Based on observation, interview and document review, Hospital A and B failed to ensure that all Emergency Department (ED) staff received mandatory education related to the care of suicidal (plan to kill self), homicidal (plan to kill others) and psychiatric (relating to a mental illness or its treatment) patients. A clinical care partner (Hospital Clinical Care Partners and Registry Clinical Care Partners who provide constant observation of patients under the supervision of Registered Nurses-CCP) 1, was unable to verbalize current Emergency Department (ED) processes and procedures (ED memorandum - memo). The lack of implementation of mandatory education related to the ED memo to include Hospital and Registry CCP's, did not ensure that all staff were aware of measures in place in an effort to provide safe care and monitoring for suicidal, homicidal and psychiatric patients. Findings: On 4/26/16 at 1:30 P.M., an entrance conference was conducted with the Assistant Director Accreditation and Regulatory Compliance (ADARC), the Quality Compliance Specialist (QCS) 1, the Assistant Nurse Manager (AN) 2 and the ED Manager (EDM). The EDM stated, on 3/16/16, after Patient 1's incident (an attempted suicide by hanging in an ED restroom), mandatory education in an ED memo was implemented and signed by all ED staff on 3/17/16. The ED memo indicated the following: "Dear ED Staff, In order to keep your psychiatric patients and yourselves safe from harm, effective immediately, the following guidelines need to be followed with our high risk, suicidal and/or homicidal patients: As per policy, all belongings must be removed from the bedside; valuables placed in the safe. Suicidal, homicidal and patients on a 5150 (involuntary hold) need to be placed in a paper gown. Suicidal, homicidal and patients on a 5150 should not be given pants with a drawstring or gowns with long tie strings. Remove all monitor wires, oxygen tubing and any other item that can be used as a weapon from the patient room. Do not let patient out of sight... unfortunately, this means even when they use the bathroom. If there is an event with a psych patient such as legitimate attempt of self-harm or physical harm to staff...you must utilize chain of command. Notify Charge Registered Nurse (RN), Notify the on-duty Assistant Nurse manager (ANII), Notify Department Manager of Director (call any time of the night), Notify the house supervisor, Notify the Attending MD on duty." On 4/26/16 at 3:00 P.M., a tour of Hospital A's ED was conducted with QCS 1 and AN 2. CCP 1 was seated in a chair outside of the doorway which led to Patient 12 and 13's shared room, and Patient 20 in an adjacent hallway bed. On 4/26/16 at 3:30 P.M., an interview was conducted with CCP 1, QCS 1 and AN 2. CCP 1 stated that she worked for a registry (contracted employee) and that she did not receive education related to recent changes in the ED when providing care of suicidal, homicidal and psychiatric patients. In addition, she stated that she heard about an incident that occurred with a patient, who attempted suicide (Patient 1) in the ED restroom. In addition, CCP 1 stated that when staff cared for suicidal, homicidal and psychiatric patients; cords, tubing and lines remained in the patient's room environment. CCP 1 stated that CCP's and ED technicians were assigned as sitters (1:3 ratio; 1 sitter in direct line of sight of 3 patients) for suicidal, homicidal and psychiatric patients. On 4/26/16 at 4:40 P.M., an interview was conducted with the EDM, AN 2, QCS 1 and the ADARC. The EDM stated that the hospital staff CCP's and registry CCP's did not receive the mandatory ED education because they were not part of the ED staff however; the EDM, AN 2, QCS 1 and the ADARC acknowledged that CCP's were assigned to care for suicidal, homicidal and psychiatric patients in the ED and should have received the education as indicated in the memo. On 4/28/16 at 11:30 A.M., an untitled document contained a list of Hospital A and B's employed CCP's and registry CCP's. The list contained a total of 50 CCP's who did not receive the mandatory education (ED memo) related to the care of suicidal, homicidal and psychiatric patients in the ED, that was made effective 3/16/16. This failure impeded the Hospital from ensuring that all ED staff were aware of safety measures implemented in an effort to provide safe care and monitoring for suicidal, homicidal and psychiatric patients.

