Based on medical record review, document review and interview, the facility did not ensure the care provided to Patient #1 in the Emergency Department (ED) was in accordance with facility policy related to patient assessment, physician notification and implementation of de-escalation techniques. Findings include: Review of policy " Emergency Department Standards of Care, " last revised 10/2018 indicates that the triage nurse responsibilities include assessing patients, assigning the appropriate triage level and documenting the triage assessment including vital signs, medication history, allergies and risk of harm to self or others. Any abnormalities identified during the assessment/reassessment should be communicated to the ED provider. Review of policy " Restraint and Seclusion- Patient Care Services, " last revised 11/2017 indicates restraints can by initiated by an RN following a thorough assessment to ensure the immediate physical safety of the patient and staff members. Prior to placing a patient in restraints, alternatives such as communication and de-escalation techniques should be considered and attempted. Behavioral management restraints are utilized to protect the patient from harming himself and others from violent and/or self-destructive behavior. Review of the medical record for Patient #1 dated 02/23/19 revealed triage was completed at 02:05 PM. The triage assessment is incomplete and does not include vital signs, home medications, allergies and risk assessment of harm to self or others. There is also no documentation to indicate that Patient #1 was refusing assessment during the initial triage or that the ED physician was notified that Patient #1 was attempting self harm by inducing vomiting. At 02:37 PM, Patient #1 was sent to the ED waiting room, accompanied by security officers despite the presence of self-harming behavior, which included sticking her fingers down her throat to induce vomiting, banging her head on the wall and stating she wanted to kill herself. Police were called and Patient #1 was restrained (by security). At 02:50 PM, Patient #1 left the ED with paramedics for evaluation at a hospital with a Comprehensive Psychiatric Emergency Program (CPEP). Review of the Emergency Medical Services patient care record dated 02/23/19 revealed upon arrival at the facility, the police, hospital security and ambulance crew were attempting to physically restrain Patient #1. Facility staff did not make any attempt to assist in the care of Patient #1. Interview on 06/13/19 at 10:40 AM with Staff (H), ED Medical Director & Physician revealed he was notified by staff that Patient #1 was in the ED waiting room, causing a disturbance and stating she wanted to hurt herself. When he arrived at the ED waiting room, Patient #1 was handcuffed and in police custody. Interview on 06/14/19 at 11:25 AM with Staff (R), ED RN, revealed Patient #1 was brought in by EMS and triaged. Patient #1 had nausea/vomiting and was making herself vomit. Patient #1 seemed ok, but she was upset. The main bay (ED) was full so Patient #1 was put in the waiting room (ED).

Based on medical record review, policy review and interview, Emergency Department staff did not ensure the assisted living facility (ALF) that the patient resided at was notified of the patient discharge for 3 of 6 patient visits (Patient #1, 25 and 26). Findings include: Review of policy ED-05, Emergency Department Standards of Care last revised 05/2017 under Discharge/Transfer revealed that appropriate hand-off communication should be provided to the next facility. Review of policy #CSC0098, Guidelines for the Discharge of the Patient and Discharge Plan last approved 05/02/17 revealed that Care Management responsibilities include arranging for transportation if applicable and completing hand-off communication with the facility the patient is being discharged to. Interview on 11/06/18 at 09:30 AM with Staff (C) and Staff (K), ED Nursing revealed that if a patient presents to the ED from an ALF, the ALF is notified prior to the patient's discharge. Review of Patient #1 ED record dated 06/03/18 revealed no documentation to indicate the ALF was contacted regarding the patient's visit and subsequent discharge. Review of Patient #25 ED record dated 06/14/18 revealed no documentation to indicate the ALF was contacted regarding the patient's visit and subsequent discharge. Review of Patient #26 ED record dated 08/04/18 revealed no documentation to indicate the ALF was contacted regarding the patient's visit and subsequent discharge. Interview with Staff (A), Patient Safety and (C), ED Nursing on 11/06/18 at 02:30 PM verified the above findings.