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.

MERCYONE WATERLOO MEDICAL CENTER 3421 WEST NINTH STREET WATERLOO, IA 50702 Feb. 24, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of hospital policies, documents, video footage, medical records, and staff interview, the hospital failed to enforce its policies and provide court committed Patient #1, who staff observed as behaving suspicious, paranoid, obsessive, and depressed with an appropriate medical screening examination within its capabilities out of 18 cases selected for review from February 16, 2016 to February 23, 2016.

Failure to ensure staff followed hospital policies and provide an appropriate medical screening examination delayed patient # 1's treatment and resulted in Patient #1 eloping (walked away) from the Emergency Department (ED) wearing paper scrubs, carrying his personal belongings, and comandeering an ambulance placing the patient and other individuals at risk for harm and/or death.

Findings include:

1. Review of the hospital policy titled, "EMTALA: Medical Screening and Stabilizing Treatment dated 4/14, included in part, "... where the medical screening examination reveals that the person has an emergency medical condition, the hospital will provide further medical examination and stabilizing treatment as required to stabilize the medical condition..."

Review of the hospital policy titled, "Unit Structure and Practice Model", dated 1/14, included in part, "...Description: The Emergency Department is a 24 bed unit...treatment rooms consist of...four exam rooms may be used for Behavioral Health patients...any individual seeking emergent...care will be properly assessed, given an appropriate medical screening examination, and appropriate services...care shall be provided by the Emergency Department physician on duty..."

Review of the hospital policy titled, "Care of Patients Presenting with Psychiatric Complaints in the Emergency Department" with a revision date of 5/15, included in part, "...PURPOSE...To provide direction regarding the care of patients who present with psychiatric complaints in the Emergency Department...the nurse caring for the patient will assess for the presence of the following symptoms...Delusions or paranoid thoughts...Threatening or aggressive behavior...Committal...If the patient is positive for any of the above symptoms, they will be placed in a behavioral health room...changed into paper scrubs, their clothing and belongings will be removed...searched and secured...they will be placed in direct observation...Direct observation of the patient will be performed by Security personnel. If Security leaves...to respond to an urgent situation, the ED Charge Nurse will assign an ED associate to perform the Direct Observation of the patient until the Security personnel returns...Direct Observation will keep the patient within his or her view at all times...Any patient who displays any of the above behaviors...will not be allowed to leave the Department...if the patient attempts to leave...a Code Strong will be called and the patient detained within the Department for his/her own safety...For all patients who are positive for any of the above symptoms...The ED provider will call the on-call Hospital psychiatrist for a consult...If the behavioral health specialty nurse comes to the ED, the nurse will report his or her findings to the on-call psychiatrist...the on-call psychiatrist will communicate the decision to the ED provider...

Review of the hospital policy titled, "Elopement Procedure, Inpatient" dated 2/16, included in part, "...The following shall receive an elopement screening...all court committed patients...for all patients deemed an elopement risk, staff will visually confirm and monitor patient's whereabouts every 15 minutes...nursing interventions aimed at avoiding elopement are to be followed and documented as follows: assess the patient's level of anxiety, fear, and frustration...recognize patient refusal of medication and non-compliant behavior may indicate the patient is at a high risk for elopement...prevention measures are to be followed and documented as follows: ...placement of the patient in a room close to nursing station..."triggers" such as clothing...should be stored out of sight of the patient...court committed patients will remain under direct observation..."

2. Review of a hospital document titled, "Covenant Medical Center Medical Staff Rules and Regulations" dated 12/3/15, included in part, "...Emergency department...EMTALA compliance: All members of the Medical Staff are expected to abide by the requirements of...EMTALA...an emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including...psychiatric disturbances)...such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy..."

Review of a hospital document titled, "Competency Tasks" Security no date, included in part, "...Officers will work with the Emergency department...to assist with placing the patient into a blue paper gown. Secure...and store all belongings...if the patient is an elopement risk then an officer will be at the door of the patient's room...if the patient is aggressive and is with staff...the officer should remain directly outside the room...if the patient attempts to elope, a security assist required will be called immediately and officers will do anything possible to prevent the patient from eloping..."

3. Review of the medical record showed patient # 1 (MDS) dated [DATE] at 6:34 PM for a psychiatric evaluation under court order. At 7:32 PM ED physician MM documented in part, "... Court Committal documents state the patient has been acting very unusual lately ... using meth ... showing signs of paranoia and delusion ... believes his daughter is possessed ... believes his parents are trying to kill him ..."

