HospitalInspections.org

COMPLIANCE WITH 489.24
CFR(s): 489.20(l)
[The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24.

This STANDARD is not met as evidenced by:
Based on observation, interviews, and record reviews, Texas Health Harris Methodist Hospital Azle (Facility A) failed to assess and provide stabilizing treatment for two of twenty patients, (Patient #1, #3) presenting to the facility's emergency department. Patients #1 and #3 did not receive stabilizing treatment while in an acute mental crisis and permitted to elope, this failure places any patient requiring close monitoring for suicidal ideation at risk of injury and death following elopement.

Based on observation, interviews, and record reviews, the facility (Facility A) failed to assess and provide stabilizing treatment or transfer for two of twenty patients (Patient #1, #3) presenting to the facility's Emergency Department (ED).

Patient #1, a 54 yo male presented to ED via private vehicle and complaints of suicidal and homicidal ideation that started a month ago. Patient #1 has a history of emotional/physical abuse with significant other. He reports having Suicidal Ideation (SI) and Homicidal Ideation (HI) with plans that patient states will be very violent. He is a daily alcohol drinker. Patient #1 was triaged and received medical screening in the ED. During BH consult Patient #1 was asked if he was homicidal? "He said "yes and no, yes I have access to guns, and, no, I have no plan of letting anyone take my guns. I do have thoughts of hurting someone else. I want to hurt the people she loves, those she most desires and I want her to feel like me, the same pain." After BH consult recommended inpatient placement, Patient #1 became agitated and wanted to leave. Facility A called Azle Police Department for Emergency Detention order. Azle PD issued Emergency Detention order due to believe that patient was in imminent danger to himself and others. Patient #1 walked out of Facility A, got in a car, and drove away. Facility A called Azle PD when he told them he was leaving, but patient had eloped prior to Azle PD arriving. Patient #1 did not receive any medication during his stay. Sheriff department located Patient #1 at home shortly after drinking alcohol in an emotional state. Sheriff transported Patient #1 to Azle PD, who then transferred him to JPS (Facility B) on 07/15/2024. Patient was admitted to Facility B later that evening under the original and additional detention warrant. Patient was placed under close observation for SI/HI at risk of injury and death. Patient #1 was admitted inpatient the next morning on 7/16/2024 to Trinity Spring Pavilion and remained there for treatment and medication until 7/22/2024.

Patient #3, a 33 yo female presented to Facility A's ED on 06/08/2024 at 0342 via private vehicle with ex-significant other stating Patient #3 told him she took multiple pills to harm herself. Patient #3initially refused to talk, but eventually admitted she took 13 pills to harm herself. Patient has history of bipolar and major depression. She has a prior suicide attempt resulting in inpatient admission in 2020. She revealed psychiatrist had removed all BH medications in the past year. Patient #3 was triaged, and medical screening completed. Patient's behavior is agitated and combative during assessment. BH assessment via telehealth completed and Patient #3 became angry after inpatient placement was recommend. Patient #3 pulled out her IV and walked out of Facility A. Facility notified Azle PD after she eloped. Patient #3 did not receive any medication during her stay. Per ED Disposition: Elopement/AMA in serious condition.

This failure placed any patient requiring close monitoring for suicidal/homicidal ideations at risk of injury and death following elopement.

Findings included:

1. Patient #1:

Medical Record Review Facility A for Patient #1:
A medical record review of Patient #1 at Hospital A from 07/15/2024 at 10:19 am to 07/15/2024 at 2:56 pm revealed the following:

A medical record review of Patient #1's Emergency Department Record reflected that Patient #1, a 54-year-old male, arrived at Facility A on July 15, 2024, at 10:19 am via private vehicle accompanied by daughter. The triage notes reflected patient #1 complaint of suicidal ideations (SI) and homicidal ideations (HI).

A review of Patient #1's Suicide Risk screening result was high. Level reviewed by RN and physician. Patient #1 was placed on the following precautions on 7/15/2024 at 10:30 am: 1:1, every 15 minutes monitoring, suicide precaution, safe clothing, and "Keep Me Safe". Bedside Patient Companion (Sitter) was ordered 7/15/2024 at 10:29 am.

A review of Patient #1 Medication Administration Records reflected Diazepam 5 mg once, not administered, refused. Lorazepam 1 mg once, held not indicated. No medication was administered to patient during stay.

