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Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1). the protection and promotion of patient rights; and 2). the hospital meets the emergency needs of patients in accordance with acceptable standards of practice.

Cross Reference:
482.13: Condition: Patient Rights
482.55: Condition: Emergency Services

Based on review of medical records (MR), review of video surveillance, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1). that the elopement protocol is implemented for a patient determined to be at high-risk for elopement, per facility policy (A0144); 2). that policies and procedures for the care of patients at risk for suicide are implemented (A0144); 3). to ensure the mechanisms in place are implemented, to keep patients safe from abuse (A0145). These failures resulted in Immediate Jeopardys (IJ), posing a serious risk of harm to the patients.

Cross Reference:
482.13(c)(2) Patient Rights: Care in Safe Setting
482.13(c)(3) Patient Rights: Patient has the right to be free from all forms of abuse or harassment

On 12/11/24 at 1:52 PM, an Immediate Jeopardy (IJ) was identified due to the facility's failure to ensure the policy and procedure was implemented for a patient determined to be at high-risk for elopement (A0144). On 12/11/24 at 2:06 PM, the IJ template was presented to the administration and a removal plan was requested. On 12/12/24 at 10:13 AM, an acceptable removal plan was received. The facility implemented the following to address the IJ: The policy related to elopement was reviewed for the protocol associated with a patient identified to be at risk for elopement. Education to all emergency department (ED) patient care staff, ED administration, and security was provided regarding the policy and their particular roles when a patient is identified to be at risk for elopement. The IJ removed on 12/12/24 at 2:49 PM after the State Survey Agency verified full implementation of the removal plan, and Condition Level non-compliance remains (A0144).

On 12/13/24 at 3:51 PM, a second IJ was identified for the facility's failure to implement mechanisms in place to keep patient's safe from abuse. On 12/13/24 at 4:30 PM, the IJ template was presented to the administration and a removal plan was requested. On 12/16/24 at 10:22 AM, an acceptable removal plan was received. The facility implemented the following to address the IJ: The policy related to abuse and suspected abuse was reviewed. Education to all ED patient care staff, ED administration, ED Psychiatric Screeners, and security was provided regarding the policy and their particular roles when a patient has been identified as a victim of abuse or suspected abuse. The IJ was removed on 12/16/24 at 2:44 PM, after the State Survey Agency verified full implementation of the removal plan, and Condition Level non-compliance remains (A0145).

On 12/16/24 at 3:05 PM, a third IJ was identified for the facility's failure to implement facility policy and ensure orders for one-to-one (1:1) monitoring and a psychiatric evaluation were implemented for a patient determined to be at moderate risk for suicide (A0144). On 12/16/24 at 3:20 PM, the IJ template was presented to the administration and a removal plan was requested. On 12/17/24 at 1:09 PM, an acceptable removal plan was received. The facility implemented the following to address the IJ: The policy related to patients determined to be at risk for suicide was reviewed. Education to all ED patient care staff, ED administration, and security was provided regarding the policy and their particular roles when a patient has been identified at risk for suicide. The IJ was removed on 12/18/24 at 11:31 AM, after the State Survey Agency verified full implementation of the removal plan, and Condition Level non-compliance remains (A0144).

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure: 1). notification to social work for emergency department (ED) patients that meet high-risk criteria (A-1103); 2). all patients seeking emergency treatment received a medical screening examination (MSE) from a qualified provider (A-1104); 3). a complete psychiatric evaluation for patients requiring a crisis Psych Emergency Services (PES) screening prior to the patient leaving the ED (A-1104); and 4). all patients discharged from the ED receive a discharge order (A-1104).

Cross Reference:

482.55(a): The services must be integrated with other parts of the hospital
482.55(a): The policies and procedures governing medical care provided in the emergency department are established by and are a continuing responsibility of the medical staff

Based on medical record review, review of video surveillance, staff interview, and review of facility documents, it was determined that the facility failed to: 1). implement interventions for patients determined to be at risk for elopement in two of 22 medical records reviewed (Patient (P)1 and P6); 2). implement policies and procedures for the care of suicidal patients in the Emergency Department (ED) in two of 22 medical records reviewed (P17 and P21).

Findings include:

Facility policy titled, "Elopement (Prevention and Response)" revised 4/24, stated, "... Strategies to Prevent Elopement: 1. Communicate to the health care team members that the patient is an elopement risk. 2. Remove outdoor clothing and other articles which would facilitate the patient's elopement and secure them out of the patient's sight ... 4. Place the patient in a room near the nursing station. 5. Place on frequent monitoring via hourly rounding and every 15-minute quick visual checks. 6. Notify Security Officers that the patient is at risk to elope so that the ED exits can be monitored ... Response to Patient Elopement Nursing Unit Staff Response/Actions: 1. Notify the operator of Code Gray/Elopement ... 3. Notify the nurse in charge and appropriate administrative personnel. 4. Search the medical area, unit, and adjacent area ... 6. Notify the [local police department] if patient is a risk of harm to self or others ... Physician Response/Action: 1. Determine if the patient has the capacity to make decisions for his/her own healthcare. 2. ... For patients who cannot make decisions or attend to their own safety, or who pose a risk to the safety of others, the response is geared to returning the patient to a safe environment as quickly as possible ... Documentation: 1. The patient progress notes must be updated by the RN [registered nurse] and the physician and should relate: a. Time/date the patient was noted to be missing b. All actions taken ... d. Police Department notification 2. The Security Department will record time of notification and all actions taken, including hospital, environmental searches and Police Department Notification ..."

