HospitalInspections.org

Based on review and interview the facility failed to:

1. provide documentation of appropriate staffing levels for the Emergency Department(ED) concerning 2 (Patient #1 and #3) of 2 patient charts.

2. have a documented working schedule for nursing coverage in the ED on 11 (7-24,28,31,2020/ 8-13,14,25-2020/ 9-5,7,9,18-2020/10-12-20) out of 99 shifts (7-5-20 thru10-12-20).

Review of Patient #1's Emergency Department chart revealed he had an order for a sitter on 7/9/20 on the 7:00PM to 7:00AM shift. Patient #1 was suicidal and needed a sitter to perform a 1:1. (1:1 is trained medical personal to stay within arm's length of the patient at all times to ensure safety.) There were two RN's in the ED until 11:00PM and then down to 1 RN and 1 RN House Supervisor (HS) until 11:00AM the next day.

Review of Patient #1's "Patient Observation Form" dated 7/9/20 revealed the HS was sitting with Patient #1 from 8:30PM to 2:30AM and again from 4:00AM to 4:45AM. The staff RN assigned to the ED documented on the Patient Observation Form as the sitter from 2:45AM till 3:45AM and then again from 5:00AM till 5:45AM. There was no documentation on the staffing schedule that any person was the sitter. There was no documentation on the working schedule on who was working in the ED if the RN was a sitter with the patient.

Review of Patient #3's chart revealed she was brought into the ED on 9/5/20 as a suicidal patient with a plan and had attempted to cut herself with a knife. There was one HS and 2 RN's assigned to the ED until 11:00PM then it would return to 1 RN and 1 HS. A sitter justification form was found dated on 9/5/20 at 9:30PM requesting a sitter for Patient #3 but was denied by the HS. The comments stated, "no sitter available." However, the "Patient Observation Form" dated 9/5/20 revealed the ED RN was the sitter from 9:45PM until 4:15AM then the form stated "canceled." There was no documentation on the working staffing schedule that the only ED RN from 11:00PM till 4:15AM was replaced by another RN.

Review of the ED nursing staff schedule on 7/9/20 and 9/5/20, 7PM to 7AM revealed the following:
1 RN scheduled from 7:00AM to 7:00PM
1(mid-shift) RN that came in from 11:00AM to 11:00PM
1 RN from 7:00PM to 7:00AM.

There was a House Supervisor (HS) assigned to work on both shifts. The facility had 4 patient beds in the ED. Review of the nurse staff working schedule did not show that a staff member was taking out of the staffing mix to be a sitter. The only documentation on the working schedule stated, "psych pt in ER." There was no mention of a sitter.

An interview was conducted with Staff #2 and #3 on 10/13/20 in the afternoon. Staff #3 confirmed there was no mention of a sitter on the working schedule. Staff #3 and Staff #2 confirmed they have not been showing if a sitter was needed on the working staff schedule. Staff #3 stated that there was a HS and a RN in the ED that took turns watching the patient. Staff #3 reported that the HS could fill in when the RN had another patient. Staff #3 confirmed that the HS was available for back up to the ED and the medical floor staff along with other duties. Staff #3 was asked if the HS was out of the staffing mix due to sitter duties who would assist with emergencies? What is the plan? Staff #3 stated, "oh I see what you mean." Staff #3 did not have an answer. Staff #3 stated that she understood what I was asking and stated that if it was on days during the week other RN's were in the building and could help. Staff #3 stated that on weekends and nights that would not be the case and there would not be anyone else available. Staff #3 confirmed there was not a sitter pool of trained personnel to pull from but may need to be considered since the ED is working at the minimum staffing grid.

Staff #2 and #3 confirmed that the minimum staffing matrix for the ED was as follows:
1 RN scheduled from 7:00AM to 7:00PM and 7:00PM to 7:00AM
1(mid-shift) RN that came in from 11:00AM to 11:00PM and 11:00PM to 11:00AM
1 RN from 7:00PM to 7:00AM and 7:00AM to 7:00PM.
A RN House Supervisor works from 6:00AM to 6:00PM and 6:00PM to 6:00AM. The HS is responsible for the ED, medical floor, and other duties in the facility.