A review of the Behavioral Health Intake Assessment dated 7/5/2024 at 1347 reflected: " ...I am an emotional wreck. My girlfriend and I broke up at the beginning of June ... This is like grieving a death. Am I suicidal, yes, and no, nothing major, trying not to act on anything. The thoughts are there, if I wanted to, I could have by now, not something I had planned. It would have been either a gun shot or a car accident. Yes, I have access to guns, and, no, I have no plan of letting anyone take my guns. I do have thoughts of hurting someone else. I don't want to hurt her, I want to hurt the people she loves, those she most desires and I want her to feel like me, the same pain I have now. You know if I didn't wake up it wouldn't bother me. I want the pain to go away ... Admitting to suicidal thoughts and homicidal thoughts, discussing use of a gun, does have access and stated, "no one is taking my guns from me." Also, with reference to suicidal thoughts, discussed an accident in his vehicle. He did states that it is not his ex-girlfriend he is having homicidal thoughts towards, "It's not her I want to hurt, I want to hurt the people she desires, then she can hurt like I am hurting ..."

Behavioral Health consulted with physician with recommendation of inpatient psych admission. Physician stated he would contact the Azle PD to request an Emergency Detention Order. Per Secure Messenger, Azle PD has placed the patient on an EDO.

The "ED Noted by Staff #L, RN dated 7/15/2024 at 1:39 pm, reflected: "security at bedside with patient explaining the Emergency Detention".

The "ED Course and Medical Decision Making, dated 7/15/2024, reflected: " ... police officer assessed patient and emergency detention order was placed. BH was continued to look into placement. Unfortunately, patient eloped out of the ER into private vehicle. Police was called again at that time."

Per Azle Police Department Narrative, on 7/15/2024 at 1256, Facility A requested a Mental Health Detention Form on their behalf due to Patient #1 presenting homicidal and suicidal signs. Per officer, he completed Emergency Mental Detention based on believe Patient #1 was in imminent danger to himself or others. At 2:54 pm Azle PD received call from Facility A stating Patient #1 had drove away from the facility. Per Azle PD report: Facility A's police officer failed to stop Patient #1 from leaving the premises despite knowing he was in imminent danger to himself and others. "I learned the hospital police refused to stop Patient #1 as they did not have a cause to detain him." Azle PD sent out an alert and Parker County Sheriff Officer (PCSO) was able to detain Patient #1 at his home shortly after drinking alcohol and was in an emotional state. PCSO transported Patient #1 to Azle PD, and a new Mental Health Detention Form was completed, and Patient #1 was transported to Facility B.

Medical Record Review Facility B for Patient #1:
Review of Hospital B's medical record reflected Patient #1 arrived at Facility B's emergency department on 7/15/2024 at 6:10 pm accompanied by Azle Police Officer #234.

Review Facility B, Patient #1's Physician's note dated 7/15/2024 at 7:37 pm reflected, "This MSE determines that this patient does have an emergency medical condition that will require secure locked environment for safety and stabilization." Note at 9:29 pm revealed: "54M presents with depression, suicidal and homicidal ideation in the context of romantic conflict and alcohol use relapse. His depression continues to worsen, and his homicidal ideation has become progressively more detailed and planned over the past week. His daughter is l, and she does not provide supportive collateral for discharge. He has multiple high-risk factors for suicide including age, race, access to weapons, alcohol use disorder, poor social support. Given these factors and his statements noted above he poses an imminent risk of harm to himself, and others and he will be admitted involuntarily, CME filed."

Per review of the Discharge Summary dated 7/22/2024 at 9:53 am, revealed Patient #1 was admitted to JPS Trinity Springs Pavilion (TSP) which was the least restrictive means available given the seriousness of his psychiatric condition. Patient received therapy, group, medication management, and psychoeducation during stay. At discharge, Patient #1 denies any suicidal ideation, homicidal ideation toward ex-girlfriend or her children, paranoia, AVH, changes in appetite, or new medication side effects on the day of discharge.

2. Patient #3:

Medical Record Review Facility A for Patient #3:
A medical record review of Patient #3 at Hospital A from 06/08/2024 at 3:42 am to 06/08/2024 4:43 am, revealed the following:

A medical record review of Patient #3's Emergency Department Record reflected that Patient #3, 33 y.o. female with a history of depression presents emergency department with her ex-boyfriend at the bedside. Patient #3 initially refused to answer questions, the ex-boyfriend states that they had recently broken up, when he got home from work this evening, she told him that she had taken an unknown number of Tylenol No. 3 to harm herself. Patient #3 ultimately admits she took 13 pills.

