaks to CPO then goes back to room P3.
?2105: Patient #3's female visitor goes in to hall and gets cup from CPO and returns to room P3.
?2115: Female visitor leaves ED and walks towards parking lot.
?2120: Patient #3 walks up hall towards restroom (out of view) with CPO.
?2122: Patient #3 back in room P3.
?2219: Female visitor returns to room P3.
?2223: Patient #3 and CPO walk toward restroom.
?2225: Patient #3 returns to P3.
?2237: Patient #3 in hallway without shirt on and wiping face. Talks to CPO then returns to room.
?2253: Patient #3 enters hall and walks towards restroom with CPO.
?2256: Patient #3 returns to room P3.
?2259: Female visitor leaves and goes to vending area in waiting room. Returns to treatment area at 2301 with canned drink in hand.
?2320: RN #2 visible at nurse's desk in hallway immediately outside of Behavioral Health rooms (including room P3). Also visible in hallway are 2 Police Officers.
?2321: Patient leaves front hallway door (not visible from Behavioral Health hallway) wearing white shirt, blue shorts, and no shoes. Walks to waiting area and exits the ED through the Walk In doors. At the same time, the female visitor enters the Behavioral Health hallway from room P3 and talks to the CPO. 3 staff members are visible in this hallway. She then leaves the treatment area, walks to the waiting area, and exits the ED through the Walk In doors, behind Patient #3.
? 2322: 2 Police Officers walk back through the Behavioral Health hallway and out of the treatment area.
?2326: CPO #1 looks in room P3 and begins to search the area.

Interview on 01/11/2012 at 1500 with CPO #1 revealed on 07/28/2011 the CPO was on duty in the DED from 1600 until midnight. Interview revealed the CPO's duty in the DED was to "look after the involuntary patients". Interview revealed the CPO walked the hallway in the behavioral health area of the DED continuously where the patient's doorways were visible. Interview revealed, "Nursing staff is in the middle of the (behavioral health) hallway. They check patients more than I do. The hall is generally full of staff. There's always one to two nurses on the hallway." Interview revealed the CPO recalled Patient #3. Interview revealed, "(On 07/28/2011) he was friendly and communicative ....not causing any issues. He was originally in blue scrubs. I don ' t recall if he said he wanted to leave. A lot of them (IVC patients) say they want to leave ....His wife or girlfriend (female visitor) came and left several times during the day ....There was an extra door from his room (P3) to another hallway (not visible from the behavioral health hallway). It's a corner room. I had checked the (extra) door earlier (in the shift) and it was locked." Interview revealed the "extra door" locks from the outside and should stay locked at all times. Interview revealed in July 2011 the type of lock on the door was a flip-style lock (not keyed). Interview revealed, "We (CPO staff) routinely checked on the door to make sure it was locked ....We had to check it when we reported in." Further interview revealed visitors should enter the behavioral health area by walking through DED and then down the behavioral health hallway, where the CPO constantly walked. Interview revealed at one point in the shift (unsure of time) the CPO found the female visitor in the patient's room, but had not seen her enter the room. Interview revealed, "I asked her how she had come in and she said 'through that door' (the extra door) ....I told her that door is locked from the outside. I checked and she had unlocked the door. I told her she must come and go through our door instead. She said 'okay'. I relocked the second door." Further interview revealed another female visitor arrived at about 1930. Interview revealed, "She came in the normal door. She came in and out several times ....She was very friendly, not doing anything out of the ordinary ....She asked if she could help him clean up at the sink in his room. I could see him at the sink. He had his shirt off and his bottom scrubs still on. She helped him clean up from the waist up. She left about 15 minutes after that. She came back 2 more times after that. The third time, about 2320, she came up and spoke to the nurse and thanked everyone and left. At that time he was in his room. We think she gave him shorts and unlocked the other door. She had to walk by it (other door) to get in. About 3 or 4 minutes after she left, I went to his room to check on him and he was gone. I walked down the hall towards the bathroom. I told the nurse to call BPD (off-duty City Police Officer works in the DED at the front desk) backup and to watch the hallway. I went to the second door (into room P3) and saw it was unlocked ....Once BPD started looking (for Patient #3), I went back to my duty of watching the other patients." Interview revealed soon after the incident (unsure of date) the lock on the extra door in room P3 was changed to a keyed lock to prevent unauthorized people from unlocking the door. Interview revealed in July 2011 CPO staff that monitored involuntary patients visualized the patients at least every 30 minutes and documented these checks on the (Respondent Acceptance) Log. Interview revealed CPO staff now visualized the patients at least every 15 minutes and documented these checks on the (Respondent Acceptance) Log. Interview revealed another change in process as a result of the elopement was the addition of a second CPO to assist in monitoring involuntary patients when the census of involuntary patients is high (more that 4).

