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Based on observation, interview, review of medical records, review of the facility's policies, review of Assessment Logs, review of Assessment & Referral Center (ARC) Initial Assessments, Referral Assessments, and review of the facility's Medical Staff ByLaws, Rules and Regulations, the facility failed to:
- Recognize the facility had a Dedicated Emergency Department (DED) that required the facility to adopt and enforce policies and procedures that complied with the Emergency Medical Treatment and Labor Act (EMTALA) regulations.
- Post signs specifying the rights of individuals with respect to examination and treatment for emergency medical conditions, and information indicating whether or not the hospital participated in the Medicaid program.
- Maintain an accurate Central Log for patients that presented to the DED for assessment and/or evaluation to rule out if an Emergency Medical/Psychiatric Condition (EMC) existed.
- Provide a Medical Screening Examination (MSE) sufficient to determine if the presence of an Emergency Medical/Psychiatric Condition (EMC) existed for two (#8 and #17) out of 21 patients' records reviewed from 05/04/18 through 06/12/18.
- Provide stabilizing treatment within the capability and capacity of the facility for one (#21) out of 21 patients' reviewed with a psychiatric condition that was allowed to elope prior to being stabilized for treatment.

1. During an interview on 06/13/18 at 1:40 PM and on 06/19/18 at 4:07 PM, Staff A, Chief Executive Officer (CEO) stated that:
- The facility did not meet the definition for a "Dedicated Emergency Department".
- The facility no longer performed MSEs but they performed assessments.
- The facility no longer utlizied an "EMTALA" Log but did log patients into the Assessment Log.
- The facility stopped accepting "walk-in" (patients that presented without a scheduled appointment) patients on 04/04/18.
- The ARC was no longer open 24-hours a day, seven days a week, but was open from 6:00 AM to 12:00 AM. However, if a patient presented to the facility seeking an assessment after ARC hours, the facility would do the right thing for the patient and staff would perform an assessment.
- Since the facility did not meet the definition for EMTALA all signage had been removed from the property including the main entrance, main lobby waiting area, ARC waiting rooms and treatment/exam rooms.
- Since the facility did not feel that they meet the EMTALA definition and no longer provided 24-hour services for "walk-in" patients without a scheduled appointment, the facility would not need to be compliant with EMTALA regulations.

During an interview on 06/14/18 at 11:58 AM, Staff D, Registered Nurse (RN), stated that when a patient presented to the facility seeking an assessment without a scheduled appointment, he documented on the Assessment Log that the patient's type of referral was a "walk-in" patient. Staff D stated that he knew that some staff would document a "walk-in" patient as having a "scheduled appointment" on the Assessment Log even though the patient was a "walk-in." Staff D stated that when a patient presented as a "walk-in" and without a scheduled appointment time, staff would schedule an appointment and the patient would be seen within minutes of walking in.

Review of the May and June Assessment Logs showed:
- From 05/04/18 through 05/31/18, out of 221 patients logged by staff, 180 patients (81%) presented as scheduled appointments and 41 patients (19%) as unscheduled.
- From 06/01/18 through 06/12/18, out of 86 patients logged by staff, 79 patients (92%) presented as scheduled appointments and seven patients (8%) as unscheduled.
- Record review of the Assessment Logs indicated that the facility had a DED and that the public may receive a MSE without requiring a previously scheduled appointment.

Review of the Assessment Logs from 05/04/18 to 06/12/18 showed:
- On 05/05/18, 05/18/18, 05/25/18, 05/27/18 and 05/28/18, Patients #5, #12, #2, #10, #15, #14 and #9 presented to the facility as "walk-in" patients.
- Review of the patients' (#5, #12, #2, #10, #15, #14 and #9) medical records showed they did not contain an inquiry call sheet that indicated a scheduled appointment time.
- On 06/05/18 and 06/09/18, Patients #7, #19 and #16 presented to the facility as "walk-in" patients.
- Review of the patients' (#7, #19 and #16) medical records showed they did not contain an inquiry call sheet that indicated a scheduled appointment time.