Review of policy and procedure "Staffing in the Emergency Department" Policy No. ED 129 stated, "House Supervisor -
Back up the Emergency Nurse in times of high census or high acuity.
Fold in and work as the ED nurse.
Attempt to fill uncovered shifts and replace staff that calls in sick.
Review the schedule for the next seven days following the staffing needs.
Make necessary adjustments to ensure the staffing is balanced amongst all shifts.
Call the administrator on call when criteria for disaster are met."

Further review of the working staffing schedule from 7/5/20 to 10/12/20 revealed there was no documentation on what nurses were assigned to work in the ED on 11 shifts.

The facility failed to protect psychiatric patients from harm by allowing the patient to leave the facility without a clear and safe discharge plan in 1 (Patient #1) of 4 (Patient #1,2,3, and 4) charts reviewed.

Review of patient #1's chart revealed he was brought to the ED via the Sheriff Department on 7/9/20 at 8:02PM for suicidal ideation and a plan. Review of the progress note from the Mental Health Authority dated 7/9/20 at 11:19PM revealed the Patient #1 was suicidal, had a plan, with a history of multiple suicide attempts.

Review of the physician notes dated 7/10/20 at 1:17AM "26 y/o male w/h/o of psyc issues/SI/prior hospitalizations presents w/worsening SI. Medically cleared and will be admitted to inpatient psyc per MHMR. Diagnosis: Suicidal Ideations." There are no beds available at this time and the patient is being held for the state hospital. Sitter was at bedside.

Review of Patient #1's chart revealed he had a sitter request in writing to the House Supervisor (HS). The chart revealed a Patient Observation Form where the patient was placed on a 1:1 observation with a sitter. (1:1 is trained medical personal to stay within arm's length of the patient at all times to ensure safety.)There was no physician order for a sitter, to place the patient on suicidal precautions, or seclusion.

Review of the Nurses Notes dated 7/10/20 at 09:00 Notes: "Pt woke up to eat breakfast patient asked me how long he would be here. I reinforced to the pt that he was on a wait list. pt stated, "Bullshit, they told me I was going to Belton" I offered the pt his breakfast, pt opened the breakfast tray, he continues to ask about when he is leaving here. Pt then states "Can you call MHMR, the lady last night told me I was leaving this morning" I told him I would review the chart and notes left by the MHMR screener. Pt pushed his breakfast away and asked if he was hungry. pt stated "yes I am hungry but I am not eating this shit, this is bullshit I am not sitting in this ER for 3-4 days waiting" I informed him I would follow up. (Fri Jul 10, 2020 09:00 01-100) Notes: is standing at bedside with me, pt is becoming slightly agitated stating "all I wanted is help, I called them to get help and no one is doing that" "I will be sitting here for days waiting on Ash, can't I go home and wait there. That lady last night did not do shit for me. Can I get a different MHMR screener?" "No reason for me to stay they are not going to help me, they never do." (Fri Jul 10, 2020 09:17) Notes: pt stating "I can leave if I want, there is no reason for me to sit here 3 or 4 days on a fucking ASH wait list. I have requested help and this is the kind of help they give me" "Great they are not gonna help me even though I asked for it, this is sad."(Jul 10. 2020 09:26) Notes: pt sitting up in bed, with his arms crossed and agitated at this point, Nurse _____ RN is at nurses station follow up on plan for the pt. (Fri Jul 10. 2020 09.29): In the last 10 minutes, patient has become very agitated because he claims that he was told something else by staff members last night. Pt says he was told he was going to a facility in Belton by the MHMR rep. When patient told he was on the ASH waitlist he became very angry and he was going to leave. "What am I supposed to do? Sit here for 3 or 4 days and do nothing in the ER. I came here for help and y 'all ain't doing nothing!" I explained to patient that he is deemed involuntary and he is under an emergency detention and that if he leaves we will call the police. Patient asked to be shown that he is involuntary and I showed him on the MHMR paperwork. Patient asked for his things, so he could leave. I brought the patient his belongings while ______ ER Physician called Caldwell PD. Patient changed and left out the door. Notes: Caldwell PD (____) here to interview and take information from us about patient. He said he will alert S.O. to also look for him. (Fri Jul 10. 2020 09.45) Notes: I called the local MHMR number at 979-567-4377 and spoke with a lady named ____, she stated she was in Grimes City and the phones were forwarded to her. I informed her that their client and our pt _____ (Patient #1) was here involuntary and he proceeded to leave AMA. I gave her the name of the case worker _______ and her ID of ____ which I got off her paperwork. _____ said she would check in to this and would call me back if she needed something. (Fri Jut 10, 2020 10:24) Notes: _____ called back from local MHMR and verbalized that he received the message that our pt _____ (Patient #1) walked out AMA, He stated that he wanted us to know that their CIT officer ________is currently out looking for him. (Fri Jul 10, 2020 10:39) Notes: I received a call from ____ again from the local MHMR, he said that his boss wanted him to call and update us. The update is that the police are currently looking for _____ (Patient #1) and if they do find him then the police were going to take him to the local MHMR office in Caldwell. He also stated that his boss said ______ (Patient #1) would not be coming back here unless they needed medical clearance. (Fri Jul 10, 2020 10.45)

