HospitalInspections.org

Based on review of policy and procedure, medical record review, facility video recordings review and staff interviews, nursing staff failed to ensure a behavioral health patient was monitored per policy and procedure for 1 of 5 behavioral health patients reviewed, (Patient #3).

The findings included:

Review of the policy "Suicide Assessment and Precautions for At-Risk-Patient(s)" last reviewed 10/22/2018 revealed, "PURPOSE: The purpose of this policy is to promote a safe environment for patients deemed at risk for self-harm and/or suicide. This policy applies to all patients in inpatient emergency (ED), ambulatory and outpatient departments or areas ...PROCEDURE: ...A patient expressing self-harm and/or suicidal ideation will be placed under 1:1 observation immediately ...Nursing Responsibilities ... Provide coverage for sitter (meals, break, etc.). Coverage must be obtained to ensure the patient remains under constant observation at all times ...Sitter Responsibilities ... Sitter will observe all tubes, drains and dressings as well as the patient's hands ...The patient will remain under one-to-one observation with the sitter at all times ..."

Review of the medical record on 03/19/2020 revealed Patient #3 was a thirty-six-year-old female admitted to the facility's Emergency Department (ED) under Involuntary Commitment (IVC) orders on 03/06/2020 by Law Enforcement Officers (LEO) as a danger to herself and others. Review of an ED "Triage Note" revealed "Pt here with (named police department) for causing a disturbance at her apartment complex ...Pt normally takes Risperdal (antipsychotic used for treatment of mental health diseases) but has not been taking ...Pt noted to be screaming/yelling/cursing at staff, patients and (named police department officers)." Review of a "Telepsychiatry Assessment Note" dated 03/06/2020 at 1505 revealed Patient #3 had an extensive psychiatric history with multiple, hospitalizations and was currently experiencing symptoms consistent with a manic phase of "Bipolar I disease, Severe (abnormally elevated mood, and energy levels with rapidly vacillating mood changes)." Review revealed, after being medically cleared, 1:1 (one to one) observation was ordered by MD #6 for Patient #3 at 1603. At 1914, 1:1 observation with a sitter was initiated (constant observation at all times). Review revealed, beginning on 03/08/2020 at 0145 four-point restraints were used when redirection and oral and intramuscular injections of medications for aggressive behaviors were not effective. Medical record review revealed after the initial restraint orders on 03/08/2020, Patient #3 was restrained multiple times for unsafe or violent behaviors through 03/12/2020 at 1258 while Patient #3 remained in the facility's ED. Review of an "ED Note" dated 03/09/2020 at 1740 by RN #11 revealed, "Pt (patient [also pt]) used her mouth and removed restraints from hands and feet, pt then ran out of the department ...Pt was found close to radiology and brought back to room ..." Review of an "ED Note" dated 03/10/2020 at 2230 by RN #8 revealed, after being placed in restraints for aggression at 2205 "Patient was standing in doorway out of restraints crouched down; When patient saw RN patient bolted passed (sic) RN and out side (sic) doors toward the ED waiting room; Pt was seen knocking on all PEDS BHH (Pediatric Behavioral Health Hall) doors ...BHH Counselor had restrained Pt ...Pt placed in Stretcher (sic) and restraints put back on ..." Review of an "ED Note" dated 03/12/2020 at 0120 by RN #8 revealed after being placed in restraints for unsafe and aggressive behavior, "RN heard noises coming from patient room and when RN approached the room patient was seen standing in doorway out of restraints; Patient bolted out of unit towards the ED waiting room..." Medical record review revealed Patient #3 was able to remove her restraints on 03/09/2020, 03/10/2020 and 03/12/2020 and leave the unlocked behavioral health area prior to staff intervention while under 1:1 observation orders. Review revealed Patient #3 sustained injury during the incident on 03/12/2020 and was admitted to an inpatient unit of the facility on 03/12/2020 at 1258 for repair of a right tibial plateau fracture (one of two long bones below the knee). Record review revealed, after sustained improvement in her medical and psychiatric condition after surgery, Patient #3 was discharged home on 03/17/2020 at 1606 with outpatient follow up by psychiatric and orthopedic services.

Review on 3/20/2020 at 0915 of facility video recordings for the facility's ED behavioral health and lobby areas recorded on 03/12/2020 revealed, at approximately 0137 on 03/12/2020 four individuals in hospital scrubs identified as staff members exited an ED behavioral health room identified as ED Behavioral Health Room 53, Patient #3's ED room. Video review revealed the last individual closed the room door and all four staff walked toward the nursing station area approximately twelve feet up the hall. No facility staff were visible on camera view near ED Room 53 after the door was closed. On 03/12/2020 at approximately 0143 the door at ED Room 53 opened, an individual identified as Patient #3 was briefly seen, and rapidly exited the doorway down a hall away from the nursing station. Two staff members at the nursing station quickly followed as Patient #3 disappeared from camera view.

Telephone interview on 03/19/2020 at 1832 with a Nursing Technician, NT #14, revealed she had been Patient #3's sitter on 03/12/2020. Interview revealed Patient #3 had not been restrained when she, NT #14, arrived for work, but Patient #3 was increasingly aggressive, and had come "out of the room forcefully and tried to kiss me..." Interview revealed Patient #3 had been placed in restraints after the incident. Interview revealed, NT #14 later noticed Patient #3 had loosened her restraints, and another staff member retied the restraints. NT #14 revealed she was behind on charting and after the restraints were retied wanted to "catch up." Interview revealed NT #14 asked RN #8 "to watch her (Patient #3) while I tried to catch up on charting from earlier and I went behind the nurse's station to chart." Interview revealed a short time later NT #14 looked up to see Patient #3 "walking to us toward the door and then she took off running."

Interview on 03/19/2020 at 1020 with RN #8 revealed she remembered Patient #3. Interview revealed NT #14 observed Patient #3 from across the hall because Patient #3 was spitting on staff when they were inside the room. RN #8 revealed she was returning to Patient #3's room when she observed the patient appear at the door and run down the hall in the opposite direction.

Telephone interview on 03/19/2020 at 0915 with a facility Security Guard, SG #16, revealed he was on duty during the incident on 03/12/2020 and responded to an urgent call from RN #8 who said "She's running again. She's running again." Interview revealed he had asked RN #8 what had happened and was told "she got out of her four points and made a run for it," but he wondered "How did a patient who was in four points get out of restraints without being seen?" Interview revealed, SG #16 was unable to understand event details during talks with staff, and "I went to the security office and found video tapes for the area." Interview revealed SG #16 noticed staff had exited Patient #3's room about 0139, "shut the door" and the "patient was left alone, and the door was closed for 5 to 6 minutes" before she was observed fleeing the unit.

Interview on 03/19/2020 at 1339 with the ED Director, RN #10, revealed she had reviewed the video recordings and stated "You can't see everything because it's blurry. Several people came out of the room and the sitter came out and sat behind the desk. A little later, 4 or 5 minutes, the patient briefly appears at the door then darts off." During interview, RN #10 indicated sitters typically should be in the room with patients under observation, but there were occasions when it was not appropriate, and in that instance, the sitter should be by the door with the door open and be doing nothing except watch the patient. Interview revealed policy was not followed, and no staff were observed outside Patient #3's room for approximately five minutes.