HospitalInspections.org

Based on record review and interview, the facility failed to ensure compliance with 489.24, in that,

~ Based on record review and interview, the facility failed to ensure a correct CENTRAL LOG information for 1 of 20 patients (Patient #3).

Patient #3 eloped on 9/25/2020. The Emergency Room log reflected Patient #3 was transferred as had been recommended.
(Cross reference to Tag 2405)

~ Based on record review and interview, the facility failed to ensure MEDICAL SCREENING EXAMINATION for all patients presenting for treatment, in that,

1 of 20 psychiatric patient (Patient #2) did not have a medical screening examination (MSE) completed and documented.

Patient #2 presented on 7/25/2020 with a chief complaint of chest pain and suicidal. Blood pressure was 160/102. There was no medical screening exam.
(Cross reference to Tag 2406)


~ Based on record review and interview, the hospital failed to ensure APPROPRIATE TRANSFER, in that,

2 of 20 detained, psychiatric patients (Patient #1 and #3) were allowed to elope and did not get transferred to a higher level of care after their recommendations for inpatient psychiatric treatment care was assessed due to behavior that is imminently threatening, destructive, or disturbing to self or others.

Patient #1 eloped, police were notified, and the patient was found by the Police on 9/25/2020. The patient was taken to another emergency room after Personnel #10 told the police dispatcher not to return the patient.

Patient #2 eloped, police were notified, and the patient was not found by the Police on 9/25/2020.
(Cross reference to Tag 2409)

Based on record review and interview, the facility failed to ensure a correct central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged, in that,

the Emergency Department Log had incorrect information listed for 1 of 20 patients (Patient #3).

Findings:

The facility's "ED (Emergency Department) Log" reflected Patient #3's disposition was listed as transfer.

Patient #3's medical record reflected, "Notification of Emergency Detention 9/24/2020 16:21...

~ ED Provider Notes 4:26 PM...Chief Complaint: Drug overdose...Arrives via EMS (by emergency medical system) with Police...Thought content includes suicidal ideation...20:45 D/W (discussed with) mental health and agrees inpatient treatment and will attempt to obtain OPC (Order of Protective Custody)...

~ BH (Behavioral Health) Assessment...9/24/2020 20:10...I am trying to kill myself. If I don't get help, I won't live...Severe hopelessness...not sleeping...don't eat...suicidal behavior (admits)...I want help...Self injury (admits) on heroin...Judgement Poor...Recommendation...Inpatient level of care due to behavior that is imminently threatening, destructive, or disturbing to self or others...(signed) 20:40...potential for non-compliance will have an OPC for transfer...

~ 9/25/2020 07:52 AM RN's Mental Health Assessment...Restlessness; Agitation; Hyperactivity...uncooperative...thought process...unable to assess...judgement: limited...Oriented X 4 Cognition: Poor attention/concentration; poor safety awareness; follows commands; impulsive...08:00 Behavior: Threatening...08:11 (nurse) requested clothes removed - patient became agitated...eloped..."

During record review and interview on 9/29/2020 ending at 4:03 PM, Personnel #5 navigated the electronic medical records. Personnel #5 was informed the ED Log said he (Patient #3) was transferred. Personnel #5 confirmed he wasn't.

Based on record review and interview, the facility failed to ensure medical screening examination for all patients presenting for treatment, in that,

1 of 20 psychiatric patient (Patient #2) did not have a medical screening examination documented.


Findings:

Patient #2 had no medical screening exam (MSE) documented although the physician placed orders 10 minutes after arrival.

Patient #2's medical record reflected, "7/25/2020 04:20 Arrival Complaint: Chest pain Suicidal...Private vehicle...Vital signs: Heart Rate 107...BP (Blood Pressure) 160/102...Pain...(0-10) 9...Acute Pain...Location: Chest...Sharp...Acuity: 2...Oriented...Obeys commands...

~ ED Triage notes...04:25...Patient reports he is out of his medication which is making him suicidal. Patient reports also he has chest pain. Patient did cocaine and marijuana today and reports he drinks all day every day...

~ ED Notes (Nursing)...CSSRS (Columbia Suicide Severity Rating Scale) Suicide Ideation...wish to be dead: no...Suicidal Thoughts: No...suicidal behavior question: No...04:26 Patient roomed in ED To room A10...

04:30 orders placed: IV x 1 (intravenous catheter), ECG 12 Lead (Electrocardiogram); CBC (Complete Blood Count with) w/Differential; Comprehensive Metabolic Panel; Lipase; Protime INR; CK (Cardiac Enzymes) Acetaminophen Level; Salicylate level; Ethanol, Urine drug screen, urinalysis, W/ Reflex to Micro and cult, if indicated; B-Type Natriuretic Peptide, Troponin I, Creatine Kinase, total serum...XR (x-ray) Chest...by (Personnel #8/Physician)...