1. On 12/10/24 at 11:10 AM, a review of P1's medical record (MR) revealed the following:

On 12/9/24 at 12:19 AM, P1 presented to the ED by ambulance with behavioral complaints. The triage nurse assessment at 12:27 AM indicated that P1 refused to speak with the triage nurse and refused vital signs assessment. The triage nurse documentation indicated that P1 was a high elopement risk, and the nurse documented that the following interventions were to be put into place for the elopement risk: place the patient in a room near the nurse's station; frequent hourly monitoring and every 15-minute visual checks; removal of shoes/clothing and secure belongings where the patient cannot access them; and placing the patient in a color identifiable gown. There was no documented evidence that Q 15 minute visual checks were completed, the patient was placed in a gown or that a belongings checklist was completed.

A psychiatric screening completed at 12:58 AM, indicated the patient had homicidal ideation (HI) with a plan. In an interview with Staff (S)1, the Director of Risk Management, and S3, the Chief Nursing Officer on 12/11/24 at 11:11 AM, S1 and S3 confirmed that the patient should have been placed on one-to-one observation for the HI. The medical record lacked documentation that P1 was placed on a one-to-one observation. Further review of the medical record indicated on 12/9/24 at 1:30 AM, the ED Provider Note documented that the patient absconded from the ED. At 2:22 AM, the Psychiatric Screener Note stated, "Confirmed P1 left the hospital declining treatment ... Contacted [On call psychiatrist] to provide update, left voicemail." Multiple attempts were made to interview both the Psychiatric screener and the ED provider, However, niether were available at the time of the survey. The medical record lacked documentation of attempts to locate the patient including notification to security, phone calls to patient, and notification to the local police department per facility policy.

On 12/11/24 at 10:45 AM, a review of the video surveillance, in the presence of S1, S3, and S16, the Security Supervisor, revealed the following:

On 12/9/24 at approximately 12:13 AM, P1 was brought into ED Room 7, located across the nurse's station. Staff were observed removing items such as chairs, garbage cans, and other equipment from the room as the patient was placed in the room. The ED provider entered the patient's room at 12:38 AM, and left at 12:40 AM.
At 12:57 AM, the patient exited the room, walked to the bathroom, and returned to Room 7 at 12:58 AM. It was observed that the patient was still wearing the clothes that he/she came to the ED with.
At 12:59 AM, the Psychiatric Screener entered Room 7 and left the room at 1:06 AM. At 1:07 AM, P1 exited Room 7, walked past the nurse's station and exited the ED via the ambulance doors.

Staff interviews were conducted after review of the video surveillance. Upon interview, S3 confirmed that the doors from which P1 eloped was the ambulance bay exit. S3 further stated that there is a security desk located at this exit, but it is not staffed during low volumes and confirmed it was not staffed at the time of P1's elopement. During the interview, S1 and S3 confirmed that the elopement policy was not followed to included, the lack of a one-to-one (1:1) sitter, the removal of outside clothes and changing into a hospital gown, and the lack of documentation of visual checks. S16 confirmed that the security department was not notified of a high-risk elopement patient, a code gray was not called and the local police were not notified.

On 12/12/24 at 10:39 AM, a review of P6's medical record revealed the following:

On 12/8/24 at 2:16 AM, P6 presented to the ED via ambulance with a chief complaint of alcohol ingestion. At 2:39 AM, the triage assessment identified P6 as an elopement risk. The medical record lacked documented evidence of elopement risk interventions as required per policy.

On 12/13/24 at 10:58 AM, S18, the Nursing Informaticist, confirmed that the medical record for P6 lacked evidence of elopement risk interventions. S18 verified that the medical record did not have a continuous observation order, belongings checklist, or the observation checklist.