Interview on 01/12/2012 at 0815 with RN #2 revealed the nurse was on duty on 07/28/2011 when Patient #3 eloped. Interview revealed the nurse took report on the patient and assumed his care at 2300. Interview revealed, "I was sitting at the desk and noticed a female family member standing in the doorway (at the end of the behavioral health hallway beside room P3) telling him (Patient #3) goodnight. She exited the doors ....I never saw the patient. I had not assessed him yet. At shift report they said he was calm, cooperative, and pleasant. (There were) no red flags that a behavioral issue was coming on ....He was awaiting placement elsewhere ....There was a police officer in the hallway." Interview revealed a little bit later, CPO #1 told RN #2 that the patient was not in his room. Interview revealed, "He (CPO #1) called the officer out front and they searched the grounds. I told the Charge Nurse and we looked in and out of our facility. I checked the hallways around the ER area ....The Charge Nurse was looking too." Further interview revealed the facility had implemented some process changes soon after the elopement. Interview revealed, "The door that had a flip lock is now a keyed lock. The Nursing Supervisor and Charge Nurse have the key. The door is locked at all times ....We had 2 officers for the longest time there in the hallway. Most days we have up to 4 involuntary patients and have 1 officer. If more patients (than 4) they call in a second officer." Interview revealed nursing staff were re-educated to assessment of behavioral health patients, including the use of sitters (with a physician's order) for patients found to be at high risk for suicide.

Interview on 01/11/12 at 1645 with Physician #1 revealed the physician evaluated Patient #3 on 07/27/2011 when he presented to the DED. Interview revealed the patient was involuntarily committed and needed inpatient behavioral health treatment because "police found him with a gun to his head and he was suicidal". Interview revealed nursing staff and "somebody else" sat in the hallway to watch the involuntary patients. Interview revealed, "This (07/28/2011) was before we could definitely have a sitter ....Now we have more sitters and our own police officers are present all the time. The nurse and physician get together and decide if a sitter is needed ....It (sitter) must be ordered (by the physician). I would order a sitter if I thought (a patient was a) flight risk or if I thought (the patient) would hurt (his)self if in (the)room by (his)self ....Management of (behavioral health) patients while here (in DED) is a lot better."

Interviews were requested with Physician #3 (other DED physician that treated Patient #3) and RN #1 (Behavioral Medicine Intake Referral Specialist). Per administrative staff, neither Physician #3 nor RN #1 were available for interview because neither of them were currently employed by the hospital.

Interview on 01/12/2012 with Physician #2 revealed the physician was the psychiatrist on duty on 07/27/2011 when Patient #3 presented to the DED. Interview revealed the intake nurse (Behavioral Medicine Intake Referral Specialist) assesses each behavioral health patient in the DED. Interview revealed the intake nurse then contacts the psychiatrist on call after the patient is medically cleared if the patient requires inpatient admission. Interview revealed, "The intake nurse doesn't always call the psychiatrist. They may plan (the patient's) disposition with the ED physician." Further interview revealed, "The intake nurse called me (about Patient #3) and told me the patient was suicidal and the labs were pending. We needed medical clearance before disposition." At this point during the interview, Physician #2 reviewed the patient's medical record. Further interview revealed, "Our unit was full and with his alcohol dependence problems he needed detox. A referral to (Hospital B)/ADATC was appropriate. The behavioral intake nurse and ED physician determined his disposition." Interview on 01/11/2012 at 1630 with the Director of Behavioral Medicine (inpatient behavioral health unit) revealed the unit routinely staffs for a maximum capacity of 25 patients. Interview revealed the patient census on 07/28/2011 was 25 (maximum capacity). Review of staffing sheets during the interview confirmed the unit had no available beds on 07/28/2011.

