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Based on interview, record review of Emergency Department (ED) and Obstetric (OB) logs, policy review, 72 hour returns to the ED, medical record review, complaint and grievance logs, event report logs, staffing, and physician on-call schedules, the hospital failed to stabilize two patients (#15 and #16) within the hospital's capacity and capability, when the patients presented to the Emergency Department (ED) with a psychiatric emergency. The facility failed to initiate measures available within the capacity and capability of the hospital, to prevent patient elopement (a patient who is physically, mentally, emotionally and/or chemically impaired wanders or walks away from a facility unsupervised prior to discharge), when the psychiatric patients were determined to be at risk for elopement. The emergency department sees an average of 5798 patients per month.

The facility had the capability and capacity to ensure both patients, who had made suicidal gestures prior to arriving to the ED, and who continued to verbalize thoughts of suicide, were prevented from eloping from the ED while they awaited in-patient admission.

Please refer to A2407 for details.

Based on interview, record review, and policy review, the hospital failed to stabilize two patients (#15 and #16) within the hospital's capacity and capability, when the patients presented to the Emergency Department (ED) with a psychiatric emergency. The facility failed to initiate measures available within their capacity and capability to prevent patient elopement (a patient who is physically, mentally, emotionally and/or chemically impaired wanders or walks away from a facility unsupervised prior to discharge), when both patients were at risk for elopement. A total of 29 patient ED records were reviewed out of a sample selected from July 28 through September 27, 2016. The ED had an average of 5798 emergency visits per month.

Findings included:

1. Record review of the facility's policy titled, "EMTALA: Provision of care and transfer/acceptance of patients with emergency medical conditions," dated 12/2008, showed that the facility will provide care within the extent of the hospital's capabilities to patients suffering from an emergency medical condition.

Record review of the facility's policy titled, "Emergency Department Management of Behavioral Health Patients," dated 05/2014, showed that behavioral health patients in the ED will have continuous observation as deemed necessary based upon their clinical and psychological presentation, and an affidavit completed.
Record review of the facility's policy titled, "Suicide Precautions," dated 05/2015, showed that:
- Patients identified as being at risk, or, with active thoughts or intent, are placed on "Suicide Precautions" to alert staff and have continuous observation with every 15 minute documentation.
- Security will be notified and patient belonging search will be conducted in accordance with policies.
- Affidavit should be completed for patients ages 18 or older and the completed document should be notarized.

Record review of the facility's policy titled, "Abduction and Elopement of Patients," dated 08/05/13, showed that adult patients at high risk for elopement may include those who had previously eloped, and showed the response to an elopement to be to immediately notify the Security Department and to notify the attending physician.

Record review of the facility's policy titled "Safety: Room Check and Search for all Inpatient Areas and ED", showed that patients are allowed supervised telephone usage as appropriate.

Record review of the facility's policy titled, "Safety Intervention Planning an Patient Safety Assistants," dated 02/2013, showed that Patients with intention to harm self, such as past suicide attempts, could be, and were "typically" observed 1:1.

2. Record review of an affidavit dated 08/07/16 for Patient #15, showed that the patient repeatedly stated "I'm going to kill myself", "I just want to die", and "The voices are telling me to kill myself". The patient also jumped out of a slow moving police vehicle.

3. Record review of Patient #15's medical record dated 08/07/16 at 2:12 PM, showed that in the ED nurse documentation:
- The patient arrived to the ED by ambulance, after a "suicide attempt" by taking 15 Xanax of unknown dosage.
- The patient repeatedly stated "I want to die", started having hallucinations and stated "Why are you here", "You can't protect your kids".
- After two and a half hours, patient showed no physical signs of the overdose, contracted for safety and was placed on suicide precautions.
- At 3:52 PM, Staff O, Registered Nurse (RN), went to the patient's room and found a blanket tied around the bed rail. When the nurse asked about it, the patient stated that she tied it around her neck to kill herself. The patient continued to repeat "I'm going to die today".
- The nurse removed the bed out of the room and provided a mattress on the floor with a blanket.
- At 4:36 PM, patient stated to Staff O, "They are so loud, so loud they hurt". When asked to clarify, the patient stated, "The voices! The voices! They are telling me to kill myself!"
- At 4:51 PM Staff Q, ED physician, documented that the patient was inconsistent with central intake's account of her story and had no physical signs of overdose and the patient was stable for discharge to the custody of law enforcement.
- The patient was discharged at 4:51 PM.