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2). Facility policy titled, "Suicide Assessment and Prevention," last revised 1/24, stated, " ...Procedure: A. Assessment of Suicide Risk: Emergency Department... If the patient shows signs/symptoms of being a self-harm risk through a positive suicide screening using the Columbia Suicide Severity Rating Scale (C-SSRS), the nursing staff will place the constant observation by staff acting in the sitter role... Levels of Risk and Intervention using the C-SSRS... Low Suicide Risk: Initiate patient search procedures, place patient in a gown, separate patient from belongings and store in a separate area. Initiate safe room protocols or place in Psych room ... ED- Refer patient to Psychiatric Emergency Services (if medically cleared) and alert Medical units ... Moderate Suicide Risk: Initiate patient search procedures, place patient in a gown, separate patient from belongings and store in a separate area. Initiate safe room protocols or place in Psych room...Emergency Department - Refer patient to Psychiatric Emergency Services (if medically cleared) and alert Medical units...Do not leave patient unattended and place on 1:1... High Suicide Risk: Initiate patient search procedures, place patient in a gown, separate patient from belongings and store in a separate area. Initiate safe room protocols or place in Psych room ...Emergency Department - Refer patient to Psychiatric Emergency Services (if medically cleared) and alert Medical units...Do not leave unattended and placed on 1:1...D. Patient Monitoring...An increased observation level may be initiated by a registered nurse in an emergency and an order obtained by an LIP [Licensed Independent Practioner]..."

Facility policy titled, "General Nursing - Observation Levels" last revised 1/24, stated, " ...Procedure ...Constant Observation or one to one (1:1) Procedure: ...Criteria: Patients who currently present an acute risk to harm self or others will be assigned to one dedicated staff member for a 1:1 observation. Criteria for this level of observation include: Suicidal/Homicidal Ideation ...Patients exhibiting acute signs and symptoms of psychosis and are not in control of their symptoms ...Elopement precautions for confused patients without decision making capacity and who do not respond to limit setting ...Staff role and responsibility ...a. The staff member continuously assess the patient's status and documents at least every 15 minutes on the Patient Monitoring Form ..."

On 12/13/24 at 1:00 PM, a review of P21's medical records, for the ED visits 12/4/24 and 12/5/24, revealed the following:

On 12/4/24 at 1:46 AM, P21 presented to the ED requesting a psychiatric evaluation. P21 reported hearing voices telling him/her to hurt [him/her]self. P21 was triaged on 12/4/24 at 1:52 AM, by an RN, and was assessed with a C-SSRS score of zero or "no risk."

On 12/4/24 at 3:00 AM, a Crisis Evaluation was ordered for P21. The Crisis Evaluation was completed on 12/4/24 at 3:49 AM. The crisis screener completed a CSSR assessment on P21 which revealed a numerical score of 4, indicating "low risk" on the C-SSRS rating scale. The crisis screener discussed P21's evaluation with the on-call Psychiatrist on 12/4/24 at 4:06 AM, and P21 was cleared for discharge with outpatient Psychiatric follow-up.

On 12/4/24 at 5:42 AM, the ED Physician documentation stated, " ...Review of Symptoms: ...Psych: Positive for: Psychosis ...Physical Exam: ...Psychological: Positive for: Responding to Internal Stimuli, Suicidal Verbalizations (denies SI [suicidal ideation], however, stating voices are telling [him/her] to hurt [him/herself]) ..." Upon review, P21's medical record lacked evidence of suicide precautions and safety interventions in place per facility policy.

On 12/5/24 at 3:00 AM, P21 presented to the ED via ambulance with SI. P21 was triaged on 12/5/24 at 3:01 AM by an RN and was assessed with a C-SSRS score of two or "low risk."

On 12/5/24 at 3:14 AM, a physician's order was placed for a Crisis Evaluation and 1:1 continuous evaluation.

On 12/5/24 at 3:33 AM, the nursing assessment indicated that P21 had a 1:1 sitter at bedside for SI and patient safety.

During the medical record review, P21's record lacked documented evidence of 1:1 sitter observation sheet and other safety interventions, such as: patient search, safe room protocols and removal of belongings, per facility policy.

On 12/13/24 at 2:45 PM, the above findings were reviewed and confirmed with S1, the Director of Risk Management. S1 stated that safety interventions should have been implemented for P21.


49174


On 12/16/24, a review of P17's medical record revealed the following:

On 10/12/24 at 4:15 PM, P17 arrived at the facility's ED with complaints of Suicidal Ideation (SI).

On 10/12/24 at 4:19 PM, P17 was triaged and was assessed as "high risk" on the Columbia Suicide Severity Rating Scale (C-SSRS) screening.

On 10/12/24 at 4:45 PM, a physician's order was placed for P17 to be on 1:1 observation.

On 10/12/24 at 5:10 PM, the first documented observation on the "Patient Monitoring Form" was completed.

On 10/12/24 at 9:27 PM, P17's crisis PES (Psychiatric Emergency Service) screening was conducted. The Behavioral Health Intake/Inquiry Form completed by the PES screener revealed that under section, "Part C: Disposition and Status" it stated, "Admitted: yes/no. If no, why Check all box(es) that apply." The PES screener documented "No" and the applicable boxes were left blank. There was no documentation why P17 was not admitted.

On 10/13/24 at 3:00 AM, P17 was discharged from the ED with his/her condition listed as "improved."

The MR lacked documented evidence that P17 was on 1:1 observation between 4:19 PM and 5:10 PM, 51 minutes.

