The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

DAVIS REGIONAL MEDICAL CENTER 218 OLD MOCKSBVILLE RD PO BOX 1823 STATESVILLE, NC 28687 Sept. 1, 2011
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy review, Medical Staff Rules and Regulations review, medical record review, physician, administrative, and staff interviews, grievance log review, hospital document review, event report review, physician credential file review, and personnel file review, the hospital's Governing Body failed to provide oversight and have systems in place to ensure the medical staff was accountable for the quality of care provided to patients, the protection of patients' rights, and an organized nursing service to ensure the safety of patients.

The findings include:

1. The hospital's governing body failed to ensure the medical staff was accountable for the quality of care provided to patients by failing to ensure Emergency Department (ED) physicians reassessed behavioral health patients each day and failing to ensure psychiatric consults were completed per policy.

~cross refer to 482.13(a)(5) Governing Body Standard: Tag A0049

2. The hospital failed to promote and protect patients' rights by failing to: provide patients with written resolutions of grievances, ensure a safe setting for patient care, and implement restraints in accordance with safe and appropriate standards of care.

~cross refer to 482.13 Patient Rights' Condition: Tag A0115

3. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care and ensure registered nurses in the Emergency Department (ED) were trained and qualified to ensure adequate monitoring of behavioral health patients in the ED.

~cross refer to 482.23 Nursing Services Condition: Tag A0385
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, Medical Staff Rules and Regulations review, medical record review, and physician, administrative and staff interviews, the hospital's governing body failed to ensure the medical staff was accountable for the quality of care provided to patients by failing to ensure Emergency Department (ED) physicians reassessed behavioral health patients each day and failing to ensure psychiatric consults were completed per policy for 4 of 5 sampled behavioral health patients that were held in the ED greater than 24 hours (#4, #3, #6, and #1).

The findings include:

Review of current hospital policy entitled "Behavioral Patients: Care of the Psychiatric Patient in the Emergency Department (ED)" dated 03/09/2011 revealed, "...III. Guidelines (Procedure):....9. When a psychiatric patient is awaiting placement to an outside inpatient treatment facility and the patient has been in the ED for greater than 24 hours while awaiting placement, the Delta Unit (behavioral heath unit) psychiatrists will be consulted for the appropriate treatment plan....The psychiatrist is responsible for writing orders in corroboration with the ED physician either in the ProMed system or on a separate Physician's Order sheet....IV. Documentation:....3. In addition, the following documents are completed on extended hold patients: a. Daily Progress/Reassessment note by ED physician...."

Review of the hospital's "Medical Staff Rules and Regulations" last approved by the Board of Trustees on 04/20/2010 revealed, "...Consultation requests are to be completed within 24 hours...."

1. Closed medical record review on 08/31//2011 for Patient #4 revealed a [AGE] year old male that was brought to the hospital's ED by police on 07/13/2011 at 0222 with "Chief Complaint: Psychiatric". Medical record review of triage nurse assessment on 07/13/2011 at 0222 revealed the patient answered "Yes" to "Suicidal/Homicidal thoughts" and "Suicidal/Homicidal". Medical record review revealed the patient was held in the ED awaiting placement until 07/18/2011 at 1608 (5 days), at which time he was transferred to the hospital's inpatient Psychiatric Unit. Medical record review revealed a physician's order for a Psychiatric Consult dated 07/14/2011 at 1101. Medical record review revealed no documentation a Psychiatric Consult was completed prior to the patient's transfer to the hospital's inpatient Psychiatric Unit (4 days after consult was ordered). Further medical record review revealed no documentation an ED physician reassessed the patient from 07/14/2011 through 07/18/2011 (4 of 5 days in ED).

Further medical record review revealed Patient #4 was brought to the hospital's ED by police on 07/28/2011 at 1258 with "Chief Complaint: Psychiatric". Review of nurse's notes on 07/28.2011 at 1258 revealed, "Pt (Patient) states he 'Needs Help' but will not elaborate. Does not answer questions except to state he does not have any thoughts of harming himself or anyone else." Medical record review revealed the patient was held in the ED awaiting placement until 08/02/2011 at 1800 (5 days), at which time he was transferred to the hospital's inpatient Psychiatric Unit. Medical record review revealed "Consult by Psychiatrist initiated at 08/01/2011 0717 (verbal order by physician #2)." Medical record review revealed no documentation a Psychiatric Consult was completed prior to the patient's transfer to the hospital's inpatient Psychiatric Unit (5 days in ED and 1 day and 11 hours after consult was ordered). Further medical record review revealed no documentation an ED physician reassessed the patient on 07/29/2011, 07/30/2011, or 07/31/2011 (3 of 5 days in ED).

Interview on 09/01/2011 at 0945 with Physician #1 (an ED physician) revealed, "We are supposed to put a note in (the computer chart) at least every 24 hours to show that we have assessed the patient." Interview revealed the physician consults the behavioral health unit's staff or Mobile Crisis (after hours) for behavioral heath assessments and that staff relays information to the psychiatrist. Interview revealed, "I don't actually speak with the psychiatrist. I've spoke with one maybe 10 times in the past year." Further interview revealed if a behavioral health patient was held in the ED for more than 24 hours "we order a psychiatry consult or we may call....The psychiatrist should come and see the patient and write a note in the chart".

Interview on 09/01/2011 at 1200 with the Chief Executive Officer (CEO) revealed the ED began to see an increase in the volume of behavioral health patients about one year ago. Interview revealed in February 2011 the CEO told psychiatrists in a Psych(iatric) Team meeting that they needed to round daily in the ED. Interview revealed psychiatrists should be consulted on behavioral health patients that have been in the ED for more than 24 hours. Interview revealed, "It's (process of psychiatrists seeing patients in the ED) probably a little spotty."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed ED physicians should reassess behavioral health patients being held in the ED each day. Interview revealed a psychiatrist consult should be done for all behavioral health patients that are held in the ED for more than 24 hours. Interview revealed psychiatrists sometimes evaluated patients in the ED but did not document their assessments. Interview confirmed there was no available documentation a Psychiatric Consult was done during either the 07/13/2011 or 07/28/2011 ED visits. Interview confirmed there was no available documentation an ED physician reassessed the patient daily during either the 07/13/2011 or 07/28/2011 ED visits.

2. Medical record review on 08/31/2011 for Patient #3 revealed a [AGE] year old female that presented to the ED via Emergency Medical Services (EMS) on 07/22/2011 at 2215. Medical record review revealed "Chief Complaint - Psychiatric". Medical record review revealed the patient was held in the ED awaiting placement until 07/26/2011 at 1920 (4 days), at which time she was transferred to another hospital for further behavioral health treatment. Medical record review revealed a Psychiatric Consult was ordered by Physician #2 on 07/26/2011 at 1353 (5 hours and 27 minutes prior to transfer to another facility). Medical record review revealed no documentation a Psychiatric Consult was completed prior to the patients transfer (4 days in ED). Further medical record review revealed no documentation an ED physician reassessed the patient on 07/24/2011 or 07/25/2011 (2 of 4 days in ED).

Interview on 09/01/2011 at 0945 with Physician #1 (an ED physician) revealed, "We are supposed to put a note in (the computer chart) at least every 24 hours to show that we have assessed the patient." Interview revealed the physician consults the behavioral health unit's staff or Mobile Crisis (after hours) for behavioral heath assessments and that staff relays information to the psychiatrist. Interview revealed, "I don't actually speak with the psychiatrist. I've spoke with one maybe 10 times in the past year." Further interview revealed if a behavioral health patient was held in the ED for more than 24 hours "we order a psychiatry consult or we may call....The psychiatrist should come and see the patient and write a note in the chart".

Interview on 09/01/2011 at 1200 with the Chief Executive Officer (CEO) revealed the ED began to see an increase in the volume of behavioral health patients about one year ago. Interview revealed in February 2011 the CEO told psychiatrists in a Psych(iatric) Team meeting that they needed to round daily in the ED. Interview revealed psychiatrists should be consulted on behavioral health patients that have been in the ED for more than 24 hours. Interview revealed, "It's (process of psychiatrists seeing patients in the ED) probably a little spotty."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed ED physicians should reassess behavioral health patients being held in the ED each day. Interview revealed a psychiatrist consult should be done for all behavioral health patients that are held in the ED for more than 24 hours. Interview revealed psychiatrists sometimes evaluated patients in the ED but did not document their assessments. Interview confirmed there was no available documentation the ED physician reassessed the patient on 07/24/2011 or 07/25/2011 (2 of 4 days in ED). Further interview confirmed there was no available documentation a psychiatrist evaluated the patient for the appropriate treatment plan during the 4 days the patient was in the ED.






3. Closed medical record review for Patient #6 revealed a [AGE] year old male that presented to the Emergency Department (ED) on 08/07/2011 at 1822 for a behavioral health evaluation. Review of the triage nurse's assessment documentation timed 1837 revealed, "Pt (patient) says that the vet(erans) admin(istration) set (sent) the police to bring him here and he says he does not know why. Pt says he wants medical attention for many sx (symptoms) other wise he might want to hurt himself....Past Medical History: Acute Exacerbation of Schizophrenia...Psychosis...." Review of Physician #1's documentation dated 08/09/2011 at 1015 on an "Examination and Recommendation for Involuntary Commitment" form revealed, "[AGE] year old male hearing voices. He states they are not telling him to harm others, but he cannot deny wanting to harm himself." Record review revealed documentation of an involuntary commitment order signed by the magistrate on 08/09/2011 at 1121. Record review revealed the patient awaited placement and remained in the ED until 08/11/2011 at 1230, at which time he was transferred to another hospital for further behavioral health treatment. Record review revealed no documentation the ED physician reassessed the patient between 08/09/2011 at 2009 and 08/11/2011 at 0711 (35 hours). Further record review revealed no documentation a psychiatrist was consulted or evaluated the patient for the appropriate treatment plan during the 4 days the patient was in the ED.

Interview on 09/01/2011 at 0945 with Physician #1 revealed, "We are supposed to put a note in (the computer chart) at least every 24 hours to show that we have assessed the patient." Interview revealed the physician consults the behavioral health unit's staff or Mobile Crisis (after hours) for behavioral heath assessments and that staff relays information to the psychiatrist. Interview revealed, "I don't actually speak with the psychiatrist. I've spoke with one maybe 10 times in the past year." Further interview revealed if a behavioral health patient was held in the ED for more than 24 hours "we order a psychiatry consult or we may call....The psychiatrist should come and see the patient and write a note in the chart".

Interview on 09/01/2011 at 1200 with the Chief Executive Officer (CEO) revealed the ED began to see an increase in the volume of behavioral health patients about one year ago. Interview revealed in February 2011 the CEO told psychiatrists in a Psych(iatric) Team meeting that they needed to round daily in the ED. Interview revealed psychiatrists should be consulted on behavioral health patients that have been in the ED for more than 24 hours. Interview revealed, "It's (process of psychiatrists seeing patients in the ED) probably a little spotty."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed ED physicians should reassess behavioral health patients being held in the ED each day. Interview revealed a psychiatrist consult should be done for all behavioral health patients that are held in the ED for more than 24 hours. Interview revealed psychiatrists sometimes evaluated patients in the ED but did not document their assessments. Interview confirmed there was no available documentation the ED physician reassessed the patient between 08/09/2011 at 2009 and 08/11/2011 at 0711 (35 hours - no documented assessment on 08/10/2011). Further interview confirmed there was no available documentation a psychiatrist was consulted or evaluated the patient for the appropriate treatment plan during the 4 days the patient was in the ED.

4. Closed medical record review for Patient #1 revealed a [AGE] year-old male that presented to the Emergency Department (ED) on 08/02/2011 at 1545 with a chief complaint of "suicide gesture". Review of triage nurse's notes at 1616 revealed, "Pt (patient) took wheelchair and was heading down hill toward the street. Pt told son that if he went home today he was going to kill himself. Sig(nificant) other left him several weeks ago. Pt very depressed." Review of the ED physician's initial assessment dated [DATE] at 1719 revealed, "...He (patient) states that he wants to run his motorized wheelchair into the road in front of traffic. He states that he financially has nothing. He doesn't want to live anymore. He has had '3' prior suicide attempts in the past." Review of physician's orders dated 08/03/2011 at 1654 revealed, "pysch(iatric) consult please." Review of physician's orders dated 08/04/2011 at 1446 revealed, "Consult by psychiatrist." Record review revealed the patient was discharged to assisted living accompanied by a family member on 08/10/2011 at 1843. Record review revealed no documentation that a psychiatrist evaluated the patient after the ED physician ordered psychiatric consults on 08/03/2011 and 08/04/2011 or during the 8 days the patient was in the ED.

Interview on 09/01/2011 at 0945 with Physician #1 revealed the physician consults the behavioral health unit's staff or Mobile Crisis (after hours) for behavioral heath assessments and that staff relays information to the psychiatrist. Interview revealed, "I don't actually speak with the psychiatrist. I've spoke with one maybe 10 times in the past year." Further interview revealed if a behavioral health patient was held in the ED for more than 24 hours "we order a psychiatry consult or we may call....The psychiatrist should come and see the patient and write a note in the chart".