At 7:55 PM a Behavioral Health Nurse G documented that patient # 1's mood was subdued and depressed and that he had previously received inpatient psychiatric treatment and alcohol and other drug abuse treatment at Covenant Medical Center.

At 9:35 PM ED Physician MM documented "at this time he [patient # 1] is calm and cooperative, we did need to have a code strong (available staff try to dissolve a potential volatile situation) and gave him Geodon," (antipsychotic medication) "- - he is not a good candidate to bring up to psych at this time, he will have to spend the night here and get re-evaluated in the morning."

Further documentation showed that from midnight to approximately 7:00 AM on 2/23/16, patient #1's behavior escalated. The patient paced around his room in the ED, and frequently stood at the entrance of his room looking out into the nurse's station area. The ED staff documented the patient was a high risk for elopement.

The ED staff documented on 2/23/16 at 7:20 AM, patient # 1 eloped from ED, comandeered an unlocked, unoccupied ambulance with keys in the ignition, drove through the ambulance bay doors and then drove away from the hospital. The medical record lacked evidence that staff implemented interventions to address the patient's escalating behaviors and need for increased supervision.

The medical record also lacked evidence that the night shift ED physician QQ had any interaction with the patient from 9:40 PM on 2/22/16 through 7:20 AM on 2/23/16 or that the on-call psychiatrist OO was contacted to provide further examination and treatment including inpatient admission to the hospital's locked psychiatric unit.

4. During an interview on 2/24/16 at 8:55 AM, Behavioral Health Registered Nurse G stated that after Patient #1 received an injection of Geodon she completed a mental health and addiction psychosocial assessment. Nurse G stated, "The patient was very energetic, paranoid, and he didn't want to stay in the ED because he thought there were tanks in the wall that might explode." Nurse G stated, "I took the assessment paper work to [ED Nurse S] and explained the patient was paranoid and worried about not being taken care of by the ED nursing staff." Nurse G stated, "We are able to secure patients at risk for elopement in our psychiatric unit because it is a locked unit."

5. During an interview on 2/24/16 at 11:20 AM, ED Physician MM reported he treated Patient #1 on the evening of 2/22/16. ED Physician MM stated, "My diagnosis after initial evaluation was methamphetamine induced psychosis. The patient was agitated, delusional, paranoid, very defensive and angry."

6. Review of documentation provided by the hospital showed that from 2/2/16 - 2/23/16, the locked psychiatric unit admitted patients with mental health illnesses combined with substance abuse issues including patients diagnosed with major depression with psychotic symptoms, methamphetamine abuse, psychosis secondary to substance abuse issues, psychotic disorder not otherwise specified, bipolar disorder and psychotic symptoms, methamphetamine abuse and rule out adjustment disorder with adjustments of emotional conduct, and recurrent major depression.

Refer to A 2406 for further details
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital documents, video footage, medical records, and staff interview, the hospital failed to provide court committed Patient #1, who staff observed as behaving suspicious, paranoid, obsessive, and depressed with an appropriate medical screening examination within its capabilities out of 18 cases selected for review from February 16, 2016 to February 23, 2016.

Failure to provide patient # 1 with an appropriate medical screening examination delayed treatment and allowed him to elope (walk away) from the Emergency Department (ED) wearing paper scrubs, carrying his personal belongings, and commandeer an unsecured, unoccupied ambulance placing himself and other individuals at risk for harm and/or death.

Findings include:

1. Review of the medical record showed patient # 1 (MDS) dated [DATE] at 6:34 PM for a psychiatric evaluation under court order. The affidavits to support committal indicated patient # 1 had abused methamphetamines, suffered a fall in his bathroom and hit his head on the toilet and blacked out for awhile. At 7:32 PM ED physician MM documented in part, "... Court Committal documents state the patient has been acting very unusual lately ... using meth ... showing signs of paranoia and delusion ... believes his daughter is possessed ... believes his parents are trying to kill him ... believes his entire family is the devil. It's possible that he recently fell in his bathroom. In the ED he is denying all of these claims and is very aggravated that we will not allow him to see his family at this time..."