During an interview with S1, the Director of Management, on 12/16/24 at 12:08 PM, S1 stated, "a nurse would document in the notes section if [he/she] was with [P17]." Upon request S1 was unable to provide documented evidence that P17 was placed on 1:1 observation. S1 further stated that placing a patient on 1:1 observation is a nurse driven protocol and could be initiated without an order.

An interview with S31, the PES Coordinator, was conducted on 12/16/24 at 12:39 PM. P17's "Behavioral Health Intake/Inquiry Form" was presented to S31 who stated, "the form needs to say why [the patient wasn't admitted] and I don't know why it doesn't."

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure the implementation of the policy and protocol for the care of a patient with suspected abuse.

Findings include:

Facility policy titled, "High Risk Screening Criteria" revised 01/24, stated, "... The Case Manager, Nurse, Physician, Family or other members of the interdisciplinary healthcare team may refer a patient to the Social Work Department ... In addition, the Social Worker will review each admission by the first business day on the assigned unit for patients meeting high-risk criteria ... Special emphasis is placed on identifying children and adults 'at risk' for neglect/abuse ... The following are considered High Risk Screening Categories ... -Suspicion of abuse/neglect (ADULT AND CHILD) ..."

Facility policy titled, "Discharge Criteria for ED Patients" revised 4/24, stated, "... At any time if there is a concern about the appropriateness of discharge or the patient's safety, that patient is to be held and the physician and appropriate administrative personnel be notified ..."

Facility policy titled, "[Facility] Identification and Reporting of Abuse and Neglect" revised 8/30/23, stated, "... It is the policy of [Facility] personnel to identify and assess suspected or alleged victims of abuse using established criteria, so to arrange follow-up, care and intervention ... NJS [New Jersey Statute] 9:6-8.16 The Child Abuse and Neglect law states: ' Any physician examining or treating any child ... is empowered to take said child into protective custody when the child has suffered serious physical injury or injuries, and the most probably inference from the medical and factual information supplied upon the child by another person by other that accidental means and the person suspected of inflicting, or permitting to be inflicted, the said injury upon the child is a person into whose custody the child would be normally returned' ... "

During the review of P15's medical record the following was revealed:

P15 is a 15-year-old minor who presented to the Emergency Department (ED) by ambulance on 8/22/24 at 9:37 PM, with complaints of anxiety and feeling unsafe at home, accompanied by his/her mother.

During the triage assessment at 9:45 PM, P15 stated that he/she feels threatened in the home. A psychiatric evaluation was ordered. Staff (S)37, the psychiatric screener, obtained collateral information from the patient's mother and documented, "Mother minimized pt's [patient's] concerns." S37 documented at 10:00 PM, that P15's mother reluctantly allowed the psychiatric screener to evaluate P15 in private. S37 documented that the patient reported his/her mother is frequently verbally abusive towards the patient; in addition, it was documented that P15 admitted to the mother being physically abusive towards him/her.

P15's case was reviewed by the on-call psychiatrist and the patient was referred for outpatient services. On 8/22/24 at 11:19 PM, S37 reported the alleged physical abuse to DCPP (Division of Child Protection and Permanency) hotline per facility policy and protocol, and documentation noted that someone would respond within 24 hours. At 11:19 PM, S37 documented that P15 and P15's friends did not feel that the patient was safe to return home. S37 documented that this information was relayed to S13, the ED provider.

On 8/23/24 at 12:22 AM, S13 discharged P15 to home with his/her mother, and potential abuser, prior to being seen by DCPP and without a social work referral as per facility policy.

On 12/13/24 at 2:06 PM, during an interview, S31, the Psychiatric Evaluation Screener Coordinator, stated that the facility needed to ensure the safety of the patient. He/She stated that if DCPP could not respond right away even after call backs then the psychiatric screener should have updated the on-call psychiatrist to keep the patient until DCPP arrived and it was determined that the patient was safe to return home. S31 confirmed that the medical record lacked documentation that S37 updated the on-call psychiatrist after it was learned that DCPP might not be at the facility immediately and that the patient stated that they did not feel safe to go home.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that social work is notified of Emergency Department (ED) patients that meet high-risk criteria for a social work referral in three of 22 medical records reviewed (Patient (P)1, P5, and P14).

Findings include:

Facility policy titled, "High Risk Screening Criteria" Revised 01/24, stated, "... The Case Manager, Nurse, Physician, Family or other members of the interdisciplinary healthcare team may refer a patient to the Social Work Department ... In addition, the Social Worker will review each admission by the first business day on the assigned unit for patients meeting high-risk criteria ... Special emphasis is placed on identifying children and adults 'at risk' for neglect/abuse ... The following are considered High Risk Screening Categories ... -Suspicion of abuse/neglect (ADULT AND CHILD) -Self neglect, unable to care for self -Homeless - No Next of Kin, disoriented and/or without identity -Change in Mental Status ... -Multiple, frequent admissions -Frequent emergency room visits ..."