Interview on 09/01/2011 at 1200 with the Chief Executive Officer (CEO) revealed the ED began to see an increase in the volume of behavioral health patients about one year ago. Interview revealed in February 2011 the CEO told psychiatrists in a Psych(iatric) Team meeting that they needed to round daily in the ED. Interview revealed psychiatrists should be consulted on behavioral health patients that have been in the ED for more than 24 hours. Interview revealed, "It's (process of psychiatrists seeing patients in the ED) probably a little spotty."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed a psychiatrist consult should be done for all behavioral health patients that are held in the ED for more than 24 hours. Interview revealed psychiatrists sometimes evaluated patients in the ED but did not document their assessments. Interview confirmed there was no available documentation a psychiatrist evaluated the patient after the ED physician ordered psychiatric consults on 08/03/2011 and 08/04/2011 or during the 8 days the patient was in the ED.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and staff interview, the hospital failed to ensure a physician's order for seclusion for 1 of 3 sampled patients restrained or secluded (#6).

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 08/2010 revealed, "...VII. Behavioral Health Restraint and Seclusion 1. Requirements for All Settings....A registered nurse may initiate restraint or seclusion in advance of the physician's order. i. As soon as possible, but no longer than one hour after the initiation of restraint or seclusion, the registered nurse shall consult with a responsible physician about the patient's physical and psychological status and obtain an order (verbal or written). ii. The initial and all subsequent restraint orders shall expire in:...4 hours for patients 18 years of age and older...."

1. Closed medical record review for Patient #6 revealed a [AGE] year old male that presented to the Emergency Department (ED) on 08/07/2011 at 1822 for a behavioral health evaluation. Review of the triage nurse's assessment documentation timed 1837 revealed, "Pt (patient) says that the vet(erans) admin(istration) set (sent) the police to bring him here and he says he does not know why. Pt says he wants medical attention for many sx (symptoms) other wise he might want to hurt himself....Past Medical History: Acute Exacerbation of Schizophrenia...Psychosis...." Record review revealed the patient awaited placement and remained in the ED until 08/11/2011 at 1230, at which time he was transferred to another hospital for further behavioral health treatment. Review of Physician #1's documentation dated 08/09/2011 at 1015 on an "Examination and Recommendation for Involuntary Commitment" form revealed, "[AGE] year old male hearing voices. He states they are not telling him to harm others, but he cannot deny wanting to harm himself." Record review revealed documentation of an involuntary commitment order signed by the magistrate on 08/09/2011 at 1121. Record review revealed on 08/09/2011 at 1234 the patient eloped from the ED. Review of nurse's notes dated 08/09/2011 at 1256 revealed, "The patient was reassessed at 12:50. returned to ED by law enforcement. Patient very angry and told law enforcement that he was going to fight if he had to come back in and be put in the room in ED. Patient very upset but in room at present. Deputies advised staff to keep him in seclusion and advised us not to go into the room or to open the door unless they are in attendance." Record review revealed a physician's order for seclusion signed and dated by Physician #1 on 08/09/2011 at 1252. Record review revealed the patient was placed in seclusion at 1255. Record review revealed a physician's order for continued seclusion signed and dated by Physician #1 on 08/09/2011 at 1700. Record review revealed no documentation of other physician's orders for seclusion. Record review revealed the patient remained in seclusion until he was released at 0200 on 08/10/2011 (8 hours after last seclusion order).

Interview on 09/01/2011 at 1615 with the Director of Quality revealed the physician should renew behavioral restraint/seclusion orders every 4 hours if the patient still requires restraint or seclusion. Interview confirmed there was no available documentation of an order for Patient #6's continued seclusion after the order on 08/09/2011 at 1700 (8 hours before the patient was released from seclusion).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0176
Based on policy review, physician credential file review, and physician interview, the hospital failed to ensure 2 of 2 sampled Emergency Department physicians completed restraint and seclusion training per policy (Physician #1 and Physician #2).

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 08/2010 revealed, "...VIII. Training of Staff Hospital and medical staff members shall receive training in the following subjects as it relates to duties performed under this policy. Such training shall take place before the new staff member is asked to implement the provisions of this policy and shall be repeated periodically as indicated in the hospital's training plan, which shall be based on the results of quality monitoring activities. 1. Physicians who order restraint or seclusion shall be trained in the requirements of this policy and shall demonstrate a working knowledge of this policy through ongoing compliance...."

1. Credential file review for Physician #1 revealed the Emergency Department (ED) physician was an active member of the medical staff who currently practiced in the ED. File review revealed no documentation the physician had been trained to the hospital's Physical Restraint and Seclusion policy.

Interview on 09/01/2011 at 0945 with Physician #1 revealed the physician had been on staff at the hospital and practiced in the ED for one year. Interview revealed the physician does order restraints and seclusion on patients in the ED as needed. Interview revealed the physician had not received any training to the hospital's restraint and seclusion policy. Interview revealed, "My last restraint training was in residency, in 2001."

2. Credential file review for Physician #2 revealed the Emergency Department (ED) physician was an active member of the medical staff who currently practiced in the ED. File review revealed no documentation the physician had been trained to the hospital's Physical Restraint and Seclusion policy.

Physician #2 was not available for interview.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and physician and staff interviews, the hospital failed to ensure a patient was seen face-to-face within 1-hour after the initiation of seclusion by a physician, licensed independent practitioner, or other qualified professional for 1 of 3 sampled patients restrained or secluded for the management of violent or self-destructive behaviors (#6).

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 08/2010 revealed, "...VII. Behavioral Health Restraint and Seclusion 1. Requirements for All Settings....b. One-hour face-to-face assessment The licensed independent practitioner or physician's assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint (seclusion)...."

Closed medical record review for Patient #6 revealed a [AGE] year old male that presented to the Emergency Department (ED) on 08/07/2011 at 1822 for a behavioral health evaluation. Review of the triage nurse's assessment documentation timed 1837 revealed, "Pt (patient) says that the vet(erans) admin(istration) set (sent) the police to bring him here and he says he does not know why. Pt says he wants medical attention for many sx (symptoms) other wise he might want to hurt himself....Past Medical History: Acute Exacerbation of Schizophrenia...Psychosis...." Record review revealed the patient awaited placement and remained in the ED until 08/11/2011 at 1230, at which time he was transferred to another hospital for further behavioral health treatment. Review of Physician #1's documentation dated 08/09/2011 at 1015 on an "Examination and Recommendation for Involuntary Commitment" form revealed, "[AGE] year old male hearing voices. He states they are not telling him to harm others, but he cannot deny wanting to harm himself." Record review revealed documentation of an involuntary commitment order signed by the magistrate on 08/09/2011 at 1121. Record review revealed on 08/09/2011 at 1234 the patient eloped from the ED. Review of nurse's notes dated 08/09/2011 at 1256 revealed, "The patient was reassessed at 12:50. returned to ED by law enforcement. Patient very angry and told law enforcement that he was going to fight if he had to come back in and be put in the room in ED. Patient very upset but in room at present. Deputies advised staff to keep him in seclusion and advised us not to go into the room or to open the door unless they are in attendance." Record review revealed an physician's order for seclusion signed and dated by Physician #1 on 08/09/2011 at 1252. Record review revealed the patient was placed in seclusion from 1255 on 08/09/2011 until 0200 on 08/10/2011 (13 hours and 5 minutes). Record review revealed no documentation the patient was assessed face-to-face by the physician within one hour of seclusion. Record review revealed the first documentation the physician assessed the patient face-to-face was on 08/09/2011 at 1700 (4 hours and 5 minutes after the patient was placed in seclusion).

Interview on 09/01/2011 at 0945 with Physician #1 revealed, "When I do the face-to-face (assessment after restraint or seclusion) I sign on the order sheet." Interview confirmed the first documentation the physician assessed the patient face-to-face was on 08/09/2011 at 1700 (4 hours and 5 minutes after the patient was placed in seclusion). Interview revealed, "I can't remember if I was there and assessed him when he went into seclusion."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed physicians should document face-to-face assessments of patients within one hour of restraint or seclusion on the restraint/seclusion order sheet. Interview confirmed the first documentation the physician assessed the patient face-to-face was on 08/09/2011 at 1700 (4 hours and 5 minutes after the patient was placed in seclusion).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, event report review, and staff interview, the hospital failed to ensure a safe setting for patient care by failing to ensure staff implemented suicide precautions and monitored behavioral health patients in the Emergency Department (ED) per policy to prevent the elopement of 4 of 11 sampled behavioral health patients in the ED (#6, #1, #5, and #4).

The findings include:

Review of current hospital policy entitled "Behavioral Patients: Care of the Psychiatric Patient in the Emergency Department (ED)" dated 03/09/2011 revealed, "...III. Guidelines (Procedure): 1. Upon arrival to the ED, psychiatric patients will be triaged and assessed by ED nursing personnel and will document in detail: a. Patient's chief complaint to include active suicidal or homicidal intent or gesture, self-harming behavior, and/or aggressive behavior. b. The Suicidal Lethality Score will be documented in the ProMed (electronic) record by the RN (registered nurse) during the primary assessment. c. A level of observation/clinical assistance will be based on but not limited to the patient's presentation and the Suicidal Lethality Score....2. All psychiatric patients will change into paper scrubs and all clothing, valuables, medications, and other belongings will be placed in clothing bag and labeled with the patient's name and be locked in secure area of the ED. 3. Psychiatric patients will be placed in ED Psych rooms 18 & 19. When there are more than two psychiatric patients in the ED, the highest acuity patients will be placed in these rooms and the remaining psychiatric patients will be placed in rooms in that area of the ED (rooms 15-17, and room 1)....6. All psychiatric patients who express active suicidal/homicidal intent, or any self-harm or aggressive will be placed on continuous observation. A reassessment of ongoing suicidal and/or homicidal risk will be completed each shift by the responsible RN....8. On-going assessments to consider include but are not limited to: a. Actively suicidal (recent attempt and/or thought with plan and/or intent) b. Homicidal intent (recent attempt and/or thought with plan and/or intent)....d. Immediate or high LWOT (Left Without Treatment)/elopement risk (demanding to leave/exhibiting behaviors with intent to leave)....IV. Documentation: 1. The following documentation is completed on all psychiatric patients: a. Emergency Department nursing assessment to include the Suicide Lethality Score....2. The following documentation is completed when indicated:...b....Constant Observation Flowsheet...."

Review of current hospital policy entitled "Suicidal Interventions/Precautions" dated 01/2009 revealed, "...IV Policy: Patients will be assessed for suicidal potential as part of the hospital's admission procedures. Staff will continue to assess the potential of each patient to commit suicide on a regular basis....Patients believed to be at significant risk for committing suicide will be placed on suicide precautions that prescribe specific steps staff will take to reduce risk....Suicide precautions will be discontinued when clinically indicated. V. Guidelines (Procedure): 1. At the time of admission or presentation to the Emergency Department, a RN will assess and screen all patients to determine if there is a need to implement interventions/precautions to prevent suicide. 2. When a patient is believed to be at risk for committing suicide, specific precautionary interventions (described below) will be initiated by any staff member. These interventions are designed to ensure close supervision and monitoring of suicidal patients....5. The following Suicide precautions will be used to address the risk factors presented by the patient. A. SUICIDE INTERVENTIONS / PRECAUTIONS will be implemented for patients who present with a significant level of depression and suicidal preoccupation....b). Staff will make visual contact with the patient every 15 minutes. c). Patient will reside in a designated area to provide close observation. Movement from the designated area will require staff escort. d). Security or nursing staff will conduct a patient search for contraband including belts, shoes, and medications each shift....The patient will be placed in paper scrubs and all belongings will be...kept in a designated area on the unit. This search and removal of belongings will be documented in the patient's chart. e). Staff will document 15-minute visual checks on the Observation Flow Sheet. Staff will document in the Nursing Notes or ProMed each shift. Documentation will include staff observations and interventions, patient activities and behaviors. f). One member of nursing staff must be in close, physical proximity to the patient at all times until the patient is admitted to the Delta unit, or appropriate designation by the Nursing Supervisor, or a transfer to an appropriate facility is made....VI Documentation:...2. Staff will document suicide interventions/precautions and patient education....3. Staff will document all measures taken to assure the safety of the patient...."