Further closed medical record review for Patient #3 revealed the patient presented to the Hospital C's DED on 07/29/2011 at 0416 (4 hours and 52 minutes after he eloped from Hospital A's DED) via emergency medical services with a gunshot wound (GSW) to his head. Review of DED resident physician documentation at 0735 revealed, "05:20. Pt is middle aged male presenting via EMS after self inflicted GSW w/ 22 gauge bullet to head. Pt was also tazed in the face by police, although unclear what happened first. Pt had GCS (Glascow Coma Scale) of 5-6, intubated on arrival for airway protection. Pt hemodynamically stable. Pt also had tazer imbedded to face with barb in place. Tazer was removed with injury to skin. Pt went to CT (computed tomography) scan and then up to SICU (surgical intensive care unit) for further management. Discussed case with (attending physician). Consult obtained from neurosurgery. Will see patient in the hospital ....Admitted to Trauma Surgery. Clinical Impression: Self-inflicted gunshot wound." Review of the neurosurgical consult note dictated on 07/29/2011 at 0829 revealed, "CT head ...demonstrates metallic fragments and hemorrhage traversing brain ...." Record review revealed the patient was treated and subsequently discharged to on 11/04/2011. Review of the physician's discharge summary dated 11/04/2011 at 1234 revealed, "The patient was taken to the OR on 7/29/2011 for endoventricular drain placement. He tolerated the procedure well, was extubated in the OR, and was transferred to the Neurosciences ICU ....He returned to the OR on 8/5/11 for tracheostomy (breathing tube in neck) tube and peg (feeding tube in stomach) tube placement. He was stable postoperatively and was transferred to the Intermediate surgical care unit on 8/14/11 and to the floor on 8/23/11. The patient continued to improve ...at the time of discharge he was tolerating G (feeding) tube feeds. Patient was voiding spontaneously through a condom catheter and have (had) his pain controlled with P.O. (by mouth) pain medication. He was assessed with serial neurological exams postoperatively which revealed improvement. The patient was assessed by Physical Therapy, Occupational Therapy and Speech Pathology and found to be suitable for discharge to home with 24/7 supervision. He will be discharged in stable condition."

Based on hospital policy review, closed medical record review, company police log review, video taped footage review, and interviews with company police officers, physicians, and nursing staff, the hospital failed to provide stabilizing treatment within its capacity and capability for 1 of 30 sampled DED patients pending admission and/or transfer with an emergency medical condition (Patients #3).

The findings include:

Review of the hospital's current policy "E.M.T.A.L.A. Compliance...." Policy Number H-PC-800-01, revised April, 2011 revealed "...LEGAL DUTIES IMPOSED: Hospital must provide an appropriate medical screening exam without delay to persons presenting for care, to determine whether and emergency medical condition exists. If an emergency medical condition does exist, the Hospital must: 1. stabilize the medical condition, or if unable to stabilize, 2. transfer the patient to a hospital that is capable of stabilizing the medical condition. ...BASIC LEGAL REQUIREMENTS: - Any person presenting to the Hospital seeking care for an emergency medical condition must be given appropriate medical screening examination by a qualified medical person to determine whether an emergency medical condition exist. - If an emergency medical condition exists, the patient must either be stabilized, or if unable to be stabilized, the patient must be transferred to a hospital that is capable of stabilizing condition. ...PROCEDURE: ...*Provide for an appropriate medical screening examination; * Provide necessary stabilizing treatment for emergency medical condition and labor within the hospital's capability and capacity; * Provide an appropriate transfer of an unstabilized individual to another medical facility...."

