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Based on staff interviews, medical record and document reviews, the hospital failed to effectively govern the activities and conduct of the hospital staff to provide safe and quality care to all patients as evidenced by:

A. The hospital failed to ensure that the emergency services requirements were met for psychiatric patients placed on medical/involuntary hold in the emergency department (ED). (Refer to A 091)

B . The governing body failed to ensure that services performed in the ED under a contract or agreement were provided in a safe and effective manner. (Refer to A 0084)

C. The hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice. (Refer to A 1100)

These failures resulted in one patient eloping from the hospital and falling to his death from a cell tower. These failures have potential for adverse outcomes for all patients. The cumulative effect of these systemic failures resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Governing Body.

Based on staff interview and document review the governing body failed to ensure that services performed in the Emergency Department (ED) under a contract or agreement were provided in a safe and effective manner. The contracted Security Department (Security) service used its company policies with guidelines and procedures for security personnel in the ED that did not match the hospital's policy for security services in the ED. The Security company's policies were not reviewed and approved by the hospital governing body or through its quality assessment and improvement program. The hospital did not ensure that Security's services were understood and consistent from the hospital and the security services standpoints to meet the ED staff and patient safety needs.

Findings:

On 5/23/12 the ED policy and procedure titled "Accountability and Responsibility Statement" (approved by the Medical Executive Committee on 7/13/2011) was reviewed. The policy charged the Emergency Services with the responsibility and accountability to the Medical Staff and Administration for operational strategies including effectiveness in the provision of safe, quality care, efficiency of organizational functioning at all levels, appropriate use of resources to improve patient health and assuring that the services were reviewed, evaluated and appropriately modified to best meet the identified needs. The Physician Chief of the Emergency Department was given the authority and responsibility for assuring that written policies and procedures were developed, maintained and revised as indicated, that overall direction in the provision of Emergency Department's services was provided, and that an overall review and evaluation was performed of the quality, comprehensiveness and appropriateness of the ED services, among other responsibilities.

On 5/23/12, a continued review of the ED policies showed that ED staff would seek involvement of the Security Department (contracted Security service) staff for various situations to ensure the safety of patients, staff and others. Examples of policies listing Security involvement were policies titled: Emergency Services Outside the ED (approved 7/12/11), Elopement Policy (approved 8/9/11), Patient Flow (approved 7/12/11), Patient Requiring Psychiatric Services (approved 7/12/11) and Psychiatric Patients in the ED (approved 7/12/11). The policies indicated that the medical and nursing staff largely relied on the Security staff for ensuring that psychiatric patients determined as potentially at danger of hurting themselves or others, were provided a safe environment. The hospital policies did not define the role of the Security staff when called for a "stand by" assistance with psychiatric patient care safety.

For example the, "Patient Flow" policy indicated, that for patients actively homicidal/suicidal or actively psychotic the patient should be roomed immediately and "...Notify Security to standby for continuous observation. Patient should not be left alone..." The P&P did not specify what the observation entailed and what actions, if any, were expected for the officers on "stand by" to take. The policy "Psychiatric Patients in the ED" indicated the responsibility of the Security staff was providing "...a visual presence to deter elopement and to assist with the initiation of restraint interventions as ordered by the physician..." The P&P also indicated that Security should be notified immediately of the presence of the patient who verbalized or otherwise exhibited an intention or desire to hurt themselves or others and were awaiting an ED physician evaluation. Also, the P&P indicated that Security should be requested to come to the ED "to stand by" for patients placed on an involuntary hold (1799.111, Health and Safety Code 1799.111 a 24 hour hold and/or 5150, Welfare and Institution Code an involuntary 72 hour hold). The policy did not instruct the "stand by" officer to take any actions, including attempting to stop a patient who is leaving the unit, even for those patients on an involuntary hold.

The reviewed policies did not define the "stand by" Security officer role. There was no clear direction for the security officer to act upon when specific activities or behaviors were observed during the monitoring of a psychiatric patient. There was no requirement that the security staff's documentation of activities and behaviors of observed patients should be reported or become a part of their medical record, what specific actions or behaviors should be reported to the clinical staff or the extent of the security officer's responsibility without the clinical staff's involvement. However, the policy did hold the Security staff accountable for the continuous monitoring of patients on a 1799.111 or 5150 hold because of the possibility that these patients can be a danger to them self or others. These patients required a psychiatric assessment and care to stabilize their psychiatric emergency medical condition and security did not have any guidance to act independently if a situation occurred, nor was there any direction as to when security was to engage the clinical staff to assist them in managing a safe environment for both the patients and staff in the ED.

In a collaborative interview with the Physician Chief of the Emergency Department and the ED Director on 5/24/12 starting at 8 a.m., both stated that it was the physician and nursing staff discretion to request Security officer to be present on the unit and have visualization of any ED patient(s) as deemed necessary, in a "stand-by" role. Standby was also requested by the ED physician when patients were placed on involuntary hold (1799.111 or 5150). The ED Chief and the Director both admitted that there was no policy or written process approved by the ED or hospital governing body that would define or establish the criteria for the "standby" role and monitoring by Security. There was no policy limiting the number of patients that a security officer could monitor at one time, although the idea was that the officer would be able to visualize all standby patients assigned to him/her. Both stated that the Security Department often determined the criteria and the number of officers necessary, based on their assessment of the situation. The Director and the Chief both agreed that Security staff was not required to have a clinical background and ultimately the clinical staff (ED physicians and nursing staff) had the responsibility for the patient care and safety in the ED. The Director and the Chief indicated that their expectation and understanding of the role of the "stand by" officer assigned to monitor psychiatric patients was to observe for any signs of patients harming self/others or leaving and to notify clinical staff. The expectation was that in the event that a patient on an involuntary hold attempted to leave, the Security would notify staff and also act to prevent the patient from leaving, using verbal and/or physical means as deemed necessary.