1. Closed medical record review for Patient #6 revealed a [AGE] year old male that presented to the Emergency Department (ED) on 08/07/2011 at 1822 for a behavioral health evaluation. Review of the triage nurse's assessment documentation timed 1837 revealed, "Pt (patient) says that the vet(erans) admin(istration) set (sent) the police to bring him here and he says he does not know why. Pt says he wants medical attention for many sx (symptoms) other wise he might want to hurt himself....Past Medical History: Acute Exacerbation of Schizophrenia...Psychosis...." Record review revealed the patient was placed in Room 16. Review of RN (registered nurse) #7's notes dated 08/08/2011 at 0210 revealed, "The patient was reassessed at 21:00....(Patient) walking in & out of room, out of ED front entrance & smoking, then back in ED & walking around talking to staff, visitors, becoming increasingly restless; (Physician #2) updated & Safety Attendant to monitor visually and constantly; see Safety Attendant's sheet." Review of RN #4's notes dated 08/09/2011 at 0939 revealed, "Patient is alert and oriented X 3....Patient states that he is not involuntary and that he wants to walk outside for some air. patient noted walking to front door, patient encouraged not to stay outside to long...." Review of RN #4's notes on 08/09/2011 at 0946 revealed, "Patient is alert and oriented X 3....Patient sitting on bench in front of the ER...." Review of RN #4's notes on 08/09/2011 at 1033 revealed, "...The patient was reassessed at 10:18. Patient states that he wants to go home, (Physician #1) in room to see patient. (Physician #1) informs me that patient is still hearing voices and that she is in the process of making patient involuntary. (Unit Secretary #1) informed that (to) ask safety aid to assist patient into blue paper scrubs." Review of Physician #1's documentation dated 08/09/2011 at 1015 on an "Examination and Recommendation for Involuntary Commitment" form revealed, "[AGE] year old male hearing voices. He states they are not telling him to harm others, but he cannot deny wanting to harm himself." Record review revealed documentation of an involuntary commitment order signed by the magistrate on 08/09/2011 at 1121. Review of RN #8's notes on 08/09/2011 at 1218 (2 hours after RN #4 instructed staff to put patient in paper scrubs) revealed, "Pt is in Room 4 taking a shower. Pt was given blue scrubs to put on after he finishes." Review of RN #4's notes dated 08/09/2011 at 1236 revealed, "The patient was reassessed at 1234. Code Gray (aggressive/combative patient code) called. Patient's primary nurse noted to be in another room at this time. (Physician #1) and staff members outside to assist patient to return to room, patient not noted to be in parking lot or in Dr office parking lot. ER sec(retary) calling police department. ER manager and other department heads in the ER." Record review revealed on 08/09/2011 at 1234 the patient eloped from the ED. Review of nurse's notes dated 08/09/2011 at 1256 revealed, "The patient was reassessed at 12:50. returned to ED by law enforcement." Record review revealed the patient awaited placement and remained in the ED until 08/11/2011 at 1230, at which time he was transferred to another hospital for further behavioral health treatment. Record review revealed no documentation the patient was placed in paper scrubs upon admission to the ED on 08/08/2011 per policy or prior to his elopement from the ED on 08/09/2011. Further record review revealed no documentation the patient was visually monitored by staff continuously after RN #7 noted the need for constant visual monitoring on 08/07/2011 at 2100, when the patient was noted to be restless and wandered in and out of the ED. Record review revealed the first documentation the patient was visually and constantly monitored by staff and on 15 minute checks was on 08/09/2011 at 1300, after the patient was returned to the ED by police and placed in seclusion (1 day and 16 hours after RN #7 noted the need for constant visual monitoring).

Interview on 08/31/2011 with RN #7 revealed the nurse did not recall the patient.

Interview on 08/31/2011 with RN #4 revealed, "I informed (Unit Secretary #1) to have the safety aid assist the patient into paper scrubs after (Physician #1) said the patient was hearing voices and she was making him involuntary....I didn't see him as a flight risk. He was calm....Paper scrubs are to deter elopement and to alert all staff that a patient is homicidal or suicidal....I expected the tech to put (paper) scrubs on right then when I told them to." Further interview revealed the nurse reported Patient #6 off to RN #8 shortly after 1100, when RN #8 came on duty, because RN #4 was the charge nurse that day. Interview revealed, "I started documenting after I heard the Code Grey because (RN #8 is new and is an agency nurse and she was in another room." Interview revealed the nurse did not witness the patient's elopement.

Interview on 08/31/2011 at 1150 with Unit Secretary #1 revealed the secretary also worked as a Safety Attendant in the ED, but not on the day Patient #6 eloped. Interview revealed. "I seem to recall some discussion about getting an aide to put him in scrubs....I think he was in street clothes when he left."

Interview on 09/01/2011 at 0830 with Nursing Assistant (CNA) #1 revealed the CNA was from the 5th floor, but sometimes floated to the ED to work as a Safety Attendant. Interview revealed the CNA worked in the ED as a Safety Attendant on 08/09/2011 during the dayshift. Interview revealed, "All psych(iatric) patients are put in paper scrubs and non-slip socks....I usually monitor no more than 5 (psychiatric) patients at a time. I sit in the middle of the desk where I can see all of the rooms that I am monitoring at once. I go to each room every 15 minutes. Rooms 18 and 19 are on video monitor...." Interview revealed the CNA remembered Patient #6 in Room 16 on 08/09/2011. Interview revealed, "I was watching him, until he left (eloped). I was also watching psych patients in rooms 11, 12, 13, and 14. He (Patient #6) was in street clothes until after his shower. When he would go outside I told his nurse, because I can't leave all of my patients....He kept going in and out of 16 after his shower. They would give him the opportunity to get fresh air. He would rest and then come out again....I don't recall being told to put him in paper scrubs....I didn't know he was involuntary....I didn't see him when he fled."

Interview on 09/01/2011 at 0945 with Physician #1 revealed, "(RN #4) said this guy wants to leave, he's ready to go home. I went in his room to talk to him. I asked him if he wanted to harm himself or others and he denied. He said he still heard voices talking to him. He admitted he was not taking his medication (at home). I told him I suggested he stay so we could get his meds right. I told him I was IVCing him and wasn't sending him home. I was concerned because he was in Room 16....16 is almost a blind spot unless you are standing right there and it's near the registration door (that leads into the lobby)....I made him involuntary because I thought he was a flight risk and wasn't stable enough for discharge. I wanted him to get a sitter, a Safety Attendant....IVC patients have a Safety Attendant watching them. There was no one watching him when I assessed him because he was voluntary....He was in street clothes....I didn't see him leave....I don't remember going outside to look for him...."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed behavioral heath patients in the ED that complain of suicidal or homicidal ideations should be placed in paper scrubs. Interview revealed behavioral health patients in the ED that complain of suicidal or homicidal ideations or are involuntarily committed are visually and constantly monitored by a Safety Attendant that watches patients either through their windows or opened doors or via video monitoring (if the patients are in Rooms 18 or 19). Interview revealed Safety Attendants position themselves so that they can see video monitors and patient room doors and usually watch up to 5 patients, depending on the census of behavioral health patients in the ED. Interview revealed in addition to maintaining constant visualization of patients, the Safety Attendant also goes to each room and checks on each patient every 15 minutes. Interview revealed the constant monitoring and 15 minute checks on each patient are documented on the "Suicide Observation Sheet", which should be kept in the patient's medical record. Interview revealed a Safety Attendant is assigned to the ED "almost" every shift. Interview revealed per the staff schedule (shared with the surveyor during interview) there was a Safety Attendant assigned to the ED who would have monitored the patient on 08/07/2011 through 08/09/2011. Interview confirmed there was no available documentation the patient was visually monitored by staff continuously after RN #7 noted the need for constant visual monitoring on 08/07/2011 at 2100, when the patient was noted to be restless and wandered in and out of the ED. Interview revealed the Director thought the observation sheets must have been lost. Further interview confirmed there was no available documentation the patient was placed in paper scrubs upon admission to the ED on 08/08/2011 per policy or prior to his elopement from the ED on 08/09/2011.

2. Closed medical record review for Patient #1 revealed [AGE] year-old male that presented to the Emergency Department (ED) on 08/02/2011 at 1545 with a chief complaint of "suicide gesture". Review of the triage nurse's notes at 1616 revealed, "Pt (patient) took wheelchair and was heading down hill toward the street. Pt told son that if he went home today he was going to kill himself. Sig(nificant) other left him several weeks ago. Pt very depressed....Suicidal/Homicidal thoughts - Yes...." Review of the ED physician's initial assessment dated [DATE] at 1719 revealed, "...He (patient) states that he wants to run his motorized wheelchair into the road in front of traffic. He states that he financially has nothing. He doesn't want to live anymore. He has had '3' prior suicide attempts in the past." Review of ED physician's notes dated 08/03/2011 at 0053 revealed, "Patient resting in NAD (no acute distress), awaiting placement." Record review revealed the next documentation of a nursing assessment was a note documented by RN (registered nurse) #5 on 08/03/2011 at 0208. Review of RN #5's noted dated 08/03/2011 at 0208 revealed, "The patient was reassessed at 16:45....Noticed Pt in room and went in to see if he was visitor or a new Pt. Pt stated he had been at 'another hospital' and 'they thought he was crazy'. I asked Pt why they thought that and he said because he was sad over losing what her referred to as 'his woman'. I was given no report on the pt and had I not stopped in to speak with him I would have had no idea he was a pt. Spoke with Dr and Dr stated he was simply in need of being medically cleared and then we would find him placement." Review of RN #5's note at 0219 revealed, "The patient was reassessed at 18:00....No change in pt. Pt insists he would never harm himself...." Review of RN #6's notes dated 08/03/2011 at 0140 revealed, "The patient was reassessed at 01:40. Assumed care for this patient at this time (0140). Pt not in room at this time. Signal M (missing patient response system) called, Nursing Supervisor notified." Review of RN #5's notes dated 08/03/2011 at 0223 revealed, "The patient was reassessed at 01:23. Police call and state they have found pt on the interstate driving his wheelchair on the shoulder and would return him to the hospital." Record review revealed documentation the physician petitioned for the patient to be involuntarily committed on 08/03/2011 at 0215. Record review revealed documentation of an involuntary commitment (IVC) order signed by the magistrate on 08/03/2011 at 0249. Review of RN #6's notes dated 08/03/2011 at 0256 revealed, "The patient was reassessed at 02:56. Pt returned to Bed 1 via W/C (wheelchair) by SPD (police). Pt located in westbound (bound) traffic lane of I-40 at I-77 (approximately 2 miles from hospital). Pt states he was going to Waffle House for food. When asked, pt states he still feels like hurting himself." Record review revealed the patient was discharged to assisted living accompanied by a family member on 08/10/2011 at 1843. Record review revealed the first documentation that the nursing staff implemented suicide precautions for the patient was on 08/03/2011 at 0258 (11 hours and 13 minutes after the patient presented to the ED with complaints of suicidal ideations). Record review revealed no documentation the patient visually and constantly monitored prior to his elopement on 08/03/2011 at approximately 0140 (9 hours and 55 minutes after he presented to the ED with complaints of suicidal ideations). Record review revealed the first documentation a Safety Attendant monitored the patient continuously and did checks on the patient every 15 minutes was at 0300 on 08/03/2011 (after the patient was returned by police after his elopement).

Interview on 09/01/2011 at 0900 with RN #6 revealed, "I was in triage until 1:00 (am) (on 08/03/2011). I assumed his (Patient #1's) care at about 1:15 (am) or 1:30 (am) from (RN #5). I went into his room with (staff name) from Mobile Crisis (non-physician, qualified professional staff that do behavioral health assessments) to do his assessment at 1:40 (am) and he wasn't in the room. I called the supervisor and the hospital operator, to call a Signal M....I think the Safety Attendant (on duty) was (CNA #2). There was no secretary. I think the Safety Attendant left around 1:00 (am) also. I called the Supervisor and they said they would have a CNA from Delta (behavioral health unit) come down. It was after he eloped before they came down." Further interview revealed there was no documentation of visually constant observation and 15 minute checks prior to the patient's elopement available because "they hadn't been doing one (observation sheet)".

Interview on 09/01/2011 at 1615 with the Director of Quality revealed RN #5 was no longer employed at the hospital and was thus not available for interview. Interview revealed behavioral heath patients in the ED that complain of suicidal or homicidal ideations or are involuntarily committed are visually and constantly monitored by a Safety Attendant that watches patients either through their windows or opened doors or via video monitoring (if the patients are in Rooms 18 or 19) and suicide precautions are immediately implemented. Interview revealed Safety Attendants position themselves so that they can see video monitors and patient room doors and usually watch up to 5 patients, depending on the census of behavioral health patients in the ED. Interview revealed in addition to maintaining constant visualization of patients, the Safety Attendant also goes to each room and checks on each patient every 15 minutes. Interview revealed the constant monitoring and 15 minute checks on each patient are documented on the "Suicide Observation Sheet", which should be kept in the patient's medical record. Interview revealed a Safety Attendant is assigned to the ED "almost" every shift. Interview revealed per the staff schedule (shared with the surveyor during interview) there was a Safety Attendant assigned to the ED who would have monitored the patient on 08/02/2011 and 08/03/2011. Interview confirmed there was no available documentation the patient was visually and constantly monitored prior to his elopement on 08/03/2011 at approximately 0140 (9 hours and 55 minutes after he presented to the ED with complaints of suicidal ideations). Interview confirmed the first available documentation a Safety Attendant monitored the patient continuously and did checks on the patient every 15 minutes was at 0300 on 08/03/2011 (after the patient was returned by police after his elopement). Interview revealed the Director thought the observation sheets must have been lost. Interview confirmed the first available documentation nursing staff implemented suicide precautions for the patient was on 08/03/2011 at 0258 (11 hours and 13 minutes after the patient presented to the ED with complaints of suicidal ideations).