Closed medical record review for Patient #3 revealed a 47 year-old male whose recent admission to Hospital A (prior to the admission named in the complaint) was from June 17-21, 2011, during which time he was treated for depression and alcohol dependence on the inpatient behavioral health unit. Record review revealed on June 21, 2011 he was discharged to home with follow up outpatient appointments scheduled at the community mental health center and plans to attend Alcoholics Anonymous meeting. Further closed medical record review for Patient #3 revealed the patient presented to Hospital A's DED on 07/27/2011 at 1536 accompanied by a city police officer under an involuntary commitment (IVC) order. Review of the Affidavit and Petition for Involuntary Commitment papers, signed by the city police officer and Magistrate on 07/27/2011, revealed, "Responded to a call in which respondent was in the woods with a gun. Respondent has the gun pointed at his eye and stated that he wanted to kill himself." Record review revealed nursing staff in the DED triaged the patient at 1622. Review of the triage assessment revealed, "...had gun to his head in woods today. SI (suicidal ideations) ....patient has had thoughts of harming self ....Acuity: 2 (on a scale of 1 to 5, with 1 being most acute/urgent). Chief Complaint: Suicidal Thoughts. "Record review revealed the patient was placed in a hallway bed on the behavioral health hall in the DED. Record review revealed the Behavioral Medicine Intake Referral Specialist (RN #1) evaluated the patient at 1808. Review of the Behavioral Intake Referral/Assessment Information form completed by RN #1 revealed, "...client with a history of depression and alcohol dependence, brought by police on petition after putting gun to head, relapsed on alcohol on day of d/c (discharge) from (Hospital A) ....Suicide Risk Assessment: ....plan to shoot self with gun, had gun in hand, removed by police ....History of Suicide Attempts: Yes ....june 2011 ...overdosed ....Hospitalized ...(Hospital A) ....Alcohol and Drug Use: ...ALCOHOL: ...Amount Used: ? gallon vodka Avg. # of Days Used/Week: 7 ....History of Seizures: Yes History of Blackouts: Yes ...PILLS: Name: percocets ....Date Last Used: unsure Amount Used: 15 Avg. # of Days Used/Week: 7 .... Have you ever been in detox or rehab? Yes ....Disposition: Nursing Diagnosis ...:Actively Suicidal Depression Alcohol Withdrawal. Based on the suicide assessment the Behavioral Medicine Intake Referral Specialist has determined the patient to be actively suicidal and has consulted with the on call Psychiatrist: (Physician #2) Date Notified: 27-Jul-11 Time Notified: 06:00 (p.m.) The Psychiatrist recommended the following: to be determined pending med(ical) clearance ....ED Physician: (Physician #1) notified of the recommended disposition ....Clinical Findings: suicidal with plan and intent/relapsed on alcohol/ivc ...." Record review revealed documentation the DED physician (Physician #1) evaluated the patient on 07/27/2011 at 1845. Review of Physician #1's notes (as read to surveyor by the physician) revealed, "HPI (history of present illness): chief complaint: suicidal thoughts ....onset/duration: today ....associated symptoms: suicidal thoughts ...loaded gun at home ....LIST OF SUBSTANCES INGESTED ....vodka ? gallon qd (each day) x 2 months ....PAST HX (history) ...COPD (chronic obstructive pulmonary disease) ....Medications ...pain pills ....) Further review of Physician #1's notes revealed the physician also completed a physical examination of the patient, at which time he found all systems to be within normal limits, with the exception of "wheezes" being noted during evaluation of the patient's breath sounds. Record review revealed at 1626 Physician #1 ordered the following lab tests: serum acetaminophen level, comprehensive metabolic panel, serum salicylate level, thyroid stimulating hormone level, urinalysis, and urine drug screen. Further record review revealed at 1626 Physician #1 ordered and nursing staff administered an intravenous bolus of 1-liter of normal saline. Record review revealed at 1802 Physician #1 ordered a serum ethanol level. Record review revealed the lab tests were completed and resulted at 1818. Review of Physician #1's notes revealed the physician reviewed the lab results and found the urine drug screen was positive for cocaine and opiods, the serum creatinine level was 2.12 (high), and the serum ethanol level was 212 (0.212% - high). Further record review revealed at 1842 Physician #1 ordered for the patient to intravenously receive 1 bag of normal saline with multivitamins, folate, thiamine, and magnesium sulfate added to the bag daily. Record review revealed nursing staff intravenously administered 1 bag of normal saline with multivitamins, folate, thiamine, and magnesium sulfate added to the bag at 2240. Record review revealed at 1850 Physician #1 ordered a one time respiratory inhalation treatment of Atrovent (bronchodilator) and Xopenex (bronchodilator). Record review revealed the respiratory inhalation treatment was administered to the patient by the respiratory care provider at 1944. Review of orders at 1908 revealed an order for a second 1-liter bolus of normal saline to be given intravenously, which the nursing staff administered at 1908. Record review revealed at 2120 Physician #1 ordered for a basic metabolic panel (BMP) with total calcium to be done. Record review revealed the BMP was completed and resulted at 2318. Review of Physician #1's notes (as read to surveyor by the physician) revealed the patient's serum creatinine level decreased to 1.43 and the patient was receiving his third liter of intravenous fluid. Review of Physician #1's notes revealed, "CLINICAL IMPRESSION Ethanol Intoxication ...Suicide Attempt ...dehydration/hypotension/renal failure - resolved w/ fluids. Time (illegible) (checked) admitted ...Condition- (checked) fair)." Review of nursing notes on 07/27/2011 at 2336 revealed, "Pt (patient) has no complaints of pain at present states feeling slightly shaky, MD aware. Denies any homicidal or suicidal ideation at present, (contracted company police officer) at bedside." Record review revealed the patient remained alert, oriented, and cooperative throughout the night of 07/27/2011. Record review revealed the patient was moved into room P3 at about 0500 on 07/28/2011. Review of RN #1's (Behavioral Medicine Intake Referral Specialist) notes on 07/28/2011 at 1018 revealed, "all clinical received by Mental Health, authorization for ADATC (Alcohol and Drug Abuse Treatment Center) pending." Review of RN #1's notes at 1236 revealed, "client has documented felony convictions for assault with a deadly weapon/indecent liberty w/child/conspiracy to escape from prison, multiple breaking and entering and larceny convictions/felony convictions for drug possession and conspiracy to sell scheduled drugs, has spent time incarcerated a total of 11 years/3mos, has been involuntarily committed twice and is facing charges for possession of firearm, which as a convicted felon he was no supposed to have in his possession ....pending acceptance to (Hospital B)/ADATC." Review of Physician #3's progress notes dated 07/28/2011 at 2234 revealed, "Pt c (with) mild tremulousness during shift. CIWA (Clinical Institute Withdrawal Assessment) ordered. Awaiting ADATC bed." Further record review revealed medications ordered by DED physicians and given by nursing staff as ordered while the patient was in the DED awaiting transfer to an ADATC bed included Ativan, Folic Acid, Haldol, Magnesium Oxide, Multivitamin, and Thiamine. Record review revealed the patient remained alert, oriented, and cooperative throughout the day and evening of 07/28/2011. Review of RN #2's notes on 07/28/2011 revealed, "(at 2300) report received, care assumed, family at bedside ....(at 2320) family member leaving, pt conversing goodnights ....at 2324 (Company Police Officer [CPO] #1) noticed pt not in room, other doorway was found to be unlocked, search was made of grounds, unable to find pt, 20 gauge (intravenous) catheter found on floor."

