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Based on document review and staff interview, the Mary Greeley Medical Center (MGMC) staff failed to ensure the hospital staff followed the hospital's policies when the staff failed to provide all appropriate stabilizing treatment to 1 of 21 patients (Patient #14) selected for review, who presented to the hospital for emergency care from July 2019 through January 2020, and requested emergency medical care. Failure to provide all appropriate stabilizing treatment resulted in Patient #14 eloping twice from the Emergency Department (ED), the second time jumping off a three-story building onto railroad tracks suffering severe head trauma, multiple bone fractures, and ultimately death. The hospital administrative staff identified an average of 2536 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.


Findings include:

1. Review of the hospital policy/procedure "Transfer Policy: Medical Screening Exam, Stabilization, and Treatment," reviewed 02/2019, revealed in part, " ...If an emergency medical condition exists, Mary Greeley Medical Center will stabilize and treat the emergency condition or transfer the individual appropriately ..."


2. Review of Patient #14's medical record revealed:

a. Patient #14's face sheet (a document listing the patient's demographics and insurance status) showed that "Patient has no active insurance coverage on file for 1/25/2020."

b. Patient #14 presented to Mary Greeley Medical Center's dedicated emergency department on 01/25/20 at 1:58 PM for treatment of a puncture wound. Triage Nurse A documented Patient #14 had lacerations (deep cut or tear in skin) on both sides of their neck and admitted they felt overwhelmed that morning and attempted to slit their throat. Triage Nurse A administered the Columbia Suicide Severity Rating Scale (see below) as part of their triage assessment. The Columbia Scale rated Patient #14 a moderate suicide risk. The Triage Nurse A removed Patient #14's personal belongings, had them change into paper scrubs, and moved them to room 1210 (medical room used for mental health patients).

(The Columbia Suicide Severity Rating Scale is an internationally recognized suicide risk assessment questionnaire. Questions range from "In the past month have you wished you were dead or wished or could go to sleep ad not wake up" through "Are you currently having any thoughts of killing or harming yourself?" Yes responses determine interventions, such as having a 1:1 sitter at the bedside, which will be implemented for patient safety.)

c. On 01/25/20 at 2:17 PM, Advanced Registered Nurse Practitioner (ARNP) L documented Patient #14 attempted suicide around 8:00 AM using a kitchen knife and an x-acto knife (pen-size tool with very sharp blade used for precision cutting/carving) to slit both sides of their neck. Patient #14 reported no previous history of suicide, no previous hospitalizations or mental health evaluations, and took no medications. Patient #14, a student, had a history of anxiety and became overwhelmed last semester and recently quit school. Patient #14 had little to no appetite, had isolated themselves from others, and was nervous and anxious.

d. On 01/25/20 at 2:47 PM, Nurse B documented Patient #14 had poor judgement and poor safety awareness.

e. On 01/25/20 at 2:50 PM, Nurse B documented Patient #14 was at high risk of elopement and not waiting for treatment.

f. On 01/25/20 at 2:56 PM, ARNP L completed suture repair of Patient #14's two neck lacerations and documented they used 10 sutures to close the 7 cm (2.5 inches) right neck laceration and 2 sutures to close the 1 cm (close to ½ inch) left neck laceration. Multiple other superficial lacerations did not require sutures.

ARNP L further documented "I have placed orders for mental health screening labs and have consulted with [Behavioral Health] nurse [Crisis Nurse E's name] for [a] full mental health evaluation. Patient is here voluntarily. He has agreed to inpatient admission. Our behavioral health unit will not be able to accept him this evening. [Crisis Nurse E's name] is calling around the state to find a bed. Impression: 1. Suicidal ideation 2. Neck laceration."

g. On 01/25/20 at 3:00 PM, Crisis Nurse E documented Patient #14 was anxious, depressed, fearful, hopeless, remorseful, suspicious, cooperative, fidgety, restless, and worried. Crisis Nurse E administered the Columbia Suicide Risk Assessment to Patient #14, with no change in responses from the earlier triage assessment.