04:42 (Police) with pt. Pt is verbal and loud stating he is suicidal but does not want us to treat him. Pt does not want to leave or move from the door...05:04 Pt is standing - pacing in hall refuses to get in room

05:06 Pt is now standing in front of RM (Room) 10 in door way refuses to actually get in room...05:07 Pt at this time does not want blood drawn PD still here...05:19 orders discontinued X-ray Chest...

05:21 remove attending...05:23 registration completed...05:33 Pt walked out of Hospital...06:00 Patient discharged..."

The electronic record reflected a subsequent visit on 8/28/2020 where Patient #2 had been brought in during CPR (Cardio-pulmonary resuscitation). The 9/29/2020 printed patient demographics face sheet reflected, "Deceased."

During record review and interview on 9/29/2020 ending at 4:03 PM, Personnel #5 navigated the electronic medical records. Personnel #5 was asked for the Medical Screening Exam. Personnel #5 stated, "I don't see one documented." Personnel #5 was asked to clarify AMA (against medical advice), LWBS (Left without being seen), and Eloped. Personnel #5 stated, "LWBS would be not seen by the provider for the MSE (Medical Screening Exam), so no MSE. AMA would be MSE and possibly BHA (Behavioral Health Assessment) completed, told patient of the determination and patient refused, but signed the AMA. Eloped would be the patient had MSE, may have left before BHA, but did not sign the AMA."

During a telephone interview on 10/02/2020 at 9:34 AM, Personnel #8/Physician was asked about Patient #2 on 7/25/2020.

Personnel #8 stated, "In the ER 10, I had other patients at the time. Ordered preliminary labs based on the triage note and our protocols. Then examine later. I remember him. Whenever I go to the room, wasn't in the room. He never went in the room. I went to him. He did not want to talk to me or any of the nurses. I went to exam 2 patients. I never really got to exam him."

Personnel #8 was asked if the medical screening exam was done. Personnel #8 stated, "No. I went twice. Not in room, don't want any lab work done. Told him we could examine without labs. Still didn't want me to touch him. Only saying I don't want anything done. He wanted to talk to police. Charge nurse called the police, Police came - (patient) did not go in room with them. Wanted to be taken to jail. Police said they couldn't take him unless he did something wrong. Police went outside and I think he followed them out."

Suicidal presentation - Personnel #8 was asked about presenting with suicidal complaint. Personnel #8 stated, "He (patient) would not answer. No answer or any answer to anybody. Did not dc (discharge) him. If he was walks out, what can you do." Personnel #8 was asked if he (patient) was oriented. Personnel #8 stated, "Yes, he knew what was going on." Personnel #8 was asked if it was normal behavior. Personnel #8 stated, "No, not normal. But I can't evaluate without an examination. No family there with him to see if they can talk to him."

Personnel #8 was asked if he took this as the patient's choice. Personnel #8 stated, "No, I tried a couple of times to see him. Very busy from 2 to 4. Catch up my things. I talked to an Officer outside. About 430 in the ambulance bay. He said if we can give medicine to calm him down. I said he doesn't want it. He refuses everything, I am not going to restrain him and have one of my nurses get hurt." Personnel #8 was asked if the police APOWW'd the patient. Personnel #8 stated, "I did not sign any papers for them. He wanted to be taken to jail. The cops left."

Personnel #8 was asked if security took him out. Personnel #8 stated, "I don't think so. I was with other patients. I was not completely aware. I don't think so."

Personnel #8 was asked if he refused to treat the patient. Personnel #8 stated, "No."

The facility's August 2019. Revised "Psychiatric Emergencies in the ED" policy required, "any patient identified as needing an evaluation to determine if they are homicidal (HI), suicidal (SI), physically endangering, in extreme crisis, or if they have an altered mental status...facilitate access to psychiatric evaluation and/or bed placement...ED staff will make every effort to ensure their safety and minimize any additional risks...patients deemed an active suicide risk, the physician and charge nurse are to be notified and suicidal precautions initiated...becomes a threat to himself or others, a Code White will be initiated...ongoing assessments to consider...High elopement risk...demanding to leave/exhibiting behaviors with intent to leave...Extended hold patients (>24 hours): Patients being held in the ED awaiting disposition by psychiatry are either voluntary of have a Peace Officer Without Warrant (APOWW), Order of Protective Custody (OPC), or Texas 5150...involuntarily detained for a 72-hour psychiatric hospitalization...licensed medical provider will perform a psychiatric assessment and documentation in the EMR at shift hand off..."