Review of the Company Police Department's Respondent Acceptance Log dated 07/27/2011 - 07/28/2011 revealed documentation by CPO staff of the Patient #3's location and behavior every 30 minutes from 07/27/2011 at 1530 through 07/28/2011 at 2300. Review of the Log revealed no documentation the patient showed indications of planning to elope from the hospital prior to his elopement on 07/28/2011 at 2324.

Review of video taped footage revealed the following events on 07/28/2011:
?2019: Patient #3 in ED Behavioral Health hallway. Speaks to CPO then goes back to room P3.
?2105: Patient #3's female visitor goes in to hall and gets cup from CPO and returns to room P3.
?2115: Female visitor leaves ED and walks towards parking lot.
?2120: Patient #3 walks up hall towards restroom (out of view) with CPO.
?2122: Patient #3 back in room P3.
?2219: Female visitor returns to room P3.
?2223: Patient #3 and CPO walk toward restroom.
?2225: Patient #3 returns to P3.
?2237: Patient #3 in hallway without shirt on and wiping face. Talks to CPO then returns to room.
?2253: Patient #3 enters hall and walks towards restroom with CPO.
?2256: Patient #3 returns to room P3.
?2259: Female visitor leaves and goes to vending area in waiting room. Returns to treatment area at 2301 with canned drink in hand.
?2320: RN #2 visible at nurse's desk in hallway immediately outside of Behavioral Health rooms (including room P3). Also visible in hallway are 2 Police Officers.
?2321: Patient leaves front hallway door (not visible from Behavioral Health hallway) wearing white shirt, blue shorts, and no shoes. Walks to waiting area and exits the ED through the Walk In doors. At the same time, the female visitor enters the Behavioral Health hallway from room P3 and talks to the CPO. 3 staff members are visible in this hallway. She then leaves the treatment area, walks to the waiting area, and exits the ED through the Walk In doors, behind Patient #3.
? 2322: 2 Police Officers walk back through the Behavioral Health hallway and out of the treatment area.
?2326: CPO #1 looks in room P3 and begins to search the area.