Based on video observation, interview, record, and document review, Hospital A failed to ensure that Emergency Department (ED) staff implemented the Bus Passes and Taxi Vouchers policy, for 1 of 46 sampled patients (1) when Patient 1, who had been discharged , returned to the Emergency Department requesting for a taxi voucher. Failure to implement this policy impeded the hospital from meeting the transportation needs of a discharged patient from the ED. Findings: Patient 1 presented to Hospital A's ED on 12/13/15 with a chief complaint of flank pain per the Emergency Department Note by Physician 2, dated 12/13/15 at 3:10 P.M. Patient 1 was discharged on [DATE] at 10:40 P.M. per the ED Patient Care Timeline, date 12/13/15. According to Physician 2's ED Note, dated 12/13/15, Patient 1's past medical history included the following: MI (myocardial infarction - heart attack), CVA (cerebrovascular accident - a sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain) with residual left sided weakness, nephrolithiasis (kidney stones) left flank pain and hematuria (blood in the urine). Per the same Note, Patient 1 had fallen several times in the last few weeks from left lower leg weakness status post CVA. On 12/16/15 at 2:45 P.M., a security camera video footage dated 12/13/15 at 11:12 P.M. was reviewed at the hospital with the Chief Nursing Officer (CNO), the Director of Security, the Director of Regulatory Affairs (DRA), Quality Compliance Specialist (QCS 1) and the Nurse Director of Emergency Services (NDES). Per the video footage, the Director of Security confirmed that the following hospital staff were present during the incident: Security Agent 1, Security Agent 2, Security Agent 3 and ED Trauma Technician (ED Tech 1). Patient 1 was observed with a cane in his right hand. Patient 1 used the cane as he ambulated out of the ED. A telephone interview was conducted with Patient 1 on 12/17/15 at 10:00 A.M. Patient 1 stated that he walked with a cane. He stated that on 12/13/15, he was discharged from the ED and walked out to the bus stop where he discovered that the bus system was closed. He stated that he returned to the ED to make a phone call to a community health group to coordinate a ride home. He stated that he made a second phone call to "medicare" and was unsuccessful. He stated that he walked up to the physician who treated him. He stated that the physician told him that they were not responsible for getting patients home and that no taxi vouchers would be given. Patient 1 alleged that he was "dragged out of the ED". He stated that out of the building, on public property, he was surrounded by 3 security agents and 1 "Caucasian" ED employee. He stated that he was grabbed in the shoulder and thrown on the ground. He stated that his cane was thrown in a trash can. Patient 1 stated that he was bleeding on his left elbow, left wrist and left hand. He stated that he did not seek medical attention for his injuries. An untimed hand-written note, dated 12/15/15, by ED Tech 1 was reviewed. The note indicated that Patient 1, who had been discharged from the ED, was allowed to use the phone in the waiting room to call for a cab. Patient 1 walked back into the ED towards the physician's area asking for a taxi home. Patient 1 was informed that "we do not provide vouchers" to patients unless criteria was met. Patient 1 was informed to leave the ED by staff. Patient 1 became verbally abusive and pushed ED Tech 1. Security assistance was activated. Per the note, a physician informed Patient 1 that vouchers were not provided and that he was discharged . Patient 1 was escorted out of the ED by security and ED Tech 1. An interview and joint document review with ED Tech 1 was conducted on 12/17/15 at 2:00 P.M. ED Tech 1 stated that he picked up a shift on 12/13/15 and was assigned as a sitter to an ED patient from 7:00 P.M. to 7:00 A.M. He confirmed that the untimed, hand-written note was his recollection of the events on 12/13/15. He recalled that Patient 1 was demanding a taxi voucher. He stated that the physician (name unknown) was not able to provide Patient 1 with a taxi voucher. An interview and joint record review with Registered Nurse (RN 1) was conducted on 12/17/15 at 2:52 P.M. RN 1 recalled caring for Patient 1, as his primary nurse, on 12/13/15 (night shift 7:00 P.M. to 7:00 A.M.) RN 1 stated that when she received the discharge orders from the physician, she generated the discharge paperwork, reviewed it with the patient