Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to follow adopted policies related to care of the psychiatric patient for seven of nine applicable medical records reviewed. (MR1, MR4, MR6, MR7, MR13, MR14, MR15) Findings include: Review of the ED policy entitled "Care of the Psychiatric and Behavioral Patients in the Emergency Department", dated December 2013, revealed "Objective: To assure psychiatric and behavioral patients are managed in a safe and effective manner while ensuring their safety and the safety of IRMC patients and staff. Triage: 1. These patients will be triaged in the same manner as any other patient and prioritized as a 1 or 2 (active threat or actual harm) or 3 (verbal threat, stated intent of harm, or expression of any time psychiatric related aliment/complaint). 2. Patient exhibiting suicidal and/or homicidal ideation, attempted suicide and/or homicide or an intentional overdose will be placed directly in exam room 4, if available, or within staff/security's direct line of sight of the patient. 3. ED Charge Nurse will be notified. 4. Nursing triage assessment will be completed by triage nurse. Special Note: Any patient exhibiting suicidal and/or homicidal ideation, attempted suicide and/or homicide or an intentional overdose, shall be immediately placed under continuous 1:1 observation by a member of the emergency room staff, security, or other responsible party. Continuous observation may not be provided by a family member(s), police officer(s), etc. Continuous observation will be maintained unless discontinued by a written physician's order. Examination Room: 1. In addition to the routine ED nursing assessment and medication reconciliation, a Psychiatric nursing assessment will be completed by the registered (sic) Nurse (RN) and is completed regardless of level of consciousness, responsiveness, or medical condition. 2. A psychiatric packet is printed immediately after the psychiatric nursing assessment is completed. Special Note: If after the initial triage, the patient expresses symptomology that is psychiatric in nature, the Psychiatric nursing assessment will be completed by the RN and psychiatric packet will be printed. 3. Patient clothing and all belongings are removed from the room and secured at the nurses' station for any patient exhibiting suicidal and/or homicidal ideation, attempted suicide and/or homicide, or an intentional overdose and any other patient thought to be at risk to self/others. RN who does the nursing psychiatric assessment is responsible for removing clothing/belongings from the patient and recording this information in the medical record. 4. All secured belongings must be checked by security/designee, placed in the nurses' station, and findings will be recorded on the inventory sheet. 5. ED Physician must perform a medical screening and psychiatric assessment. Upon completion of psychiatric screening, the ED Physician is responsible to determine need for continuous 1:1 observation. 6. ED Physician must record all routine findings in the T-System and fully complete, score, and sign the psychiatric assessment form. Physician psychiatric assessment must be done regardless of patient level of consciousness, responsiveness, or medical condition. If the ED Physician is unable to complete the assessment, the reason (s) must be clearly documented on the assessment. 7. A comprehensive discharge bundle and written plan for follow-up treatment must be completed on all psychiatric patients being discharged . Special Note: If a 201 or 302 warrant is executed on any patient, the warrant must be thoroughly completed before the patient is transferred to any behavioral health unit. 1:1 Observation: 1. ED nursing staff will provide 1:1 until such time that additional support from security or other responsible party arrives. 2. The "Special Monitoring Log" must be removed from the psychiatric packet and given to the person responsible for the 1:1 observation. If not provided by the ED staff, the person doing the 1:1 will be responsible for obtaining the log. 3. The person responsible for the 1:1 observation is required to document patient behavior/activity on the "Special Monitoring Log" every 15 minutes starting from the time of arrival and will continue until 1:1 is discontinued or the patient leaves the ED. Gaps in documentation are not acceptable. 4. Staff member assigned 1:1 will be within directly view of the patient and at a distance which would allow for immediate response ... ." 1) Review of MR1 revealed an order by the physician to "Please d/c security @ 1700. At 1725 documentation stated "Pt sitting up in bed, taking off monitor ... Security present out side of room. Dr ... aware and okay with them coming back after releasing them ... There was no Special Monitoring Log 15 Minute Check Sheet present on the medical record. Review of MR4 revealed the patient presented with suicidal ideation. Nursing documentation in the medical record indicated that security was present, and there was no physician order to discontinue security presence. During review of the medical record, it was noted that there was no Special Monitoring Log 15 Minute Check Sheet present on the record. Review of MR6 revealed the patient presented with Depression, at approximately 20:54. During review of the medical record, a physician's order timed 21:30 was noted to state that Security not needed. There was no documentation in the medical record indicating that security was present from 20:54 to 21:30, and no Special Monitoring Log 15 Minute Check Sheet was present on the record. Review of MR7 revealed the patient presented with Overdose at approximately 0238. Documentation in the medical record revealed "Transported to ICU with Security 1:1 and leather restraints as ordered." During review of the record, it was noted that there is no Special Monitoring Log 15 Minute Check Sheet documentation between 0238 and 0500. Review of MR13, revealed the patient presented for suicide attempt at approximately 0212. During review of the medical record, there was no documentation to indicate that facility staff were called for 1:1 observation, and there is no Special Monitoring Log 15 Minute Check Sheet present on the record. It was also noted that there was no physician order to indicate that 1:1 Observation was not needed. Review of MR14, revealed the patient presented for Depression, at approximately 1616, for threatening behavior, and patient had stated that they wanted to hurt a lot of people. Nursing documentation in the medical record indicated that security was at the patient's door for safety. Nursing documentation indicated that the patient left the premises at 1728. There is no Special Monitoring Log 15 Minute Check Sheet present on the record. Review of MR15, revealed the patient presented after expressing suicidal and homicidal thoughts, at approximately 2215. Nursing documentation at that time indicated that both security and police were at the patient's bedside from 2215, until discharge 2318). There is no Special Monitoring Log 15 Minute Check Sheet present on the record.