In a collaborative interview on 5/25/12 starting at 8:30 a.m. with the Manager of the contracted Security service and the hospital's Assistant Administrator for Support Services (who was responsible for various services including security), the Manager explained the role of the ED officers in the ED as follows: There was 1 ED officer assigned to the ED at all times, who was expected to provide security and safety for staff and members (patients) by showing presence (roving) in the unit and other designated areas. The ED security officer could be requested by the ED staff to provide "standby" duties. The Manager stated that "standby" could mean for the officer to be present when the patient was agitated, or for monitoring patients placed on involuntary (1799.111 and/or 5150) hold. The Manager confirmed that there was no policy or process that would specify or limit the number of patients that one officer could monitor and that officers had the discretion to call for a back-up as needed. The Manager however disagreed with the expectation that the officers should physically intervene in any way without clinical staff present to authorize and/or request their assistance. The Manager was not able to explain how a patient on an involuntary hold who attempted to leave the facility could be stopped in a timely manner, if the security officer monitoring the patient was not allowed to use any hands-on approach and the officer was the only person designated to continuously monitor the patient. The Manager presented their own (Security Department) policy for "stand-by" process and explained that security officers are only directed to observe and follow patients in the event they leave, because they could get hurt if they physically tried to make the patient stay. The expectation would be for them to call for help and follow in a safe distance. No explanation was given as to what was expected of an officer in the event a suicidal patient on involuntary hold (for example, with suicide ideations by walking into traffic) was leaving the ED and heading for the street. The Manager maintained that the process was to have hands-off only approach and to notify hospital and other staff (by a radio) and to follow the patient until clinical/hospital staff arrived. The Manager had no comment when it was pointed out that in that instance, without any other interventions or if staff did not arrive timely, the officer would essentially observe the patient walk into traffic.

Review of the Security's internal policy #7.22 titled "Stand-by Procedures" (revised 4/2010) in part indicated, "It should be thoroughly understood by all concerned that the Standby Officer's responsibilities are limited to matters of safety and security. The Officer is not trained to exercise medical/clinical judgment, and should not be expected to do so; nor should medical staff feel that the presence of the Officer relieves them of any of their normal responsibilities with respect to the patient...The Security Officer may be called upon to assist Emergency Department Staff in forcing the patient to submit to a course of action against his/her will. Such action can only be initiated by the ED staff...If a patient who is 'on a hold' attempts to leave his/her room without permission, the Officer is permitted by law to use verbal persuasion to keep the patient from leaving. Once verbal persuasion is seen to be failing, the Officer will alert Staff Members...The Security Officer will follow a 'hold' patient who is intent upon leaving for so long as the patient is on (name of hospital) property, but will not pursue beyond the Property..." Review of the Security's 5-page policy 3.4 titled "Patient Elopement" contained various steps for searching for an eloped patient and notifications of various staff. However, if the patient was found (unharmed) the policy directed that the patient "...will be returned to the facility immediately with the assistance of Security Services, if requested by the House Supervisor..." There were no documented guidelines to allow the security officer to act independently to maintain a safe environment in the ED. The roles and responsibilities for Security Services per this policy were noted: "Responsible to coordinate patient search and retrieval efforts."

Review of the hospital's contract with the Security Services (approval date 12/22/08) indicated that the Security Services will comply with the hospital policies (Section 6.8). The Security Service was responsible to perform all necessary functions described in the different security positions that were differentiated in their P&P's. Section 4 of the contract titled, "Security Officer Responsibilities," read that "Security Officers will, to the best of their ability, be responsible for the protection of patients among others" (4.1). It was indicated in section 4.2 that "...one of the duties that each Security Officer may undertake includes independently and/or assisting in the physical restraining, apprehending and /or detaining staff, members (patients), and visitors exhibiting disruptive behavior and that the Security Officer may suffer injury. It is not the intention of either party that the Security Officer has the right to refuse participation in these activities for fear of injury..." Section 5.4 of the contract indicated that the hospital was responsible through its quality assessment and improvement programs, for the services performed by the Security and retained the responsibility to ensure that the services were provided in a safe and effective manner.

A collaborative interview was conducted on 5/25/12 at 10:40 a.m. with the ED Chief, ED Director and Area Quality Leader who all concurred that the Security's P&P's and practices did not meet the expectations of the ED staff. Those policies were not approved by the medical staff or Governing Body and were not reviewed through the hospital quality assessment and improvement program, to ensure that the services delivered were provided in a safe and effective manner.

Based on staff interview, Emergency Department (ED) record and policy and procedures (P&P) review, the hospital failed to ensure that the emergency services requirements were met for psychiatric patients placed on medical/involuntary hold in the ED.

Twelve of 30 patients (1, 2, 4, 5, 10, 11, 13, 14, 15, 18, 22, 23) that were reviewed were placed on involuntary hold, with a Psychiatric Emergency Medical Condition (PEMC), were not ensured a safe environment and the patient's re-assessments were either not on-going or were performed later than the 1-hour time frame as indicated by an ESI 2 (ESI-Emergency Severity Index a tool to rate patient acuity from Level 1-most urgent to Level 5 least urgent) while awaiting psychiatric consultations and/or transfers for psychiatric hospitalization. Multiple patients reviewed also had their ESI rating decreased from ESI 2 (which included psychiatric emergencies that required hourly assessments) to ESI 3 (which required assessments every 4 hours) without any indication of changes in a patient's psychiatric condition or orders from the ED physician. This resulted in these patients receiving less frequent monitoring and assessments by the nursing staff than should have been had they remained at the correct ESI Level.

In addition, the ED did not follow its' policy in regards to always keeping psychiatric patients in full view when patients were allowed to leave their rooms and go to the bathroom unescorted and unobserved.

Findings:

Review on 5/23/12 of the ED policies and procedures showed a policy titled "Patient Flow" (approved 7/12/11) which indicated, that for patients actively homicidal/suicidal or actively psychotic the patient should be roomed immediately and "...Notify Security to standby for continuous observation. Patient should not be left alone..."

The policy "Psychiatric Patients in the ED" (approved 7/12/11) indicated that the Triage Nurse was to remember that patients who verbalize or exhibit a desire to hurt themselves or others should be considered as having an, "Emergency Medical Condition. and "should be given an emergency priority assignment." The P&P went on to read that their goal of treating these types of patients as a high priority was to maintain their safety.

The P&P also read that the primary nurse was responsible for for direct patient care, which included observation, on-going assessments and maintenance of a safe environment for the patient.

In addition, the P&P also indicated that security should be notified immediately of the presence of the patient who verbalized or otherwise exhibited an intention or desire to hurt themselves or others (having an Emergency Medical Condition) and were awaiting ED physician evaluation.

A review of a policy titled "Nurses Notes" (approved 12/13/11) indicated: the purpose was to document patient data, nursing observations and interventions, and patient progress toward expected outcome and to assure continuity of care; persons providing care were to assure all interventions/assessments were documented; the RN or designee assigned to the room is responsible for making sure the notes are started and kept up to date; patients requiring intensive care (e.g. ESI 2) should be reassessed every one hour or more frequently as condition warrants until condition stabilizes.