Ten out of 11 patients' records reviewed that presented to the facility as a walk-in did not have an inquiry call sheet in the medical record that indicated a prior scheduled appointment time. Staff did not differentiate between patients that had a scheduled appointment from patients that did not have a scheduled appointment and all patients that presented seeking an assessment/evaluation were provided services by staff.

These failures had the potential to place all patients that arrived to the facility for assessment at risk for their safety, resulting in a delay of treatment for emergency medical/psychiatric conditions. The facility census was 33.

Refer to the 2567 for additional information.

Based on observations and interview, the facility failed to post signs specifying the rights of individuals with respect to examination and treatment for emergency medical conditions, and information indicating whether or not the hospital participated in the Medicaid program at the facility's main entrance, main lobby waiting area, the two waiting areas in the Assessment & Referral Center (ARC) and in the ARC treatment/exam rooms that patients were examined. These failures had the potential to affect all patients that presented to the facility for emergency medical and/or psychiatric care and/or treatment. The facility census was 33.

Findings included:

1. Observation on all days of the survey from 06/13/18 to 06/19/18 showed no Emergency Medical Treatment And Labor Act (EMTALA) signage pertaining to Patients' Rights or Medicaid at the main entrance doors of the facility, in the main lobby waiting area, the two ARC waiting areas and in the ARC treatment/exam rooms.

During interview on 06/13/18 at 1:40 PM Staff A, Chief Executive Officer (CEO), stated that the facility did not have EMTALA signage posted anywhere on the property inside or outside. Staff A stated that the facility had not had EMTALA signs posted on the property since April 4, 2018. Staff A stated that since the facility did not meet the definition for EMTALA, all EMTALA signs throughout the facility had been removed.

Based on interview, and record review, the facility failed to ensure a Central Log was maintained for the facility's Dedicated Emergency Department (DED). In place of a Central Log, facility staff utilized an Assessment Log (a log that staff used to enter patients that presented for assessments with and/or without a scheduled appointment). The facility failed to ensure staff made consistent and accurate entries in the Assessment Log for each individual that presented to the facility seeking care for either a medical and/or psychiatric condition. This failed practice by staff had the potential to affect all patients that presented to the facility seeking an assessment/evaluation. The facility census was 33.

Findings included:

1. During an interview on 06/13/18 at 1:40 PM, Staff A, Chief Executive Officer (CEO), stated that since the facility did not meet the definition of a DED, the facility no longer used the Emergency Medical Treatment and Labor Act (EMTALA) Log they had used in the past but now used the Assessment Log to document patients that presented for assessment/evaluation.

When asked for the Central Log, Staff B, Director of Risk and Performance Improvement, provided the Assessment Log that Assessment & Referral Center (ARC) staff filled out when a patient presented to the facility for an assessment/evaluation with or without a scheduled appointment.

Review of the Assessment Log showed it did not contain all the required elements of a Central Log. The elements missing from the Assessment Log included if a patient was refused treatment, if a patient was stabilized and transferred or discharged from the facility.

During an interview on 06/14/18 at 11:58 AM, Staff C, Registered Nurse (RN), stated that not all staff accurately documented on the Assessment Log how a patient presented to the facility. Staff C stated that some staff would document a "walk-in" (patient presented without a scheduled appointment) patient as a scheduled appointment. Staff C stated that some staff would schedule the "walk-in" patient with an appointment when they presented and then assessed them within minutes after the appointment had been made.

Review of the Assessment Log dated from 05/04/18 to 05/31/18 showed:
- On several entries staff had checked the box for "walk-in" and a line was drawn though it and the box next to scheduled appointment had been checked.
- On several entries staff had documented appointment time as N/A (not applicable) and a line was drawn through it and an appointment time was entered.
- Staff had documented the arrival time a few minutes before the scheduled appointment time.
- The Assessment Log also had several entries left blank, for example, if the patient had a scheduled appointment, was transferred or was a walk-in and what type of care had been provided to rule out if an Emergency Medical/Psychiatric Condition existed.