Record review of Patient #15's medical record dated 08/07/16 at 5:59 PM, showed that
the patient returned to the ED by ambulance, after a "suicide attempt" by opening the police car door and falling to the ground while the vehicle was moving. ED nurse documentation showed that the patient presented with multiple abrasions to both elbows, left lower back, left shoulder, right ankle and right leg. No head injury was noted and the bleeding was controlled.
- Staff R, ED physician, documented that the patient expressed suicidal ideation (thoughts of suicide) and was tearful with a depressed mood. Staff R also documented that there was no acute medical issue that required immediate treatment and no contraindication to psychiatric admission at that time.
- Staff L, Central Intake, documented that she discussed the case with Staff S, Psychiatrist and he agreed to admit the patient to the Acute Psychiatric Unit 1200. In the interim, the patient was being cared for in the ED, Room #24, by Staff N, ED Nurse.
- At 7:41 PM Staff N, ED Nurse, documented that the patient was being cooperative and she allowed the patient out to the desk to use the phone. At 7:56 PM, Staff N documented that the patient stated that she sometimes still heard voices that told her to "Kill yourself". At 8:24 PM, Staff N allowed the patient to go out to the desk to use the phone again. At 8:39 PM, patient's sister was witnessed exiting to the lobby and patient attempted to follow her sister out. Staff N walked toward the patient and told her she needed to stay, but then the patient ran straight out the door to the parking lot. Staff N proceeded to run after the patient down the parking lot while the triage nurse called security. Staff N caught up to the patient and her sister and tried to talk patient into coming back in the facility, but the patient's sister then grabbed Staff N's arms to hold her down, while the patient continued to run. Security and the Police Department continued to search for the patient with no success and Staff N informed Staff R, Physician, of the elopement.

Record review of the "15 minute Observation Flowsheet" showed that Patient #15 was permitted to use the phone in the hall at 7:45 PM, 8:00 PM, 8:15 PM and then eloped at 8:30 PM.

Record review of the "Dispatch Call" log dated 08/07/16 at 8:33 PM showed a request for security to respond to an eloped patient (Patient #15).

During a telephone interview on 10/06/16 at 4:50 PM, Staff O, Dayshift ED RN, stated that Patient #15 returned by ambulance right before the shift change. Staff O stated that she informed Staff N, RN in shift change report of the patient's earlier visit to the ED where the patient tried to put her head between the bars of her bed. She expressed to her that the patient was a high risk for elopement and normally wouldn't have been allowed to be in the hall. Also, she told Staff M, sitter/monitor technician (tech), to closely watch Patient #15 due to her risk level.

During a telephone interview on 10/05/16 at 2:40 PM, Staff M, sitter/monitor tech, stated that 08/07/16 was the first time she had worked in the ED. She came on shift at 7:00 PM to watch the monitor and Patient #15 was the only patient that was actively walking around. In report, Staff M was told to keep a close eye on Patient #15 because she might try to escape. Her room was positioned to the left in front of her. Staff M stated that Staff N, RN, allowed the patient to come out of the room to make phone calls in the hall. She stated that the last time the patient came out of her room, she was getting too far out (of the room) so Staff N, tried to redirect her but the patient ran off.

During a telephone interview on 10/05/16 at 5:52 PM, Staff N, RN, stated that she came on shift at 7:00 PM on 08/07/16 and received report on Patient #15. She remembered that the patient had been hearing voices and that she was the highest risk for suicide and elopement in the ED. She stated that the patient had been cooperative, so she let her use the hall phone to call family but the patient looked to the left, saw the outside doors open and ran out. Staff N ran after her and tried to calm her. Patient's sister was also there and when Security ran out, the patient's sister held Staff N's arms so that the patient could get away. Staff N stated that approximately two weeks ago, leadership required staff to have a physician's order for patients to be allowed to use the phone in the hall. No physician's order for phone usage was noted in the patient's medical record..

