HospitalInspections.org

Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 489.24

Findings include:

1. The Hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided appropriate stabilizing treatment and/or transfer. (See A-2407)

Based on document review and staff interview, it was determined that in 1 of 20 (Pt #1) Emergency Department (ED) records reviewed, the hospital failed to ensure that all patients who came to the Emergency Department (ED) were provided appropriate stabilizing treatment and/or transfer.

Findings include:

1. Pt #1's record was reviewed throughout the survey and revelaed that Pt #1 was brought to the ED by Illinois State Police (ISP) on 4/8/25 at 7:40 PM. "ED Triage Notes" by ED RN (E #3) dated 4/8/25 at 7:48 PM indicated, "Patient presents to the ED after attempting to kill himself by running into a median with his car at 90mph (miles per hour)."

Pt #1's record included a "Petition for Involuntary/Judicial Admission" that was completed by the ISP officer. The petition noted, "this petition is being initiated by reason of: Emergency inpatient admission by certificate ... I assert that (Pt #1) is: a person with mental illness who because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed ... (Pt #1) was involved in a single vehicle crash on I-72 west bound mile post 128. (Pt #1) intentionally drove his vehicle off the roadway into the center median and struck the concrete bridge support in an attempt to commit suicide. (Pt #1) advised he accelerated as he drove off of the road to approximately 85-90mph." The form was signed and dated on 4/8/25 at 8:40 PM by the officer.

A medical screening exam was conducted by ED MD (E #4) on 4/8/25 at 7:56 PM. The "ED Provider Notes" by E #4 included, " ... History of Present Illness: (Pt #1) is a 40-year-old male ... brought in by PD[Police Department] after MVA (motor vehicle accident) while intoxicated. Patient hit median on highway at 90mph while under influence. Patient did not wear seat belt. Patient reports airbag did deploy .... Patient admits alcohol consumption. Patient expressed intention of committing suicide. Last suicide attempt at age 31 where he cut his L (left) wrist requiring sutures ... Patient denies any injuries from MVA. Petition filed by PD .... Physical Exam: ... Psychiatric: Speech: Speech is rapid and pressured. Behavior: Behavior is agitated, aggressive and hyperactive. Thought Content: Thought Content includes suicidal ideation. Thought content includes suicidal plan ...."

A "Columbia Suicide Severity Rating Scale" was completed by E #3 on 4/8/25 at 7:57 PM and indicated Pt #1 was a "High Risk" for suicide. Pt #1 was placed on 1:1 suicide observation.

E #4 completed and signed an "Inpatient Certificate" for Pt #1 on 4/8/25 at 8:00 PM. The Certificate noted, " ... Based on the foregoing examination it is my opinion that he or she is: A person with mental illness who, because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed; A person with mental illness who, because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm, without the assistance of family or others, unless treated on an inpatient basis; A person with mental illness who; refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or two above; is in need of immediate hospitalization for the prevention of such harm. I base my opinion on the following: alcohol intoxication, cocaine abuse, suicidal ideations and attempt. I believe that the individual is subject to: involuntary inpatient admission and is in need of immediate hospitalization."

Pt #1's record indicated Pt #1's initial alcohol (ETOH) bloodwork was 0.013 G/DL (grams per deciliter - legal limit 0.08) on 4/8/25 at 9:22 PM. Pt #1's urine drug screen was positive for Cannabinoids (marijuana) and Cocaine Metabolites.

Nursing note by ED RN E#5 on 4/8/25 at 11:21 PM indicated, "(Local PD) called at this time for patient elopement. Patient ran out of facility due to being irritated from writer and another nurse to take his ZYN (nicotine) pouches .... Patient then told mother to leave and then patient jumped out of the bed and ran out the door. Security trying to locate patient. Unable to get him ... (Local PD) was notified of patient leaving."

Another nursing note by E #5 on 4/8/25 at 11:45 PM indicated, "(local PD) brought patient back in room, security took belongings, sitter at bedside."

Nursing note by E #3on 4/9/25 at 1:13 AM indicated, "(Local behavioral health center) was called to evaluate the patient." Pt #1's record indicated; the local behavioral health clinician evaluated Pt at 2:00 AM. Nursing note at 2:17 AM indicated, "(Local behavioral health center) crisis worker evaluated the patient and (Pt #1) is ok for discharge with a safety plan ..."
Discharge instructions by E #4 on 4/9/25 at 2:20 AM indicated, "Follow up with (Local behavioral health center) at clinic. Recommend abstinence from cocaine and alcohol use."