Based on record review and interview, the hospital failed to ensure compliance with 42 CFR 489.24 (e)(1) and (2) Appropriate Transfer, in that,

2 of 20 detained psychiatric patients (Patient #1 and #3) were allowed to elope and did not get transferred to a higher level of care after their recommendations for inpatient psychiatric treatment care was assessed due to behavior that is imminently threatening, destructive, or disturbing to self or others.


Findings:

** Patient #1 eloped, police were notified, and the patient was found by the Police on 9/25/2020. The patient was taken to another emergency room after Personnel #10 told the police dispatcher not to return the patient.

Patient #1's medical record reflected, "9/24/2020 20:20 Notification of Emergency Detention...walking on IH 635 (Interstate Highway)...could not answer and questions...behavior was erratic...(BHA-Behavioral Health Assessment)...9/25/2020...Pt was APOWW'd (Apprehension by a Peace Officer Without Warrant) to ER (Emergency Room) by (Police) PD...Mania (admits)Hallucinations (admits)...Paranoid Ideation (admits)...Suicidal Behavior (admits)...Aggressive Behavior (admits)...Self-injurious behavior (admits)...Current Suicidal Ideation/Plan/Intent (Yes) get hit by car...Imminent Risk...Elopement risk (admits)...Violence/Aggression/Assault (admits)...Level 1: Inpatient level of care due to behavior that is imminently threatening, destructive, or disturbing to self or others...(signed) 9/25/2020 01:20..."

There was no physician re-assessment to change Patient #1's treatment recommendation from inpatient care/transfer to being about to release the patient.

Patient #1's second facility emergency room visit record reflected his 9/25/2020 ED Visit. Per physician documentation: "facility allegedly told them (police) to not take him back here, take him elsewhere - ran from police so TASER was used...refuses to answer questions...limited cooperation...presents via EMS, APOWW s/p taze (status post)...Initial Psychiatric Assessment Note...did not respond to any interview questions...Insight/Judgement: poor...Plan: Haldol 5 mg (milligrams), Ativan 2 mg and Benadryl 25 mg IM (Intramuscular) x 1 now; and (every 6 hours as needed) q6h prn...file CME for OPC and plan for inpatient stabilization...Progress Note: LMSW (Licensed Master Social Worker) 9/30/2020...admitted to the inpatient psychiatric unit..."


** Patient #3 eloped, police were notified, but the patient was not found by the Police on 9/25/2020.

Patient #3's medical record reflected, "~ Notification of Emergency Detention 9/24/2020 16:21 PM...
~ ED Provider Notes 9/24/2020 4:26 PM...Chief Complaint: Drug overdose...Arrives via EMS (Emergency Medical System) with Police...

~ BH (Behavioral Health) Assessment...9/24/2020 20:10...I am trying to kill myself. If I don't get help, I won't live...Severe hopelessness...not sleeping...don't eat...suicidal behavior (admits)...I want help...Self injury (admits) on heroin...Elopement risk (Denies)...Judgement Poor...Recommendation...Inpatient level of care due to behavior that is imminently threatening, destructive, or disturbing to self or others...(signed) 20:40...potential for non-compliance will have an OPC for transfer...

~ 9/25/2020 07:52 AM...RN's Mental Health Assessment...Restlessness; Agitation; Hyperactivity...uncooperative...thought process...unable to assess...judgement: limited...Oriented X 4 Cognition: Poor attention/concentration; poor safety awareness; follows commands; impulsive...08:00 Behavior: Threatening...08:11 (nurse) requested clothes removed - patient became agitated...08:17 eloped..."

The last observation entry on Patient #3's 1:1/line of sight documentation was at 8:15 AM.

There was no physician re-assessment to change Patient #1's treatment recommendation from inpatient care/transfer to being about to release the patient.

During record review and interview on 9/29/2020 ending at 4:03 PM, Personnel #5 navigated the electronic medical records.

Personnel #5 was asked if the physicians complete reassessment or document the agreement with the BHA (Behavioral Health Assessment). Personnel #5 indicated they should. Personnel #5 added that the BHA Assessor has a conversation with the physician. Personnel #5 was asked about suicidal/protective custody patients being allowed to leave. Personnel #5 stated, "It should not happen, but we have had employees hurt before. We don't engage with patients that refuse treatment, or refuse to enter the room for treatment."

Personnel #5 was asked about and confirmed Patient #1 - MSE (Medical Screening Exam) and BHA were completed with Recommendations for inpatient psychiatric treatment.

Personnel #5 continued, "He (Patient #1) had been combative and 4 point restraints throughout the night. No medications given. The AM nurse documented he wasn't SI or HI and at 7:15 AM released his restraints. The patient left at 7:43 AM. Police were called."Personnel #5 was asked if he had an APOWW. Personnel #5 stated, "Yes."