During a telephone interview on 10/06/16 at 5:10 PM, Staff P, Security Guard, stated that he ran outside after Patient #15 exited the building. He chased her as far as he could, but could not catch up with the patient. He drove around looking for the patient then relayed the event to the local Police Department.

During a telephone interview on 10/10/16 at 4:05 PM, Staff R, ED Physician, stated that he remembered the patient and he considered all of the behavioral health patients to be at risk for elopement. They were supposed to be on direct observation and direct line of site with video monitoring. He stated that this was poor judgment on nursing and that patients were not permitted to wander out in the hall. He stated that occasionally if it were urgent, they were allowed to go into the hall to use the phone if escorted.

During a telephone interview on 10/10/16 at 4:35 PM, Staff T, Interim ED Director, stated that she would not have expected the nurses to have allowed one-to-one (1:1, one staff member observes that patient only and at all times) patients in the hall to use the phone, unless it was urgent and a cordless phone was not available. She stated that all of the nurses carried cordless phones that the patients were allowed to use.

4. Record review of a Police Department Report dated 09/10/16, showed that Patient #16 was found unconscious and with a weak pulse (heart beat), after he hung himself in a jail cell. The patient's ligature was removed, the patient was resuscitated, and transported out of the jail for medical care.

5. Record review of an Affidavit dated 09/10/16, and signed by a Law Enforcement Officer, showed that because of Patient #16's attempted suicide, it was believed the patient posed a danger to himself.

6. Record review of Patient #16's medical record dated 09/10/16, showed that the patient arrived to the ED at 3:05 PM by ambulance after a "suicide attempt". ED nurse documentation showed that the patient's psychiatric history included post traumatic stress disorder (PTSD, a mental health condition triggered by experiencing a traumatic event) and depression. Patient #16 verbalized, "I don't have anything to live for". Staff B, ED Physician, documented that the patient expressed suicidal ideation (thoughts of suicide), ordered the patient's observation level "within line of sight at all times" for suicide precautions and elopement precautions, and contacted the Central Intake Unit for a psychiatric assessment. Staff J, Central Intake, assessed the patient at 7:40 PM, and documented that the patient had a history of suicide attempts by jumping into traffic, had current thoughts of suicide, and the patient believed suicide was the only way to solve his problems. Staff J documented that she discussed the patient's assessment with Staff B and the on-call psychiatrist, who agreed that the patient should be admitted to inpatient behavioral health services. Staff B, ED Physician, placed an order at 9:15 PM for admission to "ACUTE PSYCH VOLUNTARY", but the patient eloped from the facility before he was taken to the psychiatric unit.

7. Record review of a "Dispatch Call" log dated 09/10/16 at 9:22 PM, showed a request for all units to respond to an eloped patient (identified by the facility as Patient #16).

During a telephone interview on 10/04/16 at 12:42 PM and 3:31 PM, Staff J, Central Intake, stated that the patient had an inpatient bed awaiting him on the psychiatric unit when he eloped from the ED. Staff J stated that she believed the patient may have been suicidal when he eloped.

During an interview on 10/03/16 at 3:03 PM, Staff R, Emergency Room Technician (ERT), stated that while he monitored Patient #16 by closed circuit monitor from a nurses station (outside of the patient's room), the patient attempted to elope. Staff R stated that he chased after the patient, recovered the patient, and returned the patient to his room, but did not notify the Physician or Security about the elopement. When Staff R left the patient and returned to the monitor area, a period of approximately two minutes, the patient eloped again and was unable to be found. Staff R stated that he could have done the following to prevent the patient's elopement:
- Closed the patient's room door;
- Called security to update security staff of the patient's elopement risk; and
- Asked security staff to stand at the nurses' desk (located outside of the patient's room).

During a telephone interview on 09/29/16 at 11:00 AM, Staff E, ED RN, stated that Patient #16 was considered suicidal, and was to be admitted to the behavioral health unit when he eloped from the ED. Staff E stated that ED staff try to "do our best" to ensure that patients don't elope and added that ED staff have the ability to monitor patients 1:1 or have Security present immediately outside of the patient's room, but she did not feel it was necessary for Patient #16.















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