3. Closed medical record review for Patient #5 revealed a [AGE] year-old female that was transferred to the Emergency Department (ED) on 07/29/2011 at 0457 from another acute care hospital with a chief complaint of "Involuntary Commitment (IVC)". Review of RN (registered nurse) #3's notes timed 0517 revealed, "Patient assigned to room 1....Patient moved to room at 04:57. Time of primary assessment: 04:57....Overall Suicide Lethality Score: 40 or greater - Suicide Risk High. Suicide interventions done include:...continuous 1:1 direct observation...." Review of ED physician's notes dated 07/29/2011 at 0547 revealed, "Patient was seen earlier in (the same hospital's) ED for alleged OD (overdose) on Neurotin (anticonvulsant). Pt (patient) cleared and had denied SI (suicidal ideations)/attempt while in ED when directly questioned. After D/C (discharge) she made comments of hurting herself by walking out into street. Police took patient to (other acute care hospital). Put on IVC papers. Here for eval(uation)." Review of RN #3's notes dated 07/29/2011 at 0919 revealed, "The patient was reassessed at 07:20. Mobile Crisis (non-physician, qualified professional staff that conduct behavioral health evaluations) walked out of patient's room from evaluating patient, patient walked out of room and states that she is going outside to smoke. Patient states that she is not a child, she does not need help. When patient was asked not to go outside to smoke, she states that I don't give a (expletive) and walked out of the EMS (ambulance entry) doors. Secretary called operator and a signal M (missing patient code) paged overhead. (City) PD (police) notified. Patient got in her car with her boyfriend and left the premises. Patient's boyfriend's cell phone called and patient answered, told secretary that she will come back. Patient called back the department and states that she will come back, but she will probably go to jail for whooping someone's (expletive). (City) police officers here standing by for assistance." Record review revealed the police brought the patient back to the ED at 0826 (1 hour and 6 minutes after she eloped), at which time the patient was placed in Room 18. Record review revealed no documentation the patient was visually monitored by staff continuously on 07/29/2011 between 0457 (when staff assessed the patient to be at high risk for suicide) and 0720 (2 hours and 23 minutes later, when the patient eloped from the ED).

Interview on 09/01/2011 at 1615 with the Director of Quality revealed behavioral health patients in the ED that complain of suicidal or homicidal ideations or are involuntarily committed are visually and constantly monitored by a Safety Attendant that watches patients either through their windows or opened doors or via video monitoring (if the patients are in Rooms 18 or 19). Interview revealed Safety Attendants position themselves so that they can see video monitors and patient room doors and usually watch up to 5 patients, depending on the census of behavioral health patients in the ED. Interview revealed in addition to maintaining constant visualization of patients, the Safety Attendant also goes to each room and checks on each patient every 15 minutes. Interview revealed the constant monitoring and 15 minute checks on each patient are documented on the "Suicide Observation Sheet", which should be kept in the patient's medical record. Interview revealed a Safety Attendant is assigned to the ED "almost" every shift. Interview revealed per the staff schedule (shared with the surveyor during interview) there was a Safety Attendant assigned to the ED who would have monitored the patient the whole time she was in the ED on 07/29/2011. Interview confirmed there was no available documentation the patient was visually monitored constantly on 07/29/2011 between 0457 (when staff assessed the patient to be at high risk for suicide) and 0720 (2 hours and 23 minutes later, when the patient eloped from the ED).
Interview revealed the Director thought the observation sheets must have been lost.





4. Closed medical record review on 08/31/2011 for Patient #4 revealed a [AGE] year old male brought to the hospital's ED by police on 07/28/2011 at 1258 with "Chief Complaint: Psychiatric". Record review of nursing triaged note dated 07/28/2011 at 1258 revealed "Pt (Patient) states he 'Needs Help' but will not elaborate. Does not answer questions except to state he does not have any thoughts of harming himself or anyone else." Record review of physician documentation dated 07/28/2011 at 1304 revealed "...Pt (patient) was agitated, hallucinating, violent at (Crisis Center) intake...Symptoms are present and increased from onset. Patient states symptoms are of moderate intensity. Associated signs and symptoms: positive agitated, positive angry, positive hallucinating...." Record review of nursing documentation dated 07/28/2011 at 1305 revealed "Room Assignment: Patient assigned to room 19...Psychosocial: Patient's behavior appears depressed...Suicide Lethality assessment includes the following high intensity indicators: withdrawn or isolated - 6; few resources/support/counseling -6; destructive coping strategies - 7.; Overall Suicide Lethality Score: 11-39 - Suicide Risk Moderate.; Suicide interventions done include: medium risk interventions - direct observation/monitoring q (every) 15 min(utes), pt in line of sight of nurses station..." Record review of registered nurse (RN) #9's notes dated 07/29/2011 at 0747 revealed "...patient reassessed at 0710...PT ANXIOUS TEARING APART SHOE INSOLES STATED HE IS MAKING THEM FIT BETTER...." Record review revealed no documentation the patient was placed in a paper scrub clothing. Record review of RN #9's notes dated 07/29/2011 at 0748 revealed "(Patient #4) REQUESTING TO LEAVE SPOKE WITH MOBILE CRISIS HERE ABOUT PT STATES HE WILL BE PLACED (NAME OF CRISIS CENTER) REFUSES DUE TO THREATS ONTO STAFF MEMBERS AND SEXUAL INAPPROPRIATE GESTURES AND COMMENTS EXPLAINED SITUATION AND STATED HE UNDERSTANDS...." Record review of Nurse #9's notes dated 07/29/2011 at 1330 revealed "The patient was reassessed at 12:50 pt anxious...." Record review of Nurse #9's notes dated 07/29/2011 at 1331 revealed "pt code M (Missing Person) was (called) no one in ER seen pt leave. The patient was reassessed at 1303." Record review of Nurse #9's notes dated 07/29/2011 at 1834 revealed "The patient was reassessed at 18:34. resting quiet..." Record review revealed no nursing documentation of how the patient eloped, where the patient was found, how long the patient was missing, or what time he returned to the ED. Record review revealed no documentation the patient was visually monitored constantly or checked every 15 minutes prior to elopement (1 day after the patient was assessed to be at moderate risk for suicide).

Interview with Director of Quality on 09/01/2011 at 0825 revealed "(Nurse #9) isn't here anymore, she was a contract nurse....(she) no longer works here....Mr. (Patient #4) was her last day."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed behavioral heath patients in the ED that complain of suicidal or homicidal ideations should be placed in paper scrubs. Interview revealed behavioral health patients in the ED that complain of suicidal or homicidal ideations or are involuntarily committed are visually constantly monitored by a Safety Attendant that watches patients either through their windows or opened doors or via video monitoring (if the patients are in Rooms 18 or 19). Interview revealed Safety Attendants position themselves so that they can see video monitors and patient room doors and usually watch up to 5 patients, depending on the census of behavioral health patients in the ED. Interview revealed in addition to maintaining constant visualization of patients, the Safety Attendant also goes to each room and checks on each patient every 15 minutes. Interview revealed the constant monitoring and 15 minute checks on each patient are documented on the "Suicide Observation Sheet", which should be kept in the patient's medical record. Interview confirmed there was no available documentation the patient was visually monitored by staff continuously prior to the patient's elopement. Interview revealed the Director thought the observation sheets must have been lost. Further interview confirmed there was no available documentation the patient was placed in paper scrubs upon admission to the ED on 07/28/2011 per policy or prior to his elopement from the ED on 07/29/2011.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on policy review, medical record review, staff interview, and personnel file review, the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff supervised and evaluated patient care and ensure registered nurses in the Emergency Department (ED) were trained and qualified to ensure adequate monitoring of behavioral health patients in the ED.

The findings include:

1. The hospital's nursing staff failed to supervise and evaluate patient care by failing to continuously monitor, assess suicide risk, and/or implement suicide precautions per policy for 5 of 11 sampled behavioral health patients in the Emergency Department.

~cross refer to 482.23 (b)(3) Nursing Services Standard: Tag A0395

2. The hospital failed to ensure registered nurses in the Emergency Department (ED) were trained and qualified to ensure adequate monitoring of behavioral health patients in the ED.

~cross refer to 482.23 (b)(5) Nursing Services Standard: Tag A0397
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and staff interview, the hospital's nursing staff failed to supervise and evaluate patient care by failing to continuously monitor, assess suicide risk, and/or implement suicide precautions per policy for 5 of 11 sampled behavioral health patients in the Emergency Department (#6, #1, #5, #4, and #3).

The findings include:

Review of current hospital policy entitled "Behavioral Patients: Care of the Psychiatric Patient in the Emergency Department (ED)" dated 03/09/2011 revealed, "...III. Guidelines (Procedure): 1. Upon arrival to the ED, psychiatric patients will be triaged and assessed by ED nursing personnel and will document in detail: a. Patient's chief complaint to include active suicidal or homicidal intent or gesture, self-harming behavior, and/or aggressive behavior. b. The Suicidal Lethality Score will be documented in the ProMed (electronic) record by the RN (registered nurse) during the primary assessment. c. A level of observation/clinical assistance will be based on but not limited to the patient's presentation and the Suicidal Lethality Score....2. All psychiatric patients will change into paper scrubs and all clothing, valuables, medications, and other belongings will be placed in clothing bag and labeled with the patient's name and be locked in secure area of the ED. 3. Psychiatric patients will be placed in ED Psych rooms 18 & 19. When there are more than two psychiatric patients in the ED, the highest acuity patients will be placed in these rooms and the remaining psychiatric patients will be placed in rooms in that area of the ED (rooms 15-17, and room 1)....6. All psychiatric patients who express active suicidal/homicidal intent, or any self-harm or aggressive will be placed on continuous observation. A reassessment of ongoing suicidal and/or homicidal risk will be completed each shift by the responsible RN....8. On-going assessments to consider include but are not limited to: a. Actively suicidal (recent attempt and/or thought with plan and/or intent) b. Homicidal intent (recent attempt and/or thought with plan and/or intent)....d. Immediate or high LWOT (Left Without Treatment)/elopement risk (demanding to leave/exhibiting behaviors with intent to leave)....IV. Documentation: 1. The following documentation is completed on all psychiatric patients: a. Emergency Department nursing assessment to include the Suicide Lethality Score....2. The following documentation is completed when indicated:...b....Constant Observation Flowsheet...."

Review of current hospital policy entitled "Suicidal Interventions/Precautions" dated 01/2009 revealed, "...IV Policy: Patients will be assessed for suicidal potential as part of the hospital's admission procedures. Staff will continue to assess the potential of each patient to commit suicide on a regular basis....Patients believed to be at significant risk for committing suicide will be placed on suicide precautions that prescribe specific steps staff will take to reduce risk....Suicide precautions will be discontinued when clinically indicated. V. Guidelines (Procedure): 1. At the time of admission or presentation to the Emergency Department, a RN will assess and screen all patients to determine if there is a need to implement interventions/precautions to prevent suicide. 2. When a patient is believed to be at risk for committing suicide, specific precautionary interventions (described below) will be initiated by any staff member. These interventions are designed to ensure close supervision and monitoring of suicidal patients....5. The following Suicide precautions will be used to address the risk factors presented by the patient. A. SUICIDE INTERVENTIONS / PRECAUTIONS will be implemented for patients who present with a significant level of depression and suicidal preoccupation....b). Staff will make visual contact with the patient every 15 minutes. c). Patient will reside in a designated area to provide close observation. Movement from the designated area will require staff escort. d). Security or nursing staff will conduct a patient search for contraband including belts, shoes, and medications each shift....The patient will be placed in paper scrubs and all belongings will be...kept in a designated area on the unit. This search and removal of belongings will be documented in the patient's chart. e). Staff will document 15-minute visual checks on the Observation Flow Sheet. Staff will document in the Nursing Notes or ProMed each shift. Documentation will include staff observations and interventions, patient activities and behaviors. f). One member of nursing staff must be in close, physical proximity to the patient at all times until the patient is admitted to the Delta unit, or appropriate designation by the Nursing Supervisor, or a transfer to an appropriate facility is made....VI Documentation:...2. Staff will document suicide interventions/precautions and patient education....3. Staff will document all measures taken to assure the safety of the patient...."