During the review of Patient (P)1's medical record review for visit dates: 12/6/24, 12/7/24, 12/8/24, and 12/9/24, the following was revealed:

On 12/6/24, P1 presented to the ED with a complaint of anxiety. The ED Provider evaluated the patient and noted that the patient was " ...internally preoccupied, concern for SI [suicidal ideation] ..." and a crisis evaluation was ordered. The psychiatric screener identified that P1 had not been seen at the facility's ED prior to this date, and collateral information was collected from the county psychiatric screening center which identified that the patient had been seen as an outpatient for behavioral health at another facility. P1's affect was documented as flat, with a derealization perception, tangential thought process, and abnormal thought content. The psychiatric screener, in collaboration with the psychologist, determined that P1 was at no risk for self-harm or hurting others and provided psychiatric clearance and gave P1 information for follow-up post-discharge with an outpatient mental health and addiction services center. P1 was diagnosed with generalized anxiety disorder and was discharged. The medical record did not contain documentation of a next of kin, emergency contact, or home address for the patient. The medical record lacked evidence of a social work referral for P1.

On 12/7/24, P1 presented to the ED with complaints of possible HIV (human immunodeficiency virus), bloating, and constipation. P1 was also noted to be seeking referrals for shelter due to homelessness. The ED Provider conducted a medical screening exam and noted that the exam was unremarkable. The patient was discharged with a prescription for the medication Colace (to treat constipation), referrals to two local clinics, and to follow-up with his/her primary care physician in four to six weeks for a follow-up HIV test if still concerned. The medical record did not contain documentation of a next of kin, or emergency contact for the patient. The medical record lacked evidence of resources provided to assist with homelessness and a social work referral for the patient's recent homelessness.

On 12/8/24, P1 returned to the ED by ambulance for complaints of anxiety and a panic attack. The triage nurse assessment noted that P1 had no pertinent psychiatric history. The ED Provider note stated that the patient relayed that he/she became anxious after he/she got lost as he/she was new to the area. The ED provider also noted that the patient was seen in the ED approximately 24 hours prior for vague similar complaints. The ED Provider noted that P1 declined Anxiolytic treatment and that the provider suspects a malingering component to the patient's presentation. P1 was discharged after a brief respite in the ED with information on managing anxiety. The medical record did not contain documentation of a next of kin, or emergency contact for the patient. The medical record lacked evidence of a social work referral for the patient's recent homelessness.

On 12/9/24, P1 presented to the ED by ambulance with behavioral complaints. The Triage Nurse assessment stated that P1 refused to speak with the Triage Nurse and was refusing vital signs. The Columbia Suicide Severity Rating (CSSR) and homicidal risk assessment was not completed. A psychiatric screening conducted identified the patient has homicidal ideation (HI) with a plan. The psychiatric screening also notes that P1 had a history of suicidal ideation and currently demonstrated a lack of insight regarding care and internal preoccupation and irritability. The psychiatric screener documented that P1 continued to acute psychiatric dangerousness and P1's case was referred to a local facility for evaluation for inpatient services. The medical record did not contain documentation of a next of kin, or emergency contact for the patient. The medical record lacked evidence of a social work referral for the patient's recent homelessness and change in mental status.

During a review of P5's medical record, it was revealed the patient presented to the ED on 12/6/24 and twice on 12/8/24. The ED Provider identified P5 as being homeless on each presentation to the ED. The medical records lacked evidence of a social work referral for the patient's homelessness.

A review of P14's medical record revealed that on 8/22/24 at 1:42 PM, P14 presented to the facility ED for complaints of SI. The ED Triage Nurse indicated in the Nursing Assessments/Treatments note that P14 was homeless. P14 was discharged on 8/22/24 at 2:21 PM with a referral for community resources. The medical record lacked evidence of a referral to social work due to P14's homelessness.

On 12/11/24 at 10:10 AM, during a tour of the facility's ED, S2, Nurse Manager of the ED, S3, Chief Nursing Officer, and S12, Chief Medical Officer, were asked about the diagnosis of malingering and how the ED providers come to that particular diagnosis. S12 explained that malingering is a diagnosis of exclusion, not one of presumption. S12 stated that there is a large population of homeless, many with behavioral health issues, in the area that come to ED often for medical complaints and sometimes seek respite from the extremes of the environment. S12 stated that this population that returns frequently are known as high utilizers and states that they are monitored. S12 noted that the ED clinician should assess risk and err on the side of caution treating each visit as individual and unique, but there is some "clinician fatigue" with the high utilizers. S2 stated that he/she will work with registration to identify the high utilizers when they come to the facility ED to determine if they have a medical complaint or not. S2 stated that registration would notify him/her if a high utilizer comes to the ED and then S2 would ask the patients if there was a medical concern, and if not she would "send them on their way."