and answered his questions. She stated that she performed Patient 1's discharge and followed the hospital's discharge process. She stated that she had a discussion with Patient 1 about transportation. She remembered Patient 1 telling her that he had taken the bus to the ED. She had checked the online bus schedule which indicated that no buses were running. She stated that she asked Patient 1 if he needed a taxi or if he had a friend to call. She stated that Patient 1 replied and said he could call a friend. Per RN 1, she discharged Patient 1 and assumed that his transportation needs were met. RN 1 was not aware that Patient 1 had returned to the ED requesting for a taxi voucher. A phone interview with RN 3 was conducted on 12/18/15 at 7:35 A.M. RN 3 stated that she was the charge nurse on 12/13/15, night shift (7:00 P.M. to 7:00 A.M.) RN 3 stated that if a patient required assistance getting home and was asking for a taxi voucher or a bus pass, ED staff were instructed to see the charge nurse. She explained that the ED's social worker assisted patients with transportation needs but on a weekend and after hours, the charge nurse was that resource person. She stated that if the charge nurse was unavailable then the staff were instructed to follow their chain of command. A review of the hospital's policy titled "Bus Passes and Taxi Vouchers", specific to the ED, dated 11/12/15, was conducted. The policy indicated that "The ED is able to provide transportation assistance in the form of a bus pass or taxi voucher, when warranted. Please confer with ED SW (social worker) when questions of transportation assistance occur. If an ED SW is not on duty, please confer with a the Charge RN. All transportation assistance provisions should be documented in the patient's chart." The hospital's policy titled "Chain of Command", dated 10/17/13, was reviewed. The policy defined Chain of Command as "... an authoritative structure established to resolve administrative, clinical, or other patient safety issue by allowing healthcare staff and physicians to present an issue(s) of concern through the lines of authority until resolution is reached." Per the policy, examples include but not limited to conflicts or refusal to adhere to policies and procedures, would require staff to notify their chain of command. A telephone interview was conducted with Physician 1 on 12/17/15 at 3:50 P.M. Physician 1 stated he was the attending physician for Patient 1 who (MDS) dated [DATE] at approximately 2:19 P.M., with a complaint of flank pain. Physician 1 stated he signed over care of Patient 1 at 9:00 P.M. to another attending physician and he was not aware that Patient 1 had any issues regarding transportation to home. Physician 1 stated he recalled that Patient 1 had a history of stroke, left sided weakness, a history of falls, and that he ambulated with a cane. Physician 1 stated that since the buses were not running when Patient 1 was being discharged that it would be appropriate for Patient 1 to receive a taxi voucher taking into consideration Patient 1's history of falls, use of a cane and that Patient 1 had no other means of transportation home. An interview with Physician 2 was conducted on 12/18/15 at 3:05 P.M. Physician 2 stated he was the physician who took care Patient 1 on 12/13/15 in the afternoon who presented to the ED with a complaint of flank pain and walked with a cane. Physician 2 stated that after Patient 1 was discharged , Physician 2 heard Patient 1 being verbally threatening to an emergency room technician. Physician 2 stated Patient 1 was requesting several things and that security arrived and escorted Patient 1 out of the ED. Physician 2 stated in regards to patient transportation needs that is usually arranged by the social workers or nursing staff in the emergency department and not a routine practice of the Medical Staff. An interview with the NDES was conducted on 12/18/15 at 4:00 P.M. The NDES stated that ED Tech 1 had a sitter assignment on 12/13/15, and had no business leaving the ED when Patient 1 required security escort off hospital property. The NDES stated ED Tech 1 should have notified the primary or charge nurse (his chain of command) when Patient 1 returned to the ED requesting for a taxi voucher. She stated that it was cold and raining on the night of 12/13/15, Patient 1 should have been placed in a cab. She acknowledged that hospital's policies related to chain of command and taxi vouchers were not implemented.