A review of the ED's P&P titled, "Psychiatry" (approved 7/12/11) under, "Procedure" indicated that one of the measures to ensure that the ED provided a safe and secure environment for patients was to ensure that medical staff were to accompany any suicidal patient into the bathroom at all times.

A review of the ED records from 5/22/12 to 5/24/12 showed the following patients presented to the ED with a Psychiatric Emergency Medical Condition and were placed on an involuntary hold (1799.111, Health and Safety Code 1799.111 a 24 hour hold and/or 5150, Welfare and Institution Code 5150, an involuntary 72 hour hold) by an ED Physician, a Licensed Clinical Social Worker (LCSW), or law enforcement, while awaiting either psychiatric evaluation or a transfer to a psychiatric facility. These records had no documented ongoing assessment and monitoring by nursing staff. The records contained documentation that nursing staff changed the ESI levels of some patients prior to the evaluation by a LCSW, or after the initiation of a Psychiatric hold (1799.111 & 5150) even though these patients' presenting behaviors were unchanged or at times had escalated.

1. Patient 1 was admitted to the ED on 5/19/12 at 9:26 p.m. with suicidal ideation manifested by voices telling him to harm himself. Patient 1 was categorized as an ESI 2, roomed and placed on a 1799.111 hold by the physician at 9:44 p.m. with a security officer on standby assistance. Patient 1 was placed on a 5150 hold at 11:49 p.m. A nursing entry that began at 11:30 p.m. read that an RN (RN 1) had contracted with Patient 1 to be safe while on the unit and downgraded his ESI 2 to ESI 3. RN 1 was asked why he had decreased the acuity from 2 to 3 and he stated that Patient 1 was alert, cooperative, denied being suicidal at that time and contracted with him to be safe while on the unit. RN 1 was asked if Patient 1 was still a 5150 and he stated, "Yes." Patient 1 was allowed to walk to and from the bathroom without an escort and with the permission of the RN. On 5/20/12 at 1:43 a.m., Patient 1 fled from the ED and was found dead, of an apparent suicide, across the street from the hospital.

2. Patient 2 was an 18 year old female who was brought to the ED on 4/1/12 at 4:17 p.m., as a 5150 designated by the police department for being angry and depressed at her parents and trying to set the house on fire using nail polish remover. Upon arrival, Patient 2 was categorized as an ESI 2 at 4:17 p.m. At 4:48 p.m., the attending nurse documented that Patient 2 had "psychological distress," but verbally contracted not to harm herself or others at this time. The nurse documented that the patient was evaluated and determined to be stable to down grade to an ESI 3. This was done prior to Patient 2 being assessed by the ED doctor or LCSW. A nursing documentation (which included a description of Patient 2's demeanor) was done at 6:07 p.m., 7:51 p.m. and 10:37 p.m. Patient 2 was placed on a 5150 hold by the LCSW at 9:08 p.m. awaiting transfer to a psychiatric hospital and at 11:22 p.m., a nurse documented that the patient was calm,cooperative and stable at this time and was downgraded to ESI 4. A review of security's documented daily activity report (DAR) indicated that Patient 2 was allowed to go the bathroom without escorts at 4:55 p.m. and 1:57 p.m. (the next day).

3. Patient 4 was a 51 year old female brought to the ED on 4/1/12 at 4:57 p.m., with suicidal thoughts, categorized as a ESI 2 and placed on a 1799.111 hold at 5 p.m. with security at the bedside. Patient 4 was seen by the ED physician at 5:20 p.m. and at 6:47 p.m., a nurse documented that Patient 4 was calm, cooperative and waiting for a medical clearance. Patient 4 was then down graded to an ESI 3. Patient 4 was seen by the LCSW and placed on a 5150 hold at 10:30 p.m. and the patient remained in the ED until a bed was available. The next nursing documentation of Patient 4's demeanor was at 3:58 a.m. A nurse documented on 4/2/12 at 7:07 a.m., that Patient 4 was walking in and out of her room and but was kept on watch. A review of security's DAR indicated that Patient 4 was allowed to go the bathroom without escorts at 6:10 p.m., 10:47 p.m. and 12:34 a.m.

4. Patient 5 was a 25 year old male who was brought to the ED on 4/3/12 at 3:22 p.m. with a self-inflicted burn and complained of not wanting to exist anymore. Patient 5 was categorized as an ESI 2, put in a room and placed on a 1799.111 hold with security at the bedside. Patient 5 was seen by the LCSW and placed on a 5150 hold at 7:45 p.m. A nurse documented at 5:34 p.m., that Patient 5 was given a meal tray and that he was told they needed a urine specimen, there was no documented assessment of his demeanor and there was no re-assessment of Patient 5's condition until 7:09 p.m. Patient 5 was down graded to an ESI 3 at 11:03 p.m. A review of security's DAR indicated that Patient 5 was allowed to go the bathroom without escorts at 4:10 p.m., 5:39 p.m. and the next day 4/4/12 at 7:21 a.m., 10:16 a.m. and 1:35 p.m.

5. Patient 10 arrived to the ED on 5/19/12 at 10:34 p.m. as a 5150 designation by the police department for being a danger to herself and wandering. Patient 10's personal belongings were removed and security was at the bedside. At 11:12 p.m. a nurse documented that the patient is now cooperative and denies suicide ideation. The nurse documented that the patient was unaware of how she got to the ED or why she was there. The nurse documented that Patient 10 was reoriented to the events that brought her to the ED and she was then down graded to an ESI 3. Follow-up documentation at 2:11 a.m., showed Patient 10 was increasingly restless, agitated with crying out, singing, screaming and at one point attempted to leave the unit. A review of the documentation by the LCSW read that Patient 10 presented and continued to experience psychosis and paranoia.

6. Patient 11 presented to the ED on 5/1/12 at 10:25 a.m. with a chief complaint of suicidal ideation by overdosing and a history of suicide attempts and was triaged as an ESI 2. At 10:48 a.m. the physician wrote an order for "Security to assistance with volatile patient." The physician also ordered a psychiatric consultation.

On 5/1/12 at 10:48 a.m. the ED physician wrote an order for a 1799.111, 24-hour mental health hold, (Health and Safety Code 1799.111). At 11:15 a.m. the ED physician signed a form titled "Requesting a security presence for an involuntary hold in the Emergency Department." On this form the physician indicated that "...the presence of a Security Officer is necessary for the enforcement of this involuntary hold..."

