HospitalInspections.org

Based on observations, clinical record review, interview, and review of hospital policy for one of ten patients reviewed for risk of self-harm, the hospital failed to provide a safe environment when one patient (#1) who was being admitted on a physician emergency certificate (PEC), eloped from the Emergency Department (ED). The finding includes:

Patient (P) #1 arrived by ambulance to the ED on 11/24/20 at 2:37 PM under a police emergency examination request (PEER), for anxiety after taking prescribed psychoactive medications. Review of a Columbia Suicide Severity Rating Scale (Screening) dated 11/24/20 at 2:58 PM identified that P#1 had no suicidal ideation. Review of physician's order dated 11/24/20 at 3:16 PM directed to place P#1 on constant observation.

Provider documentation dated 11/24/20 at 3:34 PM identified the patient had a history of polysubstance abuse and was recently treated at a detoxification facility. The patient identified that he/she was prescribed Klonopin and Vistaril which caused him/her to be anxious.

Review of the patient's ED record dated 11/24/20 from 3:30 PM to 7:30 PM identified that P#1 remained quiet and calm while on constant observation with full visual contact. The record indicated from 8:00 PM to 8:15 PM, P#1 remained on constant observation with documented periods of agitation and restlessness. The record identified that at 8:19 PM, P#1 requested pain medication and a physician's order directed to administer Ibuprofen 800 milligrams (mg) and to obtain a psychiatric consultation. The ED record for the period of 8:30 PM to 9:00 PM identified that the patient was medicated with ibuprofen and was seen by psychiatry.

A psychiatry consultation completed at 9:30 PM identified that Medical Doctor (MD) #2 evaluated P#1 was at a moderately elevated level of risk to harm self. The plan of care was immediate care and treatment and P#1 would benefit from inpatient hospitalization for stabilization, medication initiation and diagnostic clarification. A physician's order was placed to administer Zyprexa 5 mg.

Review of a nurse's note dated 11/24/20 at 9:55 PM identified that the patient was to be admitted to the inpatient psychiatric unit and a Covid -19 swab was obtained. The note identified that P#1 appeared to be extremely fidgety and anxious, remained on constant observation for safety, and received Zyprexa 5 mg as ordered.

Review of the patient's clinical record dated 11/24/20 at 10:15 PM identified that the patient remained on constant observation and was calm and quiet.

Documentation by MD#1 indicated at 11:24 PM P#1, while under constant observation, P#1 got up off the stretcher and began running toward the emergency exit door in the West section of the ED. The note identified that staff was running after him/her but were unable to catch up to P#1 before he/she jumped over the wall of the parking garage. The note identified that Emergency Medical Services (EMS), already onsite in the parking lot, responded to the scene and P#1 was transferred to Hospital #2, a level 1 trauma center, at 10:53 PM.

Interview with Nurse's Aide (NA) #1 on 12/11/20 at 3:10 PM identified that on the evening of 11/24/20 she was assigned to provide constant observation to P#1. NA#1 identified that P#1 was calm, quiet and cooperative throughout the evening until, approximately, 10:30 PM when he/she sat up and got off the bed and began to walk. NA#1 stated that she immediately approached P#1 who had started walking down the hall. NA #1 alerted staff for assistance, as P#1 was not responding to redirection and kept walking. NA #1 stated that while she and staff were trying to redirect P#1 back to his/her bed, the patient suddenly bolted and ran toward the exit door that lead out to the ambulance parking area.

Interview with the Emergency Department Nursing Manager on 11/25/20 at 11:00 AM identified that on 11/24/20 when P#1 got up from his/her bed, NA #1 immediately approached P#1 and attempted to redirect however the P#1 continued to walk away from NA#1. NA #1 alerted other staff who came to assist and attempted to redirect the patient however P#1 suddenly ran down the corridor and exited out the West emergency exit door that leads to the ambulance lot. Although staff was in pursuit they were unable to reach the patient before he/she exited and ran about 200 feet across the lot, and jumped over a 4 foot guardrail before falling 16 feet. Staff immediately ran down to the lower level while alerting EMS who was onsite at the time.