h. On 01/25/20 at 3:29 PM, Crisis Nurse E documented Patient #14's initial mental health evaluation as follows: Patient #14 drove to the ED after cutting their throat with a kitchen knife and an x-acto knife with intent to kill themselves. Patient #14 thought they were dying, and when woke up, drove themselves to the ED. Patient #14 denied any previous suicide attempts, described long standing feelings of failure, they are letting everyone down, failed their classes last semester, and hinted at financial issues also being a factor. Patient #14 was agreeable to inpatient hospitalization.

i. On 01/25/20 at 3:50 PM, Nurse D documented Patient Care Technician (PCT) F informed Nurse D that Patient #14 eloped and was found by the hospital Gift Shop, approximately 150 feet away from the ED. PCT F was able to talk Patient #14 into returning to the ED, at which time, Patient #14 was moved to ED behavioral health room. (The ED staff did not place any interventions to prevent Patient #14 from eloping again).

j. On 01/25/20 at 4:17 PM, Nurse D documented Patient #14 eloped from the ED (42 minutes after the first elopement), PCT F followed to try to talk them back. The ED staff had not obtained a court order.

k. On 01/25/20 at 4:19, Crisis Nurse E documented Patient #14 asked if they could go home. Crisis Nurse E explained the need for inpatient care after months of hopeless feelings, that staff would obtain a court order if they left and the police department would return them. Crisis Nurse E called Psychiatrist B regarding admission, and Patient #14 took off running while Crisis Nurse E and the Psychiatrist B spoke on the phone. Crisis Nurse E contacted the on-call magistrate and obtained a court order for a 48-hour hold (court-ordered medical stay for mental health evaluation), then notified the local police department.

l. On 01/25/20 at 4:21 PM, Nurse D documented notifying the local police department that Patient #14 was barefoot, wearing blue paper scrubs, and heading south on Duff Avenue (a major street near the hospital).


3. Review of Patient #14's medical record from Hospital A revealed

a. On 01/25/20 at 06:55 PM, Physician A documented Patient #14 jumped from 3rd story of the Ames Power Plant, received CPR at the scene, was intubated (placing a breathing tube), and had normal heart beat after receiving epinephrine (emergency medicine). Patient #14 sustained a large avulsion (skin torn away) to the right forehead, large open wounds to both sides lower extremities. Physician A documented Patient #14 transferred to Hospital A for further trauma care and neurosurgery, which was not available at MGMC.

b. On 01/26/20 at 01:08 AM, Physician D documented that upon arrival to [Hospital A], neurosurgery evaluated Patient #14 and informed the trauma team that Patient #14 had no gag reflex or corneal (blink) reflex and that prognosis was likely poor. Physician D documented Patient #14 sustained the following major injuries: 8 cm (over 3 inches) laceration to right forehead, skull fracture with bleeding and swelling in the brain, fracture of right leg with 7 cm (approximately 2.5 inches) laceration exposing the bone, left heel fracture exposing the bone, right wrist fracture, multiple facial bone fractures. Patient #14's head CT scan revealed a suspected separation of the spinal column from the skull base.

i. Hospital A discharge summary revealed Patient #14 died on 01/26/2020 at 08:10 AM.


4. Review of video footage from Mary Greeley's cameras on 1/25/20 at 3:34 PM revealed Patient #14 walked out of the ED room. The ED staff walked behind Patient #14, but did not stop Patient #14 from leaving the ED. Patient #14 continued to walk toward the hospital's main entrance, approximately 200 feet away from Patient #14's ED room. Patient #14 walked up to the hospital's main entrance door, and stopped at the hospital's main door. Patient #14 paused and turned around. Patient #14 talked with PCT F prior to returning with PCT F to the ED. Patient #14 walked to an ED behavioral health room, and spoke with Crisis Nurse E prior to walking into the ED behavioral health room.


5. Review of video footage from Mary Greeley's cameras on 1/25/20 at 4:16 PM (42 minutes after Patient #14's initial elopement attempt) revealed Patient #14 walked out of the ED behavioral health room, pointed towards the exit to Crisis Nurse E, and then began running out of the ED. PCT F walked behind Patient #14, following the path Patient #14 ran out of the hospital. Patient #14 continued to run out of the hospital, only slowing down when Patient #14 reached the hospital's main door. Patient #14 opened the main door and ran out the front door.


