HospitalInspections.org

Based on interview, record review and policy review the hospital failed to:
- Timely and urgently educate staff following a patient elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and an attempted suicide (to cause one's own death) for two discharged patients (#45 and #46) of two medical records reviewed. (A-144)
- Follow their internal policy for prompt reporting of an attempted suicide for one discharged patient (#45) of two medical records reviewed. (A-144)
- Follow observation orders for one discharged patient (#47) of two discharged medical records reviewed. (A-144)
- Obtain a consent for treatment for eight patients (#11, #12, #13, #15, #29, #30, #31 and #32) of eight patients reviewed. (A-117)
- Provide the Important Message from Medicare (IMM, information about a patient's right to appeal discharge) for five patients (#12, #13, #14, #30 and #31) of 16 patients reviewed. (A-117)

These failed practices resulted in the noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Please refer to A-0117 and A-0144

Based on interview and record review, the hospital failed to ensure that patients on the inpatient Rehabilitation Unit (Rehab, an inpatient area staffed and medically supervised in the care and treatment of the physical restorative needs of patients) had a consent for treatment for eight current patients (#11, #12, #13, #15, #29, #30, #31 and #32) out of eight patients reviewed and failed to ensure that patients received the Important Message from Medicare (IMM, information about a patient's right to appeal discharge) for five current patients (#12, #13, #14, #30, and #31) of 16 patients reviewed.

Findings Included:

Review of hospital document titled, "Procedure for Registration Forms and Signatures," dated 12/31/18, showed:
- The Patient Access Department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process.
- The Condition of Admission and Consent is obtained for all types of registrations including inpatient.
- The consent form is signed upon registration and in conjunction with the physician's order that encompasses the entire episode of care.
- A consent is indexed to each account within the episode of care.
- If a patient was a Medicare or Managed Medicare inpatient, it is required that the Important Message from Medicare be issued within two days of the inpatient admission.

Review of Patient #11's medical record, admitted 04/25/24, showed no completed Condition of Admission and Consent.

Review of Patient #12's medical record, admitted 04/29/24, showed no completed Condition of Admission and Consent and no IMM notification.

Review of Patient #13's medical record, admitted 04/26/24, showed no completed Condition of Admission and Consent and no IMM notification.

Review of Patient #14's medical record, admitted 05/01/24, showed no completed Condition of Admission and Consent and no IMM notification.

Review of Patient #15's medical record, admitted 04/11/24, showed no completed Condition of Admission and Consent.

Review of Patient #29's medical record, admitted 04/18/24, showed no completed Condition of Admission and Consent.

Review of Patient #30's medical record, admitted 05/02/24, showed no completed Condition of Admission and Consent and no IMM notification.

Review of Patient #31's medical record, admitted 04/26/24, showed no completed Condition of Admission and Consent and no IMM notification.

Review of Patient #32's medical record, admitted 04/30/24, showed no completed Condition of Admission and Consent.

During an interview on 05/06/24 at 3:00 PM, Staff S, Inpatient Rehab Manager, stated that patients were discharged from the hospital and then admitted for inpatient rehabilitation. The nurses sent a form "Notice of Arrival" to admissions to notify them that the patient had arrived on the rehab unit. A copy of the consents arrived from the previous admission and an updated sticker was put on that copy of the consent. Registration did not come to the rehab unit to get new forms signed, they used the old forms, including the IMM.

During an interview on 05/08/24 at 9:15 AM, Staff TT, Patient Access Director, stated that patients admitted to the rehabilitation unit should have new consents. Original admission paperwork could not be used. The Patient Access Department should have obtained new signatures and this had not been done. Staff re-used signed admission forms and placed a new sticker on it. All patients should receive new documents including the IMM.

During an interview on 05/07/2024 at 10:30 AM, Staff U, Patient Access Assistant Director, stated that they didn't obtain new consents for the rehab admission or give patients a new IMM. "We just use the same paperwork that was obtained from the previous admission."

During an interview on 05/07/24 at 2:15 PM, Staff LL, Chief Nursing Officer (CNO), stated that it was in the policy that all patients that had been discharged and then admitted to the inpatient rehabilitation unit were required to have all new consents and paperwork completed for the current admission and that previous admission paperwork and consents could not be used. A new IMM must be given to patients.