On 12/13/24 at 10:00 AM, the ED high utilizer list was provided for review. The high utilizer list is a list of patients with multiple admissions/presentations to ED that is monitored by the facility. This list is reviewed and discussed in the monthly utilization review meetings. Specific patient cases are discussed at meetings on how the facility can assist the high utilizers better in the community. On 12/16/24 at 11:05 AM, S12 stated that the facility used to have a "Transitions of Care" program that would monitor and track the high utilizers when they came to the facility and in the ED. The facility paused the program and the responsibilities were integrated into the roles of the social worker and the behavioral health crisis management team. S12 confirmed that even though the responsibilities are integrated into other departments, the other departments were not specifically made aware of the specific responsibilities after the Transitions of Care program was paused.

On 12/13/24 at 2:36 PM, during an interview with S38, Director of Case Management, it was stated that there is a social worker assigned to the ED Monday through Friday from 7:30 AM to 5:30 PM. S38 stated that after hours and on weekends, a social worker is on call for the unit's needs. S38 stated that social work only sees a patient if they receive a consult from the provider in the ED. When questioned concerning the ED high utilizer patients and if he/she monitored and tracked these cases, S38 stated that he/she would only know those patients if the social worker was consulted. S38 stated that social work does not keep files on the high utilizers and therefore does not monitor or track the patients.



49174

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1). all patients seeking emergency treatment received a medical screening examination (MSE) from a qualified provider in two of 22 medical records reviewed (Patient (P) 2 and P13); 2). a complete psychiatric evaluation for patients requiring a crisis Psych Emergency Services (PES) screening prior to the patient leaving the Emergency Department (ED) one of 22 medical records reviewed (P17); 3). all patients discharged from the ED receive a discharge order in six of 22 medical records (Patient (P)2, P3, P7, P16, P19, P21); and 4). interventions in place to prevent a patient from eloping from the facility in one of 22 medical records reviewed (P1).

Findings include:

1). Facility policy titled, "Emergency Medical Treatment and Active Labor Act" last revised January 2024, states, " ...Procedure ...3. Medical Screening Examination (MSE) A. ...staff will provide all patients with a Medical Screening Examination. This examination shall be performed by a physician or other practitioner (e.g., Nurse Practitioner, Physician's Assistant) deemed qualified to perform such examination pursuant to state law and the acute care hospitals Rules and Regulations ... C. Staff will ensure that the Medical Screening Examination is performed in accordance with the patient's identified needs and with the acute care hospital's capabilities ...D. All mental health patients will first receive a medical examination to sufficiently rule out organic, toxic, or traumatic causes for the observed condition, and if necessary, receive stabilizing treatment. Upon completion of the medical examination, the mental health patient will receive a mental health assessment. Data may be gathered by non-physicians (crisis workers) but the finale [sic] evaluation will be performed by the Emergency Department physician in consultation with the on-call Psychiatrist. ..."

Facility policy titled, "Patient Refusing Treatment or Leaving Against Medical Advice" last revised January 2024, states, "Policy: A competent patient has the right to refuse treatment, including the right to leave the hospital against medical advice (AMA) at any time, for any reason..."

On 12/11/24 at 11:25 AM, a review of P2's medical records for ED visits from 12/7/24 to 12/9/24 revealed the following:

On 12/7/24 at 12:10 AM, P2 presented to the ED with a chief complaint of foot pain. The medical record indicated that P2 was seen by a provider on 12/7/24 at 1:59 AM. P2's medical record lacked evidence of an MSE, or a provider note. This finding was confirmed with Staff (S)18, the Nursing Informaticist, on 12/13/24 at 10:44 AM.

On 12/7/24 at 9:29 AM, P2 returned to the ED with a chief complaint of "tongue/feet problems." The triage nurse documented that P2 reported "mouth blisters" with no other medical complaints. The provider note dated 12/7/24 at 9:50 AM stated that P2 presented to the ED with a history of malingering behavior requesting respite. The physical exam in this note stated, "ENT: Positive for Normal ENT inspection, Moist Mucous Membranes...Extremity: Normal ROM [Range of Motion], Capillary refill < 2 seconds." This MSE did not address P2 initial presenting chief complaint of foot problem.

On 12/9/24 at 2:30 AM, P2 presented to the ED via ambulance. The triage note by the nurse stated that P2 complained of chronic foot pain secondary to being homeless. The provider note from 12/9/24 at 2:41 AM stated P2 presented to the ED for nonspecific complaint of "feeling tired." The clinical impression documented by the provider was listed as: fatigue, weakness, homeless, malingering. This MSE did not address P2's initial presenting chief complaint of foot pain.

On 12/13/24 at 12:30 PM, the above findings were reviewed and confirmed with S1, the Director of Risk Management.

On 12/13/24 at 1:00 PM, the medical record of P13 was reviewed. On 7/19/24 at 8:59 AM, P13 arrived at the ED via ambulance with a chief complaint of "odd behavior." The triage note completed at 9:12 AM, stated that P13 was not taking his/her Psychiatric (Psych) medications for the past six months and has not been sleeping well. The triage note also stated that P13 denied suicidal or homicidal ideation (SI/HI) and he/she was in a nearby ED the day prior and was diagnosed with a urinary tract infection (UTI).