6. Review of the hospital policy, "Emergency Department Environmental and Safety and Security," reviewed 03/29/18, revealed in part, "... Suicide/Elopement/Safety Precautions ... Refer to Lippincott Procedures and Skills for Mary Greeley Medical Center guideline "Suicide Precautions, Substance use, Emotional, or Behavioral Disorders in Non-[Behavioral Health] Setting...."


7. Review of Lippincott Procedures-Suicide Precautions in Non-BH Setting, Mary Greeley Medical Center, revised 10/02/19, revealed in part, "... Elopement: Refer to the Elopement Policy...."


8. During an interview on 02/05/20 at 10:05 AM, the Director of Emergency and Mobile Medical Intensive Services revealed Mary Greeley Medical Center lacked a policy directing staff on what actions to take if a patient attempted to elope from the ED.



Please refer to A-2407 for additional information.

Based on document review and staff interview, the Mary Greeley Medical Center (MGMC) staff failed to ensure 1 of 21 patients (Patient #14) selected for review, who presented to the hospital for emergency care from July 2019 through January 2020, received all appropriate stabilizing treatment. Failure to provide all appropriate stabilizing treatment resulted in Patient #14 eloping twice from the Emergency Department (ED), the second time jumping off a three-story building onto railroad tracks suffering severe head trauma, multiple bone fractures, and ultimately death. The hospital administrative staff identified an average of 2536 patients per month who presented to the hospital's dedicated emergency department and requested emergency medical care.

Findings included:

1. Observations on 1/29/20 revealed the hospital had a dedicated emergency department with 2 specialized behavioral health rooms located in the back Northwest corner of the ED. The behavioral health rooms had minimal furniture and no medical equipment in the behavioral health rooms. Both rooms had doors the staff could lock, so they could keep a patient from leaving the behavioral health room. The 2 behavioral health rooms had a small antechamber in front of the door to the 2 rooms, and a door leading to the ED. The ED staff could also lock the door from the ED to the antechamber.

Further observations on 1/29/20 revealed the hospital had a dedicated inpatient behavioral health unit. The dedicated inpatient behavioral health unit had 14 inpatient beds. The hospital had 4 dedicated "higher acuity" beds where the staff could provide closer supervision and 14 general inpatient behavioral health beds. Access to the inpatient behavioral health unit required entrance through a locked door, traversing through an approximately 8 foot long anteroom, and then passage through a second locked door. The hospital staff have camera monitoring of both doors at the nursing station and only allow entrance to the unit with hospital staff. The anteroom's design prevented both locked doors from opening simultaneously.


2. Review of Patient #14's medical record revealed:

a. Patient #14's face sheet (a document listing the patient's demographics and insurance status), under the active insurance status, revealed "Patient has no active insurance coverage on file for 1/25/2020."

b. Patient #14 presented to Mary Greeley Medical Center's dedicated emergency department on 01/25/20 at 1:58 PM for treatment of a puncture wound. Triage Nurse A documented Patient #14 had lacerations (deep cut or tear in skin) on both sides of their neck and admitted they felt overwhelmed that morning and attempted to slit their throat. Triage Nurse A administered the Columbia Suicide Severity Rating Scale (see below) as part of their triage assessment. The Columbia Scale rated Patient #14 a moderate suicide risk. The Triage Nurse A removed Patient #14's personal belongings, had them change into paper scrubs, and moved them to room 1210 (medical room used for mental health patients).

(The Columbia Suicide Severity Rating Scale is an internationally recognized suicide risk assessment questionnaire. Questions range from "In the past month have you wished you were dead or wished or could go to sleep ad not wake up" through "Are you currently having any thoughts of killing or harming yourself?" Yes responses determine interventions, such as having a 1:1 sitter at the bedside, which will be implemented for patient safety.)

c. On 01/25/20 at 2:17 PM, Advanced Registered Nurse Practitioner (ARNP) L documented Patient #14 attempted suicide around 8:00 AM using a kitchen knife and an x-acto knife (pen-size tool with very sharp blade used for precision cutting/carving) to slit both sides of their neck. Patient #14 reported no previous history of suicide, no previous hospitalizations or mental health evaluations, and took no medications. Patient #14, a student, had a history of anxiety and became overwhelmed last semester and recently quit school. Patient #14 had little to no appetite, had isolated themselves from others, and was nervous and anxious.

d. On 01/25/20 at 2:47 PM, Nurse B documented Patient #14 had poor judgement and poor safety awareness.

e. On 01/25/20 at 2:50 PM, Nurse B documented Patient #14 was at high risk of elopement and not waiting for treatment.

f. On 01/25/20 at 2:56 PM, ARNP L completed suture repair of Patient #14's two neck lacerations and documented they used 10 sutures to close the 7 cm (2.5 inches) right neck laceration and 2 sutures to close the 1 cm (close to ½ inch) left neck laceration. Multiple other superficial lacerations did not require sutures.