Based on interview, record review and policy review the hospital failed to:
- Timely and urgently educate staff following a patient elopement (when a patient makes an intentional, unauthorized departure from a medical facility) and an attempted suicide (to cause one's own death) for two discharged patients (#45 and #46) of two medical records reviewed;
- Follow their internal policy for prompt reporting of an attempted suicide for one discharged patient (#45) of two medical records reviewed; and
- Follow observation orders for one discharged patient (#47) of two discharged medical records reviewed.

Findings included:

1.Review of the hospital's undated document titled "Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) and Action Plan Framework RF #7597 - Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) Elopement," showed:
- Patient #46 was a 21-year-old who arrived on 04/20/24 at 1:04 AM, via EMS, after ingesting 20 fentanyl (a medication used to treat severe pain and was a high-risk drug for theft and personal use) laced pills.
- At 1:07 AM, he was deemed a high suicide risk, placed on one to one (1:1, continuous visual contact with close physical proximity) observation, and required an inpatient psychiatric (relating to mental illness) admission.
- At 12:30 PM, he attempted to elope but was stopped by security staff.
- At 5:07 PM, he was strapped to a gurney by two EMS crew with four buckles and was taken out to the ambulance bay.
- At 5:08 PM, Patient #46 released the buckles, apologized to EMS crew, jumped off of the gurney, and fled the area.
- At 5:09 PM, EMS crew returned to the Emergency Department (ED) and notified staff that Patient #46 had eloped.
- A briefing was completed on 04/22/24 related to the elopement of Patient #46.
- A signed attestation was to be completed by all staff in the ED by 05/10/24.
- A meeting was held on 04/23/24 to develop a new policy for the discharge of high elopement risk patients and was to be completed by 05/10/24.

Review of the hospital's document titled "Transfer Process for Behavioral Health Patients," dated 05/2024, showed it would not be in effect until 05/10/2024. A huddle was to take place before the discharge of a high elopement risk patient with the Clinical Nurse Coordinator (CNC), staff, security supervisor, providers, and EMS crew.

Review of the hospital's documents titled "Registered Nurse (RN) Group" and "Tech/Medic/Safety Group," dated 05/01/24, and "Research Medical Center Emergency Services Huddle," dated 04/26/24, showed a huddle must occur prior to the transfer of a high elopement risk patient with the CNC, staff, security supervisor, providers, and EMS crew. High elopement risk patients were to be escorted out with security and a safety coordinator.

Review of Patient #46's medical record showed:
- He was a 21-year-old who arrived at the hospital on 04/20/24, at 1:04 AM, after intentionally ingesting 20 fentanyl pills in an attempt to harm himself.
- At 5:41 AM, he was evaluated, deemed involuntary (a legal process through which a person is hospitalized and treated for mental health disorders without their consent) and required an inpatient psychiatric admission.
- At 12:30 PM, he attempted to elope but was stopped by security and placed in a room instead of a hallway stretcher.
- At 5:07 PM, EMS placed him on a stretcher to prepare for transport to an inpatient psychiatric facility.
- At 5:09 PM, EMS returned and notified security that the patient had eloped.

During interviews on 05/06/24 at 1:45 PM, and 05/07/24 at 1:32 PM, Staff C, ED Director, stated that following the elopement a new policy required a huddle with the nurse, charge nurse, patient safety coordinator, and security for any patient deemed an elopement risk. There was no assessment criteria to deem a patient as an elopement risk, it was based on nursing judgement. Education after the elopement event started immediately; however, it was not documented. The first documented occurrence for the education was in a pre-shift huddle on 04/26/24. He acknowledged this showed a delay in the education of staff following the elopement of Patient #46. Staff did not sign an attestation.

During an interview on 05/06/24 at 11:45 AM, Staff LL, Chief Nursing Officer (CNO), stated that typically more documentation related to education following an incident was completed and she was unsure why that was not done following the elopement of Patient #46. She agreed house-wide education should have been done because a similar incident could occur outside of the ED.

During an interview on 05/08/24 at 11:45 AM, Staff YY, Quality Vice President, stated that house-wide education for all staff would occur related to restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) removal and the safe transfer of behavioral health patients. A roster with staff signatures would be obtained at the time of the education. She acknowledged that no documentation of the education provided to staff was obtained, as stated in the plan of correction provided to the State of Missouri in the self-report.