At 7:55 PM Behavioral Health nurse G assessed patient # 1 and documented his mental health history included a previous admission to the psychiatric unit and addiction unit at Covenant Medical Center. Further documentation showed patient # 1's:

Mood: Subdued, Depressed, Laughing with family. Patient reports continued depression.
Affect: Tearful, Constricted, Smile occasional.
Attitude Behavior: Pleasant, Cooperative
Speech: Slow, Monotone
Though Process: Circumstantial
Thought Content: Helplessness, Trusting care providers.

Reason for continued care: Suicide Ideation comes and goes without a plan. Bullying unresolved, pessimistic prior to school attendance. Unable to escape situational cause at the moment. Continued statements by peers to kill yourself create obsessive thoughts and beliefs to do so.

Interventions Provided: Discussed coping skills prior, during, and after stress. Identified support systems. Encouraged and identified personal assets. Crisis plan created.

Plan: Continued monitoring by healthcare professionals. Placement being sought. Family support continues with visitation. Patient to continue use of positive coping and positive focus while goal oriented.

At 8:50 PM, staff documented on the "Mental Health and Addiction Psychosocial Assessment" form:

Mood: Anxious, Euphoric.
Affect: Overly Dramatic.
Attitude/Behavior: Drowsy, Cooperative, Hypervigilant, Restless.
Thought Content: Compulsive, Helplessness, and Obsessive.
Wants nothing more than to be with family.

After receiving medication IM (Intramuscular) for agitation, wide eyed, large arm movements, fluctuating voice, and overly interested.

Summary and Recommendations: Treatment for psych and drug dependency in progress as soon as evaluated by healthcare team and doctor recommendation. Resides in ED currently.

The medical record lacked evidence that Behavioral Health Nurse G notified ED Physician QQ, contacted on-call Psychiatrist OO, or notified the ED nurse regarding Patient #1's mental health assessment.

At 9:35 PM ED Physician MM documented "at this time he [patient # 1] is calm and cooperative, we did need to have a code strong (available staff try to dissolve a potential volatile situation) and gave him Geodon," (antipsychotic medication) "- - he is not a good candidate to bring up to psych at this time, he will have to spend the night here and get re-evaluated in the morning."

At 9:41 PM, ED Physician MM documented in part, "Care Management Update...Patient's care transferred to [ED Physician QQ]..."

From 1:30 AM - 5:50 AM on 2/23/16, documentation by hospital security staff on the "Security At-Risk Patient Monitoring Log" showed that patient #1 paced in his room and stood at the entrance of his room looking out into the ED nurse's station area. The ED staff documented the patient was a high risk for elopement.

At 5:30 AM on 2/23/16, the "Mental Health Progress Note" showed that patient # 1 was Anxious, Euphoric, wide eyes, talking about distrusting, paranoid, an uneasy feeling.

Affect: Incongruent with mood (Feelings of the opposite are appropriate.), laughing inappropriately, and nervous laugh, states upset and uneasy.

Attitude/Behavior: Pleasant, Suspicious, Hypervigilant (Excessive preoccupied with personal adequacy.), unable to follow instructions to stay behind carpet line of room. Forgetting.

Sleep: Decrease.
Speech: Normal, Rapid.

Thought Process: Tangential (Unable to have proper communication.), Preservations. Focused that environment poses harm.

Thought Content: Obsessive, Persecutory (A person believes they are being persecuted.), Phobic, Paranoid. Missing the meaning of statements in conversation. Losing track.

Reason for continued care: Patient is paranoid, claiming the health care personnel are not here to help and me ready to harm him. Concerned gases, oxygen from the vents are sounding strange in the walls and will explode. It is not safe in the room, not sleeping, and hyperactive.

Interventions Provided: Talked about good choices. Identified emotions and discussed consequences of not staying in room and trusting environment. Medication teaching to use as a tool to control anxiety and paranoid feeling before emotions are out of control. Discussed nicotine withdrawal and medication. Patient denies medication.

Plan: Patient is to notify the nurse if he needs nicotine gum or anxiety medication. Patient agrees to listen to health providers and work within areas to comply. Patient agrees to speak up and be honest of needs while he maintains control.

At 6:00 AM on 2/23/16 security officers changed. The new security officer did not document any patient observations on the "Log" from 6:00 AM to 7:00 AM.

At 6:36 AM, ED Physician QQ documented in part, "...Patient had a good night. Woke up around 4:45 AM and was hungry...ate breakfast, has been calm..."