Interview on 01/11/2012 at 1500 with CPO #1 revealed on 07/28/2011 the CPO was on duty in the DED from 1600 until midnight. Interview revealed the CPO's duty in the DED was to "look after the involuntary patients". Interview revealed the CPO walked the hallway in the behavioral health area of the DED continuously where the patient's doorways were visible. Interview revealed, "Nursing staff is in the middle of the (behavioral health) hallway. They check patients more than I do. The hall is generally full of staff. There's always one to two nurses on the hallway." Interview revealed the CPO recalled Patient #3. Interview revealed, "(On 07/28/2011) he was friendly and communicative ....not causing any issues. He was originally in blue scrubs. I don ' t recall if he said he wanted to leave. A lot of them (IVC patients) say they want to leave ....His wife or girlfriend (female visitor) came and left several times during the day ....There was an extra door from his room (P3) to another hallway (not visible from the behavioral health hallway). It's a corner room. I had checked the (extra) door earlier (in the shift) and it was locked." Interview revealed the "extra door" locks from the outside and should stay locked at all times. Interview revealed in July 2011 the type of lock on the door was a flip-style lock (not keyed). Interview revealed, "We (CPO staff) routinely checked on the door to make sure it was locked ....We had to check it when we reported in." Further interview revealed visitors should enter the behavioral health area by walking through DED and then down the behavioral health hallway, where the CPO constantly walked. Interview revealed at one point in the shift (unsure of time) the CPO found the female visitor in the patient's room, but had not seen her enter the room. Interview revealed, "I asked her how she had come in and she said 'through that door' (the extra door) ....I told her that door is locked from the outside. I checked and she had unlocked the door. I told her she must come and go through our door instead. She said 'okay'. I relocked the second door." Further interview revealed another female visitor arrived at about 1930. Interview revealed, "She came in the normal door. She came in and out several times ....She was very friendly, not doing anything out of the ordinary ....She asked if she could help him clean up at the sink in his room. I could see him at the sink. He had his shirt off and his bottom scrubs still on. She helped him clean up from the waist up. She left about 15 minutes after that. She came back 2 more times after that. The third time, about 2320, she came up and spoke to the nurse and thanked everyone and left. At that time he was in his room. We think she gave him shorts and unlocked the other door. She had to walk by it (other door) to get in. About 3 or 4 minutes after she left, I went to his room to check on him and he was gone. I walked down the hall towards the bathroom. I told the nurse to call BPD (off-duty City Police Officer works in the DED at the front desk) backup and to watch the hallway. I went to the second door (into room P3) and saw it was unlocked ....Once BPD started looking (for Patient #3), I went back to my duty of watching the other patients." Interview revealed soon after the incident (unsure of date) the lock on the extra door in room P3 was changed to a keyed lock to prevent unauthorized people from unlocking the door. Interview revealed in July 2011 CPO staff that monitored involuntary patients visualized the patients at least every 30 minutes and documented these checks on the (Respondent Acceptance) Log. Interview revealed CPO staff now visualized the patients at least every 15 minutes and documented these checks on the (Respondent Acceptance) Log. Interview revealed another change in process as a result of the elopement was the addition of a second CPO to assist in monitoring involuntary patients when the census of involuntary patients is high (more that 4).

Interview on 01/12/2012 at 0815 with RN #2 revealed the nurse was on duty on 07/28/2011 when Patient #3 eloped. Interview revealed the nurse took report on the patient and assumed his care at 2300. Interview revealed, "I was sitting at the desk and noticed a female family member standing in the doorway (at the end of the behavioral health hallway beside room P3) telling him (Patient #3) goodnight. She exited the doors ....I never saw the patient. I had not assessed him yet. At shift report they said he was calm, cooperative, and pleasant. (There were) no red flags that a behavioral issue was coming on ....He was awaiting placement elsewhere ....There was a police officer in the hallway." Interview revealed a little bit later, CPO #1 told RN #2 that the patient was not in his room. Interview revealed, "He (CPO #1) called the officer out front and they searched the grounds. I told the Charge Nurse and we looked in and out of our facility. I checked the hallways around the ER area ....The Charge Nurse was looking too." Further interview revealed the facility had implemented some process changes soon after the elopement. Interview revealed, "The door that had a flip lock is now a keyed lock. The Nursing Supervisor and Charge Nurse have the key. The door is locked at all times ....We had 2 officers for the longest time there in the hallway. Most days we have up to 4 involuntary patients and have 1 officer. If more patients (than 4) they call in a second officer." Interview revealed nursing staff were re-educated to assessment of behavioral health patients, including the use of sitters (with a physician's order) for patients found to be at high risk for suicide.