Personnel #5 was asked about and confirmed Patient #3 OD'd (overdosed), had 1:1 sitter, emergency detention order. MSE and BHA completed. Inpatient recommended. OPC (Order for Protective Custody) was completed.

Personnel #5 continued, "They (BHA assessors) don't submit that (OPC) until a bed is available. When the AM nurse went to assess, she asked him (Patient #3) to remove his clothes (after approximately 16 hours - 9/24 16:21 to 9/25 8:11) and he became agitated and left. Police were called."

During a telephone interview on 10/01/2020 ending at 8:58 AM, Personnel #10 was asked about the recorded phone conversation with Police Dispatcher when she called to report the patient leaving. Personnel #10 stated, "called once - when one guy left (Patient #1) and while on the phone the other guy sprinted out. Then the nurse from room 10 came and called the police again."

Personnel #10 was asked about the Police stated they spoke to you that morning after the elopement: you said nurses can't keep patients if they want to leave. Personnel #10 stated, "that is my understanding - we try to talk to them, but we can't drag on them to put them back in."

Personnel #10 was asked about saying we were not sure why he was APOWW'd (Apprehension by a Peace Officer Without Warrant) and he did not want to be here. Personnel #10 stated, "I did say that - we had just got there. I work once a week. They said he (Patient #1) was not danger to himself. I overheard them from the desk. I did not get report. There was confusion of why he had a APOWW and restraints. I heard him saying it (he did not want to be here) when running out the door."

Personnel #10 was asked about saying - He would just leave again, if they brought him back. Personnel #10 stated, "Ya, whatever I said, I said. I don't know. They (Police Department) asked me what I wanted them to do with him."


During a telephone interview on 10/01/2020 at 3:29 PM, Personnel #26 Police Officer stated there was body cam footage and audio recordings to show what has actually occurred at this hospital. Personnel #26 stated, "I don't think we found the second guy (Patient #3).


During a telephone interview on 10/02/2020 ending at 12:33 PM, Personnel #7 the physician 9/25/202 AM when 2 elopements occurred. Personnel #7 was asked if you can't determine if they are a threat, you need to keep them. Personnel #7 stated, "Yes." Personnel #7 was told the patient had been in 4 point restraints all night. Personnel #7 stated, "I took over at 06:00. I did not get that from Personnel #13 (report). I had eyes on Patient #1, I did not see Patient #3. He left before I seen him. Patient #1 was roaming about the ER saying he was wanting to go. I could tell he was answering questions for the nurses - he did not speak to me - he was moving all fours, roaming, anxious to get out. I spoke with him to go to his room - so we can take care of you and let you go. He agreed. a tech escorted him." Personnel #7 continued, "It would bide me time until I saw 10 other patients. I didn't see him a second time - I had every intention of re-evaluating the patient. He left. It was short changed."


During a body camera footage viewing and interview at on 10/02/2020 at 6:59 AM, Officer asked that is how we are trying to figure out how does someone get out of here with an APOWW. Dark Blond Haired un-named female walks in front of camera and stated, "We're not law enforcement were not enforcement officers if you read the APOWW it says they will be held by an enforcement officer. We're not an enforcement officer, we're nurses and we're not umm, we can't hold somebody against their will if they" Officer stated, "How does Parkland do that." Un-named Female stated, "I don't know. Maybe they have enforcement officers. I don't know. I don't work there. But I know we can't (inaudible) will." Un-named Female begins to walk off. Officer stated, "So if we bring an APOWW and they say they don't want to be here you all just let them go." (Believed to be un-named female) Voice stated, "If they are not suicidal or homicidal we can't hold them." Officer stated, "How do you determine that if you haven't treated them." Officer stated, "Or done an evaluation." (Believed to be un-named female) Voice stated, "Hey can you call (name of person)."


The facility's August 2019. Revised "Psychiatric Emergencies in the ED" policy required, "any patient identified as needing an evaluation to determine if they are homicidal (HI), suicidal (SI), physically endangering, in extreme crisis, or if they have an altered mental status...facilitate access to psychiatric evaluation and/or bed placement...ED staff will make every effort to ensure their safety and minimize any additional risks...patients deemed an active suicide risk, the physician and charge nurse are to be notified and suicidal precautions initiated...becomes a threat to himself or others, a Code White will be initiated...ongoing assessments to consider...High elopement risk...demanding to leave/exhibiting behaviors with intent to leave...Extended hold patients (>24 hours): Patients being held in the ED awaiting disposition by psychiatry are either voluntary of have a Peace Officer Without Warrant (APOWW), Order of Protective Custody (OPC), or Texas 5150...involuntarily detained for a 72-hour psychiatric hospitalization...licensed medical provider will perform a psychiatric assessment and documentation in the EMR at shift hand off..."