During an onsite visit on 11/25/20 at 10:00 AM, the surveyor was provided a tour of the area where the patient was cared for and the path that the patient took to the door that he/she exited from the ED. The exit was observed with signage that identified the door was equipped with a 15 second delay before opening however, upon attempt to open the door, the door opened allowing immediate exit.

Hospital staff who responded during the event, acknowledged that the exit door did not delay opening on 11/24/20 when P#1 exited.

The hospital failed to ensure that security measures were in place to provide a safe environment.

Interview with the Director of Security on 11/25/20 at 1:40 PM identified that the door was equipped with the 15 second time delay as a measure of security and should not have opened immediately. The Director identified that the security door was previously disabled since March 2020, to accommodate an additional area to triage patients during the pandemic. The Director of Security indicated once the temporary triage area was removed the door should have been restored with the 15 second delay as a measure of security. It was identified that the 15 second delay device was not functioning at the time of the incident on 11/24/20. Subsequent to surveyor identification on 11/25/20 the time delay device on the door was reconnected on 11/25/20 at 2:00 PM.

Based on observation, facility documentation review, and staff interviews, the facility failed to ensure an egress door alarm was functional. The findings include:

Patient (P) #1 arrived by ambulance to the ED on 11/24/20 at 2:37 PM under a police emergency examination request (PEER), for anxiety after taking prescribed psychoactive medications. Review of physician's order dated 11/24/20 at 3:16 PM directed to place P#1 on constant observation. Provider documentation dated 11/24/20 at 3:34 PM identified the patient had a history of polysubstance abuse and was recently treated at a detoxification facility. The patient identified that he/she was prescribed Klonopin and Vistaril which caused him/her to be anxious.

A psychiatry consultation completed at 9:30 PM identified that Medical Doctor (MD) #2 evaluated P#1 was at a moderately elevated level of risk to harm self. Documentation by MD #1 indicated on 11/24/20 at 11:24 PM P#1, while under constant observation, P#1 got up off the stretcher and began running, exiting via the emergency exit door in the West section of the ED, leading to the ambulance parking area. While in pursuit by ED staff and security P#1 continued through the parking lot and proceeded to jump over the wall of the parking garage, landing 16 feet on the lower level of the garage.

During an onsite visit on 11/25/20 at 10:00 AM, the Nurse Consultant was provided a tour of the area where the patient was cared for and the path that the patient took to the door that he/she exited from the ED. The exit was observed with signage that identified the door was equipped with a 15 second delay before opening however, upon attempt to open the door, the door opened, allowing immediate exit.

Hospital staff who responded during the event, acknowledged that the exit door did not delay opening on 11/24/20 when P#1 exited.

Interview with the Director of Security on 11/25/20 at 1:40 PM identified that the door was equipped with the 15 second time delay as a measure of security and should not have opened immediately. The Director identified that the security door was previously disabled in March 2020, to accommodate an additional tented area to triage patients during the pandemic. The Director of Security indicated once the temporary triage area was removed the door should have been restored with the 15 second delay as a measure of security. Subsequent to the Nurse Consultant identification on 11/25/20 the time delay device on the door was reconnected on 11/25/20 at 2:00 PM.

On 12/08/20 at 9:30 AM, and throughout the day, Building and Fire Safety Surveyor was provided with documentation that the delayed egress device was deactivated by a hospital employee on 03/31/20 and nonfunctional at the time of the event.

According to electronic mail correspondence dated 03/31/20 it was stated that the delayed egress device was installed as part of the ED Lockdown protocol. Additional documentation identified on 07/30/20 two facility employees noted on their security rounds that the emergency exit delayed egress bar was not active. The tented area of the ED parking lot was still set up to function as a temporary triage area during the pandemic. Notification that the delay egress device was not functional was provided to all involved departments and a work order was generated however the egress device on the door was not repaired, replaced, and reactivated when the temporary trauma area was no longer needed. The temporary triage area was dismantled in October 2020.

Hospital protocol identifies responsible departments should act upon these types of notifications and in this case, protocol was not followed to address the egress device malfunction.