At 7:15 AM the security officer documented on the "Log" that "Safety champion in doorway of room." Further documentation in the medical record showed that ED staff documented at 7:20 AM on 2/23/16, patient # 1 eloped from ED, comandeered an unlocked, unoccupied ambulance with keys in the ignition, drove through the ambulance bay doors and then drove away from the hospital.

The medical record lacked evidence that patient # 1 received an appropriate medical screening examination within the hospital's capabilities including examination by the on-call psychiatrist, examination by the night shift ED physician; interventions to address the patient's escalating behaviors such as the inability to sleep, increasing anxiety, paranoia, fear of his environment and mistrust of the ED staff; and need for increased supervision and treatment.

2. Review of a hospital document titled, "Security Department Confidential Incident Report" included in part, "...On Monday, February 22, 2016 at approximately 8:03 PM...call for security assistance regarding [Patient #1] as the patient was refusing to take mandatory IM medications...officers and staff entered the room and [Security Officer R] asked the patient several times if he would cooperate and take the medications willingly. The patient continued to refuse. Officers and staff stabilized the patient on the bed as the IM medication was given. Afterwards...we asked the patient to change into the blue scrubs which he had previously refused to do. Once changed, all staff exited the room..."

Review of a hospital document titled, "Security Incident #16-89 - Elopement" dated February 23, 2016, completed by Staff Q, Security Officer included in part, "...On Tuesday, February 23, 2016 at 6:00 AM, I came on duty and immediately reported to the ED to watch three psych patients, located in ED Rooms #17, #22, and #23. At 7:00 AM, I was relieved from watching these patients by [Security Officer H]. Between approximately 7:00 AM and 7:15 AM, a safety companion, [Staff I, RN (Registered Nurse) Behavioral Health] joined in watching the patient, the sitter was physically in the room.

Review of a document dated 2/23/16 at 7:20 AM, completed by Staff I, Behavioral Health Unit RN included in part, "I walked into room #17. I tried to get [Patient #1] to sit and lay down on the bed. I tried to move the bed in the room. It was close to the door. Patient immediately left the room and ran. I tried to run out and find the patient. The patient continued to run. The patient ran out the back door of the ED. I then called out for security to assist."

3. Review of hospital video footage recorded on 2/23/16 at 7:18 AM on the hospital security cameras, showed Patient #1 wearing blue paper scrubs and carrying a bag with his personal belongs exited the nurse's station at the same time a staff member entered the nurse's station. The patient turned left, walked approximately 32 feet, and attempted to open an alarmed, locked door. The patient then turned left and traveled approximately 172 feet through an outer corridor of the ED. At the end of the outer ED corridor, the patient turned right and walked 42 feet to the entrance of the ambulance bay. Patient #1 continued to walk approximately 100 feet to where Patient #1 entered an unlocked, unoccupied ambulance that had keys in the ignition. At that time, the video footage showed the patient placed the ambulance in reverse and backed through the closed ambulance bay doors and drove away.

4 a. During an interview on 2/24/16 at 8:40 AM, Staff H, Security Officer stated "On 2/22/16 I was observing 2 patients, including [Patient #1], via the monitoring screens." (Observation showed the monitor screens are located approximately 55 feet away from ED room 17.) Staff H said, "At 7:15 AM, "I could see [Staff I, Behavioral Health RN] standing in the doorway of the patient's room." Staff H stated, "I briefly took my eyes off the monitor when I turned to watch [Security Officer Q] assist another psych patient to the bathroom." Staff H stated, "The next thing I knew [Staff I, Behavioral Health RN] came up to me and [Patient #1] in room 17 is gone." Staff H stated, "I did not see the patient leave the room and when I heard the alarm sound on the emergency egress exit door, I went to see if the patient was there. I opened the door and asked the construction crew if they had seen a patient dressed in blue paper scrubs run by and they said no." Staff H stated, "After that, I returned to the patient's room but the patient and his belongings bag were gone." Staff H stated, "I went to the security office to get the keys to the security van and as I exited through the ambulance garage I found out the ambulance was gone."

b. During a follow up interview on 2/25/16 at 1:50 PM, Staff H, Security Officer reported the monitoring screens in the ED nursing station face both directions. Staff H stated, "On the morning of 2/23/16, at the time [Patient #1] eloped, I would have been facing the opposite direction and since [Staff Q, Security Officer] left his post to assist with toileting another patient, no one was facing in the direction of [Patient #1's] room." Staff H stated, "My attention to the monitor was distracted because I was looking in the direction of [Staff Q, Security Officer]."