After a psychiatric consultation by LCSW on 5/1/12 at 1:35 p.m. the patient was placed on a 5150 (72-hour involuntary hold) with recommendations for psychiatric hospitalization. The record showed that the patient was transferred via an ambulance on 5/1/12 at 5:02 p.m.

Review of the ED record showed no nursing documentation of ongoing monitoring and reassessments. The nurses decreased the ESI to 3 at 4:30 p.m. (which required less frequent reassessments) even though the patient was still in a Psychiatric Emergency Medical Condition while awaiting the transfer.

7. Patient 13 presented to the ED on 5/20/12 at 4:04 p.m. with a chief complaint of suicidal ideation and was triaged as an ESI 3 instead of an ESI 2. At 4:25 p.m. the physician ordered a psychiatric consultation and initiated a 1799.111 hold and requested security at the bedside.

After a psychiatric consultation by LCSW on 5/20/12 at 6:31 p.m., it was determined that the patient no longer met the criteria for an involuntary 5150 hold and at 6:58 p.m. the patient was discharged. Review of the ED record showed no nursing documentation of ongoing monitoring and reassessments prior to the LCSW's consultation.

8. Patient 14 presented by ambulance (with law enforcement) to the ED on 5/20/12 at 3:25 p.m. with a chief complaint of wanting to hurt others. At 4:47 p.m. the ED physician wrote an order for a 1799.111 hold.

After a psychiatric consultation by the MFT (Marriage Family Therapist) on 5/20/12 at 5:49 p.m. the patient was placed on a 5150 hold with the recommendations for psychiatric hospitalization and was transferred via an ambulance on 5/20/12 at 11:19 p.m. Review of the ED record showed no nursing documentation of ongoing monitoring and reassessments.

9. Patient 15 presented by ambulance (with law enforcement) to the ED on 5/20/12 at 8:50 p.m. with the nurse's documentation that the patient wanted to die by running into traffic. The patient arrived on a 5150 hold after initially presenting to a psychiatric facility. After a psychiatric consultation by LCSW on 5/20/12 at 11:22 p.m. the patient's 5150 was upheld with the recommendations for psychiatric hospitalization. The record showed that the patient was transferred via an ambulance on 5/21/12 at 9:25 a.m.

The physician notes on 5/21/12 at 1:25 a.m. documented that the patient was agitated, inappropriate, labile, however Patient 15's ESI 2 level was downgraded to ESI 3 at 2:31 a.m. on 5/21/12 while the patient was awaiting transfer to a psychiatric hospital. The review of the ED record showed no documentation of ongoing monitoring and reassessments.

10. Patient 18 was brought in by law enforcement to the ED on 5/12/12 at 2:04 a.m. suicidal, on a 5150 hold by law enforcement, after grabbing a knife and threatening to kill self. The patient had a psychiatric consultation by a physician on 5/12/12 at 2:13 a.m. and the patient was to be admitted to a psychiatric hospital. The record showed that the patient was transferred via an ambulance on 5/12/12 at 12:30 p.m.

Review of the ED record showed that there was a security officer at the standby, but no documentation of ongoing nursing monitoring was found in the record. Again, ESI 2 on arrival was downgraded to ESI 3 at 2:14 a.m. on 5/12/12 while the patient was awaiting transfer to a psychiatric hospital. At 3:39 a.m. nursing notes indicated that the patient was agitated and wanted to leave.

11. Patient 22 was admitted to the ED on 3/1/12 at 5:24 p.m. and was identified as an ESI 2 for suicidal ideation and alcohol intoxication. Review of the ED record showed that on 3/1/12 at approximately 6:30 p.m. Patient 22 was placed on a 1799.111 hold by the ED physician and at approximately the same time Patient 22's ESI status was decreased to level 3 with the nursing documentation noting the the patient denies suicidal ideation and was cooperative event though the physician had just placed the patient on the 1799.111 hold. On 3/2/12 11:36 p.m., 5 hours after being placed on the 1799.111, nursing documentation noted that the patient was awake, alert and oriented x 4 (person, place, time and date), calm and cooperative and denied suicidal ideation along with a physical assessment. The next nursing assessment was at 1:03 a.m. After this assessment there were no more musing assessments documented. At 6:40 p.m., Security was notified of the 1799.111 hold and it was noted by nursing that security had this patient under direct observation per protocol.

12. Patient 23 was admitted to the ED on 2-1-12, at 11:13 p.m., and was identified as an ESI 2 for suicidal ideation and depression. On 2/2/12 at 12:22 a.m. the facility's LCSW completed a psychiatric evaluation and identified that Patient 23 still had suicidal ideation and was not able to agree to contract for safety and was placed on a 5150 hold. ED documentation revealed that at 5:43 a.m. on 2/2/12 Patient 23 was downgraded from an ESI 2 to ESI 3 with no documentation of re-assessment by nursing as to why this occurred other than that Patient 23 had been medically cleared for transfer to a psychiatric facility. Patient 23's vital signs were checked by nursing at 4:55 a.m. There is no documentation of nursing assessments between 1:54 a.m. and 4:55 a.m. A review of Security's documentation showed that Security personnel were monitoring room B 24 from 11:33 p.m. to 6 a.m. the next morning.

In an interview with the ED Director on 5/24/12 at 8 a.m., the Director stated that a Security officer was usually present on the unit and was requested for a "stand-by" when patients were placed on an involuntary hold (1799.111 or 5150) but that security personnel did not document in the patient's medical record. They maintained logs which were part of the security department's documentation.

Review of documentation by the Security staff of observations for the patients described above showed that the Security officers simultaneously monitored 2-3 (or more) patients that required to be continuously monitored.

The Director confirmed that the ongoing monitoring of psychiatric patients was not documented by nursing and that nursing staff did not perform monitoring of psychiatric patients with emergency medical conditions at the ESI 2 level of every hour. The Director stated that there was no policy or direction for staff to decrease the ESI levels of psychiatric patients in the ED and had no explanation as to the reason for downgrading ESI for acute psychiatric patients.