1. Closed medical record review for Patient #6 revealed a [AGE] year old male that presented to the Emergency Department (ED) on 08/07/2011 at 1822 for a behavioral health evaluation. Review of the triage nurse's assessment documentation timed 1837 revealed, "Pt (patient) says that the vet(erans) admin(istration) set (sent) the police to bring him here and he says he does not know why. Pt says he wants medical attention for many sx (symptoms) other wise he might want to hurt himself....Past Medical History: Acute Exacerbation of Schizophrenia...Psychosis...." Record review revealed the patient was placed in Room 16. Review of RN (registered nurse) #7's notes dated 08/08/2011 at 0210 revealed, "The patient was reassessed at 21:00....(Patient) walking in & out of room, out of ED front entrance & smoking, then back in ED & walking around talking to staff, visitors, becoming increasingly restless; (Physician #2) updated & Safety Attendant to monitor visually and constantly; see Safety Attendant's sheet." Review of RN #4's notes dated 08/09/2011 at 0939 revealed, "Patient is alert and oriented X 3....Patient states that he is not involuntary and that he wants to walk outside for some air. patient noted walking to front door, patient encouraged not to stay outside to long...." Review of RN #4's notes on 08/09/2011 at 0946 revealed, "Patient is alert and oriented X 3....Patient sitting on bench in front of the ER...." Review of RN #4's notes on 08/09/2011 at 1033 revealed, "...The patient was reassessed at 10:18. Patient states that he wants to go home, (Physician #1) in room to see patient. (Physician #1) informs me that patient is still hearing voices and that she is in the process of making patient involuntary. (Unit Secretary #1) informed that (to) ask safety aid to assist patient into blue paper scrubs." Review of Physician #1's documentation dated 08/09/2011 at 1015 on an "Examination and Recommendation for Involuntary Commitment" form revealed, "[AGE] year old male hearing voices. He states they are not telling him to harm others, but he cannot deny wanting to harm himself." Record review revealed documentation of an involuntary commitment order signed by the magistrate on 08/09/2011 at 1121. Review of RN #8's notes on 08/09/2011 at 1218 (2 hours after RN #4 instructed staff to put patient in paper scrubs) revealed, "Pt is in Room 4 taking a shower. Pt was given blue scrubs to put on after he finishes." Review of RN #4's notes dated 08/09/2011 at 1236 revealed, "The patient was reassessed at 1234. Code Gray (aggressive/combative patient code) called. Patient's primary nurse noted to be in another room at this time. (Physician #1) and staff members outside to assist patient to return to room, patient not noted to be in parking lot or in Dr office parking lot. ER sec(retary) calling police department. ER manager and other department heads in the ER." Record review revealed on 08/09/2011 at 1234 the patient eloped from the ED. Review of nurse's notes dated 08/09/2011 at 1256 revealed, "The patient was reassessed at 12:50. returned to ED by law enforcement." Record review revealed the patient awaited placement and remained in the ED until 08/11/2011 at 1230, at which time he was transferred to another hospital for further behavioral health treatment. Record review revealed no documentation the patient was placed in paper scrubs upon admission to the ED on 08/08/2011 per policy or prior to his elopement from the ED on 08/09/2011. Further record review revealed no documentation the patient was visually monitored by staff continuously after RN #7 noted the need for constant visual monitoring on 08/07/2011 at 2100, when the patient was noted to be restless and wandered in and out of the ED. Record review revealed the first documentation the patient was visually and constantly monitored by staff and on 15 minute checks was on 08/09/2011 at 1300, after the patient was returned to the ED by police and placed in seclusion (1 day and 16 hours after RN #7 noted the need for constant visual monitoring).

Interview on 08/31/2011 with RN #7 revealed the nurse did not recall the patient.

Interview on 08/31/2011 with RN #4 revealed, "I informed (Unit Secretary #1) to have the safety aid assist the patient into paper scrubs after (Physician #1) said the patient was hearing voices and she was making him involuntary....I didn't see him as a flight risk. He was calm....Paper scrubs are to deter elopement and to alert all staff that a patient is homicidal or suicidal....I expected the tech to put (paper) scrubs on right then when I told them to." Further interview revealed the nurse reported Patient #6 off to RN #8 shortly after 1100, when RN #8 came on duty, because RN #4 was the charge nurse that day. Interview revealed, "I started documenting after I heard the Code Grey because (RN #8 is new and is an agency nurse and she was in another room." Interview revealed the nurse did not witness the patient's elopement.

Interview on 08/31/2011 at 1150 with Unit Secretary #1 revealed the secretary also worked as a Safety Attendant in the ED, but not on the day Patient #6 eloped. Interview revealed. "I seem to recall some discussion about getting an aide to put him in scrubs....I think he was in street clothes when he left."

Interview on 09/01/2011 at 0830 with Nursing Assistant (CNA) #1 revealed the CNA was from the 5th floor, but sometimes floated to the ED to work as a Safety Attendant. Interview revealed the CNA worked in the ED as a Safety Attendant on 08/09/2011 during the dayshift. Interview revealed, "All psych(iatric) patients are put in paper scrubs and non-slip socks....I usually monitor no more than 5 (psychiatric) patients at a time. I sit in the middle of the desk where I can see all of the rooms that I am monitoring at once. I go to each room every 15 minutes. Rooms 18 and 19 are on video monitor...." Interview revealed the CNA remembered Patient #6 in Room 16 on 08/09/2011. Interview revealed, "I was watching him, until he left (eloped). I was also watching psych patients in rooms 11, 12, 13, and 14. He (Patient #6) was in street clothes until after his shower. When he would go outside I told his nurse, because I can't leave all of my patients....He kept going in and out of 16 after his shower. They would give him the opportunity to get fresh air. He would rest and then come out again....I don't recall being told to put him in paper scrubs....I didn't know he was involuntary....I didn't see him when he fled."

Interview on 09/01/2011 at 0945 with Physician #1 revealed, "(RN #4) said this guy wants to leave, he's ready to go home. I went in his room to talk to him. I asked him if he wanted to harm himself or others and he denied. He said he still heard voices talking to him. He admitted he was not taking his medication (at home). I told him I suggested he stay so we could get his meds right. I told him I was IVCing him and wasn't sending him home. I was concerned because he was in Room 16....16 is almost a blind spot unless you are standing right there and it's near the registration door (that leads into the lobby)....I made him involuntary because I thought he was a flight risk and wasn't stable enough for discharge. I wanted him to get a sitter, a Safety Attendant....IVC patients have a Safety Attendant watching them. There was no one watching him when I assessed him because he was voluntary....He was in street clothes....I didn't see him leave....I don't remember going outside to look for him...."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed behavioral heath patients in the ED that complain of suicidal or homicidal ideations should be placed in paper scrubs. Interview revealed behavioral health patients in the ED that complain of suicidal or homicidal ideations or are involuntarily committed are visually and constantly monitored by a Safety Attendant that watches patients either through their windows or opened doors or via video monitoring (if the patients are in Rooms 18 or 19). Interview revealed Safety Attendants position themselves so that they can see video monitors and patient room doors and usually watch up to 5 patients, depending on the census of behavioral health patients in the ED. Interview revealed in addition to maintaining constant visualization of patients, the Safety Attendant also goes to each room and checks on each patient every 15 minutes. Interview revealed the constant monitoring and 15 minute checks on each patient are documented on the "Suicide Observation Sheet", which should be kept in the patient's medical record. Interview revealed a Safety Attendant is assigned to the ED "almost" every shift. Interview revealed per the staff schedule (shared with the surveyor during interview) there was a Safety Attendant assigned to the ED who would have monitored the patient on 08/07/2011 through 08/09/2011. Interview confirmed there was no available documentation the patient was visually monitored by staff continuously after RN #7 noted the need for constant visual monitoring on 08/07/2011 at 2100, when the patient was noted to be restless and wandered in and out of the ED. Interview revealed the Director thought the observation sheets must have been lost. Further interview confirmed there was no available documentation the patient was placed in paper scrubs upon admission to the ED on 08/08/2011 per policy or prior to his elopement from the ED on 08/09/2011.

2. Closed medical record review for Patient #1 revealed [AGE] year-old male that presented to the Emergency Department (ED) on 08/02/2011 at 1545 with a chief complaint of "suicide gesture". Review of the triage nurse's notes at 1616 revealed, "Pt (patient) took wheelchair and was heading down hill toward the street. Pt told son that if he went home today he was going to kill himself. Sig(nificant) other left him several weeks ago. Pt very depressed....Suicidal/Homicidal thoughts - Yes...." Review of the ED physician's initial assessment dated [DATE] at 1719 revealed, "...He (patient) states that he wants to run his motorized wheelchair into the road in front of traffic. He states that he financially has nothing. He doesn't want to live anymore. He has had '3' prior suicide attempts in the past." Review of ED physician's notes dated 08/03/2011 at 0053 revealed, "Patient resting in NAD (no acute distress), awaiting placement." Record review revealed no documentation of a primary nursing assessment that included a Suicidal Lethality Score upon the patient's admission to the ED. Record review revealed the next documentation of a nursing assessment was a note documented by RN (registered nurse) #5 on 08/03/2011 at 0208. Review of RN #5's noted dated 08/03/2011 at 0208 revealed, "The patient was reassessed at 16:45....Noticed Pt in room and went in to see if he was visitor or a new Pt. Pt stated he had been at 'another hospital' and 'they thought he was crazy'. I asked Pt why they thought that and he said because he was sad over losing what her referred to as 'his woman'. I was given no report on the pt and had I not stopped in to speak with him I would have had no idea he was a pt. Spoke with Dr and Dr stated he was simply in need of being medically cleared and then we would find him placement." Review of RN #5's note at 0219 revealed, "The patient was reassessed at 18:00....No change in pt. Pt insists he would never harm himself...." Review of RN #6's notes dated 08/03/2011 at 0140 revealed, "The patient was reassessed at 01:40. Assumed care for this patient at this time (0140). Pt not in room at this time. Signal M (missing patient response system) called, Nursing Supervisor notified." Review of RN #5's notes dated 08/03/2011 at 0223 revealed, "The patient was reassessed at 01:23. Police call and state they have found pt on the interstate driving his wheelchair on the shoulder and would return him to the hospital." Record review revealed documentation the physician petitioned for the patient to be involuntarily committed on 08/03/2011 at 0215. Record review revealed documentation of an involuntary commitment (IVC) order signed by the magistrate on 08/03/2011 at 0249. Review of RN #6's notes dated 08/03/2011 at 0256 revealed, "The patient was reassessed at 02:56. Pt returned to Bed 1 via W/C (wheelchair) by SPD (police). Pt located in westbound (bound) traffic lane of I-40 at I-77 (approximately 2 miles from hospital). Pt states he was going to Waffle House for food. When asked, pt states he still feels like hurting himself." Record review revealed the patient was discharged to assisted living accompanied by a family member on 08/10/2011 at 1843. Record review revealed the first documentation that the nursing staff implemented suicide precautions for the patient was on 08/03/2011 at 0258 (11 hours and 13 minutes after the patient presented to the ED with complaints of suicidal ideations). Record review revealed no documentation the patient visually and constantly monitored prior to his elopement on 08/03/2011 at approximately 0140 (9 hours and 55 minutes after he presented to the ED with complaints of suicidal ideations). Record review revealed the first documentation a Safety Attendant monitored the patient continuously and did checks on the patient every 15 minutes was at 0300 on 08/03/2011 (after the patient was returned by police after his elopement). Further record review revealed no documentation nursing staff reassessed the patient's suicide risk during the following shifts: 7P (1900-0700) on 08/04/2011, 7A (0700-1900) and 7P on 08/05/2011, and 7A on 08/06/2011 (4 of 16 shifts reviewed).

Interview on 09/01/2011 at 0900 with RN #6 revealed, "I was in triage until 1:00 (am) (on 08/03/2011). I assumed his (Patient #1's) care at about 1:15 (am) or 1:30 (am) from (RN #5). I went into his room with (staff name) from Mobile Crisis (non-physician, qualified professional staff that do behavioral health assessments) to do his assessment at 1:40 (am) and he wasn't in the room. I called the supervisor and the hospital operator, to call a Signal M....I think the Safety Attendant (on duty) was (CNA #2). There was no secretary. I think the Safety Attendant left around 1:00 (am) also. I called the Supervisor and they said they would have a CNA from Delta (behavioral health unit) come down. It was after he eloped before they came down." Further interview revealed there was no documentation of visually constant observation and 15 minute checks prior to the patient's elopement available because "they hadn't been doing one (observation sheet)".

Interview on 09/01/2011 at 1615 with the Director of Quality revealed RN #5 was no longer employed at the hospital and was thus not available for interview. Interview revealed behavioral heath patients in the ED that complain of suicidal or homicidal ideations or are involuntarily committed are visually and constantly monitored by a Safety Attendant that watches patients either through their windows or opened doors or via video monitoring (if the patients are in Rooms 18 or 19) and suicide precautions are immediately implemented. Interview revealed Safety Attendants position themselves so that they can see video monitors and patient room doors and usually watch up to 5 patients, depending on the census of behavioral health patients in the ED. Interview revealed in addition to maintaining constant visualization of patients, the Safety Attendant also goes to each room and checks on each patient every 15 minutes. Interview revealed the constant monitoring and 15 minute checks on each patient are documented on the "Suicide Observation Sheet", which should be kept in the patient's medical record. Interview revealed a Safety Attendant is assigned to the ED "almost" every shift. Interview revealed per the staff schedule (shared with the surveyor during interview) there was a Safety Attendant assigned to the ED who would have monitored the patient on 08/02/2011 and 08/03/2011. Interview confirmed there was no available documentation the patient was visually and constantly monitored prior to his elopement on 08/03/2011 at approximately 0140 (9 hours and 55 minutes after he presented to the ED with complaints of suicidal ideations). Interview confirmed the first available documentation a Safety Attendant monitored the patient continuously and did checks on the patient every 15 minutes was at 0300 on 08/03/2011 (after the patient was returned by police after his elopement). Interview revealed the Director thought the observation sheets must have been lost. Further interview confirmed there was no available documentation of a primary nursing assessment that included a Suicidal Lethality Score upon the patient's admission to the ED or the nursing staff reassessed the patient's suicide risk during the following shifts: 7P (1900-0700) on 08/04/2011, 7A (0700-1900) and 7P on 08/05/2011, and 7A on 08/06/2011 (4 of 16 shifts reviewed). Interview confirmed the first available documentation nursing staff implemented suicide precautions for the patient was on 08/03/2011 at 0258 (11 hours and 13 minutes after the patient presented to the ED with complaints of suicidal ideations).

