HospitalInspections.org

Based on observation/tour, medical record reviews, video surveillance interview, Incident Reports review, EMS (emergency medical services) report review, Emergency Department Log review, police investigation report review, policies and procedures review, and interviews, it was determined that the facility failed to ensure that an individual with presenting signs and symptoms of psychiatric complaints received an appropriate medical screening examination within the capabilities of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (P#2) of six sampled patients emergency department medical records reviewed.


Cross refer to A-2406 as it relates to the facility's failure to provide an appropriate Medical Screening Examination for P#2, when he presented to the ED with psychiatric complaints.

Based on medical record reviews, video surveillance, Incident Reports, EMS (emergency medical services) report, Emergency Department Log, police investigation report, observations, policies and procedures, and interviews, it was determined that the facility failed to ensure that an individual with presenting signs and symptoms of psychiatric complaints received an appropriate medical screening examination within the capabilities of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for one (P#2) out of six sampled patients emergency department medical records reviewed.


Findings:

The facility's Emergency Department Log, revealed that Patient #2 arrived at the hospital's emergency department on 08/13/2022 at 2:24 P.M. The patient's "Chief Complaint" was listed as "depressed, mental strain." Patient #2's disposition stated "LWBS (left without being seen) before triage". The Discharge disposition was listed as "Home or Self Care, and Hospital discharge Destination was listed as "Home."

A review of P#2's medical record revealed that P#2, a 52 year old male presented to the Emergency Department (ED) and was registered as a patient on 8/13/22 at 2:47 p.m. with a chief complaint (primary reason for patient seeking medical care) of depressed, mental strain. Further review revealed that P#2 was called for the first time by a triage nurse at 4:41 p.m., then again at 4:51 p.m., and then the final triage call was at 5:05 p.m., with no response from P#2. Continued review revealed that at 9:17 p.m. P#2's ED disposition (final destination) was set to LWBS (left without being seen) before triage.

A review of the facility's "Video Surveillance" revealed the following:

1. The video titled "High Tower (HT) Discharge Dock"

On 8/13/22 at 2:37:26 p.m.: P#2 appeared to be walking behind the High Tower (HT) building away from the discharge dock.

2. The video titled "HT South Walkway"

On 8/13/22 at 2:38:54 p.m.: P#2 appeared to be walking behind a group of trees on the walkway towards the hospital.

3. The video titled "HT Main Entrance"

On 8/13/22 at 2:39:16 p.m.: P#2 is appeared to be walking in front of the High Tower lobby doors.

At 2:39:33 p.m.: P#2 is waking into the lobby doors.

At 2:39:38 p.m.: P#2 is observed talking with black man and appears to be getting directions.

At 2:40:06 p.m.: P#2 appears to be wandering lost.

At 2:40:21 p.m.: P#2 is observed talking with a black male and white female and appears to be getting directions.

At 2:40:28 p.m.: P#2 is observed walking in the direction that the male and female were pointing. P#2 walked out of view.

4. The video titled "HT OP Waiting Room"

On 8/13/22 at 2:40:48 p.m.: P#2 appears to be walking through the outpatient waiting room in the direction of the Emergency Department (ED).

At 2:41:06 p.m.: P#2 turns left and walks out of view.

At 2:42:22 p.m.: P#2 walks back into view and continues walking in the direction of the ED.

5. The video titled "ER Registration"

On 8/13/22 at 2:47:08 p.m.: P#2 appears at the registration window speaking to the female registration coordinator.

At 2:49:09 p.m.: Observed registration coordinator placing white registration arm band on P#2's left wrist.

At 2:49:46 p.m.: P#2 walks away from registration window in the direction of the waiting area.

At 2:53:35 p.m.: P#2 walks past the registration windows and sits in a chair to the right of the waiting area.

At 2:54:23 p.m.: P#2 stands up from his chair and walks past the registration windows.

6. The video titled "ER Main Lobby"

On 8/13/22 at 2:46:17 p.m.: A nurse in purple scrubs opens door from the ED. P#2 walks out and nurse in purple scrubs points P#2 in the direction of the registration windows.

At 2:46:25 p.m.: P#2 walks over to the triage desk.

At 2:46:33 p.m.: Male registration coordinator walks out of registration booth and points P#2 in the direction of the registration windows.

At 2:47:07 p.m.: P#2 walks over to registration window.