On 7/19/24 at 9:22 AM, an ED provider ordered a PES (Psychiatric Emergency Services) Crisis Evaluation for P13. The ED Provider Note completed by a Physician's Assistant (PA), indicated that outside ED visit records were "not available/not reviewed." The provider note also contained a reassessment timed for 9:20 AM which stated, "Crisis c/s [consult], aware of patient but understaffed - warned assessment may take a while." An updated documentation by the PA at 11:00 AM stated, "Patient requesting d/c [discharge]. Discussed with ER attending physician, patient AOx3 [alert and oriented to person, place, and time], denying SI/HI/hallucinations and has outpt [outpatient] psychiatric care. Patient seen and cleared yesterday at [facility name]. Due to these reasons, attending physician comfortable with AMA [against medical advice]. All risks/benefits of care dsicussed [sic] with the patient, verbalized understanding. Patient signed AMA paperwork."

On 7/19/24 at 11:04 AM, P13 signed out AMA without clearance from the PES Screeners. P13 was notified of the risks of leaving AMA by the PA and P13 and the PA signed the AMA paperwork.

On 12/16/24 at 2:50 PM, during an interview with S24, Crisis Intervention Specialist, and S25, the Crisis Intervention Specialist, both S24 and S25 confirmed that once a patient has a referral to the crisis screeners, the patient cannot sign out AMA. Both S24 and S25 confirmed that a patient needs to be cleared by the Psychiatrist before signing out AMA.

On 12/16/24 at 2:57 PM, during an interview with S20, the Physician's Assistant, it was stated that the decision to allow the patient to leave AMA would be patient specific and would require a thorough evaluation and a consultation with the attending physician. S20 further stated that if a patient meets the criteria for a crisis evaluation, they likely do not have the capacity to sign out AMA.

On 12/16/24 at 3:00 PM, an interview was conducted with S33, a Registered Nurse (RN). S33 indicated that if a patient was pending a crisis evaluation, he/she cannot leave AMA, they have to wait for clearance from Psychiatry. This was confirmed by S21, an RN, on 12/16/24 at 3:06 PM and S36, the ED Physician on 12/18/24 at 10:46 AM.


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2). Facility policy titled, "Suicide Assessment and Prevention" last revised 1/24, states, "... A full suicide assessment will be completed by a Licensed Independent Practitioner (LIP-MD/DO, PA, APN) or Psych Emergency Services (PES). If the assessment is performed by PES [Psychiatric Emergency Services], the results will be communicated to the LIP. The assessment completed by the LIP or PES will determine the level of risk and interventions and monitoring necessary to maintain patient safety. PES and the Psychiatrist will determine disposition and referrals as indicated."

On 12/16/24, a review of P17's medical record revealed the following:

On 10/12/24 at 4:15 PM, P17 arrived at the facility's ED with complaints of Suicidal Ideation (SI). At 4:19 PM, P17 was triaged and scored "high risk" on the Columbia Suicide Severity Rating Scale (C-SSRS) screening. The triage nurse documented interventions to be implemented for a high risk suicidal patient. Interventions included a patient search, placing the patient in a room near the nurse's station, initiating the safe room protocols, not leaving the patient unattended, and placing the patient on 1:1 observation. The medical record lacked documentation that these interventions were put into place per facility policy.

On 10/12/24 at 9:15 PM, P17 was medically cleared for a crisis evaluation by the ED physician.

On 10/12/24 at 9:27 PM, P17's crisis PES screening was conducted. The Behavioral Health Intake/Inquiry Form completed by the PES (Psychiatric Emergency Service) screener revealed that under section, "Part C: Disposition and Status" it stated, "Admitted: yes/no. If no, why Check all box(es) that apply." The PES screener documented "No" and the applicable boxes were left blank. The medical record lacked the documented reason why the patient was not admitted.

On 10/12/24 at 11:23 PM, the ED Physician Documentation note stated, "crisis called to inform me that the patient will be discharged by [psychiatrist] with diagnosis of MDD (Major Depressive Disorder)."

On 10/13/24 at 3:00 AM, P17 was discharged from the ED with his/her condition listed as "improved."

On 12/16/24 at 12:39 PM, during an interview with S31, the PES Coordinator, P17's "Behavioral Health Intake/Inquiry Form" was presented to S31 who stated the form, "needs to say why [the patient wasn't admitted] and I don't know why it doesn't."

3). A review of the Medical Staff Rules and Regulations approved by the Board of Directors on June 23, 2022, states, " ...11. Patient Discharge: A. Patients shall be discharged only on written or telephone order of the attending practitioner. The attending practitioner shall make every effort to discharge the patient as soon as possible within the dictates of reasonably proper care and treatment of the patient. Should a patient leave the hospital against the advice of the attending practitioner, or without proper discharge, a notation of the incident shall be made on the patient's medical record and, where possible, the patient shall sign a release. ..."

