HospitalInspections.org

482.13 Tag A-0115

The information reviewed during the survey provided evidence the facility failed to ensure a safe environment was provided for two patients that were involuntarily committed (302). The patient admitted to St. Luke's Bethlehem Hospital-Allentown Campus had a 302 commitment for homicidal ideation with aggressive behavior and the patient at Saint Luke's Bethlehem Campus had a 302 for suicidal ideation following a suicide attempt. Not receiving care in a safe setting was evidenced by both patients eloped the facility grounds.

A discussion took place with the survey team and the facility's administrative staff (EMP1), regarding the survey team's concerns related to Patient's Rights on September 23, 2021 at 3:58 PM.


Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting

Based on review of facility policy, review of medical records, and interview with staff (EMP), it was determined the facility failed to provide each Medicare beneficiary a notice of 'An Important Message from Medicare' (IM) upon admission or before discharge for three of three medical records reviewed (MR4, MR9 and MR11).

Findings include:

Review on September 23, 2021, of facility policy "Important Message from Medicare (224)" revised June 24, 2021, revealed "... III Procedure ... A. Initial Notice-Hospital Registration will provide and review the IM with all beneficiaries enrolled in Medicare ... The initial IM will be given within two (2) calendar days of admission, and the signature of the beneficiary or representative must be obtained ... B. Follow-up notice - A follow-up notice is required and must be given to the beneficiary or representative as far in advance as possible before discharge, but no more than 2 calendar days and no less than (4) hours before the discharge is written ... The beneficiary is representative's signature should again be obtained when the follow-up notice is given ..."


Review on September 24, 2021, of MR4 revealed the patient was admitted to the facility on September 7, 2021, and is currently an inpatient receiving care. Further review of MR4 revealed no documentation that an IM was provided upon admission.


Review on September 24, 2021, of MR9 revealed the patient was admitted on September 12, 2021, and discharged on September 22, 2021. Further review of MR9 revealed no documentation that an IM was provided upon admission or prior to discharge.


Review on September 24, 2021, of MR11 revealed the patient was admitted on September 12, 2021, and discharged September 22, 2021. Further review of MR11 revealed no documentation that an IM was provided upon admission.

Interview on September 24, 2021, with EMP2 confirmed the there was no documented evidence for the IM documentation as stated above for MR4, MR9, and MR11.

Based on review of facility documents, and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure two patients that were involuntarily committed (302) were provided a safe environment, as evidenced by both patients eloping from the facility property.


Findings include:

Review on September 23, 2021, facility document "Patient Guide" revealed "Rights and Responsibilities ... Care Delivery ... Receive care in a safe setting ..."

Review on September 23, 2021, of facility document "Security Incident Report" dated September 5, 2021, revealed "This officer ... responded to an elopement from the ED (emergency room) Room 12, patient is a 302 (involuntary commitment) and pushed thru his 1:1 (continuous in person safety monitoring) and ran out the broken egress doors ... APD (Allentown Police Department) found [patient] and returned him ..."


1.Review of MR1 on September 23, 2021, of physician documentation "Progress Note," revealed "This is a 26-year-old [gender] with a history of PTSD (post traumatic stress disorder) who presents for evaluation of homicidal ideation, assaulting [gender removed] father and police officer ... patient is a danger to self and others. Will likely require a 302 ..."

Interview on September 23, 2021, at approximately 10:45 AM with EMP4 confirmed they were on duty the day the patient eloped and confirmed the patient in MR1 was ordered a 302 commitment and on a 1:1 continuous observation for homicidal ideation and aggressive behavior. Further interview confirmed the lock on the secured egress doors to the ED behavioral health area was broken and reported on August 30, 2021.


2.Review of MR2 on September 23, 2021, revealed the patient attempted suicide with a multi-drug overdose and transferred to a medical-surgical unit for treatment and stabilization. Further review revealed the patient was considered a danger to self and a 302 commitment was obtained. Further review revealed the patient was ordered and provided 1:1 continuous observation after two unsuccessful elopement attempts.


Review on September 23, 2021, of MR2 physician documenation "Progress Notes" dated September 11, 2021, revealed "Patient wants to go home. I explained to [the patient] they were under a 302 and could not go home as [they] are a danger to self ... patient states [they will come back on Monday ... Patient was pacing the hall abd opened the door to the stair [sic] and ran down. I told nursing to to contact security and I followed the patient ..."

Interview on September 24, 2021, at approximately 10:00 AM with EMP4 confirmed the patient was admitted to the unit for stabilization care after a multi-drug overdose and was on continuous 1:1 observation. EMP4 confirmed it was during the physician consultation with the patient that the patient pushed passed the physician and the 1:1 staff member and eloped thru the fire emergency door. EMP4 confirmed the physician and other staff members immediately followed the patient down the stairs and out the door, and security and police were contacted.

Interview on September 23, 2021, at approximately 12:30 PM with EMP2 confirmed at the time of the survey the disposition of the patient was unknown.

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Based on observation, facility documents and interview with staff (EMP), it was determined the facility failed to maintain a safe physical environment in the emergency department (ED) to meet the safety needs of the patient population served.

Findings include:

An observation tour conducted on September 23, 2021, at 10:45 AM of the ED behavioral health unit with EMP2 and EMP3 revealed three (3) private anti-ligature rooms. Further observation revealed the area was protected with two (2) locked security doors.

Review on September 23, 2021, facility document "Patient Guide" revealed "Rights and Responsibilities ... Care Delivery ... Receive care in a safe setting ..."

Review on September 23, 2021, of facility document "[name of manufacturer] Work Order" dated August 30, 2021, revealed "One side of delayed egress (doors), no power, not working."

Review on September 23, 2021, of facility document "Purchase Order" dated August 31, 2021, revealed parts to repair the broken security door were purchased and delivery was expected September 24, 2021.

A request was made to EMP3 on September 23, 2021, at 11:30 AM for a plan that provided a safe setting for patients in the behavioral health ED during the time the doors were inoperable. None provided.

An interview conducted on September 23, 2021, at approximately 11:30 AM with EMP3 confirmed the egress doors were not functioning properly and repair service was onsite, and parts were ordered the day the door malfunction was detected. Further interview with EMP3 confirmed there was no written back-up plan that provided security to the area until the doors were repaired.