The patient in this case was a 26-year-old male with a past medical history of schizophrenia with audible and visual hallucinations, alcohol abuse, and use of illegal substances. He also had an extensive medical history of non-compliance. Medical records indicated that the patient was doing well by living alone in an apartment, no longer hearing voices and remaining calm and cooperative during meeting groups and psych assessments.
The patient presented to the ED via EMS following a call from the patient’s grandmother advising that the patient was hearing voices and had caused a disturbance in her house. EMS noted the patient stated he did not have any of his medication at the time.
The patient was placed in the ED psychiatric holding room and the initial assessment revealed no suicidal ideations. His behavior was appropriate but anxious. Because the patient was experiencing anxiety, the treating physician ordered Haldol and left the holding room. After the nurse administered the Haldol via IM, the patient requested water to drink. As the nurse was exiting the holding room to get a cup of water, the patient told the nurse that he had to go. He suddenly and unexpectedly ran out the door and the ED altogether. The police were contacted and given the patient’s name, clothing description, location and direction that he was running in. Three days later, the patient’s body was found floating in the river.
During the patient’s brief stay of less than one hour, he exhibited no indications of danger to himself or others. He also showed no signs indicating that a Physician’s Emergency Certificate, or PEC, was necessary. The Medical Review Panel found that at the time the treating physician met with the patient and recommended Haldol to help calm him, the patient was there entirely of his own free will. Despite a unanimous panel opinion in favor of the treating physician and facility, suit was filed with numerous allegations including global neglect of the patient’s mental health safety needs.
Patients presenting to the ED with a history of mental illness or claims from a family member that the patient is exhibiting symptoms of a diagnosed mental illness should be assessed by a physician as soon as possible. During the assessment, the physician will determine if the patient needs to be placed under a Physician’s Emergency Certificate (PEC). In order to be placed under a PEC, the patient must be suicidal, homicidal and/or violent. If the physician feels that the patient needs immediate psychiatric treatment, then the patient is considered to be a danger to himself and/or others, unwilling, gravely disabled and/or unable to seek voluntary admission.
In this claim, the patient was assessed by a physician who determined he did not meet the criteria of a PEC. The physician ordered medication that was administered to address the anxiety the patient was experiencing. Shortly after receiving the medication, the patient eloped from the emergency room.
What is an elopement? An elopement occurs when a patient leaves the premises or area without authorization and/or any necessary supervision to do so. In this case, the patient did leave the facility. However, he was not under a PEC and voluntarily decided to leave the facility without receiving further treatment. Based on the assessment by the physician, the patient was not a danger to himself or others so the plan of care was developed and implemented appropriately. An organization does not have the authority to hold a patient against his will if he is being seen on a voluntary basis.
When a patient with this type of medical history presenting with symptoms of mental illness who is not under a PEC and not a danger to himself or others elopes, what should staff members do? Staff members should follow the facility’s policy on what to do if a patient elopes, leaves without being seen or leaves against medical advice. Thorough documentation regarding the patient’s assessment, current medical condition, communication among healthcare providers and details regarding the patient’s exit is imperative.
Notifying law enforcement is appropriate if the staff truly feels that the patient may be in any type of danger after leaving the facility. If law enforcement is notified, the healthcare provider needs to provide accurate details of the current situation. It is not appropriate to make assumptions or judge patients based on medical history, especially for patients with a medical history of mental illness. A PEC is only implemented when patients truly meet the criteria and are in need of immediate psychiatric treatment. Healthcare organizations are encouraged to educate staff on PEC criteria versus voluntary admission for treatment.
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