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301 NORTH HIGHWAY 21

PILOT KNOB, MO 63663

COMPLIANCE WITH 489.24

Tag No.: C2400

STABILIZING TREATMENT

Tag No.: C2407

Based on interview, record review and policy review, the hospital failed to provide further examination and treatment within its capability and capacity to stabilize one patient (#31) of 34 Emergency Department (ED) records reviewed from 08/01/22 through 02/27/23. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an emergency medical condition (EMC). The hospital's combined average monthly ED census over the past six months was 571.

Findings included:

Review of the hospital's policy titled, "EMTALA Guidelines," revised 05/05/22, showed all patient's that present to the hospital seeking care shall receive a medical screening examination (MSE) to determine if an EMC exists. An EMC can be any condition that is a danger to the patient or could result in a risk of dysfunction or impairment to the smallest bodily part or organ if not treated. Psychiatric (relating to mental illness) disturbances including severe depression (extreme sadness that doesn't go away), insomnia, suicidal ideation (SI, thoughts of causing one's own death) or attempt, dissociative (a mental health condition that involves feeling of being detached from reality, being outside of your own body, or experiencing memory loss) state, or an inability to comprehend danger or to care for themselves.

Review of the hospital's policy titled, "Missing Person Emergency Code," revised 04/04/22, showed staff are to notify the charge nurse (CN) or nurse manager if they are unable to locate a person or patient of any age. Law enforcement (LE) should be notified so that officers can be dispatched to assist with the search for the missing person/patient. In the event that a patient has gone missing, nursing staff should complete an incident/event report and forward it to administration.

Although requested, the hospital failed to provide any incident/event reports related to Patient #31's 12 elopements (when a patient makes an intentional, unauthorized departure from a medical facility) from the hospital.

Although requested, the hospital failed to provide a policy specific to elopement precautions and interventions.

Review of Ambulance District D's (county Emergency Medical Services [EMS, emergency response personnel, such as paramedics, first responders, etc.]) document titled, "Patient Care Record," dated 12/17/22 at 1:52 PM, showed the ambulance arrived at Residential Care Facility (RCF) B to transport Patient #31 to the nearest ED for psychiatric problems. Patient #31 had been involved in an altercation with another resident and was being discharged from their facility. Patient #31 told the ambulance crew, "another resident had been harassing me repeatedly, so I pinned her against the building and punched her in the face." She was cooperative during the transport.

Review of the hospitals transfer documentation sent with Patient #31 from RCF B, showed she had been admitted to their RCF from Hospital C on 11/17/22. Her admitting diagnosis was bipolar disorder (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows). There was clear documentation that Patient #31 has a court appointed legal guardian (a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs). Other diagnoses included unspecified psychosis (false beliefs or seeing/hearing/smelling/feeling things that are not there occurring in the absence of insight into their nature), anxiety (a feeling of fear or worry experienced intermittently) disorder, schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) and seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness). She was only allowed to leave the premises with a responsible party.

Review of RCF B's document titled, "Notice of Discharge for Emergency Situation - Facility Unable to Meet Needs of Resident," dated 12/17/22, provided to the hospital by Patient #31, showed she was emergently discharged from the RCF due to safety concerns. She attempted to elope multiple times, physically attacked other residents and staff, was verbally abusive to residents and staff, and made threatening remarks that "everyone should be shot." The discharge location was listed as Hospital C ED.

Review of the 14th Judicial Circuit Court document titled, "Successor Letters of Guardianship of an Incapacitated Person and Conservatorship of a Disabled Person," dated 06/30/21, provided by the hospital, showed Patient #31 had been identified as an incapacitated and disabled person. She had an assigned, court appointed, legal guardian. A six page letter, outlining Patient #31's behavioral issues and unsuccessful residential placements, was attached. Behaviors included shattering the windows of a previous guardian ' s office, multiple suicide attempts, consuming feces, smoking marijuana and methamphetamine, stuffing the toilets to flood them, consuming alcohol, barricading herself in her room with furniture, smearing feces over walls in her room and hallways, smearing feces over computer equipment, jumping in front of cars, elopement, assaulting other residents and staff members, engaging in sexual encounters, and attempted arson.