Based on observations, clinical record review, policy and procedure review and staff interviews the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice when:

A. The hospital failed to ensure that patient services were integrated with the contracted Security service. The emergency department (ED) clinical staff utilized security staff for monitoring psychiatric emergent patients in the ED without clearly defining their duties and expectations and the level of collaboration and responsibilities among the clinical and security staff. (Refer to A 1103)

B. The hospital failed to establish and follow the policy and procedures (P&P's) governing medical care provided in the ED for 12 of 30 sampled patients (1 ,2, 4, 5, 10, 11, 13, 14, 15, 18, 22, 23) with psychiatric emergency medical conditions. These patients were not provided with continuous monitoring/observation and appropriate care and were not ensured a safe environment (protected from self-harm or harm to others) after being placed on an involuntary medical or psychiatric hold. (Refer to A 1104, A 0091)

These failures resulted in one patient eloping from the emergency department and falling to his death from a cell tower. These failures have the potential for adverse outcomes for all patients. The cumulative effect of these systemic failures resulted in the inability of the hospital to comply with the statutorily-mandated Condition of Participation for Governing Body.

Based on observation, staff interviews and review of facility documents, the hospital failed to ensure that patient services were integrated with the contracted Security service. The hospital failed to ensure that the monitoring services provided by the emergency department (ED) staff and security personnel to 1 of 30 sampled ED patients, (Patient 1) who was on an involuntary hold (5150, Welfare and Institution Code 5150, an involuntary 72 hour hold), were communicated and coordinated in order to maintain a safe environment for him while in the ED. Patient 1 was able to leave the ED and exit the hospital without restraint or pursued by any staff. Patient 1 was found across the street from the facility dead, from an apparent fall from a cell tower.

Findings:

On 5/22/12 at 10:30 a.m., the Department met with the ED Manager to review Patient 1's medical record. Patient 1 was a 21 year old male who presented to the ED with his parents on 5/19/12 at 9:26 p.m., with complaints that, "voices were telling him to harm himself." Patient 1 was triaged as an "ESI 2" (ESI-Emergency Severity Index, a tool to rate patient acuity from Level 1-most urgent, to Level 5 least urgent) and roomed. Per nursing documentation, all of Patient 1's clothing and personal belongings were taken and stored outside of the room. Documentation showed that the contents of the room was reviewed for any safety hazards to ensure that there was nothing sharp or if there were any objects that could cause harm to the patient or anyone else. A hospital document titled, "Requesting A Security Presence For An Involuntary Hold In The Emergency Department" showed that at 9:44 p.m., the ED physician placed Patient 1 on a, "Section 1799.111 of the California Health & Safety Code, "Which indicated that Patient 1 could not be safely released from the hospital and could be held in the ED a total of 24 hours from arrival. Nursing documentation showed that security had been called for "bedside patient observation."

A review of the 5/19/12 ED physician's notes indicated that Patient 1 had experienced a, "psychotic break" (term used to describe an occasion of a person experiencing an episode of acute primary psychosis-loss of contact with reality) one week ago and had made statements about harming himself. Patient 1 had been prescribed the medication Abilify (anti-psychotic medication) but had stopped taking it about 4 months ago. A review of the ED physician's notes read that Patient 1's presentation "Was consistent with psychosis and clearly had some suicidal ideation also." The physician's notes indicated that the physician had cleared Patient 1 medically for, "psychiatric hospitalization."

On 5/19/12 at approximately 10:23 p.m., the facility's, "Licensed Clinical Social Worker" (LCSW) was on-site for Patient 1's consultation/assessment. The assessment indicated (in part) that Patient 1 had, "severe psychiatric symptoms, current impulsivity (individuals tend to act without forethought. They may react rapidly and without planning, often without regard to the consequences on themselves or others) and was at a high risk for suicide." The LCSW wrote that Patient 1 needed psychiatric hospitalization and at 11:49 p.m., placed Patient 1 on a 5150 (72 hour detention hold for evaluation and treatment) hold pending an in-patient bed in a psychiatric facility.

Nursing documentation read that about 11:30 p.m., Patient 1's family was at the bedside and that the patient was alert, oriented and cooperative and that security personnel were on standby and remained, "in visual contact" with Patient 1. The nurse (RN 1) documented that Patient 1 had, "contracted to be safe on unit" and RN 1 downgraded the patient from Level 2 acuity to a Level 3. At 1 a.m., RN 1 documented that Patient 1 was resting comfortably in bed, the room door was closed and the patient was, "being observed through the door." At 1:43 a.m., RN 1 documented that Patient 1 was seen running through the exit door wearing a gown and blue shorts. RN 1 wrote that, "security was unable to stop him." The police department was notified and they discovered him across the street from the facility at the base of a 30 foot cell phone tower which he had apparently jumped from. Patient 1 was returned to the ED via emergency medical services (EMS) in full cardiac and respiratory arrest (no heart beat or breathing) and after resuscitative efforts was pronounced dead at 2:39 a.m.

The ED Manager was asked if staff pursue patients who elope from the ED and she stated, "No, it is a safety risk issue for staff to pursue patients who run out of the unit." The ED Manager was asked how many patients can be watched by a security guard at one time and she stated, "It's usual that 1 security guard will watch 2" standby patients at one time.'

On 5/22/12 at 1:20 p.m., the facility's contracted Security Manager (SM) was interviewed. The SM was asked what the role of the ED standby officer was and she stated, to recognize and verbally deescalate potential behavioral problems and work in conjunction with staff as a, "team" to reduce the possibility of tension related to patient holds. The SE was asked if they are to pursue a patient who elopes and she stated that they do not pursue individuals past the facility campus and that their policy (P&P) stated that an officer assigned to the ED does not pursue a patient if that officer has more than one standby hold. The SM produced a contract P&P titled, "Post Orders For Security Services," (revised 1/11) which read that an ED-assigned officer could not leave the post at any time during the shift without properly notifying and proper relief by the shift. In addition, the P&P indicated that if a patient's behavior escalated to aggressiveness, the officer was to notify staff who would decide what the intervention would be. The SM was asked if this was the hospital's P&P and she stated that this was the contract services P&P and it was the one that security followed. The SM was asked what the total number of psychiatric patients security will watch at a time and she stated, "One officer to five psychiatric holds is not unusual and it is based on the patients' behaviors."

On 5/22/12 at 2:50 p.m., the hospital's surveillance video of Patient 1 was reviewed with the facility's Security Manager (SM) and the ED Manager. A security officer (SE 1) was observed to be standing between Patient 1's room (26) and another patient (10) who was also a 5150 in room 25. The rooms were next to each other. Patient 1 was observed to leave his room unattended two times and the SM stated that he went to the bathroom. At one point SE 1 is observed to walk to the doorway of room 25 and her back is turned so that she is no longer in visual contact with Patient 1's room. Patient 1 is observed to walk up to the window of his closed door and look out through the window. Patient 1 then opened his door and very quickly ran through the exit door that was to the left and in close proximity of his doorway. The video showed SE 1 and RN 1 in the registration area looking down the hall, presumably watching Patient 1 flee the hospital. Further footage showed Patient 1 running quickly through the hallways without interference of facility staff and exiting the hospital.