3. Closed medical record review for Patient #5 revealed a [AGE] year-old female that was transferred to the Emergency Department (ED) on 07/29/2011 at 0457 from another acute care hospital with a chief complaint of "Involuntary Commitment (IVC)". Review of RN (registered nurse) #3's notes timed 0517 revealed, "Patient assigned to room 1....Patient moved to room at 04:57. Time of primary assessment: 04:57....Overall Suicide Lethality Score: 40 or greater - Suicide Risk High. Suicide interventions done include:...continuous 1:1 direct observation...." Review of ED physician's notes dated 07/29/2011 at 0547 revealed, "Patient was seen earlier in (the same hospital's) ED for alleged OD (overdose) on Neurotin (anticonvulsant). Pt (patient) cleared and had denied SI (suicidal ideations)/attempt while in ED when directly questioned. After D/C (discharge) she made comments of hurting herself by walking out into street. Police took patient to (other acute care hospital). Put on IVC papers. Here for eval(uation)." Review of RN #3's notes dated 07/29/2011 at 0919 revealed, "The patient was reassessed at 07:20. Mobile Crisis (non-physician, qualified professional staff that conduct behavioral health evaluations) walked out of patient's room from evaluating patient, patient walked out of room and states that she is going outside to smoke. Patient states that she is not a child, she does not need help. When patient was asked not to go outside to smoke, she states that I don't give a (expletive) and walked out of the EMS (ambulance entry) doors. Secretary called operator and a signal M (missing patient code) paged overhead. (City) PD (police) notified. Patient got in her car with her boyfriend and left the premises. Patient's boyfriend's cell phone called and patient answered, told secretary that she will come back. Patient called back the department and states that she will come back, but she will probably go to jail for whooping someone's (expletive). (City) police officers here standing by for assistance." Record review revealed the police brought the patient back to the ED at 0826 (1 hour and 6 minutes after she eloped), at which time the patient was placed in Room 18. Record review revealed no documentation the patient was visually monitored by staff continuously on 07/29/2011 between 0457 (when staff assessed the patient to be at high risk for suicide) and 0720 (2 hours and 23 minutes later, when the patient eloped from the ED).

Interview on 09/01/2011 at 1615 with the Director of Quality revealed behavioral health patients in the ED that complain of suicidal or homicidal ideations or are involuntarily committed are visually and constantly monitored by a Safety Attendant that watches patients either through their windows or opened doors or via video monitoring (if the patients are in Rooms 18 or 19). Interview revealed Safety Attendants position themselves so that they can see video monitors and patient room doors and usually watch up to 5 patients, depending on the census of behavioral health patients in the ED. Interview revealed in addition to maintaining constant visualization of patients, the Safety Attendant also goes to each room and checks on each patient every 15 minutes. Interview revealed the constant monitoring and 15 minute checks on each patient are documented on the "Suicide Observation Sheet", which should be kept in the patient's medical record. Interview revealed a Safety Attendant is assigned to the ED "almost" every shift. Interview revealed per the staff schedule (shared with the surveyor during interview) there was a Safety Attendant assigned to the ED who would have monitored the patient the whole time she was in the ED on 07/29/2011. Interview confirmed there was no available documentation the patient was visually monitored constantly on 07/29/2011 between 0457 (when staff assessed the patient to be at high risk for suicide) and 0720 (2 hours and 23 minutes later, when the patient eloped from the ED).
Interview revealed the Director thought the observation sheets must have been lost.




4. Closed medical record review on 08/31/2011 for Patient #4 revealed a [AGE] year old male brought to the hospital's ED by police on 07/13/2011 at 0222 with "Chief Complaint: Psychiatric". Record review of nurse's triage assessment on 07/13/2011 at 0222 revealed the patient answered "Yes" to Suicidal/Homicidal thoughts" and "Suicidal/Homicidal." Record review of nursing notes dated 07/13/2011 at 0226 revealed "Room Assignment: Patient assigned to room 19...Psychosocial: Patient appears anxious, nervous, hostile...Safety: patient placed in paper scrubs...." Record review revealed the patient remained in the ED awaiting placement and was admitted into the hospital's inpatient psychiatric unit on 07/18/2011 at 1608 (5 days, 13 hours, and 46 minutes after he presented to the ED). Record review revealed no documentation ED nursing staff reassessed the patient for ongoing suicidal and/or homicidal risk each shift per hospital policy from 07/13/2011 at 0222 (initial triage assessment) through 07/18/2011 at 1608 (5 days, 13 hours, and 46 minutes after he presented to the ED). Record review revealed the patient was transferred to the hospital's inpatient psychiatric unit on 07/18/2011 at 1608 and subsequently discharge home on 07/21/2011 at 1311.

Further medical record review revealed Patient #4 was returned to the hospital's ED by police on 07/28/2011 at 1258 with "Chief Complaint: Psychiatric". Record review of nursing triaged note dated 07/28/2011 at 1258 revealed "Pt (Patient) states he 'Needs Help' but will not elaborate. Does not answer questions except to state he does not have any thoughts of harming himself or anyone else." Record review of physician documentation dated 07/28/2011 at 1304 revealed "...Pt (patient) was agitated, hallucinating, violent at (Crisis Center) intake...Symptoms are present and increased from onset. Patient states symptoms are of moderate intensity. Associated signs and symptoms: positive agitated, positive angry, positive hallucinating...." Record review of nursing documentation dated 07/28/2011 at 1305 revealed "Room Assignment: Patient assigned to room 19...Psychosocial: Patient's behavior appears depressed...Suicide Lethality assessment includes the following high intensity indicators: withdrawn or isolated - 6; few resources/support/counseling -6; destructive coping strategies - 7.; Overall Suicide Lethality Score: 11-39 - Suicide Risk Moderate.; Suicide interventions done include: medium risk interventions - direct observation/monitoring q (every) 15 min(utes), pt in line of sight of nurses station..." Record review of registered nurse (RN) #9's notes dated 07/29/2011 at 0747 revealed "...patient reassessed at 0710...PT ANXIOUS TEARING APART SHOE INSOLES STATED HE IS MAKING THEM FIT BETTER...." Record review revealed no documentation the patient was placed in a paper scrub clothing. Record review of RN #9's notes dated 07/29/2011 at 0748 revealed "(Patient #4) REQUESTING TO LEAVE SPOKE WITH MOBILE CRISIS HERE ABOUT PT STATES HE WILL BE PLACED (NAME OF CRISIS CENTER) REFUSES DUE TO THREATS ONTO STAFF MEMBERS AND SEXUAL INAPPROPRIATE GESTURES AND COMMENTS EXPLAINED SITUATION AND STATED HE UNDERSTANDS...." Record review of Nurse #9's notes dated 07/29/2011 at 1330 revealed "The patient was reassessed at 12:50 pt anxious...." Record review of Nurse #9's notes dated 07/29/2011 at 1331 revealed "pt code M (Missing Person) was (called) no one in ER seen pt leave. The patient was reassessed at 1303." Record review of Nurse #9's notes dated 07/29/2011 at 1834 revealed "The patient was reassessed at 18:34. resting quiet..." Record review revealed no nursing documentation of how the patient eloped, where the patient was found, how long the patient was missing, or what time he returned to the ED. Record review revealed the patient remained in the ED awaiting placement and was admitted into the hospital's inpatient psychiatric unit on 08/02/2011 at 1800 (5 days, 5 hours, and 2 minutes after he presented to the ED). Record review revealed no documentation the patient was visually monitored constantly or checked every 15 minutes prior to elopement (1 day after the patient was assessed to be at moderate risk for suicide). Record review revealed no documentation ED nursing staff reassessed the patient for ongoing suicidal and/or homicidal risk each shift per hospital policy from 07/28/2011 at 1258 through 1800 on 08/02/2011 when patient transfer to the inpatient psychiatric unit.

Interview with Director of Quality on 09/01/2011 at 0825 revealed "(RN #9) isn't here anymore, she was a contract nurse....(she) no longer works here....Mr. (Patient #4) was her last day." Interview revealed RN # 9's contract was terminated due to unsatisfactory performance.

Interview on 09/01/2011 at 1615 with the Director of Quality revealed behavioral heath patients in the ED that complain of suicidal or homicidal ideations should be placed in paper scrubs. Interview revealed behavioral health patients in the ED that complain of suicidal or homicidal ideations or are involuntarily committed are visually constantly monitored by a Safety Attendant that watches patients either through their windows or opened doors or via video monitoring (if the patients are in Rooms 18 or 19). Interview revealed Safety Attendants position themselves so that they can see video monitors and patient room doors and usually watch up to 5 patients, depending on the census of behavioral health patients in the ED. Interview revealed in addition to maintaining constant visualization of patients, the Safety Attendant also goes to each room and checks on each patient every 15 minutes. Interview revealed the constant monitoring and 15 minute checks on each patient are documented on the "Suicide Observation Sheet", which should be kept in the patient's medical record. Interview confirmed there was no available documentation the patient was visually monitored by staff continuously prior to the patient's elopement. Interview revealed the Director thought the observation sheets must h
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on staff interview and personnel file review, the hospital failed to ensure registered nurses (RNs) in the Emergency Department (ED) were trained and qualified to ensure adequate monitoring of behavioral health patients in the ED for 4 of 7 sampled RNs currently employed in the ED (RNs #7, #10, #11, and #6).

The findings include:

Interview on 08/31/2011 at 1600 with the Director of Quality revealed revealed the ED's census of behavioral health patients had increased in the past year. Interview revealed all nurses that work in the ED are responsible for monitoring and providing care to behavioral health patients in the ED. Interview revealed the hospital recognized staff in the ED needed some training specific to caring for behavioral health patients. Interview revealed, "We have a behavioral health specialist nurse coming within about 2 weeks to provide some education to staff regarding care of psychiatric patients." Further interview revealed CPI (non-violent crisis intervention) training was available at the hospital but the ED staff were not currently required to complete the training. Interview revealed only 3 of 13 RNs currently employed in the ED had received CPI training.

1. Review of RN #7's personnel file revealed the nurse was currently employed in the ED. Review revealed no documentation of behavior de-escalation training for behavioral health patients. Interview on 08/31/2011 at 1540 with RN #7 revealed the nurse had no behavioral health nursing experience and had received no behavior de-escalation training. Interview revealed, "I am not a psych(iatric) nurse. I don't have psych experience."

Interview on 09/01/2011 at 1615 with the Director of Quality confirmed there was no available documentation that RN #7 had any behavior de-escalation training for behavioral health patients.

2. Review of RN #10's personnel file revealed the nurse was currently employed in the ED. Review revealed no documentation of behavior de-escalation training for behavioral health patients. Interview on 08/31/2011 at 1445 with RN #10 revealed the nurse had no behavioral health nursing experience and had received no behavior de-escalation training.

Interview on 09/01/2011 at 1615 with the Director of Quality confirmed there was no available documentation that RN #10 had any behavior de-escalation training for behavioral health patients.

3. Review of RN #11's personnel file revealed the nurse was currently employed in the ED. Review revealed no documentation of behavior de-escalation training for behavioral health patients. Interview on 08/31/2011 at 1830 with RN #11 revealed the nurse had no behavioral health nursing experience and had received no behavior de-escalation training.

Interview on 09/01/2011 at 1615 with the Director of Quality confirmed there was no available documentation that RN #11 had any behavior de-escalation training for behavioral health patients.

4. Review of RN #6's personnel file revealed the nurse was currently employed in the ED. Review revealed no documentation of behavior de-escalation training for behavioral health patients. Interview on 09/01/2011 at 0900 with RN #6 revealed the nurse had no behavioral health nursing experience and had received no behavior de-escalation training at the hospital. Interview revealed, "I had CPI (non-violent crisis intervention) training at (another hospital) about 4 years ago."

Interview on 09/01/2011 at 1615 with the Director of Quality confirmed there was no available documentation that RN #6 had any behavior de-escalation training for behavioral health patients.


NC 381
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, Event Log review, letter review and staff interviews, the hospital failed to ensure staff reported the elopement of a behavioral health patient from the Emergency Department (ED) as an adverse event for 1 of 5 sampled behavioral health patients that eloped from the ED (Patient #3).

The findings include:

Review on 09/01/2011 of hospital's policy titled, Event Reporting and Tracking Policy (Revision Date: 2010) revealed "I. Purpose: To provide a systematic mechanism for the collection , evaluation, and analysis of data to allow for early intervention and the reduction of risk exposure and to improve patient safety, care and satisfaction. II. Definitions: Event: An event is described as any happening which is not consistent with the routine operation of the facility..."

Closed medical record review on 08/31/2011 for Patient #3 revealed a [AGE] year old female that presented to the ED via Emergency Medical Services (EMS) on 07/22/2011 at 2215. Medical record review revealed "Chief Complaint - Psychiatric". Record review of nurses triage assessment dated [DATE] at 2215 revealed "Brief Assessment: Pt brought in due (by) to deputy. Patient was found at a gas station and stated to them that she needs help, has a blank stare and not answering questions. Patient states has been in the woods a while, and is hitch hiking to CA (California)...." Record review revealed the patient's family member had the patient involuntarily committed (IVC) on 07/23/2011 at 0130. Record review revealed the patient eloped from the ED on 07/23/2011 at 0225 and was returned to the ED by law enforcement at 0300. Record review revealed the patient was placed in Room 19 upon her return to the ED. Record review revealed the patient eloped from the ED again on 07/23/2011 at 0805 and was returned to the ED by law enforcement at 0824. Record review of nurse's note dated 07/23/2011 at 0824 revealed "The patient was reassessed at 0824. Patient brought back by (City Name) police officers after they found her walking down interstate....Patient to be moved to room 17 per Dr (Physician #1) and patient is to be restrained...." Record review revealed Patient #3 was placed in bilateral soft wrist and ankle restraints per physician's orders on 07/23/2011 at 0830 and was released from restraint on 07/24/2011 at 0759 (23 hours and 29 minutes in restraint). Record review revealed the patient was transferred to another facility on 07/26/2011 at 1920.