Interview on 01/11/12 at 1645 with Physician #1 revealed the physician evaluated Patient #3 on 07/27/2011 when he presented to the DED. Interview revealed the patient was involuntarily committed and needed inpatient behavioral health treatment because "police found him with a gun to his head and he was suicidal". Interview revealed nursing staff and "somebody else" sat in the hallway to watch the involuntary patients. Interview revealed, "This (07/28/2011) was before we could definitely have a sitter ....Now we have more sitters and our own police officers are present all the time. The nurse and physician get together and decide if a sitter is needed ....It (sitter) must be ordered (by the physician). I would order a sitter if I thought (a patient was a) flight risk or if I thought (the patient) would hurt (his)self if in (the)room by (his)self ....Management of (behavioral health) patients while here (in DED) is a lot better."

Interviews were requested with Physician #3 (other DED physician that treated Patient #3) and RN #1 (Behavioral Medicine Intake Referral Specialist). Per administrative staff, neither Physician #3 nor RN #1 were available for interview because neither of them were currently employed by the hospital.

Interview on 01/12/2012 with Physician #2 revealed the physician was the psychiatrist on duty on 07/27/2011 when Patient #3 presented to the DED. Interview revealed the intake nurse (Behavioral Medicine Intake Referral Specialist) assesses each behavioral health patient in the DED. Interview revealed the intake nurse then contacts the psychiatrist on call after the patient is medically cleared if the patient requires inpatient admission. Interview revealed, "The intake nurse doesn't always call the psychiatrist. They may plan (the patient's) disposition with the ED physician." Further interview revealed, "The intake nurse called me (about Patient #3) and told me the patient was suicidal and the labs were pending. We needed medical clearance before disposition." At this point during the interview, Physician #2 reviewed the patient's medical record. Further interview revealed, "Our unit was full and with his alcohol dependence problems he needed detox. A referral to (Hospital B)/ADATC was appropriate. The behavioral intake nurse and ED physician determined his disposition." Interview on 01/11/2012 at 1630 with the Director of Behavioral Medicine (inpatient behavioral health unit) revealed the unit routinely staffs for a maximum capacity of 25 patients. Interview revealed the patient census on 07/28/2011 was 25 (maximum capacity). Review of staffing sheets during the interview confirmed the unit had no available beds on 07/28/2011.

Further closed medical record review for Patient #3 revealed the patient presented to the Hospital C's DED on 07/29/2011 at 0416 (4 hours and 52 minutes after he eloped from Hospital A's DED) via emergency medical services with a gunshot wound (GSW) to his head. Review of DED resident physician documentation at 0735 revealed, "05:20. Pt is middle aged male presenting via EMS after self inflicted GSW w/ 22 gauge bullet to head. Pt was also tazed in the face by police, although unclear what happened first. Pt had GCS (Glascow Coma Scale) of 5-6, intubated on arrival for airway protection. Pt hemodynamically stable. Pt also had tazer imbedded to face with barb in place. Tazer was removed with injury to skin. Pt went to CT (computed tomography) scan and then up to SICU (surgical intensive care unit) for further management. Discussed case with (attending physician). Consult obtained from neurosurgery. Will see patient in the hospital ....Admitted to Trauma Surgery. Clinical Impression: Self-inflicted gunshot wound." Review of the neurosurgical consult note dictated on 07/29/2011 at 0829 revealed, "CT head ...demonstrates metallic fragments and hemorrhage traversing brain ...." Record review revealed the patient was treated and subsequently discharged to on 11/04/2011. Review of the physician's discharge summary dated 11/04/2011 at 1234 revealed, "The patient was taken to the OR on 7/29/2011 for endoventricular drain placement. He tolerated the procedure well, was extubated in the OR, and was transferred to the Neurosciences ICU ....He returned to the OR on 8/5/11 for tracheostomy (breathing tube in neck) tube and peg (feeding tube in stomach) tube placement. He was stable postoperatively and was transferred to the Intermediate surgical care unit on 8/14/11 and to the floor on 8/23/11. The patient continued to improve ...at the time of discharge he was tolerating G (feeding) tube feeds. Patient was voiding spontaneously through a condom catheter and have (had) his pain controlled with P.O. (by mouth) pain medication. He was assessed with serial neurological exams postoperatively which revealed improvement. The patient was assessed by Physical Therapy, Occupational Therapy and Speech Pathology and found to be suitable for discharge to home with 24/7 supervision. He will be discharged in stable condition."

NC00077617