These inconsistencies documented by staff made it difficult to accurately track the care provided to each patient that presented for a Medical Screening Examination to rule out if an Emergency Medical/Psychiatric Condition existed.

Based on interview, record review, and policy review, the facility failed to provide a complete medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) within the facility's capacity and capability for 2 patients (#17 and #8) of 21 medical records reviewed from 05/04/18 through 06/13/18. This failure allowed patients to be discharged without a complete MSE to determine if an EMC existed, which could have resulted in injury or death.

Findings included:

1. Review of the facility's policy titled, "Initial Assessment and Referral," revised 05/2018, showed directives that an initial assessment for each individual requesting services would be provided. Initial assessments are used to determine the needs of an individual and to make the appropriate treatment recommendations or referrals.

Review of the facility's policy titled, "Scope of Service: Assessment & Referral Center (ARC)," revised 04/2018, showed the purpose and objective of the ARC once patient needs are identified, is to provide appropriate disposition.

2. Review of Patient #17's medical record dated 05/23/18, showed the 21-year-old male arrived via law enforcement for psychiatric evaluation following elopement from the group home property in which he resided. The patient eloped from the group home after he became angry and threatened to harm staff and threatened to damage their personal vehicle. The patient had a history of Autism (a complex neurobehavioral condition that includes impairments in social interaction, developmental language, and communication skills, combined with rigid, repetitive behaviors) and was low functioning (limited ability to communicate and manage behavior).

Review of Patient #17's Intake Assessment dated 05/23/18, showed:
- The patient threatened to harm himself and others, had a suicide plan to jump out of a car, and reported that he wished he would not wake up;
- A family history of depression, delusions, and schizophrenia (a serious mental disorder in which reality is interpreted abnormally; extremely disordered thinking and behavior that impairs daily functioning and can be disabling);
- The patient's history included attempted suicide (to inflict self-harm as a means to end life), psychiatric hospitalization for threatened suicide, with behavioral changes over the previous six months that included poor impulse control (failure to resist temptation), aggression (behavior intended to cause physical or mental harm), and irritability;
- The patient had poor insight and poor judgment;
- The patient's suicide risk, elopement risk, mental status (appearance, behavior, speech, visual contact, and mood), level of care determination, initial problems identified/justified for level of care chosen, recommended care, and mobile assessment disposition were not documented by ARC staff;
- The patient was discharged after an incomplete psychiatric evaluation with outpatient referrals; and
- The medical record did not contain a sufficient MSE to determine whether or not an EMC existed.

During an interview on 06/19/18 at 4:00 PM, Staff K, Licensed Professional Counselor (LPC) - Intake Assessor, stated:
- The disposition should be located on page eight of the intake assessment; however, upon concurrent review with Staff K, the patient's disposition is not clearly indicated;
- After review of Patient #17's medical record, she conducted the intake assessment for
Patient #17 on 05/23/18 at 9:18 PM;
- The patient was referred to outpatient/community resources as the Referral Resources Form was in the patient's medical record;
- She contacted the psychiatrist on-call; however, failed to document the level of care determination and recommended care on the intake assessment; and
- The intake assessment was not complete, including level of care determination and recommended care.

During a telephone interview and concurrent review of Patient #17's medical record on 6/28/18 at 10:03 AM, Staff M, Psychiatrist, stated:
- The intake assessment was incomplete;
- The patient's suicide risk, elopement risk, mental status (appearance, behavior, speech, visual contact, and mood), level of care determination, initial problems identified/justified for level of care chosen, recommended care, and mobile assessment disposition were not documented by ARC staff;
- The disposition listed in the record is not the disposition of the patient, it is a summary of his presentation;
- The Intake Assessors are the eyes and ears for the psychiatrists on-call and they must present a comprehensive assessment;
- Documentation must include the rationale for the decision that is made on a patient's disposition;
- When you give a verbal order, you hope the nursing staff write down what you have ordered after they have read the order back to you;
- There is no expectation for psychiatrists to review assessments or documentation of nursing staff or Intake Assessors;
- Psychiatrists don't ever review or sign assessments or orders from the ARC. If the patient is admitted, the ARC assessments are part of the record;
- Psychiatrists do not review the ARC assessments if the patients are not admitted; and
- Something has to be done about how they document on patients.