On 5/23/12 at 5:01 a.m., SE 1 was interviewed over the telephone. SE 1 was asked what was the highest number of patients she had been on standby for and she stated, "Five." SE 1 stated that she came on-duty that night at 10 p.m. and was notified to go to the ED for a, "standby hold" in room 26 (Patient 1) that was just initiated. SE 1's daily activity report (DAR) for Patient 1 indicated that between 9 p.m. to 1 a.m., Patient 1 remained in his room other than one time to go to the bathroom. SE 1 was asked why Patient 1 was allowed to go to the bathroom alone and she stated that, "The medical staff is supposed to escort the patients, not security. Staff was available, but they gave permission to Patient 1 to go to the bathroom unattended." SE 1's DAR showed that at 10:40 p.m., another patient (10) who had been designated as a 5150, arrived and was the second "standby" patient for SE 1. The DAR showed at 1:30 a.m., Patient 10 was back and forth to the nurse's station and SE 1 had advised the patient to stay in her room. At 1:40 a.m., SE 1 documented that Patient 10 was standing in her room doorway, screaming and crying. At 1:43 a.m., SE 1 documented that she informed Patient 10 to stay in her room and that the patient continued to come out to the nurse's station and at that time she escorted Patient 10 back to her room. SE 1 stated that Patient 10 was very loud and disruptive and she "constantly tried to leave her room." SE 1 was asked if she had a process for getting additional help for standby's and she stated that she could call for back-up if she was devoting most of her time to one patient. SE 1 stated that Patient 10 was not aggressive she, "Just came out of her room multiple times." An entry timed at 1:43 a.m. on Patient 1's DAR read that he had ran out of his room and out the double doors and continued through the lobby. SE 1 was asked when she discovered Patient 1 had eloped and she stated, "When I heard the slam of the double doors being opened, I yelled out in the unit and immediately called my supervisor on my radio." SE 1 stated that she was in the doorway of Patient 10's room. SE 1 was asked if she was standing so that she was in visual contact with Patient 1's room and she stated, "No." SE 1 was asked what happened next and she stated that RN 1 asked her if security was going to follow him and she said that she had notified her supervisor. SE 1 was asked why she did not follow Patient 1 and she stated she could not because she had another standby who was, "constantly trying to leave."

On 5/23/12 at 5:15 a.m., the Security Supervisor (SS) was interviewed over the telephone. SS stated that when the SE 1 notified him, he immediately dispatched 2 officers, one who was stationed in the hospital front lobby and one who was responsible for canvassing the interior of the hospital and medical office buildings. The SS stated that he received a transmission from the lobby officer who told him a visitor who had just come in had told him that he saw Patient 1 running across the street to the shopping mall. The SS was asked if any of the officer's went out to the area to look for the Patient and he stated that they do not respond past the hospital campus.

On 5/23/12 at 5:38 a.m., RN 1 was interviewed via telephone. RN 1 stated that it is the responsibility of the ED staff to take full responsibility of of psychiatric patients in the unit. RN 1 stated that the room had been cleared and Patient 1's personal items were removed from the room and that the patient needed to be continuously monitored. RN 1 was asked why the patient went to the bathroom unattended and he stated that he gave the patient permission to go alone. RN 1 was asked why he had decreased the acuity from 2 to 3 and he stated that Patient 1 was alert, cooperative, denied being suicidal at that time and contracted with him to be safe while on the unit. RN 1 was asked if Patient 1 was still a 5150 and he stated, "Yes." RN 1 stated that he was sitting, charting at the nurse's station and was faced toward rooms 25 and 26. RN 1 stated that his head was down while visualizing the monitor screen. RN 1 was asked if he saw Patient 1 standing at the window of his door and look out and he stated, "No." RN 1 was asked when he found out Patient 1 had eloped and he stated, "When SE 1 screamed out that Patient 1 was leaving, I ran to Patient 1's room and it was empty." RN 1 was asked if he told SE 1 to follow the patient and he stated that no, she had another standby in the unit.

On 5/23/12 at 5:55 a.m., the ED Nursing Director (EDD) was interviewed over the phone. The EDD stated that staff no longer pursue eloped patients due to safety issues. The EDD stated that staff and security work together when monitoring these patients and when they need to they will contact the police department if there are any safety issues.

A review of the ED's P&P titled, "Psychiatry" (approval date 7/12/11) read (in part) that a patient who is placed on a 5150 hold who attempts to leave the area, "shall be restrained (if all efforts at verbal defusing have failed) using a reasonable amount of force by the Emergency Department staff and Security."

Based on staff interview, Emergency Department (ED) record and policy and procedures (P&P) review, the hospital failed to follow and/or implement their P&P's in order to ensure that the emergency services requirements were met for psychiatric patients placed on medical/involuntary hold in the ED.

Twelve of 30 patients (1,2,4,5,10,11,14,15,18,22, 23) that were reviewed were placed on involuntary hold, with a Psychiatric Emergency Medical Condition, were not ensured a safe environment and the patient's re-assessments were either not on-going or were performed later than the 1-hour time frame (as indicated by an ESI 2) while awaiting psychiatric consultations and/or transfers for psychiatric hospitalization. Multiple patients reviewed also had their Emergency Severity Index (ESI-Emergency Severity Index, a tool to rate patient acuity from Level 1-most urgent, to Level 5 least urgent) decreased from ESI 2 (these are psychiatric emergencies, among others, requiring hourly assessments) to ESI 3 without any indication of changes in condition or orders from the ED physician. This resulted in these patients receiving less frequent monitoring and assessments by the nursing staff than were indicated as necessary.

Findings:

Review on 5/23/12 of the ED policies and procedures showed a policy titled "Patient Flow" (approved 7/12/11) which indicated, that for patients actively homicidal/suicidal or actively psychotic the patient should be roomed immediately and "...Notify Security to standby for continuous observation. Patient should not be left alone..."

The policy "Psychiatric Patients in the ED" (approved 7/12/11) indicated that the Triage Nurse was to remember that patients who verbalize or exhibit a desire to hurt themselves or others should be considered as having an, "Emergency Medical Condition. and "should be given an emergency priority assignment." The P&P went on to read that their goal of treating these types of patients as a high priority was to maintain their safety.

