HospitalInspections.org

Based on document review, medical record review, observation and staff interview, it was determined the facility failed to ensure procedure was followed for removing ALL of the patient 's belongings, in one (1) out of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care in the facility's Emergency Department (ED).

Findings:

A policy was reviewed titled "Emergency Department Behavioral Health Unit (BHU) Policy and Procedure", effective date 2/26/23. The policy has a section titled "Purpose" which states, in part, "To establish guidelines for care of mental health and substance abuse disorder patients in the Emergency Department." The policy has a section titled "Procedure" which states, in part, " 8. Maintain the safety of the patient, staff, and others. a. Patient will be placed in paper scrubs. b. Emergency department staff will collect and hand off all belongings to security personnel for inventory of patients belongings as outlined in security procedure. Documented list will be scanned into the medical record under the media tab. c. If patient is being discharged to home and does not require inpatient treatment, patient will be given their belongings along with their discharge paperwork. d. If patient requires admission to an inpatient facility, patient will not be provided their belongings ... 10. Utilize restraints only if patient is an immediate danger to self, staff, or others. Contact local law enforcement if potential danger to staff, or others. See Restraint policy. 13. Encourage patient to remain in ED until the medical and mental health screening and referral is complete. If the patient insists on leaving, the staff member who heard the patient state ' I want to harm myself or others ' must initiate the mental hygiene petition."

A medical record review was conducted for patient #1. The patient presented to the facility's Emergency Department (ED) on 06/09/24 via Emergency Medical Services (EMS) at 11:03 a.m.

At 11:17 a.m. a note by Employee (Emp) #5 states, "Pt (patient) placed in paper scrubs, belongings bagged up and given to security. Security at the bedside. Constant monitoring in place. Safety measures maintained." Emp #1 documented "ED Course" at 11:58 a.m. and it states, "Patient eloped from the emergency department shortly after blood collection. [Patient #1] denies suicidal and homicidal ideation during interview. Attempts were made to contact [other facility] to confirm whether patient reported homicidal or suicide ideation to them." The patient was listed as eloped at 12:15 p.m.

A video review was conducted of the facility ED on 6/12/24 at 11:00 a.m. with Emp #2. The video started on 06/09/24 at 11:00 a.m. and shows the following: Please note Emp #2 explains the camera time is approximately five (5) minutes ahead, so actual time would be five (5) minutes prior to time listed.
11:21 a.m. Patient handed paper scrubs
11:22 a.m. Patient ambulates into BHU pod restroom (ligature free) and closes door
11:24:45 a.m. Patient back to room, put belongings bag on the floor, put shoes on the floor (slip-on shoes, no laces), lays on bed and covers up with personal blanket
11:26:24 a.m. Patient sitting at edge of bed, put shoes back on
11:31:47 a.m. Patient stands at doorway of the room
11:34:05 a.m. ED technician comes into the room with an ECG machine. Pushes belongings bag out of the way, against the wall
11:38:45 a.m. Security personnel obtains belongings bag, leaves the blanket and shoes with patient

An interview was conducted with Emp #4 on 6/12/24 at 2:14 p.m. Emp #4 was asked about the process for taking a patient's belongings if they are found to be suicidal. Emp #4 stated "Well, [Patient #1] denied SI, but our process would be to take the patient's clothes and give them paper scrubs to put on. Their belongings are inventoried and put in a locker for safety. The patient is searched for weapons. If the patient is suicidal, we will do one (1) to one (1) monitoring." Emp #4 was asked why Patient #1's belongings were not taken. Emp #4 stated, "At that point, [Patient #1's] blanket and shoes should have been taken and put in the locker."