HospitalInspections.org

Based on document review and interview the facility failed to follow it's established policy for treatment of patients who present with mental health issues from 3 (#14, #23, #30) of 30 patients and failed to have a process to meet the triage needs of 2 (#2 and #3) of 30 patients presenting with mental health issues who did not safely stay in the Emergency Department lobby waiting to receive a medical screening.


This deficient practice had the likelihood to effect all patients of the community.


Findings included.


On 2/4/2020 at 1:00 PM medical records were reviewed in the conference room. During this medical record review the following patients were identified as Left Without Being Seen (LWBS): #14, #23, and #30.

Patient #14 arrived in the Emergency department. The medical record listed mode of arrival as (walk-in, taxi, bus, foot). A single form was identified, with the following information. A hand written patient name, no signature. Address of written patient name, with telephone number. A date, no time.

Below the pre-printed sentence, "What brings you to the ER (Sic) today", Chief Complaint: suicidal thoughts. Date of birth was complete, social security number was complete. Primary care physician was completed. The preferred pharmacy was completed and the location of the pharmacy was complete.

No other current information was entered for this patient. The time electronically credited to this patient as, "time of arrival", was 1910. Hand written on a blank form titled "Emergency Department Physician H&P", was 19:20 "Not in lobby" and entry initialed BW. The next sentence was timed 19:50 "Left without triage", and the initial BW.

A review of the Emergency department discharge inquiry report identified 2 patients who left without being seen (LWBS)
pt # #23 arrived in the Emergency Department 12/3/2019 at 17:11 and was not found in the lobby at 17:41. This patient's diagnosis was alcohol toxicity.

Patient #30 arrived in the Emergency Department on 12/2/2020 at 18:52, with situational anxiety. She was not found in the lobby at 22:00.

The following patients were permitted to leave against medical advice, (AMA). Patient #2, and #3)

Patient #2 was brought to the ED by police officers. Pt #2 was observed "walking a dog down the highway, without the dog". Pt #2 was dragging a dog leash. This patient was unable to give any identifying information other than his first name. He was allowed to walk out of the ED. Documentation was identified as follows: 12/24/2019 "pt attempting to walk out of ER, asked pt if he needed anything. Pt states, "I just want to go.." Pt does not speak very clearly, unable to understand clearly. reported to *** House supervisor". Left AMA.

Patient #3 was identified on the "ED Discharge Inquiry Report. 12/28/2019 19:59 arrival time. "Suicidal", Left AMA 12/28/2019 at 22:25.

A review of the Policy "Safe care of suicidal Patient",

I. "Patients who require medical clearance prior to transfer to an appropriate treatment facility will be placed in a safe setting. The primary focus of this policy is to assure that the suicidal patient does not engage in actions that will cause self-harm.

III. All patients shall be offered a Suicide Risk Screening to determine if a danger to self (e.g. suicide or self harm) is present.
A. This screening shall be performed at the time of presentation to the emergency department and on admission to the hospital.
B. The patient shall be asked an initial screening question to determine if suicidal or self-harm ideation is present.
C. Suicidal Risk Screening is not necessary if cognitive or physical impairment keeps the patient from being able to answer the questions.
E. If the answer to the question if positive.....The nurse will
A. initiate suicide precautions.
B. Notify the patient's physician of positive Suicidal Risk Screening an initiation of Suicidal Precautions.
G. For patient safety:
a. Move patient closer to nurse's station or other designated areas
e. Place pt on continuous in-person 1:1 (with competent staff who have been trained to monitor patients who are at risk for suicide.

I. If patient insists on leaving the facility call code grey (SIC) and notify law enforcement."

The facility did not have a process to treat patient's with mental health diagnosis who were unable to focus and remain in the ED lobby while waiting to be triaged and failed to follow their established policy for the safe care of patients who presented with suicidal ideation.

On the morning of 2/5/2020, an interview with the Quality Manager confirmed the above findings.