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The information reviewed during the survey provided evidence the facility failed to ensure a safe environment was provided for a patient that presented to the emergency department at St. Luke's Hospital-Upper Bucks requesting an inpatient psychiatric admission. After staff learned the patient was currently identified as an active 302 involuntary psychiatric patient, they failed to provide a safe setting, evidenced by the patient eloping prior to registration in the Emergency Department.

A discussion took place with the survey team and the facility's administrative staff (EMP1), regarding the survey team's concerns related to Patient's Rights on September 30, 2021 at 12:27 PM.

Based on review of facility policy, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide each Medicare beneficiary a notice of 'An Important Message from Medicare' (IM) upon admission or before discharge and failed to obtain patient acknowledgement of receipt of the IM document for two of two medical records reviewed (MR5 and MR7).

Findings include:

Review on September 30, 2021, of facility policy "Important Message from Medicare (224)" revised June 24, 2021, revealed "... III Procedure ... A. Initial Notice-Hospital Registration will provide and review the IM with all beneficiaries enrolled in Medicare ... The initial IM will be given within two (2) calendar days of admission, and the signature of the beneficiary or representative must be obtained ... B. Follow-up notice - A follow-up notice is required and must be given to the beneficiary or representative as far in advance as possible before discharge, but no more than 2 calendar days and no less than (4) hours before the discharge is written ... The beneficiary is representative's signature should again be obtained when the follow-up notice is given ..."

Review on September 30, 2021, of MR5 revealed the patient was admitted to the facility on September 23, 2021, and discharged on September 26, 2021. Further review of MR5 revealed no documentation that an IM was provided upon admission or upon discharge from the facility.

Review on September 30, 2021, of MR7 revealed the patient was admitted to the facility on September 20, 2021, and was discharged September 24, 2021. Further review of MR7 revealed no documentation the patient signed and dated the IM that was received on admission as acknowledgement of receipt and no documentation the IM was provided to the patient upon discharge.

Interview on September 30, 2021, with EMP2 confirmed the there was no documented evidence for the IM documentation as stated above for MR5 and MR7.

Based on review of facility documents medical records (MR) and interview with staff (EMP) it was determined the facility failed to ensure a patient with a involuntary commitment (302)was provided a safe environment as evidenced by eloping from the facility property.


Findings include:

On September 30, 2021, a request was made to EMP1 for a policy regarding the care of patients that presented to the emergency department, on an active 302, prior to receiving treatment. None was provided.

Review on September 29, 2021, of MR1 revealed "Discharge Disposition-Elopement/er" The documentation was dated September 11, 2021, at 10:30 PM

Interview with EMP6 on September 30, 2021, at 10:20 AM confirmed a patient presented to the ED requesting an inpatient psychiatric admission on September 11, 2021, at approximately 7:48 PM. EMP6 confirmed they registered the patient identified in MR1 and the patient proceeded to the ED waiting area. Further interview with EMP6 confirmed they did not know the patient was currently identified as a 302 commitment.

Interview on September 30, 2021, at approximately 11:00 AM with EMP1 confirmed the documentation in MR1 confirmed the patient eloped from the waiting room September 11, 2021, at 10:30 PM.

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Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to provide a safe environment for a patient identified as at-risk to themselves as evidenced by not providing a safe environment and leaving the patient in the waiting room.

Findings include:

Review on September 30, 2021, of a facility time line communication, not dated, revealed at approximately 8:00 PM the ED staff was faxed a copy of the 302 commitment for the patient identified in MR1.

Interview on September 30, 2021, at approximately 1:30 PM with EMP7 confirmed they were the charge nurse for the ED and working in triage on September 11, 2021, at the time the patient MR1 presented to the ED. Further interview with EMP1 confirmed they were informed a 302 patient had eloped earlier in the day from another facility within the hospital network and may arrive at St. Luke's Hospital Upper Bucks for care and treatment. Continued interview with EMP7 confirmed they did not notify the staff member working at the ED registration area the current status of MR1.

Interview on October 1, 2021, at 8:45 AM with EMP6 confirmed they were aware the patient in MR1 was in the ED waiting area. Further interview with EMP6 confirmed they were aware the patient in MR1 was on an active 302 and were "to busy" and "no available staff to talk with patient" to escort them to the treatment area and provide a safe environment.

Based on review of facility policy, medical records (MR) and interview with staff (EMP) it was determined the facility failed to safeguard private health information from unauthorized disclosure for seven of seven medical records reviewed. (MR12, MR13, MR14, MR15, MR16, MR17 and MR18).

Findings include:
Review on September 30, 2021, of facility policy "St. Luke's Code of Conduct" not dated revealed "... HIPPA Requirements Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that requires us to keep patients ' protected health information (PHI) safe and confidential. Employees, providers, and other health care partners are generally permitted to share PHI without patient authorization only for treatment, payment and healthcare operations ..."
During an observation tour of the Emergency Department (ED) on September 30, 2021, at approximately 1:15 PM revealed an unlocked sexual assault cart located outside of ED bay 10. Further observation revealed a facility document identified as "Sexual Assault Nurse Examiner Evidence Log" dated March 15, 2015 to June 7, 2018, located in the top drawer of the unlocked cart. Continued observation revealed the name, date of birth and date of the exam for seven patients. (MR12, MR13, MR14, MR15, MR16, MR17 and MR18).

Interview on September 30, 2021, at 1:15 PM with EMP4 confirmed the identification of seven patients and their personal health information, was located in the first drawer of the unlocked sexual assault cart.