Review of Patient #31's ED record, dated 12/17/22 at 2:56 PM, showed that:
- She was 49-year-old female that presented to the ED for evaluation of her aggression from RCF B, via EMS.
- She had been involved in a physical altercation with another resident and was being emergently discharged from the RCF.
- She had a long history of violent actions, including urinating on public sidewalks, shattering windows of her previous guardian's (a person appointed by a judge to take care of and manage the property and rights of a person who is considered incapable of administering his or her own affairs) office, physical assaults, and arson.
- She denied having any SI.
- She remained in the hospital's ED from 12/17/22 through 02/08/23.
- On 12/17/22, she was placed on one to one (1:1, continuous visual contact with close physical proximity) observations upon arrival and a mental health examination (MHE) was ordered.
- On 12/17/22 at 5:20 PM, the MHE recommended inpatient psychiatric treatment related to Patient #31's multiple assaults, delusional (false ideas about what is taking place or who one is) thinking, and poor insight. It was clearly documented that she was disabled and had a legal guardian.
- On 12/19/22 at 8:50 AM, a second MHE was completed, the recommendation was for stabilization and discharge with follow-up outpatient services. Patient #31 had reported that she felt stable and that the hospital was working on her next residence. She felt she did not need psychiatric stabilization, only social work or case management services.
- On 12/19/22, 1:1 observation was discontinued after her second psychiatric evaluation.
- On 12/20/22 at 11:15 AM, Patient #31 exited the ED and was located in the main hospital, she was escorted back to her room.
- On 12/20/22 at 12:48 PM, Patient #31 walked out of the ED, LE was notified.
- On 12/20/22 at 1:06 PM, Patient #31 was returned to the ED by LE.
- On 12/21/22 at 9:00 AM, Patient #31 walked out of the ED to the parking lot, she returned when asked.
- On 12/21/22 at 1:30 PM, Patient #31 walked out of the ED. She was located and observed to have obtained a cigarette lighter. Staff were able to escort her back and to remove the lighter.
- On 12/22/22 at 6:42 PM, Patient #31 eloped from the ED, LE were notified and they returned her.
- On 12/25/22 at 9:20 AM, Patient #31 walked out of the ED to the parking lot.
- On 12/25/22 at 11:00 AM, an EMS crew delivering a patient to the ED notified staff that they had observed Patient #31 walking down the road in her gown and socks.
- On 12/25/22 at 11:05 AM, ED staff received a phone call from the local church that Patient #31 was there and stated she had been discharged. LE was notified.
- On 12/25/22 at 12:26 PM, Patient #31 was returned to the ED by LE.
- On 12/25/22 at 6:33 PM, staff contacted LE due to a violent outburst by Patient #31 in her assigned ED room. She became angry, broke an over the bed table, and beat a hole through the wall. Her guardian was contacted, she encouraged LE to arrest Patient #31 for destruction of property. LE refused to arrest Patient #31, damages would only result in a summons.
- On 12/30/22 at 1:15 PM, Patient #31 eloped, LE was notified and she was returned to the ED.
- On 01/01/23 at 5:19 PM, Patient #31 was found walking on Main Street in Ironton, MO, approximately two miles away. She was escorted back to the ED by LE.
- On 01/13/23, Patient #31 had a third MHE from a different contractor. The recommendation was that she remain in the ED until placement could be found at a Mental Health Facility that could provide intensive treatment. Recommendation was based on her history of arson, physical aggression (behavior that is intended to harm another individual), thoughts of harming peers and staff, destructive outburst, depression, manic impulsive behavior, emotional lability (abnormal variability in mood with repeated, rapid, and abrupt shifts in emotional expression), hostility, agitation (a state of feeling irritated or restless), paranoia (excessive suspiciousness without adequate cause), persecutory and religious delusions, and auditory and visual hallucinations (AH, VH, hearing or seeing things that are not there).
- On 01/19/23 at 2:34 PM, documentation showed Patient #31 requested to go out to smoke alone, staff documented she was not allowed out on her own.
- On 01/21/23 at 12:53 PM, documentation showed Patient #31 was allowed to go out to the parking lot to walk. No documentation of staff members accompanying her.
- On 02/04/23 at 4:37 PM, documentation showed Patient #31 had been outside walking on the parking lot. She received a phone call and when staff went to get her, they could not locate her. She returned.
- On 02/05/23 at 7:02 PM, Patient #31 asked to go out for a walk and returned on her own.
- On 02/08/23 at 6:08 PM, Patient #31 was unable to be located on the hospital campus. Her guardian was notified. The patient's guardian contacted LE.
- On 02/08/23 at 6:30 PM, the hospital discharged Patient #31 due to her elopement.

