HospitalInspections.org

Based on medical record (MR) review, document review, and interview, in 1 (one) of 1 (one) MRs, the facility staff did not fully implement their de-escalation protocol, as per facility policy.

This failure placed all patients at risk for harm.

Findings:

The facility policy and procedure (P&P) titled, "Patient and Visitor Abusive / Discriminatory Behavior Policy," last dated 2/2024, instructed staff to "Contact Patient Services Administration (PSA) and/or Administrator On Call (AOC) [as] resources who may assess and attempt to employ various additional dispute resolution and service recovery de-escalation techniques," when attempts to de-escalate are ineffective.

Review of Patient #2's MR identified that this patient presented to the Emergency Department (ED) on 2/21/2024 at 11:16PM. After examination by the physician, the patient refused medication or additional treatment. Patient #2 remained sleeping in the ED for approximately 6 hours, until they were discharged at 05:47AM. Upon notification of discharge, Patient #2 became angry and belligerent, yelled and screamed at staff, and urinated on the floor.

During interview of Staff K (physician provider) on 3/19/2024 at 3:50PM, Staff K stated that Patient #2 had no psychiatric history, was not exhibiting signs or symptoms of psychosis, but that the patient was very angry about being discharged because he wanted to continue to sleep in the ED. Security staff were called, and the patient was escorted out of the facility.

Upon request, the facility could not furnish documented evidence that facility staff had notified the PSA or AOD as per facility policy.

During interview of Staff J (Senior Director of Quality and Patient Safety) on 3/20/2024 at 11:25AM, Staff J confirmed there was no notification to the PSA or AOD as required by the facility policy.