At 2:49:47 p.m.: P#2 walks away from registration window in the direction of the waiting area and stands next to the ED entrance doors.

At 2:50:21 p.m.: P#2 walks up to registration window.

At 2:53:17 p.m.: P#2 turns around and walks away from the registration window towards the ED entrance doors.

At 2:53:28 p.m.: P#2 turns and walks in the direction of the smaller waiting area and sits in a chair.

At 2:54:24 p.m.: P#2 gets up from his chair and walks in the direction of the ED entrance doors and stops. He stands at the door for a few seconds.

At 2:55:10 p.m.: P#2 walks from the ED entrance doors in the direction of the larger waiting area. He walks past the chairs and out of view.

At 2:55:38 p.m.: P#2 walks back into view. He walks past the chairs in the larger waiting area.

At 2:55:55 p.m.: P#2 walks slowly and stands in front of the vacant triage desk.

At 2:56:59 p.m.: P#2 paces and fidgets with an object in his hands in front of vacant triage desk.

At 2:57:22 p.m.: P#2 turns around and faces the entrance doors to the ED.

At 2:58:15 p.m.: Nurse walks to triage desk. P#2 walks over to nurse. The nurse and P#2 have a brief verbal exchange and she turns and walks away through a door behind the triage desk.

At 2:58:31 p.m.: Registration coordinator walks out of the registration booth towards the triage desk where P#2 is standing.

At 2:58:47 p.m.: Registration coordinator and P#2 have brief verbal exchange and points in the direction of the smaller waiting area. Registration coordinator walks back into the registration booth. P#2 walks over to the smaller waiting area.

At 2:59:04 p.m.: P#2 wanders around in smaller waiting area. Out of view, behind white pillar most of the time.

At 3:02:28 p.m.: P#2 walks over to the larger waiting area, past the chairs and then out of view.

At 3:04:48 p.m.: P#2 walks in view and walks past larger waiting area. He the walks past the triage desk, and the registration booth.

At 3:05:06 p.m.: P#2 walks out of the ED through the automatic sliding doors.

7. The video titled "ER Main Entrance"

On 8/13/22 at 3:04:36 p.m.: P#2 walks out of the ED's automatic sliding doors and turns to his left. He leans against a pillar then turns around and puts his right hand on top of his head.

At 3:05:01 p.m.: P#2 walks to the other side of the ED doors and sits in a chair. He takes his backpack off his left shoulder and places it on his lap. P#2 proceeds to begin looking through his backpack.

At 3:07:37 p.m.: P#2 stands up from his chair and walks to his right and sat on the ground next to a black bench.

At 3:08:40 p.m.: P#2 begins to pull items from his bag and places them on the ground next to him.

At 3:13:04 p.m.: P#2 begins to put the items back into his backpack as he remains sitting on the ground.

At 3:15:57 p.m.: P#2 stands up from the ground, puts his backpack on his left shoulder and walks down the walkway away from the ED.

8. The video titled "OP Drive Thru"

On 8/13/22 at 4:00:04 p.m.: P#2 appears in view walking down the walkway with an object in his hands and his duffle bag on his right shoulder. He continues walking to the end of the walkway and through the trees until he is out of view.

9. The video title "Smoking Hut OP"

On 8/13/22 at 4:00:45 p.m.: P#2 appears to walking down the walkway, he walks over to a sprinkler between two rocks and uses his left hand as cup to scoop water from the sprinkler 4-5 times.

At 4:01:20 p.m.: P#2 walks away from the sprinkler and continues down the walkway among the trees and out of view.

A review of the EMS narrative dated 8/13/22 at 5:59 p.m. revealed the following: Patient (#2) had been cut down from tree prior to our arrival lividity (discoloration of skin due to pooling of blood after death) was noted. Obvious defiguration to neck. Cut mark from what appeared to be rope across neck. Approx 3-4 CM (centimeters) lac (laceration) down left forearm. Jagged lac in left palm. Pupils fixed and dilated (black center of eyes are larger than normal). Paracord (parachute cord) on tree approx. 6 ft (feet) from ground. Hospital band with patient's information on his left wrist. EMS advised to place pads (defibrillation pads) on the patient and see if he has a cardiac rhythm (electrical activity of the heart) and asystole (cardiac standstill when all electrical activity has stopped) was noted.

