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Based on interview and record review, the facility failed to uphold a patient's right to receive care in a safe setting. The facility failed to ensure:

a. timely implementation of suicide precautions for a patient who presented with suicidal ideation; and

b. documentation & investigation of a serious patient safety event (elopement) per facility policy. (citing Patient # 1)

Findings include:

TX 00304570

a. Suicide Precautions:

Review of facility policy titled " Care of the Suicidal Patient Procedure # 1946", effective 04/04/17, read:"...3 Suicide Precautions: 3.1 Patients considered at risk for suicidal behavior should have suicide precautions implemented immediately..."

Review of facility "Room Sweep Checklist" read: " 1. Upon admission, the patient sitter (PS) and the patient nurse...will use the Room Sweep Checklist to clear the room for patient safety. Scan into patient chart..."

Review of the form titled "Room Sweep Checklist" showed an extensive listing of items to be removed including personal items (medication, mirrors, pencils, pens, etc..) and room items (all phones, oxygen flowmeters, ambubags, monitor cables, TV remote cords, otoscopes, etc...). The form had boxes to check by each series of items to check, verifying removal.

Review of the emergency department (ED) record for Patient # 1, dated 1-14-19, revealed patient arrived at 8:10 a.m. with arrival complaint: altered mental status (AMS); sexual assault evaluation (SAE).

Further review showed : 8:17 a.m.: chief complaint updated: AMS ....pt desires to harm herself... 8:18 a.m. ...." Triage Focused Assessment" included full review of body systems..." Psychiatric: X "patient wants to donate her organs and die .... Sexual Assault Evaluation: SAE-yes ..." 8:35 a.m.: "Triage completed ...Triage Plan: Patient Acuity 2 ..."

During an interview on 01-17-19 at 11:05 a.m. with ED Registered Nurse (RN ) # 13, she said "when a patient comes in with suicidal ideation: the patient is placed in a gown; patient belongings are taken & secured into a bag and placed in a cart outside the door. No cell phone or jewelry is allowed. The room is 'sweeped' and all hazards are removed. There is a sitter at the bedside and they accompany the patient to the bathroom, if they go. The sitter stays with the patient the entire time."

On 01-17-19 at 11:30 a.m. with RN # 6 reviewed Patient # 1's electronic medical record (EMR) with surveyor. When requested to review documentation of suicide precautions implementation, the EMR showed the first documentation was:

" 01-14-19 (0951) : Behavioral Health Assessment : patient wearing double gowns, observed by direct patient caregiver; belongings inspected, interventions: sitter... continuous 1:1, clothing checked, etc..." The suicide interventions were again documented this same date at 1027, 1100, 1200, and 1300.

At time of record review, RN # 6 stated the suicide precautions for Patient # 1 should have been implemented and documented at the time of ED admission, which was 8:17 a.m.

The facility was unable to locate a scanned "Room Sweep Checklist" completed on 01-14-19 for Patient # 1.

Elopement & Patient Event Report:

Review of facility policy titled "Patient Event Reporting Procedure# 1976," effective 09/07/2016, read: "Procedure 1. Definition of a Patient Event: 1.1 Reportable Patient Event-Any unanticipated event or circumstance that subjects a patient..to risk of bodily injury...3. Reporting of Safety Events: 3.1 The intent of the reporting system is for all patient events to be reported..The online event reporting form should be completed by a workforce member...or physician who observed or is directly involved in a reportable event...This should be done as soon as possible after the patient event and within 24 hours. ..."

Further review of Patient # 1's record revealed:

01-14-19 ( 9:24 a.m.) ED Notes Addendum: "Patient # 1 is a 16-year-old female sitting on stretcher. Pt was brought into EC ( emergency center) via Harris County Sheriff's Office and EMS for Suicidal ideation. Pt report she wants to die. When PT (patient) was escorted by the sitter to the restroom, PT ran out of the open door. Security called to help bring PT back to EC. PT was found outside of the hospital and escorted by (sic) to room, away from any outside doors. PT care was handed off to RN # 13, RN due PT uncomfortable with a male nurse ..."

During an interview on 01-17-19 at 11:25 a.m. with ED/RN # 12 she stated " ...at one point the patient ( #1) eloped. She got out of one the ER doors and through the building next door and onto the playground. Several of us ran after her, including security. We were able to get her back into the ER. She seemed to calm down a bit after a while..."

During an interview on 01-17-19 at 1:15 p.m. with assistant ER Director # 4, she said she was unable to locate a documented "Patient Event" report (also known as a "safety scoop") for the elopement of Patient # 1 on 01-14-19. She went on to say there should have been one completed; this would have triggered an investigation.

Based on interview and record review, the facility failed to ensure a registered nurse supervised and evaluated the care for 1 of 1 patients (citing Patient # 1).

Nursing staff :

a. failed to conduct RN reassessments appropriate to patient's acuity level and circumstance; and

b. failed to inform the receiving hospital of patient's current condition prior to transfer.

Findings include:

TX 00304570

RN Reassessments:

Record review of Patient #1's electronic medical record (emr) was conducted with facility RN # 6.

Review of the EMR revealed Patient # 1 arrived by ambulance to the facility on 01-14-19 at 8:17 a.m.

The following initial RN nursing assessment was documented in Patient # 1's medical record:

"1-14-19 at 818 a.m.: RN nursing assessment (documented a complete review of body systems); vital signs: blood pressure: 125/78; Pulse: 77; Respirations:18..." documented by RN # #19.

8:35 a.m.: "Triage completed ...Triage Plan: Patient Acuity 2 ..."

RN # 6 was unable to locate any additional documented nursing assessments. The only other vital signs recorded were by a medical assistant at 1103 a.m. .

Patient # 1 eloped from the facility at 9:24 a.m. ;and was transferred to another facility at 2:52 p.m. There was no documented RN re-assessment after Patient # 1's elopement or prior to discharge.

During an interview on 01-17-18 at 12:30 p.m. with RN # 6 , she said when a patient was triaged as Acuity 2, they should be reassessed by a nurse every hour and prior to discharge or transfer.

Report of Patient Condition to Receiving Hospital:

Review of facility policy titled "Transfer of Patient to and from [ ] Hospital Procedure # 1993", effective 08/27/2018, read:"...2.2.1.9 the nurse taking care of the Patient should call report to the receiving hospital..."

Record review of all nursing documentation and facility Memorandum of Transfer, dated 01-14-19 for Patient # 1 failed to reveal any nurse-to-nurse communication of patient condition (report) to receiving hospital.

Interview on 01-17-19 at 11:05 a.m. with ER/ RN # 13, when asked the patient's condition at discharge, she said the last recorded vital signs were at 11:03 a.m. RN # 13 went on to say she was not aware the patient had left. "I came out of another patient's room and saw Patient # 1 walking out with a police officer. He may have just showed up and taken her out without telling anyone; I'm not sure."

Record review of receiving facility "Transfer Center Notes" show Patient # 1 arrived at their facility at 2:21 p.m. on 01-14-19. There are notations made at 6:50 p.m. and 7 p.m. stating there was no nurse-to-nurse report called from transferring hospital.