During an interview on 05/06/24 at 3:05 PM, Staff PP, Patient Safety Manager, stated that she knew more documentation of the education provided to staff after the elopement of Patient #46 was required and that education was not completed urgently.

During interviews on 05/06/24 at 2:45 PM, and 05/07/24 at 2:45 PM, Staff H, Nurse Manager, stated that education following the elopement event started immediately via an electronic messaging system and in-person huddles. She acknowledged the first written documentation regarding the education was dated 04/26/24 and that no other written records related to education were documented before this date. She stated that did show a delay in educating staff regarding the elopement of Patient #46.

Review of the hospital's undated document titled "RCA and Action Plan Framework, IR #7651 - Suicide Attempt," showed:
- Patient #45 arrived 04/23/24, at 6:57 PM, from a long-term care facility with a chief complaint of attacking staff at the facility.
- At 7:10 PM, violent restraints were applied due to violent, self-destructive behavior and aggression towards staff.
- At 7:53 PM, the restraints were removed from the patient and placed at the foot of the bed;
- On 04/24/24 at 1:10 AM, a monitor tech observed the patient grabbing the restraints and wrapping them around her neck. The monitor tech alerted the medic. The medic and monitor tech removed the restraint from around her neck and patient was observed as slightly cyanotic (blue to purplish discoloration of the skin due to low oxygen presence in the blood.)
- At 1:11 AM, a call was placed over the radio for staff assist.
- At 1:25 AM, violent restraints were applied due to violent, self-destructive behavior and aggression towards staff.
- At 1:25 AM, the physician noted suicide attempt by strangulation using restraint strap. She was cyanotic with ligature (anything which could be used for the purpose of hanging or strangulation) marks to her neck. Overall suicide risk was high.
- At 4:06 AM, the restraints were removed from patient and removed from the room.
- The investigation showed that synthetic restraints were left on the bed.
- Ligature risks, that were not essential for patient care, were not removed from the room after use of the intervention was discontinued.
- Safety huddle messages began on 04/26/24.
- Education was to be completed by 04/30/24; which included rounding by the charge nurse during the shift and a check of patients in restraints or recently removed restraints to ensure proper room set up for a suicide safe (a room that has been cleared of any objects a patient might use to harm themselves or others) environment.

Review of hospital document titled, "Serious Safety Event (SSE) Identification, Notification and Management," dated 04/01/24, showed:
- An event may be considered a SSE if it is a preventable adverse patient event, is indicative of a serious gap in safety systems, policies, or processes and directly increases risk of future occurrence of an SSE.
- When a SSE has occurred, the supervisor would immediately notify patient safety/risk management.
- Patient Safety/Risk Management would notify executive leaders and other key individuals, as appropriate and initiate an internal response within 60 minutes of discovery of the event.

Review of the hospital's undated document titled, "Pre-shift Huddle Agenda," showed when working in Pod 3 or with Suicidal Ideation (SI) patients, staff are not to pre-load the bed with restraints. Restraints should only remain at the bedside when actively in use on the patient. Restraints are single use and straps may be cut to decrease excess strap length.

Review of the hospital's document titled, "Emergency Services Huddle," dated 05/03/24 showed restraints were not to be left in the room and must be removed once the patient is taken out of the restraint. Restraints were for single patient use, and excess slack should be cut off to prevent any ligature risks.

Review of hospital's document titled, "Attestation Program Tracking Form, maintaining a psych safe environment in the Emergency Department," showed a list of handwritten names with no signatures, dated 04/29/24 through 05/07/24.

Review of Patient #45's medical record showed:
- She was a 48-year-old female who was transferred to the ED on 04/23/24 from a long-term facility for aggressive behavior towards staff.
- She had been brought in with physical restraints applied and when staff attempted to remove them, she became combative, and restraints were re-applied on 04/23/24 at 7:10 PM.
- Restraints were removed and a face-to-face evaluation by the physician was done on 04/23/24 at 8:05 PM.
- On 04/24/24 at 1:10 AM, she wrapped a restraint around her neck in a suicidal gesture.
- Ligature marks were noted on the neck and the patient became combative when staff attempted to remove the restraint from around her neck, the restraints were reapplied and the patient was sedated.
- Restraints were removed at 4:10 AM and she was placed on high risk for suicide.