There was no physician order to hold the patient for medical clearance and safety. There was no documentation that the physician went into the patient's room and assessed his agitation or change in condition. There was no warrant on the patient's chart. Review of the MHMR screening revealed that inpatient hospitalization was recommended and that the ER physician and house supervisor agreed. There was no information found on voluntary or involuntary status.

The nurse gave the patient his belongings and he was allowed to leave with no documentation from physician that he has stable, had made a safety plan, or was no longer suicidal. There was no discharge plan for safety outside of an institution. The nurse had documented that the patient left Against Medical Advice (AMA) but there was no form on the chart. There was no documentation that the physician discussed the AMA with the patient or implications of leaving AMA.

Review of the policy and procedure AMA, Discharge Against Medical Advice Policy No. 103 " Procedures- The Nurse will:
1. Notify attending physician and House Supervisor that a patient decided to leave without a physician order;
2. Return belongings and medications to patient;
3. Not facilitate patient's ability to leave, i.e. provide cab fare, unless approved by Admin on call;
4. Request that patient sign release form. If patient refuses, document on form and in nurses notes;
5. Enter report in IRIS."

Review of the policy and procedure Discharge Policy No. ED 132 "
Test patient's ambulation status prior to discharge to assess that they are at baseline. If not notify the physician. Provide the patient with written and verbal discharge instructions for illness, injury and prescriptions the patient will be expected to take post-discharge.
Provide the patient with the written instructions for referral to include name and phone number(s) for referral. Document the patient's understanding of discharge instructions through re-verbalization by the patient or family member, mode of transportation, and condition at the time of discharge.
Document the designated driver for those patients that have received narcotics or any type of sedative medication while in the ESD.

Upon nurse completion of the patient being discharged home, the nurse will:
Scan the discharge paperwork into the health record and
Enter the discharge location date, and time into Meditech. It is not always identical to the time the patient is removed from PICIS.

LWBS - as soon as the patient was identified as leaving Admits, discharges,and transfers - as soon as the patient leaves the department
HOLD -the time the patient turned to HOLD status on the bed tracking log
EXPIRED- time of death."

An interview was conducted with Staff #2 and #3 on 10/13/20 in the afternoon. Staff #2 stated, "the patient wanted to leave, and we just couldn't stop him." Staff #2 confirmed there was no documentation from the physician that the patient was assessed when agitated,that the physician had not spoken to the patient about waiting for a bed, or if the patient was no longer suicidal and could make a contract for safety while waiting for a bed at home. Staff #3 confirmed that the ED staff had let patients leave the ED while they were still suicidal, homicidal, or psychotic. Staff #3 stated that they could use restraints or even chemical restraints as needed but did not feel they had the right to force the patient to stay. Staff #3 and #2 confirmed there was no a clear process in place to hold the psychiatric patient to prevent the patient from harm while waiting for placement.

The facility failed to have a completed Emergency Department Log in 102 out of 1,489 entries.
Review of the Emergency Department (ED) Log from 7/1/20 to 10/12/20 revealed the log had incomplete data as follows:

July 2020, 31 out of 416 patient visits were missing departure date, time and disposition.
August 2020, 29 out of 429 patient visits were missing departure date, time and disposition.
September 2020, 35 out of 481 patient visits were missing departure date, time and disposition.
October 2020, 7 out of 163 patient visits were missing departure date, time and disposition.

An interview with Staff #3 was conducted on 10/13/20 in the afternoon. Staff #3 confirmed there were gaps in the ED log. Staff #3 stated that they must put the departure in two different places in the computer. Staff #3 stated it can get confusing and the ED log does not always get updated.