The P&P also read that the primary nurse was responsible for direct patient care, which included observation, on-going assessments and maintenance of a safe environment for the patient.

In addition, the P&P also indicated that security should be notified immediately of the presence of the patient who verbalized or otherwise exhibited an intention or desire to hurt themselves or others (having an Emergency Medical Condition) and were awaiting ED physician evaluation.

Review of policy titled "Nurses Notes" (approved 12/13/11) indicated: the purpose was to document patient data, nursing observations and interventions, and patient progress toward expected outcome and to assure continuity of care; persons providing care were to assure all interventions/assessments were documented; the RN or designee assigned to the room is responsible for making sure the notes are started and kept up to date; patients requiring intensive care (e.g. ESI 2) should be reassessed every one hour or more frequently as condition warrants until condition stabilizes.

A review of the ED's P&P titled, "Psychiatry" (approved 7/12/11) under, "Procedure" indicated that one of the measures to ensure that the ED provide a safe and secure environment for patients in the ED was that medical staff were to accompany any suicidal patient into the bathroom at all times.

A review of the ED records from 5/22/12 to 5/24/12 showed the following patients presented to the ED with a Psychiatric Emergency Medical Condition and were placed on an involuntary hold (either 1799.111, Health and Safety Code 1799.111 a 24 hour hold and/or 5150, Welfare and Institution Code 5150, an involuntary 72 hour hold) by a ED Physician, Licensed Clinical Social Worker (LCSW), or law enforcement, while awaiting either psychiatric evaluation or a transfer to a psychiatric facility. These records had no documented ongoing assessment and monitoring but included documentation that nursing staff changed the ESI levels of some patients prior to the evaluation by a LCSW, after initiation of a Psychiatric hold (1799.111 & 5150) were placed and even if the behaviors that attributed to them presenting to the ED were unchanged or escalated.

1. Patient 1 was admitted to the ED on 5/19/12 at 9:26 p.m. with suicidal ideation manifested by voices telling him to harm himself. Patient 1 was categorized as an ESI 2, roomed and placed on a 1799.111 hold by the physician at 9:44 p.m. with security standby assistance. Patient 1 was placed on a 5150 hold at 11:49 p.m. A nursing entry that began at 11:30 p.m. read that an RN contracted with Patient 1 to be safe while on the unit and downgraded his ESI 2 to 3. Patient 1 was allowed to walk to the bathroom without an escort and with the permission of the RN. On 5/20/12 at 1:43 a.m., Patient 1 eloped from the ED and was found dead, of an apparent suicide, across the street from the hospital.

2. Patient 2 was an 18 year old female who was brought to the ED on 4/1/12 at 4:17 p.m., as a 5150 designated by the police department for being angry and depressed at her parents and trying to set the house on fire using nail polish remover. Upon arrival, Patient 2 was categorized as an ESI 2 at 4:17 p.m. At 4:48 p.m., the attending nurse documented that Patient 2 had "psychological distress," but verbally contracted not to harm herself or others at this time. The nurse documented that the patient was evaluated and determined to be stable to down grade to an ESI 3. This was done prior to Patient 2 being assessed by the ED doctor or LCSW. Nursing documentation that described Patient 2's demeanor in the ED was at 6:07 p.m., 7:51 p.m. and 10:37 p.m. Patient 2 was placed on a 5150 hold by the LCSW at 9:08 p.m. awaiting transfer to a psychiatric hospital and at 11:22 p.m., a nurse documented that the patient was calm, cooperative and stable at this time and was downgraded to ESI 4. A review of security's documented daily activity report (DAR) indicated that Patient 2 was allowed to go the bathroom without escorts at 4:55 p.m. and 1:57 p.m. (the next day).

3. Patient 4 was a 51 year old female brought to the ED on 4/1/12 at 4:57 p.m., with suicidal thoughts, categorized as a ESI 2 and placed on a 1799.111 hold at 5 p.m. with security at the bedside. Patient 4 was seen by the ED physician at 5:20 p.m. and at 6:47 p.m., a nurse documented that Patient 4 was calm, cooperative and waiting for a medical clearance. Patient was then down graded to an ESI 3. Patient 4 was seen by the LCSW and placed on a 5150 hold at 10:30 p.m. and the patient remained in the ED until a bed was available. The next nursing documentation of Patient 4's demeanor was at 3:58 a.m. A nurse documented on 4/2/12 at 7:07 a.m., that Patient 4 was walking in and out of her room and kept on watch. A review of security's DAR indicated that Patient 4 was allowed to go the bathroom without escorts at 6:10 p.m., 10:47 p.m. and 12:34 a.m.

4. Patient 5 was a 25 year old male who was brought to the ED on 4/3/12 at 3:22 p.m. with a self-inflicted burn and complained of not wanting to exist anymore. Patient 5 was categorized as an ESI 2, put in a room and placed on a 1799.111 hold with security at standby. Patient 5 was seen by the LCSW and placed on a 5150 hold at 7:45 p.m. A nurse documented at 5:34 p.m., that Patient 5 was given a meal tray and that he was told they needed a urine specimen. There was no re-assessment of Patient 5's condition until 7:09 p.m. Patient 5 was down graded to an ESI 3 at 11:03 p.m. A review of security's DAR indicated that Patient 5 was allowed to go the bathroom without escorts at 4:10 p.m., 5:39 p.m. and the next day 4/4/12 at 7:21 a.m., 10:16 a.m. and 1:35 p.m.

5. Patient 10 arrived to the ED on 5/19/12 at 10:34 p.m. as a 5150 designation by the police department for being a danger to herself and wandering. Patient 10's personal belongings were removed and security was at the bedside. At 11:12 p.m. a nurse documented that the patient is now cooperative and denies suicide ideation. The patient was unaware of how she got to the ED or why she was there. Patient was reoriented to the events that brought her to the ED and she was then down graded to an ESI 3. Follow-up documentation at 2:11 a.m., showed Patient 10 was increasingly restless, agitated with crying out, singing, screaming and at one point attempted to leave the unit. A review of the documentation by the LCSW read that Patient 10 presented and continued to experience psychosis and paranoia.

6. Patient 11 presented to the ED on 5/1/12 at 10:25 a.m. with a chief complaint of suicidal ideation by overdosing or other means and a history of suicide attempts (Psychiatric Emergency Medical Condition) and was triaged as an ESI 2. At 10:48 a.m. the physician wrote an order for "Security to assistance with volatile patient." The physician also ordered psychiatric consultation.