During Patient #31's 54 day ED admission, laboratory testing was completed once, on 12/17/23. Her vital signs were obtained on nine out of the 54 days. She eloped a total of 12 separate occasions without changes to her plan of care or adjustment of interventions.

During an interview on 02/28/23 at 11:10 AM, Staff F, ED Physician, stated that he provided on-going care for Patient #31. She was considered to be stable and her 1:1 observation had been removed. Patient #31 had a guardian and was not able to make her own decisions. She was roomed in ED room two for constant visualization. She was allowed to go outside for walks and to smoke, but staff were to be with her at all times.

During an interview on 02/28/23 at 4:15 PM, Staff B, ED Nurse Manager, stated that Patient #31 had been emergently discharged from her RCF and arrived to the hospital via EMS District D. According to the paperwork from the RCF, she was supposed to have been taken to Hospital C (nearby acute care hospital) for a MHE, where they had an inpatient psychiatric unit. The EMS crew told the hospital that they brought her to them because they were the closest ED. Payment transport would not have been received had they taken her to Hospital C, since it was further away. The hospital ordered a MHE with tele-psychiatry and placed her on 1:1 observation upon arrival. She was assigned to ED room two, their psychiatric safe room, for constant visualization. The hospital was informed that Patient #31 had a history of becoming violent with staff members, breaking out the windows of a business, and setting fire to a bed with her roommate still in the room. After Patient #31 had her second MHE, the 1:1 observation was discontinued, but staff continued to constantly visualize her. She was placed on elopement precautions, which included visualization, flagging the chart, and flagging the dashboard on the patient monitor (electronic patient tracking board in the ED that all staff are able to see). After the second MHE was completed, the hospital considered her to be discharged. She remained in the ED as a boarder, pending transfer and placement to an appropriate residential facility. They did not admit her to inpatient status, because it was "easier to find placement for ED patients as opposed to inpatients." Patient #31 was very manipulative, and disruptive. She would approach other ED patients and family members to ask for money and cigarettes. Patient #31 had eloped from the ED multiple times. Staff would contact LE and she would return to the ED. She tried to establish a contract with Patient #31, giving her different privileges. It would work for a couple days, then Patient #31 would act out, so staff would take a privilege away. Patient #31's guardian was contacted multiple times, but she refused to come pick up the patient. On 02/08/23, Staff I, ED CN, could not locate Patient #31 on the hospital campus. Staff I, called her and she told him to contact Patient #31's guardian.

Observation on 02/28/23 at 09:19 AM, showed Staff D, Certified Nursing Assistant (CNA), checking a patient into the ED for treatment. Staff D was not able to visualize individuals who entered or left the department. She then assisted the patient into a wheelchair and escorted her into an ED examination room, leaving the ED area without any visible staff.

During an interview on 02/28/23 at 12:30 PM, Staff K, CNA, stated that Patient #31 had left the hospital several times. The ED would receive calls from the gas station staff or the church people notifying the hospital that she was at their locations. They were able to identify her since she wore a hospital bracelet. She would then return to the hospital. Patient #31 was not physically violent with staff, but she would have outbursts where she would yell and curse, or throw things. That usually happened when staff tried to enforce rules or when she was told no.

During an interview on 02/28/23 at 12:05 PM, Staff J, Licensed Practical Nurse (LPN), stated that Patient #31 was always in and out of her room, walking through the ED. Once the 1:1 was removed, Patient #31 had access to regular clothing and would go out to walk around the parking lot alone. She was aware that Patient #31 had a guardian. At times, she would yell and throw things, become manipulative or would be paranoid. She had eloped on multiple occasions, but would return. On 02/08/23, no one witnessed her departure and staff were unable to locate her.