Physician note by E #4 on 4/9/25 at 2:21 AM indicated, "ED Course/ Medical Decision Making: Alcohol intoxication and cocaine abuse with aggressive behavior - easily triggered when expressed that driving under influence put others at risk and harm, patient then became belligerent and angry, using foul language with pressured speech and yelling discriminating comment that he cannot understand me (in reference to my Chinese accent), calling female nurse 'c' with foul language, requesting to go to DMH or jail instead. MVA - patient likely have refused EMS at scene. Here for medical and psychiatric clearance after being arrested by PD at scene ...Patient eloped in his own street clothing thru unlocked door. Patient was then brought back by PD at 11:30 PM. Security been instructed to change patient into paper scrub and remove all personal items from room. Repeat ETOH zero, drawn upon returned from elopement. Hence medically cleared. (local mental health program) evaluated patient who is now denying suicidal ideation or plan and able to proceed with contract of safety plan with (local mental health program). Hence cleared for discharge.

Pt #1 was discharged home alone at 2:56 AM on 4/9/25.

2. The Sentinel Event log was reviewed from 04/01/25-7/2/25. The log included one event on 4/9/25 for Pt #1. The log indicated, "Specific Event Type: Patient - Condition Unexpected Decline... Sentinel Event: Suicide." The sentinel event for Pt #1 was reviewed and indicated: "Investigation status: Preliminary investigation. RCA (root cause analysis) Unexpected Death Following ED Visit ... Determination Date: 6/10/2025; Entered on: 6/10/2025; To Be Completed By 7/25/25 .... Event title - Initial RCA Meeting ... Date 6/9/2025 ... Description: IDPH (Illinois Department of Public Health) arrived onsite to conduct a focused survey. It was determined that they were here for a complaint visit based on report of patient that was an ED patient that was discharged. After discharge, patient committed suicide ...."

3. Coroner's case report for Pt #1 indicated, " ... Investigator notified: 4/9/2025 06:06 (6:06 AM). Case Brief: 40 years old ... investigated on 4/9/202 at 6:06 AM. Suspected behaviors include ... Suspected COD (Cause of Death) is Drugs/Poisoning. Overdose by pills with a suspected manner of Suicide." Pt #1's Autopsy Report indicated "Date of Death: April 9, 2025 ... Time of Death: 10:42 AM ... Date of Autopsy: April 9, 2025... Time of Autopsy: 4:00 PM .... Summary Diagnoses: 1. Cocaine intoxication with cocaine metabolite at 920ng/ml (nanograms per milliliter - positive urine test is above 150ng/ml ... 6. Investigation history of psychiatric illness and recent hospitalization. 7. Presence of additional lamotrigine (mood stabilizer), olanzapine (anti-psychotic), clonazepam and metabolite 7-amino clonazepam (benzodiazepines - used in the treatment of anxiety), naloxone (narcotic reversal medication), and caffeine in the blood .... Cause of Death Opinion: The cause of death of this 40-year-old male, (Pt #1) is cocaine intoxication ..."

4. An interview was conducted with E #4 on 7/2/25 at 11:30 AM. E #4 stated, "(Pt #1) came in after motor vehicle accident. (Pt #1) was brought in by PD. They have a petition for him because of suicidal ideation. (Pt #1) disclosed that (Pt #1) was suicidal so they brought the patient here for medical eval and clearance. (local mental health center) came in to evaluate the pt and said that (Pt #1) was okay for discharge. We rely on their (the local mental health center's) assessment. They said (Pt #1) was safe for discharge with safety plan. I discharged (Pt #1) with a follow up with them. I did not call a psychologist." E #4 confirmed completing the certificate for involuntary emergency admission for Pt #1. E #4 stated, "(Pt #1) denied being suicidal after (Pt #1) was brought back to the hospital after elopement and continued to deny suicidal ideations at discharge."

5. An interview was conducted with Quality Manager (E #1) on 7/2/25. E #1 stated, "We were unaware the pt had committed suicide until your last visit. Staff looked online and saw (Pt #1's) obituary. We have started an RCA (Root Cause Analysis), but it is preliminary. We were waiting on the results of the last investigation to roll it out."