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Based on record review, interview, surveillance video and policy review, it was determined, the facility failed to provide a safe environment, that fostered patients emotional health and safety, failed to de-escalate a patients agitation and failed to mitigate risks for injury to patients and staff in the area. The deficient practice affected 1 of 10 sampled patients, (Patient #2) as evidenced by a failure to obtain a timely psychiatric consult to mitigate risks upon admission, failure to communicate a patient's history to the provider prior to consultation, failure to communicate a patient's condition in private, failure to develop assault precautions after a sentinel event and failure to implement safety measures to protect patients and staff in the area.

The findings included:

Record review revealed Patient #2 presented to the Emergency Department (ED) on 03/03/25 at 2:51 PM due to a drug overdose.
Patient #2 was treated and stabilized, while in the ED, and family members requested a psychiatric consult.
ED Nurses Notes dated 03/03/25 at 6:14 PM documented, Patient #2 asked the family member to leave.
At 6:18 PM on 03/03/25, the nurse documented Patient #2 was calm, cooperative and the father was at the bedside.
At 6:20 PM on 03/03/25, the nurse noted the patient's father requested a psychiatric consult.

The medical record for Patient #2 indicates the psychiatric consult was ordered on 03/03/25 at 5:59 PM and Patient #2 was transferred from the emergency department to the inpatient unit at 6:25 PM. The consultation was not completed prior to the transfer.

The Psychiatric Consult dated 03/03/25 at 10:10 PM documented in part, Patient #2 has history of polysubstance abuse who presented to the ED by Emergency Medical Services after being found in a car with an altered mental status. An overdose with withdrawal was suspected. The patients father requested a psychiatric consult ... ... ...Patient requires inpatient psychiatric stabilization, as any lesser restrictive environment could lead to further decompensation and even death. Risk Assessment: High risk for self-harm.
Recommendations/Plan: Initiate Involuntary Hold.
Refer to: Baker Act Receiving Facility for Involuntary Inpatient Psychiatric Treatment.
Recommend inpatient psychiatric admission with suicide, assault and elopement precautions.

A phone interview with Staff A, the primary nurse caring for Patient #2, was conducted on 03/24/25 at 10:35 AM revealed, the staff arrived for her shift at 7:00 PM, at the time the patient was sleeping and about half an half-hour later the patient was calling requesting something to eat and pain medication. The patient wanted to leave but agreed to stay until the pending consult was completed. Staff A explained, she set up the Teleconsultation, it took thirty to forty minutes and when completed, the provider told her that the patient had answered all her questions appropriately. Then Staff A shared with the provider that the patient's father had stated the patient was an addict, and so was the partner. The patients father reported, he was a danger to himself. At this time, the patient overhead the conversation, was upset and she gave the phone to the nurse practitioner, who was in the hallway. The nurse practitioner told the patient that he could not leave, security was already on the unit, and the patient remained in the hallway trying to leave. The primary nurse stated there was no time to initiate one-to-one safety precautions, everything happened at once and security handled the situation until the police arrived.

An interview with the Director of Patient Safety on 03/24/25 at 11:29 AM revealed, a clarification as to why the psychiatric consult for Patient #2 was not completed while the patient was in the emergency department. The Director stated when the order for the consultation was placed in the system, the patient had already been categorized as admitted to the unit.

A phone interview with the Nurse Practitioner conducted on 03/24/25 at 11:34 AM revealed, her first interaction with Patient #2, while the patient was in the hallway, the patient was trying to leave the hospital. Prior to that, the primary nurse had called her to notify her that the family did not want him to leave the hospital, they were going to sue the hospital if he was allowed to leave, and the patient was going to kill himself. The practitioner then asked the nurse to escalate the psychiatric consultation from routine to STAT (immediate). The Nurse Practitioner explained she was walking down the hallway and saw the patient in the hallway surrounded by staff and the primary nurse gave her the phone, she then spoke to the psychiatrist who told her that the patient was going to be placed under Baker Act (A Florida law that allows for involuntary mental health examinations for people with psychological issues) because he was agitated and unable to make clear decisions.