ARNP L further documented "I have placed orders for mental health screening labs and have consulted with [Behavioral Health] nurse [Crisis Nurse E's name] for [a] full mental health evaluation. Patient is here voluntarily. He has agreed to inpatient admission. Our behavioral health unit will not be able to accept him this evening. [Crisis Nurse E's name] is calling around the state to find a bed. Impression: 1. Suicidal ideation 2. Neck laceration."

g. On 01/25/20 at 3:00 PM, Crisis Nurse E documented Patient #14 was anxious, depressed, fearful, hopeless, remorseful, suspicious, cooperative, fidgety, restless, and worried. Crisis Nurse E administered the Columbia Suicide Risk Assessment to Patient #14, with no change in responses from the earlier triage assessment.

h. On 01/25/20 at 3:29 PM, Crisis Nurse E documented Patient #14's initial mental health evaluation as follows: Patient #14 drove to the ED after cutting their throat with a kitchen knife and an x-acto knife with intent to kill themselves. Patient #14 thought they were dying, and when woke up, drove themselves to the ED. Patient #14 denied any previous suicide attempts, described long standing feelings of failure, they are letting everyone down, failed their classes last semester, and hinted at financial issues also being a factor. Patient #14 was agreeable to inpatient hospitalization.

i. On 01/25/20 at 3:50 PM, Nurse D documented Patient Care Technician (PCT) F informed Nurse D that Patient #14 eloped and was found by the hospital Gift Shop, approximately 150 feet away from the ED. PCT F was able to talk Patient #14 into returning to the ED, at which time, Patient #14 was moved to ED behavioral health room. (The ED staff did not place any interventions to prevent Patient #14 from eloping again).

j. On 01/25/20 at 4:17 PM, Nurse D documented Patient #14 eloped from the ED (42 minutes after the first elopement), PCT F followed to try to talk them back. The ED staff had not obtained a court order.

k. On 01/25/20 at 4:19, Crisis Nurse E documented Patient #14 asked if they could go home. Crisis Nurse E explained the need for inpatient care after months of hopeless feelings, that staff would obtain a court order if they left and the police department would return them. Crisis Nurse E called Psychiatrist B regarding admission, and Patient #14 took off running while Crisis Nurse E and the Psychiatrist B spoke on the phone. Crisis Nurse E contacted the on-call magistrate and obtained a court order for a 48-hour hold (court-ordered medical stay for mental health evaluation), then notified the local police department.

l. On 01/25/20 at 4:21 PM, Nurse D documented notifying the local police department that Patient #14 was barefoot, wearing blue paper scrubs, and heading south on Duff Avenue (a major street near the hospital).

m. On 01/25/20 at 6:55 PM, Physician A documented Patient #14 jumped from third story of the Ames Power Plant, received CPR at the scene, was intubated (placing a breathing tube), and had normal heart beat after receiving epinephrine (emergency medicine). Patient #14 sustained a large avulsion (skin torn away) to the right forehead, large open wounds to both sides lower extremities. Physician A documented Patient #14 transferred to Hospital A for further trauma care and neurosurgery, which was not available at MGMC.

n. On 01/25/20 at 6:15 PM, Nurse D documented patient transferred out by Mary Greeley ambulance to Hospital A.