During an interview on 05/08/24 at 9:00 AM, Staff VV, Monitor Tech, stated that she noticed on the video monitor that Patient #45 used the restraints that were left at the bedside and attempted to strangle herself. She stated that she immediately called for help and went to Patient #45's room as staff attempted to remove the restraints from around her neck.

During an interview on 05/07/24 at 2:30 PM, Staff MM, Medic, stated that she was called to Patient #45's room for an attempted suicide after the patient attempted to strangle herself with the restraints that were left at the bedside. She stated that the patient had been previously restrained, and staff left the restraints at the bedside. She stated that the restraints were long and definitely a ligature risk.

During an interview on 05/08/24 at 8:50 AM, Staff UU, Charge RN, stated he was called to Pod 3 for additional staff support on 04/24/24 at 1:00 AM. Patient #45 had used restraints left at the bedside in an attempt to strangle herself. She had ligature marks on her neck. He immediately removed everything that was a safety risk from her room. He did not notify the house supervisor of the event. He notified Administration at the Charge Nurse Meeting at 7:30 AM. He participated in safety huddles during his next scheduled shift.

During an interview on 05/08/24 at 10:30 AM, Staff YY, Quality Vice President, stated that the charge nurse did not report the event to the house supervisor. She stated that once the house supervisor was notified, they would notify the administrator on call. Administration was not aware of the event until 6:30 AM, five hours following the event. She stated that it was policy to immediately notify the house supervisor.

During an interview on 05/07/24 at 1:45 PM, Staff C, ED Director, stated that he was notified of the event on 04/24/24 at 6:30 AM. He reviewed the documentation of education that was submitted associated with the self-report to the State of Missouri and stated that "this was not appropriate education for the suicide attempt."

During an interview on 05/07/24 at 2:15 PM, Staff LL, CNO, stated that the education submitted for the self-report "was not appropriate" and that she expected additional education to have been done. She stated that her expectation of the charge nurse was to immediately notify the house supervisor of any events of self-harm or suicide attempt. The house supervisor would then notify the administrator on-call.

During an interview on 05/07/24 at 2:45 PM, Staff H, ED Manager, stated that the education that was submitted for the self-report was "not appropriate" and stated that they started education immediately in huddles but did not get attestations of the education. He stated he was not aware of the event until the Charge Nurse Meeting the morning of 04/24/24 at 7:00 AM.

During an interview on 05/07/24 at 3:15 PM, Staff PP, Patient Safety Manager, stated that she could not make the units submit education. She submitted the education that was given to her for the self-report. She stated that the education she submitted for the self-report was not adequate.

Review of the hospital's policy titled, "Behavioral Health: Levels of Observation," dated 10/2022, showed:
- One to one observation was ordered on a patient who is at immediate risk of harm to self and/or others (unable to make an alternative plan for safety and actively seeking ways to harm self and/or others).
- Line of sight (LOS, continuous visual contact with the patient) patient was to remain within visual contact of a staff member. Staff were to always monitor the patient to ensure safety, while maintaining the patient's privacy as much as possible.
- Patients who no longer meet criteria for elevated observation levels must have a physician order to discontinue LOS or 1:1 observation.
- Fifteen-minute checks, on admission, safety checks will be conducted in a random manner on all patients to maintain a secure and safe environment a minimum of every 15-minutes unless more intensive monitoring is ordered.
- The RN may place a patient on 1:1 observation, but only a physician may discontinue this level.
- Nursing staff will document in the progress note that 1:1 status is being maintained, criteria for continued 1:1 observation, or progress made in transitioning to a lesser level of observation.
- Patient location and behavior shall be documented every 15 minutes in addition to documentation in the progress note.
- The physician will document the assessment and criteria the patient meets for 1:1 status in the physician's progress notes daily.