3. Review of Patient #8's medical record dated 05/20/18, showed a 43-year-old female presented with her daughters with a scheduled appointment to be evaluated for opiate (a drug/narcotic that contains opium or its derivatives, used in medication for inducing sleep and/or relieving pain) detoxification (detox - the process of removing toxic substances from the body, for example, drugs and/or alcohol).

Review of the patient's Inquiry Call Sheet dated 05/20/18, showed that the patient was at another facility's emergency department (ED) when the patient's daughter called for an appointment for the patient to be evaluated for inpatient opiate detoxification treatment. The patient was at the other facility's ED undergoing assessment for a 72-hour detox following intervention by family.

Review of the patient's Intake Assessment dated 05/20/18, showed:
- The patient reported she used Oxycodone (opioid - medication used to treat moderate to severe pain) 70 to 80 milligrams (mg) daily times seven years.
- The patient denied Suicide Ideations (SI - thoughts of harming self), however; staff assessed and documented the patient's suicide risk level was scored at moderate risk with five to nine risk factors identified.
- The patient had lost a grandson seven months ago.
- The patient reported the following withdrawal symptoms: Sweats, anxiety, and cravings.
- Staff documented the patient's Current Mental Status as:
- Behavior: Anxious, restless, and agitated;
- Mood: Depressed, anxious, hopeless, helpless, feelings of guilt, mood swings, tearful, labile (emotionally unstable), and withdrawn;
- Affect: Blunted (reduction in the intensity of an individual's emotional response);
- Thought Process: Flighty/Racing thoughts (rapid thought patterns); and
- Judgment: Poor (the inability to make appropriate decisions).
- Level of Care Determination: Condition requires a medically monitored detoxification (process used to safely manage the acute physical symptoms of withdrawal associated with stopped drug use).
- Initial Problems Identified/Justified for Level of Care Chosen: Medical detoxification.
- Recommended Care: Admit Adult Unit.
- Staff L, Registered Nurse (RN), Intake Assessor, documented that she had consulted with the psychiatrist on 05/21/18 at 12:30 AM, and received an order to admit the patient to the Adult Unit.

The Intake Assessment did not contain the psychiatrist's signature that he was consulted on 05/21/18 at 12:30 AM, and that he agreed with the Intake Assessor's assessment of the patient.

Review of the facility's Refusal To Permit Medical Treatment or Transfer form dated 05/21/18, showed the patient signed the form and Staff L, RN, Intake Assessor, witnessed the patient's signature.

Review of the patient's Intake Assessment dated 05/20/18, showed it did not contain documentation that Staff L, RN, Intake Assessor, notified or updated the psychiatrist that the patient had decided to refuse inpatient opiate detoxification treatment and if the psychiatrist consented with the patient's decision to discharge against medical advice.

During an interview on 06/13/18 at 5:13 PM, Staff C, Licensed Clinical Social Worker (LCSW), Director of Intake/ARC, stated that psychiatrists did not review or co-sign the Intake Assessment or the Referral Recommendations & Crisis Safety Plan.

During an interview on 06/19/18 at 4:30 PM, Staff L, RN, Intake Assessor, stated that she documented the patient's Intake Assessment and consulted the psychiatrist on-call. Staff L stated that her documentation did not have details to reflect if she informed the psychiatrist that the patient had decided to refuse inpatient opiate detoxification treatment and if he consented to the patient leaving against medical advice. Staff L stated, "I honestly don't ever include in my documentation if the patient does not want to be admitted."