The facility's "Incident Reports dated within 03/1/22 and 08/22/22 was reviewed. The Incident Report revealed that an incident dated 8/13/22, File ID 33402, from the department lobby was reported. Continued review of the brief factual description of the incident revealed patient (#2) left ED before being triaged and was found on hospital property deceased.

A review of the city Police Department Detective's (VPDD) Report, Case # 2208130142, dated 8/13/22, completed by City Police Detective PDD (NN) revealed that PDD NN arrived to the facility on 8/13/22 in reference to P#2 hanging from a tree. Continued review revealed that PDD NN spoke with SO FF who informed him of the details after he arrived on scene. Further review revealed that PDD NN observed a deep ligature mark on P#2's neck consistent with hanging and he had what appeared to be a self-inflicted cut to his wrist near his hospital band. The paracord (a nylon rope originally used for the suspension lines of parachutes) was wrapped around a tree branch just above where P#2 was laying. A bag belonging to P#2 was next to the tree. It appears that he used the bag to stand on while wrapping the cord around the branch, and then stepped off the bag to tighten the cord around his neck. Continued review revealed that PDD NN concluded his investigation stating that it is his opinion and the opinion of the Coroner that P#2 hung himself and this case should be best classified as suicide.

An observational/tour of the facility's environment outside of the Heart Tower building on 8/29/22 at 5:00 p.m. with the Accreditation Manager and the Director of Quality revealed the tree that Patient (P) #2 used to commit suicide by hanging himself from the tree is located next to the Heart Tower building, approximate three minute walk from the Emergency Department. Continued tour/ observation revealed this area did not have video surveillance.


A review of the "Emergency Medical Treatment and Patient Transfer Policy (EMTALA)" policy, Policy #2.002, effective June 1991, last revised December 2021 revealed A. Medical Screening Examination. "1. An appropriate medical screening examination to determine whether an Emergency Medical Condition exists will be provided, within the Capabilities of the Dedicated Emergency Departments, to the following individual: an individual who presents to a Dedicated Emergency Department, on the campus, or other areas or structures that are located within 250 yards of the campus and request examination or treatment for a medical condition or has such a request made on his or her behalf. 3. A Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether an Emergency Medical Condition does nor does not exist ... 4. An individual presenting to a Dedicated Emergency Department with a request for examination or treatment for a medical condition will receive an MSE appropriate given their presentation, complaints, and symptoms to determine whether an Emergency Medical Condition exists .... B. Emergency Medical Condition. 1. The purpose of the Medical Screening Examination is to determine if an individual is experiencing an Emergency Medical Condition".


A review of the "Suicide Prevention" policy, Policy #2.009, effective May 1986, last revised October 2020 revealed the purpose is to provide guidelines on minimizing the risk of suicide or homicidal ideations by a patient, including pediatric patients, while under medical management in the non-psychiatric setting. Policy. A. all patients aged 4 years old or greater presenting to the Emergency Department (ED) or Direct admissions, who are being evaluated or treated for behavioral health conditions as their primary reason for care or shows signs/symptoms of inflicting self-harm, are screened for suicidal ideation using the "Columbia-Suicide Severity Rating Scale (C-SSRS). Procedure. A. Screening Criteria. 1. Utilize the "Columbia-Suicide Severity Rating Scale (C-SSRS)." 2. Utilize additional assessment tools to identify patients with behaviors, mental status, or conditions that may indicate a risk of imminent suicide: a. positive suicide screening, b. high risk factors such as medical/psychosocial concerns, intoxication with alcohol or drugs, chronic pain, or terminal illness. Any life changing event, acute trauma, PTSD, a tattoo of a semi-colon, previous suicide attempt, environmental stressor, c. emotional state, d. possible abuse/neglect, e. homicidal ideations. 3. Incorporate suicide screening and assessment criteria as a part of ED and admitted patients assessment tools reassessment evaluation, plans of care and hand-off tools as a part of the risk assessment.


A review of the "Patient Acuity Guidelines" policy, Policy #ECU 43, effective May 1994, last revised 3/29/19, revealed all patients presenting to a SGHS Emergency Department should be seen by an Emergency Department provider (e.g. Medical Doctor, Doctor of Osteopathic Medicine, Physician's Assistant, Advanced Practice Nurse Practitioner) as soon as possible. 1. Triage Assessment. All patients presenting to the ED should have a routine triage assessment performed including a primary and focused secondary assessment. All patients should be triaged upon arrival (goal is within fifteen (15) minutes).


