Facilities must report patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting. Excludes deaths resulting from self-inflicted injuries that were the reason for admission/presentation to the healthcare facility.

Facilities must report patient death or serious injury associated with patient elopement (disappearance), excluding events involving competent adults with decision-making capacity who leave AMA or voluntarily leave without being seen. The term “elopement” and “competent” adult should be interpreted in accordance with prevailing legal standards in applicable jurisdictions. Of note, an assessment that identifies patients at “risk” of elopement or a chief complaint and findings of risk accompanied by organizationally defined measures to be taken when risk is identified could be useful in both prevention and event analysis.

Facilities must report discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person. Release to “other than an authorized person” includes removing the patient/resident without specific notification and approval by staff, even when the person is otherwise authorized. Examples of individuals who do not have decision-making capacity include: newborns, minors, adults with Alzheimer’s. Individual healthcare organizations or other relevant jurisdictional authorities may have specific requirements for assessing decision-making capacity.