During a telephone interview on 06/28/18 at 9:49 AM, Staff M, Psychiatrist, stated that:
- Patient #8's Intake Assessment did not include documentation by Staff L, RN, Intake Assessor, how the decision making process was reached for the patient's disposition.
- The Intake Assessment did not include follow-up documentation that Staff L had consulted with him about the patient's desire to leave the facility AMA after he had given an order for the patient to be admitted for inpatient opiate detox treatment.
- The documentation should be reflected in the patient's chart of the decision process and any follow-up communication with the psychiatrist when a change takes place with the patient being assessed.
- Something needed to be done with staffs' lack of documentation.
- The Intake Assessors are the eyes and ears for the psychiatrist and his decision about the patient would be made on the clinical presentation given by the Intake Assessor.
- He did not review Intake Assessors' documentation to see if he was in agreement with their documented assessment/evaluation of the patient.
- There is no expectation for psychiatrists to review assessments or review documentation of nursing staff or Intake Assessors.
- He does not review assessments if patients are not admitted.
- The documentation of the decision-making process or what information is relayed to the psychiatrist is not documented.

Staff failed to document if the psychiatrist consented to the patient's decision to leave against medical advice. There was no order found in the patient's medical record for the patient to be discharged, the psychiatrist did not co-sign the Intake Assessment to indicate that he consented with the assessment and evaluation. The patient's medical record does not reflect if the patient received a completed medical/psychiatric screening examination to rule out if an emergency medical/psychiatric condition exists.


18018

Based on interview, record review, policy review, and video recording review, the facility failed to stabilize one (#21) patient within the facility's capacity and capability, when the patient presented to the facility's Dedicated Emergency Department (DED) seeking assessment for a psychiatric condition. The facility failed to initiate measures available within their capacity and capability to prevent the patient from elopement (a patient that is physically, mentally, emotionally and/or chemically impaired wanders or walks away from the facility unsupervised prior to discharge), when the patient reported to staff that he wanted to leave the facility. A total of 21 patients' Assessment & Referral Center (ARC) records were reviewed out of a sample selected from 05/04/18 through 06/13/18. The facility census was 33.

Findings included:

1. Review of the facility's policy titled, "Admission Safety," dated 04/2018, showed that:
- The facility will provide a safe and secure environment for individuals and staff in the Assessment & Referral Center area. All individuals will be screened upon arrival in order to treat more severe, at risk individuals in a timely manner.
- ARC staff will triage all potential individuals presenting for assessment.
- All individuals will be observed with documented 15-minute safety checks by an Intake Specialist or designee beginning when the individual arrives in the facility lobby.

Review of the facility's policy titled, "Initial Assessment and Referral," dated 05/2018, showed that the facility's policy is to provide an initial assessment for each individual requesting services. This assessment is used to determine the needs of an individual and to make the appropriate treatment recommendations or referrals.

Review of the facility's policy titled, "Scope of Service; Assessment & Referral Center," dated 04/2018 showed the type of intervention provided by the ARC will be specialized to meet the specific needs of the individual.

Review of the facility's policy titled, "Discharge Against Medical Advice," dated 05/2017, showed that:
- In instances when a patient wants to leave against medical advice (AMA), the patient is informed of the potential risks involved.
- Notify the Nurse Manager (during business hours) or House Supervisor (after business hours) and request he or she talk to the patient and assess their current risk for suicide/homicide ideation, as well as address the reason(s) for their request to leave AMA.
- If the patient leaves AMA, the nurse will request the patient sign the "Patient Request for Discharge/AMA" form at the time of release. If the patient refuses to sign the form, this will be documented and signed by two witnesses.
- The RN will complete the AMA Discharge Progress Note.

Review of the facility's policy titled, "Elopement Response," dated 7/2017, showed information relevant to elopement is communicated promptly and accurately to the patient's physician, family, and authorities.