3. Review of Patient #14's medical record from Hospital A revealed:

a. On 01/26/20 at 9:25 AM, Physician C documented Patient #14 was originally seen at the MGMC for psychiatric care where Patient #14 eloped. During Patient #14's elopement, Patient #14 made their way to the third story of building while being chased and performed a "swan dive" down to railroad tracts at the bottom. Once at Hospital A, Patient #14 received 3 units of blood to help low blood pressures.

b. On 01/26/20 at 1:08 AM, Physician D documented that upon arrival to Hospital A, neurosurgery evaluated Patient #14 and informed the trauma team that Patient #14 had no gag reflex or corneal (blink) reflex and that prognosis was likely poor. Physician D documented Patient #14 sustained the following major injuries: 8 cm (over 3 inches) laceration to right forehead, skull fracture with bleeding and swelling in the brain, fracture of right leg with 7 cm (approximately 2.5 inches) laceration exposing the bone, left heel fracture exposing the bone, right wrist fracture, multiple facial bone fractures. Patient #14's head CT scan revealed a suspected separation of the spinal column from the skull base.

c. Hospital A discharge summary revealed Patient #14 died on 01/26/2020 at 8:10 AM.


4. Review of video footage from Mary Greeley's cameras on 1/25/20 at 3:34 PM revealed Patient #14 walked out of the ED room. The ED staff walked behind Patient #14, but did not stop Patient #14 from leaving the ED. Patient #14 continued to walk toward the hospital's main entrance, approximately 200 feet away from Patient #14's ED room. Patient #14 walked up to the hospital's main entrance door, and stopped at the hospital's main door. Patient #14 paused and turned around. Patient #14 talked with PCT F prior to returning with PCT F to the ED. Patient #14 walked to an ED behavioral health room, and spoke with Crisis Nurse E prior to walking into the ED behavioral health room.


5. Review of video footage from Mary Greeley's cameras on 1/25/20 at 4:16 PM (42 minutes after Patient #14's initial elopement attempt) revealed Patient #14 walked out of the ED behavioral health room, pointed towards the exit to Crisis Nurse E, and then began running out of the ED. PCT F walked behind Patient #14, following the path Patient #14 ran out of the hospital. Patient #14 continued to run out of the hospital, only slowing down when Patient #14 reached the hospital's main door. Patient #14 opened the main door and ran out the front door at 4:17 PM.

6. Review of the Ames Police Department report from 1/25/20 involving Patient #14 revealed the police dispatcher received the first call from a citizen regarding Patient #14 at 4:19 PM (3 minutes after Patient #14 left the hospital). Patient #14 was heading toward the city's power plant. The hospital staff notified the police dispatcher at 4:20 PM (4 minutes after Patient #14 left the hospital) that Patient #14 left the hospital. Patient #14 jumped off the third story of the power plant at 4:34 PM (18 minutes after Patient #14 left the hospital). The first responders on-scene started CPR at 4:38 PM (22 minutes after Patient #14 left the hospital).

7. Review of the hospital's inpatient behavioral health unit from 3:00 PM to 7:00 PM on 1/25/20 revealed the hospital had 4 patients in the higher acuity bed unit (out of 4 beds) and 4 patients in the general inpatient behavioral health unit (out of 14 beds, leaving 10 beds available for a patient).

8. During an interview on 2/4/20 at 11:00 AM, Registration Clerk N revealed Patient #14 was comfortable staying as an inpatient behavioral health patient at the hospital. However, Patient #14 was worried very concerned about insurance and how Patient #14 would pay for the hospitalization.

9. During an interview on 1/30/20 at 3:00 PM, Advanced Registered Nurse Practitioner O (ARNP, a nurse with advanced education allowing them to diagnose patients and prescribe medication) revealed Patient #14 was willing to voluntarily seek inpatient behavioral health care and admission to the hospital's behavioral health unit. ARNP O was sitting at the nursing station across from Patient #14's ED room when Crisis Nurse E informed ARNP O that Patient #14 made a serious suicide attempt and Patient #14 would require inpatient behavioral health care. Crisis Nurse E indicated they would discuss Patient #14's care with Psychiatrist B to determine the next step in Patient #14's care.

10. During an interview on 1/30/20 at 3:00 PM, Crisis Nurse E revealed Patient #14 engaged in a highly impulsive suicide attempt, went to sleep thinking they would die, and then denied suicidal thoughts when Patient #14 presented to the hospital's ED. After Patient #14 attempted to elope the first time, the ED staff placed Patient #14 in an ED behavioral health room, which allowed for visual observation from a window outside the room and on video monitors at the nurses' station. Patient #14 was frequently moving around the ED behavioral health room and walking into the antechamber between the ED behavioral health rooms and the main ED space. The ED staff did not place any interventions to address Patient #14's elopement attempt, such as using a 1:1 sitter or obtaining a court order to keep Patient #14 against their will at the hospital for behavioral health treatment.