A review of the "Emergency Department Assessment and Documentation Standards" policy, Policy #ECU 52, effective June 2020, no revision date, revealed each patient presenting to the Emergency Department will be assessed and monitored to determine an appropriate plan of care and response to treatment. These assessments will be documented in Electronic Healthcare Record (EHR). Procedure. I. Assessment of Patient. 1. All patients presenting to the Emergency Department should have a Medical Screening Exam. 2. The nursing staff will gather baseline data needed in order to plan, implement, and evaluate the care needed for patients. 6. The triage assessment will include, but not limited to Triage 1: arrival info; arrival documentation; chief complaint; suicide risk screening.


A telephone interview was conducted with Security Officer (SO) FF on 8/30/22 at 4:40 p.m. SO FF stated that he has worked as a security officer at the facility, acting in a law enforcement capacity, as a deputy sheriff with the (Name of County) County Sheriff Department for three and half years. SO FF continued to explain that on the day P#2 was found, he had been patrolling (keep watch over an area) the facility parking lot and had patrolled the specific area where P#2 was found, approximately 20 minutes earlier than when he was discovered. He continued to explain that when he pulled under the awning in front of the building, a white male and a white female were frantically waving their arms to get his attention and waved him over to come in their direction. He continued to say as he pulled up to the male and female, the female was crying and stated, "there is somebody hanging from the tree and I have kids in the car so we don't want to get any closer." SO FF continued to explain that the female motioned that the body was hanging from a tree near the Heart Tower building. He continued to say that he drove his car to the Heart Tower, which is located next to the ED, and could see a white male hanging from a tree.

SO FF continued to explain that as soon as he arrived on the scene where P#2 was hanging from the tree, he could see the cord, that resembled a parachute cord, wrapped around his neck and tied to the tree. He continued to say that P#2's feet were barely touching the ground and his black bag was positioned under his feet, which appeared to be what P#2 stood on. SO FF continued to say that in an effort to render aid he took his pocket knife to cut the cord, drop P#2 down to the ground, and checked for a pulse. SO FF stated although P#2 did not have a pulse, he began chest compressions (applying pressure to the chest in order to help blood flow through the heart in an emergency situation) until the paramedics (a person trained to give emergency medical care to the injured or ill) arrived. He continued to say that he noticed P#2's neck which appeared to be broken. SO FF continued to say that when the paramedics arrived they stated that "there is some morbidity (illness) in the back of his neck, which is an indicator the patient is past any help." SO FF continued to say that the paramedics wanted to confirm life or death and they hooked P#2 to their monitor and the paramedic stated, "there is no sign of life" and then the paramedic declared P#2 dead." SO FF stated the paramedics were able to identify P#2 because he still had his white hospital bracelet on his wrist. SO FF continued to say that the city Police Department (VPD1) arrived on the scene after the paramedics declared P#2 deceased. He continued to say that he remained on the scene with the paramedics and VPD1 until the crime scene was cleared.


A telephone interview was conducted with Registered Nurse (RN) EE on 8/31/22 at 11:30 a.m. RN EE stated that he has worked at the facility since 2020 as a Triage Nurse/Coordinator. He confirmed that he could not recall P#2 or his visit to the ED on 8/13/22. RN EE continued to explain that the responsibilities as a Triage Coordinator (TC) is to manage the lobby and keep the patient flow moving from registration, to triage coordinator, to the triage nurse. He continued to say that as the TC it's his responsibility to ask the patient additional questions related to their medical history as well as the reason for their visit. He continued to explain that during this process the TC will ask a series of questions related to suicidal and homicidal ideations and tendencies, as well as depression and psychiatric evaluations. RN EE stated if the patient answers yes to any of these questions they immediately move up in acuity and seen next by the triage nurse.


The facility failed to ensure that their own policy and procedure was followed as evidenced by failing to ensure that patient #2's request for an evaluation for his psychiatric medical condition ("Depressed and Mental Strain) as stated on the hospital's ED Log received an appropriate medical screening examination given his presentation of psychiatric complaints, and symptoms to determine whether or not an emergency medical condition existed on 8/13/2022.