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Based on interview and record review, the hospital failed to ensure the nursing staff had initiated PET to release 5150 hold as per the hospital's P&P related to the patients presenting to the ED on a 5150 hold for two of five sampled patients (Patients 1 and 2). This failure created the increased risk of poor health outcomes to the patients receiving services in the hospital.

Findings:

Review of the hospital's P&P titled Admission-Criteria/Direct Admission Requirement dated December 2024 showed in part:

* Purpose: to define criteria for admission according to severity of illness with a need for intensity of services.

* Policy: Admission Criteria and Patients Served:...Patients have a Conservator/Public Guardian with rights to authorize mental health treatment, who is willing to consent to admission.

- The Exclusion Criteria: (Each case is evaluated on an individual basis by a designated clinician). Patients that have been placed on a Lanterman-Petris-Short (LPS) hold (5150).

Review of the hospital's document titled Emergency Department Psychiatric Patient Process dated December 2023 showed for the psychiatric patient presents to the ED and medically clear and on Emergency Hold, call the Prime Orange County Call Center to initiate Psychiatric Evaluation Team (PET) if appropriate to release hold or determine bed availability and initiate transfer.

1. On 1/23/25 0900 hours, an interview with concurrent review of Patient 1's closed medical record was conducted with the CNO and BHU Director.

Review of Patient 1's closed medical record showed the patient was presented to the ED on 12/17/24, with the chief complaint of aggressive behaviors.

Review of the Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment dated 12/16/24 at 1550 hours, showed Patient 1 was placed on a 5150 hold.

Review of the ED Provider Notes dated 12/17/24 at 2017 hours, showed Patient 1 was a DTS/DTO and placed on a 5150 hold on 12/16/24 at 1550 hours.

Further review of Patient 1's closed medical record showed on 12/18/24, the patient was presented with a document titled Voluntary Admission Behavioral Health by a BHU staff member. The Voluntary Admission Behavior Health form showed the patient's signature on the form and the date/time was 12/18/24 at 0945 hours. The patient was admitted to the BHU on 12/18/24 at 1100 hours.

However, further review of Patient 1's closed medical record did not show if the patient's conservator/legal guardian was contacted to consent for the psychiatric treatment of Patient A as per the hospital's P&P.

On 1/23/25 at 1330 hours, an interview with concurrent record review was conducted with the BHU Director. When asked, the BHU Director stated the PET located in another hospital. The PET could sometimes be delayed, they could break a hold. The BHU Director further stated the reason to break a hold was to minimize patient's discomfort in the ED. When asked, the Director stated the hospital was a non-LPS facility and could ask patients to sign voluntarily. The social workers would handle the paperwork and would ensure the conservator makes the decision to treat the patient.

On 1/23/25 at 1030 hours, an interview was conducted with RN 1. When asked, RN 1 stated RN 1 performed the psychiatric evaluation of the patient on a 5150 hold in the ED, and offered the patients voluntary form to sign for admission to the BHU.

2. Review of Patient 2's closed medical record showed the patient was presented to the ED on 11/25/24 at 1409 hours, with chief complaint of aggressive behavior.

Review of the Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment showed Patient 2 was placed on a 5150 hold on 11/25/24 at 1857 hours.

Further review of Patient 2's closed medical record showed the patient was presented with a document titled Voluntary Admission Behavioral Health on 11/27/24. The document showed the patient's signature on the form and the date/time was 11/27/24 at 0930 hours. And the patient was admitted to the BHU on 11/27/24 at 1046 hours.

However, Patient 2's closed medical record did not show documented evidence the patient's conservator/legal guardian was contacted regarding consent for psychiatric treatment of the patient as per the hospital's P&P.

On 1/23/25 at 1100 hours, an interview and concurrent closed medical record review was conducted with the BHU Director. When asked, the BHU Director stated patient presented to the ED on a 5150 hold were assessed and evaluated by the BHU Director or a designee/charge nurse. Patients were asked to sign the voluntary admission form for admission to the unit. The BHU Director further stated the patients admitted to the BHU were either conserved or voluntary admission. If a patient on a conservatorship and LPS, the nursing staff obtained a consent from the conservator/legal guardian regarding the patient's mental health treatment.

On 1/23/25 at 0945 hours, an interview and concurrent closed medical record review was conducted with the ED Director. The ED Director stated patients presented to the ED on a 5150 hold, the ED staff notified the BHU for further evaluation and treatment. When asked about the ED Psychiatric Patient Process algorithm dated December 2023, the ED Director stated he was not aware.

On 1/27/25 at 0945 hours, an interview with concurrent closed medical record review was conducted with RN 2. When asked, RN 2 stated when a patient who was in the ED, on a 5150 hold, and medically stable, the BHU charge nurse or the unit director would assess and evaluate the patient for admission to the unit.

On 1/23/25 at 1005 hours, during the interview with the CNO, the CNO stated the Emergency Department Psychiatric Patient Process algorithm dated December 2023 was posted in the ED and Geropsych unit.

On 1/27/25 at 1330 hours, the above findings were verified by the CNO.