c. During an interview on 2/23/16 at 5:35 PM, Staff B, emergency medical technician (EMT) stated, "About 7:15 AM, I heard [EMT D] yell, "Hey, stop, don't get in there!" I looked out of the window of the ambulance and saw a male patient in blue scrubs run towards ambulance #5." Staff B stated when she heard [EMT D] she got out of the ambulance and the male patient started the ambulance and drove in reverse through the closed ambulance doors." EMT B stated, "At that point [EMT D] went into the ED and told the nurses and security officers what happened." Staff B reported they do not leave keys in the ambulances unless they are taking a patient out of the ambulance and transporting into the ED.

d. During an interview on 2/24/16 at 8:20 AM, Staff F, Director of the Behavioral Health Unit reported, on 2/22/16 there was a bed available on the locked unit at the time when Patient #1 presented to the ED. Staff F stated, "Based on the behavioral health nurse assessment of the patient on 2/22/16 at 8:15 PM, the patient did not fit the criteria for admission."

e. During an interview on 2/24/16 at 8:55 AM, Staff G, Behavioral Health RN reported on 2/22/16 at 7:50 PM, after Patient #1 received an injection of Geodon (a medication used to treat schizophrenia and manic symptoms of bipolar disorder) she completed a mental health and addiction psychosocial assessment. Staff G stated, "The patient was very energetic, paranoid, and he didn't want to stay in the ED because he thought there were tanks in the wall that might explode." Staff G stated, "I took the assessment paper work to [Staff S, ED RN] and explained the patient was paranoid and worried about not being taken care of by the ED nursing staff." Staff G stated, "We are able to secure patients at risk for elopement in our psychiatric unit because it is a locked unit." When asked what criteria is used to admit a patient to the locked unit, Staff G stated, "Individuals with self-harm or harm to others or destruction of property would be placed in our locked unit." Staff G stated, "Patient #1 did not qualify for inpatient admission because he was not exhibiting self-harm behaviors or harm to others at the time of the assessment. I was not worried about his safety in the ED." Staff G said, "This is a nursing judgment."

f. Review of documentation provided by the hospital showed that from 2/2/16 - 2/23/16, the locked psychiatric unit admitted patients with mental health illnesses combined with substance abuse issues including patients diagnosed with major depression with psychotic symptoms, methamphetamine abuse, psychosis secondary to substance abuse issues, psychotic disorder not otherwise specified, bipolar disorder and psychotic symptoms, methamphetamine abuse and rule out adjustment disorder with adjustments of emotional conduct, and recurrent major depression.

g. During an interview on 2/24/16, Staff I, Behavioral Health RN reported on the morning of 2/23/16 she was assigned to go to the ED to monitor Patient #1. Staff I stated, "When I arrived to the ED [Staff G, Behavioral Health RN] reported the patient was paranoid and was standing at the door of the room a lot." Staff I stated, "I thought the patient was on elopement precautions." Staff I stated, "When I got to the room at 7:15 AM, I saw his bed was close to the door. He was restless, a little agitated, and he looked off and on at me. Patient #1 was standing at the door next to the nursing corridor and I was in the room. Psychiatric nurses don't want the patient's bed next to the door. I went up to the head of the bed. I was 6 to 7 feet away from the patient. I looked up and the patient was gone." Staff I stated, "I walked out of the room and there was no staff in the inner corridor (nurse's station) by his room but they were at the other end of the inner corridor." Staff I stated, "[Staff J, Interpreter] was at the double doors and she said [Patient #1] went right out his room to the exit doors." Staff I stated, "I went that way and went through the exit door and could not see him. I reported [Patient #1 was gone to [Staff H, Security Officer] When asked if Staff I knew the patient, Staff I stated, "I wish I would have went with security to see [Patient #1] until I knew his cares better."

h. During an interview on 2/24/16 at 11:00 AM, Staff J, Interpreter stated, "I was there between 7:15 AM and 7:20 AM. When I was entering the ED from the hallway a male dressed in blue paper scrubs came through the exit door (Patient #1's room) into the interior corridor (nursing station corridor). He walked by me when coming out of the ED nursing corridor and he went down the hallway towards the alarmed exit door." Staff J stated, "I went into the ED and did not talk to him. A nurse was standing by the exit door after I entered and asked me where the man went." Staff I reported the nurse looked down the hallway and did not see the patient. Staff J reported the nurse then asked her which way the patient went. Staff I stated, "I told the nurse the patient went down the hallway towards the buzzer alarm door." Staff J stated, "I said hello to him. I didn't know if he was dressed in scrubs like the nurses."