Review of Patient #21's medical record dated 06/10/18 showed:
- Staff documented on the patient's Inquiry Call Sheet dated 06/10/18 at 2:41 PM, that the patient called and requested an appointment to be evaluated for alcohol dependency.
- The patient documented on the Patient Profile form dated 06/10/18 that:
- The recent events/problems that brought about his request for help today included: Alcohol, depression, pills, "weed" (marijuana) and suicidal.
- Alcohol/Drug Abuse: Yes, last night and this morning.
- Suicidal Thoughts/Feelings, please describe: Yes, "doesn't feel like living".
- Staff documented on the patient's Initial Medical Screening Examination dated 06/10/18 at 5:25 PM, that the patient reported that he had "a lot" of alcohol last night.
- Staff documented on the patient's Intake Assessment dated 06/10/18 a 5:27 PM:
Presenting Problems and Significant History (What brought the patient here today?): The patient reported that he needed help with alcohol. He stated that when he came off it, he was depressed and suicidal. The patient reported he drank hard liquor and beer daily after work and on the weekends. He usually started drinking at 6:00 AM and would drink until 1 or 2 AM. The patient reported that he was always depressed and suicidal until I drink. "I do want to die all the time." The patient reported lately he did not have a plan but will just act on how "I feel."
- Current Treatment: The patient is currently under the care of a psychiatrist and therapist.
- Previous Treatment: May 2018, admitted to inpatient care in another psychiatric facility following an attempted hanging. May 2018, admitted to inpatient care at this facility for complaints of alcohol, suicidal ideations (SI - thoughts of harming self), and depression.
- Does the individual report an increase in the intensity and/or frequency of suicidal thoughts in the last week? Yes, more often, like every day. The patient reported that he wished he would not wake up in the morning every day.
- Family History: Depression - mother; Completion of suicide attempt - cousin; intense mood swings - everyone; alcoholism - both parents; and drug dependency - both parents.
- Staff documented that they consulted with Staff H, Psychiatrist, on 06/10/18 at 7:14 PM and the level of care chosen was for Inpatient Medical Detoxification (a process used to safely manage the acute physical symptoms of withdrawal associated with stopped drug use).

Review of the facility's Refusal To Permit Medical Treatment or Transfer form dated 06/11/18, Staff C, Licensed Clinical Social Worker (LCSW), Director of Intake documented on the form that the patient refused to permit further psychiatric evaluation for the recommended level of inpatient care. Under Staff C's signature, she wrote "While in hallway patient stated he would not sign and just wants to leave."

Staff C, LCSW, Director of Intake failed to:
- Follow the facility's policy related to Discharge Against Medical Advice and Elopement Responses.
- Document the incident in a timely manner. Staff C did not complete the refusal to treat form until the next day, 06/11/18, after the patient had eloped from the ARC/Intake on 06/10/18.
- Document the patient had been informed of the potential risks involved with leaving AMA.
- Document that the weekend House Supervisor (Staff D, Registered Nurse) was notified the patient had stated he wanted to leave the ARC, so Staff D could assess the patient's current risk for SI and address his reasons requesting to leave AMA.
- Have another staff witness the patient's refusal to sign the AMA form.
- Complete the AMA Discharge Progress Note.
- Did not notify the local law enforcement after the patient eloped from the ARC.

Observation on 06/19/18 at 11:15 AM of the ARC/Intake showed that after you passed through the security double doors, there is a hallway and at the end of the hallway was a door with an exit sign above it. The exit door did not have an alarm system on it when the door was opened.

During an interview on 06/19/18 at 11:15 AM, Staff C, LSCW, Director of Intake, stated that the exit door at the end of the hallway of the ARC/Intake did not alarm when the door was opened.

Review of the facility's video recording on 06/19/18 at 2:55 PM, dated 06/10/18, showed the patient standing in the ARC hallway with Staff C, Staff G, Licensed Professional Counselor (LCP), Intake Assessor, and the patient's two female support systems. After a few minutes passed, Staff C and Staff G left the hallway and entered through a closed doorway that lead to the ARC office and left the patient and the two females standing in the hallway. The two females left the hallway and entered into the ARC waiting area, which left the patient standing in the hallway unattended. The patient was left unattended in the hallway for several minutes. The patient walked to the end of the hallway to the exit door. The patient pushed against the door with the right side of his upper body. The patient gave the door another hard push and the door opened. The patient eloped through the exit door and out of the facility.