On 5/1/12 at 10:48 a.m. the ED physician wrote an order for mental health hold, 24-hours, 1799.111 (Health and Safety Code 1799.111). At 11:15 a.m. the ED physician signed a form titled "Requesting a security presence for an involuntary hold in the Emergency Department" to initiate 1799.111. On the preprinted form (signed by the ED physician) the physician indicated that "...the presence of a Security Officer is necessary for the enforcement of this involuntary hold..."

After a psychiatric consultation by LCSW on 5/1/12 at 1:35 p.m. the patient was placed on a 5150 hold with recommendations for psychiatric hospitalization. The record showed that the patient was transferred via an ambulance on 5/1/12 at 5:02 p.m.

Review of the ED record showed no nursing documentation of ongoing monitoring and reassessments. The nurses decreased the ESI to 3 at 4:30 p.m. (requiring less frequent reassessments) even though the patient continued to have Psychiatric Emergency Medical Condition while awaiting transfer.

7. Patient 13 presented to the ED on 5/20/12 at 4:04 p.m. with a chief complaint of suicidal ideation and was triaged as an ESI 3. At 4:25 p.m. the physician ordered psychiatric consultation and initiated a 1799.111 hold and requested security at the bedside.

After a psychiatric consultation by LCSW on 5/20/12 at 6:31 p.m. the patient was determined not meeting the criteria for involuntary 5150 hold and at 6:58 p.m. the patient was discharged. Review of the ED record showed no nursing documentation of ongoing monitoring and reassessments while the patient awaited psychiatric consultation.

8. Patient 14 presented by ambulance (with law enforcement) to the ED on 5/20/12 at 3:25 p.m. with a chief complaint of wanting to hurt others. At 4:47 p.m. the ED physician wrote an order for a 1799.111 hold.

After a psychiatric consultation by the MFT (Marriage Family Therapist) on 5/20/12 at 5:49 p.m. the patient was placed on a 5150 hold with the recommendations for psychiatric hospitalization. The record showed that the patient was transferred via an ambulance on 5/20/12 at 11:19 p.m. Review of the ED record showed no nursing documentation of ongoing monitoring and reassessments.

9. Patient 15 presented by ambulance (with law enforcement) to the ED on 5/20/12 at 8:50 p.m. with complaint of wanting to die by running into traffic (as noted in the nursing flowsheets). The patient arrived on a 5150 hold after initially presenting to a psychiatric facility. After a psychiatric consultation by LCSW on 5/20/12 at 11:22 p.m. the patient's 5150 was upheld with the recommendations for psychiatric hospitalization. The record showed that the patient was transferred via an ambulance on 5/21/12 at 9:25 a.m.

The physician notes on 5/21/12 at 1:25 a.m. documented that the patient was agitated, inappropriate, labile, however the ESI 2, on arrival, was downgraded to ESI 3 at 2:31 a.m. on 5/21/12 while the patient was awaiting transfer to psychiatric hospital, without indication that the psychiatric emergency medical condition resolved. The review of the ED record showed no documentation of ongoing nursing monitoring and reassessments.

10. Patient 18 was brought in by law enforcement to the ED on 5/12/12 at 2:04 a.m. suicidal, on a 5150 hold by law enforcement, after grabbing a knife and threatening to kill self. The patient had a psychiatric consultation by a physician on 5/12/12 at 2:13 a.m. and the 5150 was upheld with the disposition for psychiatric hospitalization. The record showed that the patient was transferred via an ambulance on 5/12/12 at 12:30 p.m.

Review of the ED record showed that there was security standby, but no documentation of ongoing monitoring was found in the record. Again, ESI 2 on arrival was downgraded to ESI 3 at 2:14 a.m. on 5/12/12 while the patient was awaiting transfer to a psychiatric hospital, without indication that the psychiatric emergency medical condition resolved. At 3:39 a.m. nursing notes indicated that the patient was agitated and wanted to leave.

11. Patient 22 was admitted to the ED on 3/1/12 at 5:24 p.m. and was identified as an ESI 2 for suicidal ideation and alcohol intoxication. Review of the ED record showed that on 3/1/12 at approximately 6:30 p.m. Patient 22 was placed on a 1799.111 hold by the ED physician. However, at approximately the same time Patient 22's ESI status was decreased to level 3 with the nursing documentation noting the the patient denies suicidal ideation and was cooperative event though he was just placed on the 1799.111 mental health hold. On 3/2/12 11:36 p.m., 5 hours after being placed on the 1799.111, nursing documentation noted that the patient was awake, alert and oriented x 4 (person, place, time and date), calm and cooperative and denied suicidal ideation along with a physical assessment. The next nursing assessment was at 1:03 a.m. After this assessment there were no more musing assessments documented. At 6:40 p.m., Security was notified of the 1799.111 hold and was noted by nursing to have this patient under direct observation per protocol.

12. Patient 23 was admitted to the ED on 2-1-12, at 11:13 p.m., and was identified as an ESI 2 for suicidal ideation and depression. On 2/2/12 at 12:22 a.m. the facility's LCSW completed a psychiatric evaluation and identified that Patient 23 still had suicidal ideation and was not able to agree to contract for safety and was placed on a 5150 hold. ED documentation revealed that at 5:43 a.m. on 2/2/12 Patient 23 was downgraded from an ESI 2 to ESI 3 with no documentation of re-assessment by nursing as to why this occurred other than that Patient 23 had been medically cleared for transfer to a psychiatric facility. Patient 23's vital signs were checked by nursing at 4:55 a.m. There is no documentation of nursing assessments between 1:54 a.m. and 4:55 a.m. A review of Security documentation showed that Security personnel were monitoring room B 24 from 11:33 p.m. to 6 a.m. the next morning.

In an interview with the ED Director on 5/24/12 at 8 a.m., the Director stated that a Security officer was usually present on the unit and was requested for a "stand-by" when patients were placed on an involuntary hold (1799.111 or 5150) but they did not document in the medical records. They maintained logs which were part of the security department's documentation.

Review of documentation by the Security staff of observations for the patients described above showed that the Security officers simultaneously monitored 2-3 (or more) patients that required to be continuously monitored.

The Director confirmed that the ongoing monitoring of psychiatric patients was not documented and that nursing staff did not perform monitoring of psychiatric patients with emergency medical conditions at adequate frequencies. The Director had no explanation as to the reason for downgrading ESI for acute psychiatric patients.