Review on 08/31/2011 of the hospital's Event Report Logs from July through August 2011 revealed no documentation of Patient #3's two elopements from the ED on 07/23/2011 had been reported as an adverse event by staff.

Review on 08/31/2011 of a letter provided by Risk Management staff revealed, "ER (emergency room ) Complaint, 07/25/2011, Patient: (Patient #3), Brother: (Name)...'I am upset that she (Patient #3) was an IVC (involuntarily committed) patient and there was no one watching her and she was able to elope from there twice'...Upset that someone from the hospital didn't call and inform him of the second elopement...."

Interview on 09/01/2011 at 0900 with Risk Management staff revealed there was not an event report for Patient #3. Interview revealed "The patient advocate took the call from him (Patient #3's Brother) and wrote up the letter. I went to (RN #2 - Interim ED [Emergency Department] Nurse Manager) and said we need to look at this. We went to Physician #2 ..." Interview revealed Physician #2 felt "what had been done was sufficient and the brother was not the Health Care Power of Attorney." Interview revealed the elopements of Patient #3 from the hospital's ED should have been reported as an adverse event. Interview confirmed there was no available documentation either of the patient's 2 elopements from the ED was reported by staff as an adverse event.

Interview on 09/01/2011 at 1615 with the Director of Quality revealed the elopement of behavioral health patient from the ED should be reported by staff as adverse events to ensure the events are investigated. Interview confirmed there was no available documentation either of Patient #3's two elopements from the ED were reported as adverse events.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, Event Log review, letter review and staff interviews, the hospital failed to ensure staff reported the elopement of a behavioral health patient from the Emergency Department (ED) as an adverse event for 1 of 5 sampled behavioral health patients that eloped from the ED (Patient #3).

The findings include:

Review on 09/01/2011 of hospital's policy titled, Event Reporting and Tracking Policy (Revision Date: 2010) revealed "I. Purpose: To provide a systematic mechanism for the collection , evaluation, and analysis of data to allow for early intervention and the reduction of risk exposure and to improve patient safety, care and satisfaction. II. Definitions: Event: An event is described as any happening which is not consistent with the routine operation of the facility..."

Closed medical record review on 08/31/2011 for Patient #3 revealed a [AGE] year old female that presented to the ED via Emergency Medical Services (EMS) on 07/22/2011 at 2215. Medical record review revealed "Chief Complaint - Psychiatric". Record review of nurses triage assessment dated [DATE] at 2215 revealed "Brief Assessment: Pt brought in due (by) to deputy. Patient was found at a gas station and stated to them that she needs help, has a blank stare and not answering questions. Patient states has been in the woods a while, and is hitch hiking to CA (California)...." Record review revealed the patient's family member had the patient involuntarily committed (IVC) on 07/23/2011 at 0130. Record review revealed the patient eloped from the ED on 07/23/2011 at 0225 and was returned to the ED by law enforcement at 0300. Record review revealed the patient was placed in Room 19 upon her return to the ED. Record review revealed the patient eloped from the ED again on 07/23/2011 at 0805 and was returned to the ED by law enforcement at 0824. Record review of nurse's note dated 07/23/2011 at 0824 revealed "The patient was reassessed at 0824. Patient brought back by (City Name) police officers after they found her walking down interstate....Patient to be moved to room 17 per Dr (Physician #1) and patient is to be restrained...." Record review revealed Patient #3 was placed in bilateral soft wrist and ankle restraints per physician's orders on 07/23/2011 at 0830 and was released from restraint on 07/24/2011 at 0759 (23 hours and 29 minutes in restraint). Record review revealed the patient was transferred to another facility on 07/26/2011 at 1920.

Review on 08/31/2011 of the hospital's Event Report Logs from July through August 2011 revealed no documentation of Patient #3's two elopements from the ED on 07/23/2011 had been reported as an adverse event by staff.

Review on 08/31/2011 of a letter provided by Risk Management staff revealed, "ER (emergency room ) Complaint, 07/25/2011, Patient: (Patient #3), Brother: (Name)...'I am upset that she (Patient #3) was an IVC (involuntarily committed) patient and there was no one watching her and she was able to elope from there twice'...Upset that someone from the hospital didn't call and inform him of the second elopement...."

Interview on 09/01/2011 at 0900 with Risk Management staff revealed there was not an event report for Patient #3. Interview revealed "The patient advocate took the call from him (Patient #3's Brother) and wrote up the letter. I went to (RN #2 - Interim ED [Emergency Department] Nurse Manager) and said we need to look at this. We went to Physician #2 ..." Interview revealed Physician #2 felt "what had been done was sufficient and the brother was not the Health Care Power of Attorney." Interview revealed the elopements of Patient #3 from the hospital's ED should have been reported as an adverse event. Interview confirmed there was no available documentation either of the patient's 2 elopements from the ED was reported by staff as an adverse event.

Interview on 09/01/2011 at 1615 with the Director of Quality revealed the elopement of behavioral health patient from the ED should be reported by staff as adverse events to ensure the events are investigated. Interview confirmed there was no available documentation either of Patient #3's two elopements from the ED were reported as adverse events.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy review, medical record review, grievance log review, hospital document review, staff and physician interview, event report review and physician credential file review, the hospital failed to promote and protect patients' rights by failing to: provide patients with written resolutions of grievances, ensure a safe setting for patient care, and implement restraints in accordance with safe and appropriate standards of care.

Findings include:

1. The hospital failed to provide patients with written notice of the grievance resolution.

~ cross refer to 482.13(a)(2)(iii) Patient Rights' Standard: Tag 0123

2. The hospital failed to ensure a safe setting for patient care by failing to ensure staff implemented suicide precautions and monitored behavioral health patients in the Emergency Department (ED) per policy to prevent the elopement of behavioral health patients in the ED.

~ cross refer to 482.13(c)(2) Patient Rights' Standard: Tag 0144

3. The hospital failed to modify patients' care plans to show the use of restraint or seclusion for patients that were restrained or secluded.

~ cross refer to 482.13(e)(4)(i) Patient Rights' Standard: Tag 0166

4. The hospital failed to ensure a physician's order for patients that were restrained or secluded.

~ cross refer to 482.13(e)(5) Patient Rights' Standard: Tag 0168

5. The hospital failed to ensure Emergency Department physicians completed restraint and seclusion training per policy.

~ cross refer to 482.13(e)(11) Patient Rights' Standard: Tag 0176

6. The hospital failed to ensure a patient was seen face-to-face within 1-hour after the initiation of seclusion by a physician, licensed independent practitioner, or other qualified professional for patients that were restrained or secluded for the management of violent or self-destructive behaviors.

~ cross refer to 482.13(e)(12) Patient Rights' Standard: Tag 0178

7. The hospital failed to ensure the physician or other licensed independent practitioner that conducted the face-to-face evaluation within 1 hour after the initiation of restraint or seclusion evaluated the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion for patients that were restrained or secluded for the management of violent or self-destructive behaviors.

~ cross refer to 482.13(e)(12) Patient Rights' Standard: Tag 0179
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, grievance log review, hospital document review, staff interview, and event report review, the hospital failed to provide a patient with a written notice of the resolution of a grievance for 2 of 3 sampled grievances (Patients #3 and #10).

The findings include:

Review on 09/01/2011 at 0800 of hospital's policy titled, "COMPLAINT/GRIEVANCE PROCESS (Revision Date: 09/10)," revealed "...III. Definitions...A 'patient grievance' is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care...Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding their patient care ...Guidelines: ...2. When there is a patient grievance...Patient grievances require written response to the patient/patient representative within seven (7) days...."

1. Closed medical record review on 08/31/2011 for Patient #3 revealed a [AGE] year old female that presented to the ED via Emergency Medical Services (EMS) on 07/22/2011 at 2215. Medical record review revealed "Chief Complaint - Psychiatric." Record review revealed the patient's family member had the patient involuntarily committed (IVC) on 07/23/2011 at 0130. Record review revealed the patient eloped from the ED twice on 07/23/2011 (from 0225-0300 and from 0805-0824). Record review revealed the patient was returned to the ED by police after each elopement. Review of nursing documentation dated 07/24/2011 at 0846 revealed, "Call received from (Patient #3's brother), person sounds verbally hostile on the phone, he states that I don't know what kind of care that you give there...I (Nurse #3) would inform the ER (emergency room ) Manager of his concerns. (Interim ED Nurse Manager - Nurse #2) informed of family member phone call. called her at her home. (Physician #2) informed of family comments." Medical record review revealed no further documentation of brother's complaint or response to complaint.

Review of the hospital's Grievance Log for March 2011 through August 2011 revealed no grievance logged for Patient #3.

Review on 08/31/2011 of a letter provided by Risk Management staff revealed, "ER Complaint, 07/25/2011, Patient: (Patient #3), Brother: (Name)...'I am upset that she (Patient #3) was an IVC patient and there was no one watching her and she was able to elope from there twice'...Upset that someone from the hospital didn't call and inform him of the second elopement...."

Interview on 09/01/2011 at 0900 with Risk Management (RM) staff revealed, "I took the call from him (Patient #3's brother) and wrote up the report (letter). Interview revealed RM staff spoke to the Interim ED Manager (Nurse #2) and Physician #2 about Patient #3 and the brother's complaint but a report of the complaint and investigation was not done. Interview revealed the complaint was a grievance and should have been treated as such and a written response should have been sent to the complainant. Interview confirmed the hospital staff did not send a written notice of the resolution of the grievance to Patient #3's brother.

2. Review on 08/31/2011 at 1600 of an Event Report dated 06/22/2011 for Patient #10 revealed the patient arrived at the hospital's Emergency Department (ED) on 05/23/2011 at 2228 with a complaint of toothache and left without being seen by the physician on 05/24/2011 at 0314. Report review revealed an attached letter dated 06/22/2011 from the ED Nurse Manager (Nurse #1) to the Risk Management staff. Letter review revealed Nurse #1 received a verbal complaint from Patient #10 on 05/24/2011 regarding his care and treatment during his ED visit that began on 05/23/2011. Letter review revealed the nurse manager informed the patient she would investigate the patient's complaint. Report review revealed Risk Management staff corresponded by phone with Patient #10 on 06/22/2011. Report review revealed no documented evidence that Risk Management staff or Nurse #1 provided the patient with a written notice of the resolution of a grievance.

Interview on 09/01/2011 at 0900 with Risk Management staff revealed, "I spoke to (Patient #10) on the phone...." Interview confirmed Patient #10's verbal complaint on 05/24/2011 was a grievance. Interview confirmed the hospital staff did not send a written notice of the resolution of the grievance to Patient #10.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and staff interview, the hospital failed to modify patients' care plans to show the use of restraint or seclusion for 3 of 3 sampled patients restrained or secluded for the management of violent or self-destructive behaviors (#3, #6, and #5).

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 08/2010 revealed, "...V. General Provisions (Applicable to Medical and Behavioral Health Restraint)...3. Care Plan: The patient's written plan of care shall be modified to address restraint...."

1. Closed medical record review on 08/31/2011 for Patient #3 revealed a [AGE] year old female that presented to the ED via Emergency Medical Services (EMS) on 07/22/2011 at 2215. Medical record review revealed "Chief Complaint - Psychiatric." Record review revealed the patient eloped from the ED twice on 07/23/2011 (from 0225-0300 and from 0805-0824). Record review of nurse's note dated 07/23/2011 at 0824 revealed "The patient was reassessed at 0824. Patient brought back by (City Name) police officers after they found her walking down interstate...Patient to be moved to room 17 per Dr (Physician #1) and patient is to be restrained..." Record review revealed Patient #3 was placed in restraint per physician's order on 07/23/2011 at 0830 and was released from restraint on 07/24/2011 at 0759 (23 hours and 29 minutes in restraint). Record review revealed no modification of the written care plan to address the restraint of the patient on 07/23/2011 from 0830 to 07/24/2011 at 0759.

Interview on 09/01/2011 at 1615 with the Director of Quality revealed staff should include the use of restraint and/or seclusion in patients' care plans. Interview confirmed there was no available documentation the patient's care plan was modified to include the use of restraint.




2. Closed medical record review for Patient #6 revealed a [AGE] year old male that presented to the Emergency Department (ED) on 08/07/2011 at 1822 for a behavioral health evaluation. Record review revealed on 08/09/2011 at 1234 the patient eloped from the ED. Record review revealed the patient was returned to the ED by law enforcement at 1250. Record review revealed the patient was placed in seclusion per physician's order on 08/09/2011 at 1255, where he remained until 0200 on 08/10/2011 (13 hours and 5 minutes), at which time he was calm and was released. Record review revealed no documentation the patient's plan of care was modified to include the use of seclusion.

Interview on 09/01/2011 at 1615 with the Director of Quality revealed staff should include the use of restraint and/or seclusion in patients' care plans. Interview confirmed there was no available documentation the patient's care plan was modified to include the use of seclusion.