While Patient #14 was in the ED behavioral health room, Crisis Nurse E spoke with Patient #14. Crisis Nurse E informed Patient #14 they had engaged in a serious suicide attempt and Patient #14 would require inpatient behavioral health care. Crisis Nurse E informed Patient #14 they did not know if Mary Greeley had an available inpatient behavioral health bed (Mary Greeley had 10 open inpatient behavioral health beds at the time). Patient #14 inquired where Crisis Nurse E would transfer Patient #14. Crisis Nurse E informed Patient #14 they would probably transfer to Waterloo or Cedar Rapids (each approximately 100 miles from Ames).

Crisis Nurse E contacted Psychiatrist B to discuss the plan of care for Patient #14. During the call, Patient #14 ran out of the ED. Crisis Nurse E hung up the phone and called the on-call magistrate to request a 48-hour court order to hold Patient #14 against their will for medical treatment at the hospital.

11. During an interview on 2/5/20 at 4:00 PM, Psychiatrist B revealed they were in the hospital on the general inpatient pediatric unit at the time Patient #14 presented and eloped from the ED. Psychiatrist B was seeing a patient in the hospital when Crisis Nurse E initially called Psychiatrist B. Psychiatrist B finished talking with the other patient and called Crisis Nurse E. Crisis Nurse E was informing Psychiatrist B about Patient #14 when Patient #14 eloped from the hospital. Psychiatrist B had not made a decision about admitting Patient #14 to the hospital's inpatient behavioral health unit or transferring Patient #14 when Patient #14 eloped the second time.

12. During an interview on 1/30/20 at 2:30 PM, PCT F revealed they saw Patient #13 eloping from the ED at approximately 3:34 PM. PCT F followed Patient #14 to the hospital's main entrance and convinced Patient #14 to return to the ED. While PCT F followed Patient #14, PCT F called Nurse B and inquired if Patient #14 had a court order requiring Patient #14 to stay at the hospital. Nurse B informed PCT F that Patient #14 was not under a court hold at that time. When PCT F escorted Patient #14 to the ED, PCT F placed Patient #14 in an ED behavioral health room. The ED staff did not place any additional interventions such as providing closer observation through a 1:1 observer or obtain a court order to keep Patient #14 in the hospital at that time.

PCT F saw Patient #14 elope again at approximately 4:16 PM. PCT F followed Patient #14 out of the hospital. PCT F contacted Nurse D to inquire if the ED staff had obtained a 48-hour court hold for Patient #14. Nurse D informed PCT F that Patient #14 was not under a 48-hour court hold. PCT F followed Patient #14 to the corner of the hospital's property.

PCT F did not follow Patient #14 further, as Patient #14 had left the hospital's property. Once a patient leaves the hospital's property, the hospital staff do not follow the patient, but instead provide a description of the patient and their direction of travel to the Ames police department, who then will try to find and return the patient.


13. During an interview on 02/04/20 at 3:30 PM, the Director of Behavioral Health revealed the ED staff relied upon the Columbia Suicide Severity Rating Scale to determine a patient's risk of committing suicide. If the patient did not answer "yes" to the question "are you currently having any thoughts of killing or harming yourself," the ED staff would not automatically order an intervention such as placing the patient on 1:1 observation, even if they answered "yes" to the other questions in the Columbia Scale. Since Patient #14 answered "no" to the question "are you currently having any thoughts of killing or harming yourself," the ED staff did not place Patient #14 on 1:1 observation, despite Patient #14's attempt to kill themselves approximately 6 hours prior to presenting to the ED or Patient #14's attempt to elope from the ED.

The Director of Behavioral Health indicated they did not know why Crisis Nurse E informed Patient #14 they would transfer to another hospital. Crisis Nurse E had not spoken with Psychiatrist B at the time Crisis Nurse E informed Patient #14 they would transfer to another hospital. Psychiatrist B would make the decision about admitting Patient #14 to Mary Greeley's inpatient behavioral health unit, not Crisis Nurse E.

14. Review of the hospital's ED logs revealed the hospital staff admitted 8 patients with suicidal ideations to the inpatient behavioral health unit during the month of January 2020.