A review of Patient #3's Suicide Risk revealed high suicide risk. Level reviewed by RN, and physician. Patient #3 was placed on the following precautions on 7/15/2024 at 3:55 am, Keep Me Save protocol and high suicide risk precaution. Per RM Assessment at 3:57, sitter was present.

A review of the Medication Administration Records reflected; normal saline IV bolus given. No other medication administered during stay.

A review of the Behavioral Health Intake Assessment dated 6/8/2024 at 4:06 am reflected Patient #3 reported she took pill to hurt herself due to break up with significant other. Patient scored high on suicide risk screening and suicide risk precautions were completed. Patient's significant other brought her to ED, Patient did not want to come to ED. Patient has had a previous suicide attempt in 2020 and was admitted to inpatient psych facility. BH Clinician spoke with physician regarding recommendation of inpatient psych. Patient #3 was advised that she can go voluntary and if she refuses, law enforcement will be called for EDO. Patient #3 "was medically stable for transfer."

The "ED Noted by RN dated 6/8/2024 at 4:41 am, revealed "Post behavior health assessment pt ambulated from the room and exited the ED. Security aware and Azle
PD called. Upon entering the room, the PIV was found lying on the bed. Physician aware."

The "ED Noted by RN dated 6/8/2024 at 4:48 am, revealed "Called pt and she reports that she is fine and will not be returning to the ED and is refusing inpatient as
recommended by behavior health."

Interview:

During an interview with Facility A Staff #C, ED Manager RN on 8/27/2024 at 1205 pm, was asked how does a Notification of Emergency Detention Warrant (EDW) affect how the staff treats/handles the patient with mental crisis? Staff #C stated the patients with behavioral, suicidal, and homicidal ideations are placed in either room #3 or #4 due to its proximity to the nurse's station. Doctors and staffs are all made aware of the patient's status and the Keep Me Safe protocol is set in place. Staff #C stated that facility now has security in the emergency room for the past two months.

During an interview with Facility A Staff #E, Charge Nurse, on 8/28/2024 at 9:57 am, if a patient has a Notification for Detention Warrant and wanted to leave the Facility, what would she do? Staff #E replied that she would ask them not to leave and explain the importance of remaining for treatment or transfer; but she cannot stop a patient that wants to leave the facility. If patient had a detention warrant, she would call the local police and hope they arrived before the patient leaves the facility. She stated they are leaving Against Medical Advice (AMA) but if they do not sign the AMA documents, then they are considered an elopement. Staff #E was asked if it made any difference if patient was had elevated risk for SI or HI? She stated she would have to let them leave because she does not have the ability to detain them, only the police can do that.

During an interview with Facility A Staff #A, Director of Quality on 8/27/2024 at 10:00 am, when asked why a patient with mental crisis was allowed to leave the facility. Staff #A replied Patient #1 had both security and THR Peace Officer at bedside. THR Peace Officer let him leave because it is not their detention warrant. He stated the person that does the detention is the person that issued the detention warrant. In the case of Patient #1 that would be Azle PD. Staff #A stated Facility A would not restrain because that is against his rights Staff #A was asked even if they consider Patient #1 harmful to himself and others? Staff #A replied if a patient wants to leave AMA or elope, Facility A does not have the right to restrain the patient. When asked why THR Peace Officer did not detain Patient #1, Staff #A stated THR Peace Officer are currently there in a security role. THR does not have a policy in place that would allow the THR Peace Officer to detain patient under an Emergency Detention Warrant written by the local police department.

Facility A Policy Review:

A review of the facility provided policy, Medical Screening Examinations and Patient Transfers Policy, (last reviewed 10/7/2022) revealed:
4.1.6 Providing stabilizing treatment to persons with an Emergency Medical Condition. An Emergency Medical Condition is considered stabilized when the Emergency Medical Condition has been resolved although the underlying medical condition may persist ...
A psychiatric patient may be considered stable when he or she is protected and prevented from injuring or harming him/herself or others.

5.12 Stabilize - To stabilize means with respect to an Emergency Medical Condition, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the patient from a facility ...