3. Closed medical record review for Patient #5 revealed a [AGE] year-old female that was transferred to the Emergency Department (ED) on 07/29/2011 at 0457 from another acute care hospital with a chief complaint of "Involuntary Commitment (IVC)". Record review revealed the patient eloped from the ED at 0720. Record review revealed the police brought the patient back to the ED at 0826. Record review revealed the patient was placed in seclusion per physician's order at 0830, where she remained until 1100 (2 hours and 30 minutes), at which time she was calm and was released. Record review revealed no documentation the patient's plan of care was modified to include the use of seclusion.

Interview on 09/01/2011 at 1615 with the Director of Quality revealed staff should include the use of restraint and/or seclusion in patients' care plans. Interview confirmed there was no available documentation the patient's care plan was modified to include the use of seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and staff interview, the hospital failed to ensure the physician or other licensed independent practitioner that conducted the face-to-face evaluation within 1 hour after the initiation of restraint or seclusion evaluated the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion for 3 of 3 sampled patients restrained or secluded for the management of violent or self-destructive behaviors (#3, #6, and #5).

The findings include:

Review of current hospital policy entitled "Physical Restraint and Seclusion" dated 08/2010 revealed, "...VII. Behavioral Health Restraint and Seclusion 1. Requirements for All Settings....b. One-hour face-to-face assessment The licensed independent practitioner or physician's assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint (seclusion)...."

1. Closed medical record review on 08/31/2011 for Patient #3 revealed a [AGE] year old female that presented to the ED via Emergency Medical Services (EMS) on 07/22/2011 at 2215. Medical record review revealed "Chief Complaint - Psychiatric." Record review revealed the patient eloped from the ED twice on 07/23/2011 (from 0225-0300 and from 0805-0824). Record review of nurse's note dated 07/23/2011 at 0824 revealed "The patient was reassessed at 0824. Patient brought back by (City Name) police officers after they found her walking down interstate...Patient to be moved to room 17 per Dr (Physician #1) and patient is to be restrained..." Record review revealed Patient #3 was placed in bilateral soft wrist and ankle restraints per physician's order on 07/23/2011 at 0830 and was released from restraint on 07/24/2011 at 0759 (23 hours and 29 minutes in restraint). Review of the "Physician Orders for Restraint/Seclusion Behavioral Health" dated 07/23/2011 at 0830 revealed, "Face-to-face assessment within 1 hour by: MD Signature (signed by Physician #1) Date 07/23/2011 Time 0830." Record review revealed no documentation the physician evaluated the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the restraint within one hour of the patient's restraint.

Interview on 09/01/2011 at 0945 with Physician #1 revealed, "When I do the face-to-face (assessment after restraint or seclusion) I sign on the order sheet. The assessment may be documented in the nurse's notes. I don't document the assessment..."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed physicians should document face-to-face assessments of patients within one hour of restraint or seclusion on the restraint/seclusion order sheet. Interview revealed the Director thought the documentation on the order sheet was sufficient. Interview revealed the Director was not aware of the regulatory requirement that the physician evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the seclusion. Interview confirmed there was no available documentation the physician evaluated the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the restraint.






2. Closed medical record review for Patient #6 revealed a [AGE] year old male that presented to the Emergency Department (ED) on 08/07/2011 at 1822 for a behavioral health evaluation. Record review revealed on 08/09/2011 at 1234 the patient eloped from the ED. Record review revealed the patient was returned to the ED by law enforcement at 1250. Record review revealed a physician's order for seclusion signed and dated by Physician #1 on 08/09/2011 at 1252. Record review revealed the patient was placed in seclusion from 1255 on 08/09/2011 until 0200 on 08/10/2011 (13 hours and 5 minutes). Record review revealed the first documentation the physician assessed the patient face-to-face was on 08/09/2011 at 1700 (4 hours and 5 minutes after the patient was placed in seclusion). Review of the "Physician Orders for Restraint/Seclusion Behavioral Health" dated 08/09/2011 at 1700 revealed, "Face-to-face assessment within 1 hour by: MD Signature (signed by Physician #1) Date 08/09/2011 Time 17:00." Record review revealed no documentation the physician evaluated the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the seclusion within one hour of the patient's seclusion.

Interview on 09/01/2011 at 0945 with Physician #1 revealed, "When I do the face-to-face (assessment after restraint or seclusion) I sign on the order sheet. The assessment may be documented in the nurse's notes. I don't document the assessment....I can't remember if I was there and assessed him when he went into seclusion."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed physicians should document face-to-face assessments of patients within one hour of restraint or seclusion on the restraint/seclusion order sheet. Interview revealed the Director thought the documentation on the order sheet was sufficient. Interview revealed the Director was not aware of the regulatory requirement that the physician evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the seclusion. Interview confirmed there was no available documentation the physician evaluated the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the seclusion.

3. Closed medical record review for Patient #5 revealed a [AGE] year-old female that was transferred to the Emergency Department (ED) on 07/29/2011 at 0457 from another acute care hospital with a chief complaint of "Involuntary Commitment (IVC)". Record review revealed the patient eloped from the ED at 0720. Record review revealed the police brought the patient back to the ED at 0826 (1 hour and 6 minutes after she eloped), at which time the patient was placed in Room 18. Record review revealed a physician's order for seclusion signed and dated by Physician #2 on 07/29/2011 at 0830. Record review revealed the patient was placed in seclusion from 0830 until 1100 (2 hours and 30 minutes). Review of the "Physician Orders for Restraint/Seclusion Behavioral Health" dated 07/29/2011 at 2030 revealed, "Face-to-face assessment within 1 hour by: MD Signature (signed by Physician #2) Date 07/29/2011 Time 8:30." Record review revealed no documentation the physician evaluated the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the seclusion within one hour of the patient's seclusion.

Interview on 09/01/2011 at 1615 with the Director of Quality revealed physicians should document face-to-face assessments of patients within one hour of restraint or seclusion on the restraint/seclusion order sheet. Interview revealed the Director thought the documentation on the order sheet was sufficient. Interview revealed the Director was not aware of the regulatory requirement that the physician evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the seclusion. Interview confirmed there was no available documentation the physician evaluated the patient's immediate situation, reaction to the intervention, medical and behavioral condition, or the need to continue or terminate the seclusion. Further interview revealed Physician #2 was not available for interview.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, letter review, event report review, and staff interview, the hospital failed to analyze the cause of an adverse patient event for 3 of 5 sampled adverse patient events reported (Patients #3, #6, and #5).

The findings include:

Review of current hospital policy entitled "Event Reporting and Tracking Policy" dated 03/15/2010 revealed, "...V. Procedure: Event Reporting/Event Investigation Procedure:....2. Upon completion, the Event Report is given to the Associate's Supervisor, Manager, or Director prior to the end of their shift. 3. The Associate's Supervisor, Manager, or Director ensures that the Event Report is complete and then initiates the Event Investigation prior to the end of the reporting Associate's shift....The Event Investigation form is completed by the Supervisor, Manager, or Director under the section so designated on the form....5. The Event Report, Event Investigation form, and any supporting documents shall be forwarded to the Risk Manager within three (3) business days of the date of the event, or sooner....7. Upon receipt, the Risk Manager shall review the Event Report, Event Investigation form and supporting documents for: a. Severity/Outcome; b. Completion of the Event Report and Event Investigation forms; c. The need for additional information to complete the investigation....Event Follow-up and Tracking Procedures:....1. If upon receipt the Risk Manager determines that the Event Report and Event Investigation are complete, the Risk Manager shall complete the following: a. The Risk Manager signs and dates the Event Investigation indicating the event is closed....2. If upon receipt the Risk Manager determines that the Event Report, Event Investigation, or both need additional information or additional investigation, the Risk Manager shall complete the following:...c. The Event Report and Event Investigation are returned to the designated person for completion with instructions to return by the assigned date...."

1. Closed medical record review on 08/31/2011 for Patient #3 revealed a [AGE] year old female that presented to the ED via Emergency Medical Services (EMS) on 07/22/2011 at 2215. Medical record review revealed "Chief Complaint - Psychiatric". Record review of nurses triage assessment dated [DATE] at 2215 revealed "Brief Assessment: Pt brought in due (by) to deputy. Patient was found at a gas station and stated to them that she needs help, has a blank stare and not answering questions. Patient states has been in the woods a while, and is hitch hiking to CA (California)...." Record review revealed the patient's family member had the patient involuntarily committed (IVC) on 07/23/2011 at 0130. Record review revealed the patient eloped from the ED on 07/23/2011 at 0225 and was returned to the ED by law enforcement at 0300. Record review revealed the patient was placed in Room 19 upon her return to the ED. Record review revealed the patient eloped from the ED again on 07/23/2011 at 0805 and was returned to the ED by law enforcement at 0824. Record review of nurse's note dated 07/23/2011 at 0824 revealed "The patient was reassessed at 0824. Patient brought back by (City Name) police officers after they found her walking down interstate....Patient to be moved to room 17 per Dr (Physician #1) and patient is to be restrained...." Record review revealed Patient #3 was placed in bilateral soft wrist and ankle restraints per physician's orders on 07/23/2011 at 0830 and was released from restraint on 07/24/2011 at 0759 (23 hours and 29 minutes in restraint). Record review revealed the patient was transferred to another facility on 07/26/2011 at 1920.

Review on 08/31/2011 of a letter provided by Risk Management staff revealed, "ER (emergency room ) Complaint, 07/25/2011, Patient: (Patient #3), Brother: (Name)...'I am upset that she (Patient #3) was an IVC (involuntarily committed) patient and there was no one watching her and she was able to elope from there twice'...Upset that someone from the hospital didn't call and inform him of the second elopement...."
Interview on 09/01/2011 at 0900 with Risk Management staff revealed there was not an event report for Patient #3. Interview revealed "The patient advocate took the call from him (Patient #3's Brother) and wrote up the letter. I went to (RN #2 - Interim ED [Emergency Department] Nurse Manager) and said we need to look at this. We went to Physician #2 ..." Interview revealed Physician #2 felt "what had been done was sufficient and the brother was not the Health Care Power of Attorney." Interview revealed the elopements of Patient #3 from the hospital's ED should have been written up as an event report and the elopements should have been investigated. Interview confirmed there was no available documentation either of the patient's 2 elopements from the ED was investigated to determine causes of the events.
Interview on 09/01/2011 at 1615 with the Director of Quality revealed all adverse events, including behavioral health patient elopements from the ED, should be investigated and results of the investigation should be documented on Event Reports. Interview confirmed there was no available documentation Patient #3's elopements from the ED were investigated to determine causes of the events.





2. Review on 09/01/2011 of an Event Report for Patient #6 (a behavioral health patient in the Emergency Department - ED) dated 08/09/2011 and prepared by the ED Interim Nurse Manager revealed documentation the patient eloped from the ED on 08/09/2011 at 1255. Report review revealed the patient complained of hearing voices and "wanting to harm himself. Would not say he would not...." Report review revealed the patient was changed to involuntary commitment. Report review revealed, "Pt became very angry and went through lobby and out front door. (Rooms) 18 & 19 both occupied at time & unable to put him in it." Report review revealed, "Event Investigation: Code M (missing patient) called & Pt returned on foot by law enforcement. Very angry & law enforcement advised seclusion & not to open door unless one of them here...." Review of note written at bottom of the report page revealed, "Pt in seclusion & has been medicated but cont(inues) to beat on door and yell." Report review revealed no documentation of an investigation of the patient's elopement to determine the cause of the event. Report review revealed, "Risk Manager/Designee Action(s) Taken: (checked) No Action."

Interview on 09/01/2011 at 1615 with the Director of Quality revealed all adverse events, including behavioral health patient elopements from the ED, should be investigated and results of the investigation should be documented on Event Reports. Interview confirmed there was no available documentation Patient #6's elopement from the ED was investigated to determine the cause of the event.

3. Review on 09/01/2011 of an Event Report for Patient #5 (a behavioral health patient that was involuntarily committed [IVC] and in the Emergency Department - ED) dated 07/29/2011 and prepared by RN #3 revealed documentation the patient eloped from the ED (Emergency Department) on 07/29/2011 at 0720. Report review revealed the patient told the staff she was going outside to smoke and that she was not a child and didn't need help. Report review revealed, "When asked not to go smoke she said, 'I don't give a (expletive)' and walked out the EMS (ambulance entry) doors." Report review revealed the patient was returned to the ED by police at 0826. Review of ED Interim Nurse Manager's "Event Investigation" documentation on the report dated 08/04/2011 (6 days after the elopement) revealed the patient was involuntarily committed when she went outside and ran with her boyfriend. Review of the Manager's documentation revealed the patient was very angry and was placed in seclusion after police returned her to the ED. Further report review revealed, "Severity Index: RCA (root cause analysis) conducted re: recent elopements....Risk Manager/Designee Action(s) taken: (checked) No Action...(signed by Risk Manager on 08/05/2011." Report review revealed no documentation of an investigation of the patient's elopement to determine the cause of the event.

Interview on 09/01/2011 at 1615 with the Director of Quality revealed all adverse events, including behavioral health patient elopements from the ED, should be investigated and results of the investigation should be documented on Event Reports. Interview revealed a RCA had been conducted on 07/28/2011 (the day before Patient #5 eloped) to evaluate the cause of an increase in the number of elopements of behavioral health patients from the ED. Interview confirmed there was no available documentation Patient #5's elopement from the ED was investigated to determine the cause of the event.