On 12/11/24 at 11:25 AM, a review of medical records revealed the following:

On 12/7/24 at 12:10 AM, P2 presented to the ED with a chief complaint of foot pain. P2 was discharged on 12/7/24 at 6:16 AM. This medical record lacked evidence of a discharge order from an ED provider.

On 12/13/24 at 10:44 AM, S18, the Nursing Informaticist, confirmed P2's medical record from 12/7/24 at 12:10 AM did not have a discharge order.

On 12/6/24 at 2:43 PM, P3 presented to the ED with a chief complaint of "ETOH" (alcohol). P3 was discharged home on 12/7/24 at 4:32 AM. The medical record lacked evidence of a discharge order from an ED provider.

On 12/13/24 at 10:54 AM, S18 confirmed P3's medical record from 12/7/24 at 2:43 PM did not have a discharge order.

On 12/8/24 at 5:56 AM, P7 presented to the ED with a chief complaint of "anxiety." P7 was discharged home on 12/8/24 at 12:24 PM. The medical record lacked evidence of a discharge order from an ED provider.

On 12/13/24 at 11:04 AM, S18 confirmed P7's medical record from 12/8/24 at 5:56 AM did not have a discharge order.

On 10/12/24 at 3:52 AM, P16 presented to the ED with a chief complaint of "anxiety." P16 was discharged home on 10/12/24 at 6:25 AM. The medical record lacked evidence of a discharge order from an ED provider.

On 11/24/24 at 1:24 AM, P19 presented to the ED with a chief complaint of "abd pain" (abdominal pain). P19 was discharged home on 11/24/24 at 6:00 AM. The medical record lacked evidence of a discharge order from an ED provider.

On 11/20/24 at 7:54 PM, P21 presented to the ED with a chief complaint of a headache. P21 was discharged home on 11/20/24 11:10 PM. The medical record lacked evidence of a discharge order from an ED provider.

On 12/5/24 at 3:00 AM, P21 presented to the ED with a chief complaint of "SI per EMT" (suicidal ideations per emergency medical technicians). P21 was discharged home on 12/5/24 at 7:01 AM. The medical record lacked evidence of a discharge order from an ED provider.

On 12/13/24 at 11:04 AM, S18 explained that the ED has a patient tracker with a status column. According to S18, the ED provider can change the patient status to ready for discharge, but he/she explained that this is not a discharge order. S18 reported that the nurse still needs to obtain a discharge order and instructions from a provider before a patient is to be discharged.

On 12/13/24 at 12:30 PM, the above findings were reviewed and confirmed with S1, Director of Risk Management.

4). Facility policy, titled, "Elopement (Prevention and Response)", revised 04/2024, states, " ... Strategies to Prevent Elopement: 1. Communicate to the Health Care Team Members that the patient is a high elopement risk. 2. Remove outdoor clothing and other articles which would facilitate the patient's elopement and secure them out of the patient's sight ... 6. Notify security officers that the patient is at risk to elope so that the ED exits can be monitored. 7. Use bed exit alarm if available; if the patient exits the bed while unattended, the staff will be alerted ... 12. When possible, the patient will be informed of the staff's concern about possible elopement, and the fact that special precautions to provide for his/her safety are being implemented ... Documentation: 1. The patient progress notes must be update by the RN and the physician and should relate: a. Time/Date the patient was noted to be missing. b. All actions taken. c. Family/guardian notification d. Police Department notification 2. The Security Department will record the time of notification and all actions taken, including hospital, environmental searches, and Police Department notification ..."

On 12/9/24 at 12:19 AM, P1 presented to the ED by ambulance with behavioral complaints. The Triage nurse assessment at 12:27 AM indicated that P1 refused to speak with the triage nurse and refused vital signs assessment. The triage nurse was unable to complete the Columbia Suicide Severity Rating (CSSR) and homicidal risk assessment. The triage nurse identified P1 as a high elopement risk, and documented interventions to be implemented for a high elopement risk patient. Interventions included placing the patient in a room near the nurse's station; frequent hourly monitoring and every 15-minute visual checks; removal of shoes/clothing and secure belongings where the patient cannot access them; and placing the patient in a color identifiable gown. The medical record lacked documentation that these interventions were put into place per facility policy. A psychiatric screening completed at 12:58 AM identified the patient with homicidal ideation (HI) with a plan. In an interview with Staff (S)1, Director of Risk Management, and S3, Chief Nursing Officer on 12/11/24 at 11:11 AM, S1 and S3 confirmed that the patient should have been placed on one-to-one observation for the HI. The medical record lacked documentation that P1 was placed on a one-to-one observation. An ED Provider Note at 1:30 AM indicated that the patient absconded from the ED. The Psychiatric Screener Note at 2:22 AM stated that it was confirmed P1 left the hospital declining treatment. The medical record lacked documentation of attempts to locate the patient including notification to security, phone calls to patient, and notification to the local police department per facility policy.