A phone interview with the Psychiatrist conducted on 03/24/25 at 1:21 PM revealed, the provider had conducted the Teleconsultation for Patient #2. During the examination, the patient was calm and able to answer all her questions. At that time, the patient did not meet criteria for involuntary admission. The psychiatrist contacted the primary nurse after the consultation was completed and was advised that the patient's family had stated the patient was a danger to himself, he had overdosed in the past and the patient overheard the conversation. She could hear the patient screaming at the nurse, he seemed very agitated and therefore, her recommendations changed to initiate the Baker Act. The nurse then handed the phone to the Nurse Practitioner who agreed with the plan as she was witnessing the patient's agitation.

A phone interview with Staff B, the Charge Nurse, conducted on 03/24/25 at 1:47 PM revealed, she was on duty on 03/03/25. Patient #2, upon her arrival to the unit was hungry and requested food. She went in and out of the room multiple times addressing his requests. Staff B recalls calling in the tele psychiatry consult. Patient #2 told her he was waiting for his ride and recalled the nurse had told the patient that he was going to be Baker Acted. The Nurse Practitioner was involved, the practitioner was aware of the patient's behavior and spoke to the psychiatrist. The patient kept trying to leave and the security team stopped him. Then they called the police.

An interview with the Vice President of Quality conducted on 03/24/25 at 2:02 PM revealed, an audit of the timeframe for the tele psychiatry consult revealed, the consult was first requested on 03/03/25 at 5:59 PM, the psychiatrist responded to the request at 7:11 PM. The Teleconsultation was not completed at that time because it was the staff change of shift and a second request for a teleconsultation was made at 8:56 PM. The patients medical record validates the consult was conducted at 10:10 PM.

Review of the Police report dated 03/03/25 revealed the following was documented in part, "Responded to a call in reference to a disturbance with a Baker Act patient trying to leave the hospital ... ...engineering staff stated he just happened to be in the area and heard the commotion, the patient was trying to escape and he stood in his way, there was a tussle and they went to the floor .....attending doctor stated the patient was walking down the hallway being loud and she tried to calm him down telling him he needed to go back to his room, she told him he could not leave he is under Baker Act, he did not listen and became more upset ...the patient pushed past her as he passed but did not strike her after he pushed her. The nurse at the desk stated she called 911, the patient tried to push past them and they all fell to the ground, eventually the patient got up and returned to his room."

The review of the video surveillance conducted on 03/21/25 and 03/24/25 validated, Patient #2 was left alone multiple times, walking up and down the hallway, despite security being at the nurses' desk, prior to the actual incident, the patient potentially could've entered other patients' rooms, but this did not occur.

The facility policy titled, "Baker Act, last revised on 07/2022 documents:
"SAFETY OF BAKER ACT PATIENTS
I. When a patient is identified as a "Baker Act" for suicide ideation all precautions need to be in place to protect the patient from harm to self or others. The list of Baker Act safety precautions should include but are not limited to:
a. Patients will be placed in a camera room for continuous direct observation. Patients who have an active suicide or homicide attempt will have a sitter.
b. Patients are to be placed in a safe room away from exits and free from cords, cell phones, telephone lines, any sharp objects or objects that could be used to inflict harm etc.
c. Sharps containers should be removed from the room.
d. All the clothes are to be removed and taken out of the room including shoes. The patient should wear a hospital gown while hospitalized.
e. Under no circumstances is the patient to be left alone or with a visitor. In addition, visitation is limited.
f. All efforts are made to provide privacy however; the patient must be visualized at all times, even while in the bathroom.
g. Check body and hair for any items that patient could use to inflict harm to them.
h. A thorough search of valuables will be conducted and documented. Any items that can potentially cause harm to the patient will be removed."

The facility policy titled Elopement, last revised on 08/2022 documents, "Assessment of Patients:
Nursing and medical providers will assess every patient for elopement and competency to care for his/herself.
Elopement precautions will be initiated on patients who are deemed an elopement risk.
Every psychiatric patient is to be considered a potential elopement risk.
Every patient on a Baker Act is to be considered a potential elopement risk.
Prevention Precautions:
Patients with elopement risk shall not be permitted off the unit except for ordered diagnostics until approved by the physician.
They shall have their shoes removed and be placed in paper gowns or scrubs while they are on elopement precaution. Signage will be placed outside the door to alert staff of potential elopement risk.