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Based on observation, interview and record review, the facility failed to ensure Patient 30, a suicidal 5150 patient (5150 - a section of the California Welfare and Institutions Code which allowed a qualified person to involuntarily confine a person suspected to have a mental disorder that makes them a danger to self, a danger to others, and/or was gravely disabled), was kept safe and was stabilized following her presentation to the facility's emergency department (ED). Patient 30 was brought to the facility via ambulance after taking 12 Klonopin (drug used to treat anxiety) tablets and left prior to the completion of a medical and psychiatric evaluation. This had the potential to result in Patient 30's harm or death.


On May 18, 2015, at 9:45 a.m., a tour of the facility's emergency department was conducted. A sitter (facility staff placed to watch a patient) was observed sitting outside rooms 5, 6, 7, and 8.

During a concurrent interview, with Registered Nurse (RN) 1, RN 1 stated the patients in those rooms were in the facility under a "5150 hold." RN 1 stated the patients were waiting to be seen by a psychiatric nurse practitioner (PNP). RN 1 stated the PNP was qualified to release patients from the legal hold, and then the physician would determine the disposition of the patient.

The record for Patient 17, one of four patients currently on a 5150 hold, was reviewed. Patient 17 presented on May 15, 2015, at 3:08 p.m., after ingesting "two handfuls of seroquel (an anti-psychotic)." Patient 17 was placed on a legal hold (5150) on May 15, at 3:29 p.m., and a sitter was placed nearby.

The record for Patient 30 was reviewed. Patient 30, a [AGE] year old female, was brought to the facility by ambulance, on April 20, 2015, at 6:40 p.m. The ambulance run sheet indicated Patient 30, had a history of anxiety and "Bipolar (Mental disorder characterized by periods of elevated mood and periods of depression)." Documentation in the "Comments" section indicated: "Pt. (patient) sts (states) ingested 15 1-mg (milligram) Klonopin approximately 1 hr (hour) PTA (Prior to admission)."

According to the "ED Triage Report," Patient 30's chief complaint was "Overdose ingestion," and Patient 30 was "Suicidal took 15 Klonopin tabs 1 mg each." Patient 30 was identified as a level 3 acuity (urgent- will have a rapid medical exam by a healthcare provider).

Patient 30's "ER Nursing Record," indicated, at 6:45 p.m., the patient was placed in bed "Hall 5." Patient 30 was identified as suicidal.

On April 20, 2015, at 6:50 p.m., Patient 30 was seen by the provider and the following was documented: "...Pt states took 12 one mg Klonopin pills at 5 p.m. to calm herself down but also considered killing herself. H/O (history of) previous suicide attempt by klonopin overdose years ago. Also cut her left wrist tonight to try to kill herself ...5150 written by PD (police department) PTA." In the section titled, "Psych," Patient 30 was identified as anxious, depressed and had "suicide ideation (thoughts about suicide)." Diagnoses included depression and suicidal ideation.

According to the RN documentation, the following occurred on April 20, 2015:

a. At 6:49 p.m., the RN introduced self to the patient, and the RN assessment was completed;

b. At 7:18 p.m., the RN administered 50 mgs of activated charcoal (involved the administration of more than 2 doses of oral activated charcoal to enhance elimination of drugs ingested in acute poisoning. The charcoal interrupts the circulation of absorbed drugs, whereas unabsorbed drugs will be adsorbed to activated charcoal).

c. At 7:40 p.m., poison control was called by the charge nurse, and RN was instructed to observe for lethargy;

d. At 8 p.m., the patient was assisted to the restroom for an urinalysis, but no urine was obtained as the patient "forgot;"

e. At 8:30 p.m., the RN came back to the patient's bedside to have her drink more activated charcoal. Patient 30 was not in her bed. The RN searched for the patient, the charge nurse and security were notified, and "security will search premises;" and

f. At 8:50 p.m., there was no sign of Patient 30 on the premises, and the police were notified.

Patient 30's disposition was documented as "eloped," on April 20, 2015, at 8:50 p.m.

Patient 30's record contained a "SAD Persons Scale (an assessment tool for suicide risk)," that was not completed.

Instructions on the form indicated the patient should be placed in a room as close to the nurse's station as possible to ensure constant observation. In addition, interventions included placing the patient as far away from exits as possible; gowning the patient in a hospital gown; and performing visual patient checks, at a minimum of every 15 minutes, and documenting in the nursing notes.

During an interview with the Emergency Department Director (EDD), on May 19, 2015, at 10:15 a.m., the EDD stated a patient on a 5150 hold did not have the right to leave the facility, and "we try everything we can to keep the patient here, but we can't physically hold them." The EDD stated a sitter was used for 5150 patients to make sure the patient did not hurt themselves. The EDD reviewed Patient 30's record and stated there was no evidence a sitter was used. The EDD stated they probably did not have a sitter for Patient 30. The EDD stated Patient 30 should have had a sitter at the bedside upon her admission to the ED.

The Emergency Department was observed with the EDD on May 19, 2015, at 10:30 a.m. The area for Hallway beds was observed. According to the EDD, Hallway Bed 5 would be located to the right of the nursing station, in the main ED hallway. The EDD stated a gurney would be placed next to the wall with privacy curtains surrounding the area. Hallway Bed 5 was halfway between the door exiting into the lobby and the ambulance entrance door.

On May 20, 2015, at 10:25 a.m., RN 2 was interviewed. RN 2 stated she currently had two patients on 5150 holds. RN 2 stated if a 5150 patient wanted to leave, "we can't physically hold them." RN 2 stated the sitter can speak with a patient to redirect someone attempting to leave, and notify the nurse and security personal if the patient leaves the facility.

During an interview with Physician (MD) 1, on May 19, 2015, at 11:30 a.m., MD 1 stated a 5150 hold was a request for an involuntary hold of a patient. The MD reviewed Patient 30's record and stated the patient was seen by the physician assistant (PA) at the time of her admission. MD 1 stated if the patient had not been admitted with a 5150 in place, the PA would have written a 5150 for this patient. MD 1 stated this patient should have had a sitter, as the sitter can speak with and redirect the patient to remain. The MD agreed that if a sitter was present the police department would have been contacted sooner.

There was no evidence the patient ever returned to the ED.

The facility policy titled, "Fifty-One Fifty Patients in the Emergency Department," with a last revised date of February 2015, was reviewed. The policy included the following:

a. The policy described the procedure for the provision of care for patients who are brought to the Emergency Department on a 5150 and for patients who come in and require a 5150 assessment;

b. A patient on a 5150 hold, would be transferred to a 5150 designated facility after the patient was medically cleared;

c. Nursing staff will complete a SAD Persons scale assessment on all 5150 patients and implement necessary requirements.

The facility policy and procedure titled "EMTALA and COBRA Compliance (Patient Transfer & Emergency Medical Treatment & Active Labor Act)," with a last revised date of February 2015, was reviewed. The policy indicated the facility would comply with EMTALA regulations at all times. The policy indicated an emergency medical condition was a medical condition manifested by acute symptoms of sufficient severity (including psychiatric disturbances) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy.

The policy defined, "Stabilize: To provide medical treatment of the emergency medical condition necessary to assure, with reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual."

The policy further defined, "Stabilized: With respect to an emergency medical condition that does not involve a pregnant woman with contractions, that no material deterioration of the emergency medical condition is likely ..."