During an interview on 06/14/18 at 11:58 AM, Staff D, RN, stated that:
- He was working as House Supervisor on 06/10/18, when Patient #21 presented to the facility.
- He performed the Initial Medical Screening Examination for the patient and during the exam, the patient stated to him, "Please let them admit me."
- Staff C, LCSW, Director of Intake, was talking on the phone when Staff D asked her if she had notified local law enforcement that the patient had eloped. Staff C, LSCW, Director of Intake, stated that she was "taking care of it." Staff D thought that Staff C was on the phone with local law enforcement at that time to report the patient had eloped from the ARC.
- Staff C received the AMA order for the patient after the patient had already eloped from the facility.
- The two females with the patient stated to Staff D that they thought the patient was placed on a 96-hour hold (application used for mental health, alcohol and drug involuntary commitment for treatment).

During an interview on 06/14/18 at 12:51 PM, Staff C, LCSW, Director of Intake, stated that:
- She was working the day that Patient #21 presented to the ARC with a scheduled appointment to be evaluated and he was accompanied by two female support systems.
- She was orienting Staff G, LPC, Intake Assessor, and that Staff G had completed the assessment for the patient on her own.
- When Staff G completed the assessment, she went over it with her and did not have any questions or concerns of the assessment made by Staff G.
- Staff G had assessed the patient at moderate risk for suicide based on the responses he made during her assessment.
- The patient had been admitted to inpatient therapy by Staff H, Psychiatrist.
- Staff G informed her that Staff H consented to the patient being put on a 96-hour hold.
- She did not think that the patient was a candidate for a 96-hour hold based on information available to her at the time of the assessment and discussions she had with the patient's support system. The patient's support system refused to fill out paperwork for a 96-hour hold on the patient.
- After she had reviewed all the available information and discussed with the patient's support system, she called Staff H to ensure he had been given "clear" information from Staff G about the patient's current condition/status.
- She talked with the patient and he denied being suicidal at that time.
- She did not consider the patient leaving the ARC as a patient "elopement" because while she was on the phone with Staff H, she received an AMA order to discharge the patient.
- She did not document when she re-called Staff H or the date and time she received the AMA discharge order.
- She did not know why Staff E, Administrative Assistant, called the "security code" (a code called when a patient leaves the facility without prior discharge orders or orders from the medical doctor/psychiatrist) for when the patient left because she had AMA discharge orders for the patient and she did not consider his departure as an elopement.

During an interview on 06/14/18 at 3:36 PM, Staff E, Administrative Assistant, stated that:
- She was working on 06/10/18 when the patient eloped from the ARC.
- She could hear a loud banging noise coming between the ARC area and the Chief Executive Officer's office.
- She could not visualize what was going on but could hear the loud noise.
- There was an exit door at the end of the hallway in the ARC.
- The two female support systems of the patient were in the lobby of the ARC and she could hear them say, "He's gone, He's gone, how did he get out"?
- When she heard them say the patient was gone and how did he get out was when she called the security code over-head and per the hand-held system.
- When the House Supervisor (Staff D) and two Psychiatric Safety Technicians (PST F and PST J) arrived, she gave them a description of the patient, what he was wearing, and the direction he had gone.

During an interview on 06/18/18 at 7:48 PM, Patient #21 stated that:
- He had an appointment to be evaluated in the ARC.
- He got nervous and just left the facility when he heard staff were going to place him on a 96-hour hold.
- He did not understand why staff were going to place him on a 96-hour hold when he was voluntary.
- He stated that Staff G did his assessment, she was new, and that Staff C informed him she was calling Staff H about the 96-hour hold.
- He did not sign anything because he did not give them time to get any paperwork ready for him to sign.
- He did contact the facility later to let them know he was ok and he knew he needed help and that he did want help but he did not want to be placed on a 96-hour hold.