During an interview on 02/28/23 at 11:25 AM, Staff I, ED CN, stated that he was working when Patient #31 arrived at the hospital from her RCF for a MHE after having assaulted another resident. She was placed on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm), admitted to ED room two, placed in a safety gown, and assigned a 1:1 observer. She had been angry at the world, somewhat combative. The hospital had been aware that she had a guardian, but the guardian had not been aware that she was being emergently discharged from RCF B. At times, she would have a fit and throw things. After a couple of days, her MHE was repeated and the 1:1 observation was removed. At that point, she was awaiting placement. The hospital does not have a locked unit, there are no locking doors to prevent patients from exiting the ED area. Her assigned room, ED room two, was approximately 30 feet from the ED exit. The hospital does not have security, they use local LE if needed. He was working on 02/08/23, when Patient #31 eloped. No one observed her leaving, and staff were unable to locate her. He notified Staff B, ED Nurse Manager, and was told to contact her guardian. When he spoke with the guardian he provided her with the phone number for local LE. He did not notify LE. She had eloped multiple times before, gone to the church or to the gas station, but returned. Staff were unable to detain patients, only encourage them to not leave.

During an interview on 03/02/23 at 11:10 AM, Staff A, Chief Nursing Officer (CNO), stated that she considered elopement to mean that a patient left without permission. She was not aware that Patient #31 had eloped multiple times. She would expect staff to provide constant visualization of the patient and to have a 1:1 sitter in place to prevent elopement. Without a 1:1 observer, it would be impossible to maintain constant visualization of any patient in ED Room two. The registration clerk could assist, but if staff became busy, it would be easy for a patient to exit the ED without being seen. She had not been aware that the hospital had a policy related to "missing persons", until state agency (SA) team asked about it. Her expectation would be that staff would follow the policy, notify LE immediately if a patient went missing and complete an incident/event report. That did not happen with Patient #31. Staff E, Chief Executive Officer (CEO)/ED Medical Director, had been in touch with the hospital's lawyer for advice on Patient #31. He was advised by the hospital's attorney that staff should notify Patient #31's guardian if/when she eloped, not to notify LE. That was why Staff I, ED CN, notified the guardian, not LE. She verified with the hospital's Risk Manager, that no incident/event reports had been completed related to Patient #31.

During an interview on 03/02/23 at 8:30 AM, Staff C, Employee Health/Infection Prevention, stated that the hospital was not a psychiatric hospital. They did not have an inpatient psychiatric unit and did not admit psychiatric patients. The hospital did not admit Patient #31 because placement would become difficult. It was easier to find placement for a psychiatric patient in the ED as opposed to on a medical/surgical unit. ED staff would have greater visibility of the psychiatric patient in ED room two as opposed to a patient room.

During an interview on 03/01/23 at 10:15 AM, Staff E, CEO/ED Medical Director, stated that under EMTALA each patient would receive a complete MSE and stabilization for any EMC identified. For psychiatric patients that would include a MHE with tele-psychiatry. He was aware that Patient #31 had eloped multiple times, but the hospital did not have a locked area for psychiatric patients. The hospital did not have enough staff to provide 1:1 observation.

During an interview on 03/07/23 at 4:00 PM, Staff O, Chief of Police, stated that his department had responded to the hospital on several occasions when Patient #31 had gone missing. He did not have any written reports because once LE would arrive, she would have already returned to the hospital. He had witnessed her anger and frustration, but she would usually calm down once LE arrived. She was kept in ED room two, without a bathroom or television, just a stretcher. He was not aware that she had eloped on 02/08/23 and did not understand why his department was not contacted, especially since they had been involved on numerous occasions. He was aware that the hospital was frustrated with the inability to secure placement for Patient #31. He spoke with the EMS department about their reason for bringing her to this hospital. He was told that they would not receive reimbursement for the transport of the patient unless she was taken to the nearest ED. Patient #31 was supposed to have been transported to Hospital C, which would have been an additional three to four miles. The county's prosecuting attorney was aware of the situation with Patient #31and had recommended that the hospital discharge her to her guardian. The guardian refused to pick her up.

During a telephone interview on 03/09/23 at 10:10 AM, Staff P, CEO EMS District D, stated that EMS crews transport patients on a daily basis from RCFs. When RCF B contacted EMS for transportation, they called 911 instead of arranging a non-emergent transport. By calling 911, the ambulance crew transported to the nearest ED for medical treatment or medical clearance. Patient #31 was transported to the nearest ED for medical clearance. He stated that this ED had attempted to go on psychiatric diversion in the past. He had to explain to them that there was no such thing as a psychiatric diversion. He was told by the hospital that they were not able to care for psychiatric patients and that the EMS district should quit bringing psychiatric patients to their ED.

HospitalInspections.org

IRON COUNTY MEDICAL CENTER

COMPLIANCE WITH 489.24

STABILIZING TREATMENT