i. During an interview on 2/24/16 at 11:40 AM, ED Physician NN stated, "[Patient #1] was my patient. I just took over care of him at 6:00 AM on 2/23/16. It was a very busy morning and [ED Physician QQ] finished up on the patients he was seeing. We were both there until 7:00 AM." ED Physician NN stated, "[Patient #1] was a dual committal for psych and substance abuse. The patient was paranoid and had Ativan (medication to treat anxiety disorders)." ED Physician NN stated, "The patient was agitated when he came in our department and calmed during the night. [Patient #1] was in a room with a sitter so I went to evaluate 2 chest pain patients." ED Physician NN stated, "I then heard staff yell that a patient was in the ambulance garage." When asked if ED Physician NN assessed Patient #1, ED Physician NN stated, "I did not evaluate the patient because of the chest pain patients that had come in."

j. During an interview on 2/24/16 at 11:50 AM, Staff K, ED RN stated, "I was the nurse on duty when the incident occurred with [Patient #1]. During the night he was paranoid." When asked if she assessed Patient #1, ED RN K stated, "I was at the other end of the ED. I did not have a chance to evaluate him."

k. During an interview on 2/24/16 at 12:50 PM, Staff L, ED Manager stated, "It was busy, there were 3 psych patients in the ED including [Patient #1]." The ED Manager reported when she walked out of the break room she heard the alarm on the door at the end of the hallway leading to the ambulance garage. The ED Manager stated, "I looked to the left and saw [Staff Q, Security Officer]. I told him the alarm was going off. At that point, I didn't know what was going on. Within seconds, I heard a loud crash and the EMS staff was hollering that somebody stole their ambulance." When asked if the EMS staff reported who stole the ambulance, the ED Manager stated, "They said it was a patient. I asked the nurses what patient was missing. The nurses looked in room #17 and we discovered it was [Patient #1]." The ED Manager stated, "The safety companion (psychiatric nurse from 5E) did not verbally notify anybody." The ED Manager stated, "We never had safety companions. It has just been since the flood on the unit." The ED Manager reported the psychiatric nurses started in the ED on 2/15/16. However, the psych nurses did not receive orientation to the ED Behavioral Health processes.

l. During an interview on 2/26/16 at 11:00 AM, Staff M, ED RN stated, "I took Patient #1 from [ED nurse S] between 11:30 PM and midnight. I was there when he first came in on 2/22/16." ED RN M stated, "The first part of the night [Patient #1] was resting peacefully. When the patient woke up he was pacing around the room so I went in and talked with him. He said he wanted to go home. I asked him if he wanted anything to calm his nerves. He said no." When asked what the patient's demeanor was, ED nurse M stated, "He was looking out the door every time I interacted with him. He seemed a little down and wanted to go home." When asked if the ED physician was aware of Patient #1's behaviors, ED RN M stated, "[ED Physician QQ] was aware the patient was pacing most of the night but it was a verbal exchange of information and most likely it would not be documented in the medical record."

m. During a follow up interview on 2/25/16 at 10:20 AM, Staff F, Behavioral Health Unit Director acknowledged [Staff G, Behavioral Health RN] completed the initial mental health assessment for Patient #1. When asked if behavioral health nursing staff update ED physician's regarding a patient's mental health assessment or contact the on-call psychiatrist, Staff F stated, "They talk with the nursing staff. If the provider is available they will talk with them. If not, then the Behavioral Health nurse would share it with the nurse." When asked if the Behavioral Health RN documented the physician updates, Staff F stated, "It is a verbal report. I can guarantee there is nothing documented.

n. During an interview on 2/25/16 at 12:15 PM, Staff S, ED RN stated she provided care to Patient #1 on 2/22/16 until midnight. ED RN S reported when the patient first presented to the ED he was anxious and agitated. ED RN S verified ED Physician QQ was the patient's primary provider. ED RN S reported she did not remember if she spoke with ED Physician QQ about Patient #1 or if ED Physician QQ assessed the patient during her shift.