During an interview on 06/19/18 at 9:45 AM, Staff F, PST, stated that:
- She was working the day the patient eloped from the facility and responded to the security code.
- She was directed to go out to the parking lot to look for the patient but did not see him anywhere on the facility grounds.
- The two females that were with the patient told her that they thought the patient was going to be put on a 96-hour hold and that he told them if he did not get admitted to the facility he was going to commit suicide.
- At the end of her shift at 11:00 PM, the patient called the facility to let them know he returned home.

During an interview on 06/19/18 at 10:15 AM, Staff G, LPC, Intake Assessor, stated that:
- She did the Intake Assessment for the patient when he presented to the facility for evaluation.
- The patient was relaxed and did not show any signs or symptoms of being anxious during the assessment.
- The patient reported that he wanted to be admitted for "detox" and he was positive about being admitted.
- Staff C, LCSW, Director of Intake, called the Staff H, Psychiatrist, about the patient and to receive an order for inpatient detox.
- She later called Staff H to give him an update that the patient reported that he wanted to leave.
- She did not document the phone call with Staff H in the patient's medical record.
- She informed the patient that he could leave but there was paperwork that needed to be filled out.
- When asked, the two female support systems of the patient refused to fill out 96-hour hold paperwork (affidavits) for the patient.
- The patient did not sign the paperwork because she did not have time to get the paperwork for refusal to treat before the patient left.
- When the patient left, he did not say anything and he did not make a comment that he would not sign the paperwork.
- She gave the paperwork to Staff C to fill out.
- Staff C notified Staff H that the patient left before a refusal to treat could be presented to the patient and before the AMA discharge had been ordered by Staff H.

During a telephone interview on 06/19/18 at 1:25 PM, Staff J, PST, stated that:
- She was working the day that the patient eloped from the facility and responded to the security code.
- When she went outside she saw the two female support systems of the patient and they were "frantic" because the patient was gone and not on facility property.
- The two female support systems of the patient reported that he told them that if he did not get admitted he was going to "kill" himself.
- When the patient was told by staff that he was going to be put on a 96-hour hold, he "busted" through the door and left.
- When the patient left, Intake staff was getting an order for AMA discharge after the patient had already left the facility.
- Staff C was on the phone and when staff asked her if she called the police, Staff C "shooed" them away and informed them she was on the phone with the psychiatrist (Staff H).
- Intake (ARC) staff did not follow the facility's policy when they did not notify the local law enforcement that the patient had left the facility and did not go looking for the patient when he had left the facility.
- Based on her observations the Intake staff called the psychiatrist (Staff H) to get an AMA discharge order after the patient had already left the facility property.
- Staff C told the psychiatrist (Staff H) that the patient was sad at times and Staff G had gave Staff H a miss-representation of the patient's status related to a need for a 96-hour hold.

During a telephone interview on 06/20/18 at 11:05, Staff H, Psychiatrist, stated that:
- He received three calls from facility staff related to the patient.
- The first call was from Staff C, she reported that the patient presented and seeking detox treatment for alcohol due to heavy drinking. Staff H ordered the patient to be admitted for inpatient detox treatment for alcohol.
- The second call was from Staff G, she reported that the patient no longer wanted to be admitted as an inpatient. The patient had SI with a past attempt with hanging. The patient's support system was not comfortable with the patient leaving related to the patient's past suicide attempt. Staff G was unsure if the patient needed to be placed on a 96-hour hold and based on the information given to Staff H, he was in agreement if the patient warranted a 96-hour hold he would order the patient to be placed on a 96-hour hold for the patient's safety.
- The third call was from Staff C, and she reported that the patient's SI was chronic and not current and denied intent to commit suicide. Staff C stated that the patient did not meet criteria for a 96-hour hold and the patient's family refused to fill out 96-hour hold paperwork.
- During the third call, Staff C informed him that the patient had just "eloped" from the ARC.
- He did not give Staff C an order for AMA discharge before the patient eloped from the facility.

The facility failed to provide stabilizing treatment for the patient when he was left unattended in the hallway of the ARC/Intake with access to an exit door without a security alarm. The patient was able to breach the exit door and elope from the facility. The facility failed to provide a safe and secure environment for the patient when he was being assessed/evaluated for his psychiatric condition.