Review of Patient #47's medical record showed:
- He was a 30-year-old male with a history of schizophrenia (serious mental disorder that affects a person's ability to think, feel, and behave clearly) who presented to the ED on 10/12/23 with auditory hallucinations (hearing things that are not heard by others, imaginary) and homicidal ideations (HI, thoughts or attempts to cause another's death). Prior to arrival at the ED, he told his guardian (the person appointed by a judge to manage the property and rights of another person who is considered incapable of doing so themselves) he needed to go to the hospital, he was hearing voices. Without warning, he attacked his guardian with a kitchen knife. After the ED provider's evaluation, he assaulted a police officer and chased a nurse practitioner (NP, a nurse who has advanced clinical education and training).
- He was admitted to the Behavioral Health Unit (BHU), placed on every 15-minute checks and no roommate.
- On 10/13/23, he attacked a peer by hitting him multiple times in the face with a closed fist. His plan of care showed increased chance of harming self or others.
- On 10/19/23, he attempted to swing at a peer.
- On 10/24/23, he punched a peer during shift change.
- On 11/01/23, he entered the dayroom, immediately approached the back of a peer and attempted to choke/strangle them.
- On 11/07/23, he punched a peer in the back of the head four or five times with closed fists.
- On 11/08/23, his mental status exam was positive for HI. An order was written to restrict him to the unit.
- On 11/11/23, he was reported to have been aggressive with a female staff member without warning.
- On 11/23/23, a peer came to the nurses' station window and stated that Patient #47 punched him in the face and ran back to his room.
- On 11/30/23, he attempted to choke a peer.
- On 12/01/23, his plan of care showed he failed to follow measures to prevent injury, danger or loss.
- On 12/06/23, he had a physical altercation with a peer.
- On 12/13/23, he randomly choked a peer.
- On 12/14/23, he was on the back of a staff member with his arms around their neck choking them. He later came out of his room and lunged at staff trying to punch them.
- On 12/15/23, he hit a peer in the back of the head. When he was approached by a RN, he attacked the RN. He then headbutted a staff member.
- On 12/26/23, he was involved in altercation with Patient #48. He had a small laceration above the left side of his lip. Later he walked to a peer that was not looking at him and struck him with a closed fist in the face. The observation orders were changed to LOS, while out of his room.
- On 12/26/23, 12/27/23, 12/28/23, 12/30/23, 01/07/24, 01/08/24, 02/09/24 and 03/02/24, he refused to discuss SI and/or HI.
- On 12/27/23, 12/28/23 and 12/30/23 his observation did not follow the LOS order, he was on 1:1 observation.
- On 12/29/23, his observation did not follow the LOS order, he was on every 15-minute checks.
- On 12/30/23, the provider progress note (PPN) showed precautions every 15-minutes checks.
- On 12/31/23 through 01/17/24, his observation did not follow the LOS order, he was on 1:1 observation.
- On 01/01/24 and 01/03/24, the PPN showed precautions every 15-minutes.
- On 01/04/24, he charged at a Mental Health Technician (MHT). The PPN showed precautions every 15-minute checks.
- On 01/07/24, the PPN showed precautions 1:1.
- On 01/16/24, the PPN showed precautions LOS during the day and 1:1 at night.
- On 01/22/24, an order was placed to restrict him to the unit.
- On 01/23/24, the PPN showed precautions 1:1.
- On 01/24/24 through 01/26/24, his observation did not follow the LOS order, he was on every 15-minute checks.
- On 01/29/24, he punched another male patient.
- On 02/01/24, he had a witnessed fall. He jumped up and charged at a MHT and the intervening RN. Twenty minutes later he jumped out of bed and charged at the MHT. Later he attempted to swing at and bite the medical provider. When released from a therapeutic hold (treatment technique in which a violent patient is physically contained by people), he attempted to charge at the staff. After he was released from seclusion (the involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving), he charged through the seclusion room door and attempted to attack the MHT. Later the patient ran out of his room, put his hands around a staff member's neck and started choking him. His observation did not follow the LOS order, he was on every 15-minute checks.
- On 02/05/24, the PPN showed precautions LOS and 1:1 when out of room. His observation did not follow the LOS order, he was on every 15-minute checks.
- On 02/06/24, he ran out of his room, put his hands around a staff member's neck and started choking him. His observation order was changed to 1:1.
- On 02/09/24, he grabbed the 1:1 observer's neck. When other staff arrived, he continued to strike, kick and lunge at them. Later staff attempted to offer dinner, the patient threw the food and lunged at the RN.
- On 02/10/24, he randomly, completely unprovoked, lunged at the 1:1 staff member.
- On 02/16/24, he advanced towards the 1:1 observer and was de-escalated. While debriefing he again lunged at the MHT.
- On 02/18/24, he banged his head against the bathroom door. The RN attempted to assess him, he lunged at the RN, put his hands around the RN's neck and began to squeeze.
- On 02/19/24, he sexually assaulted the 1:1 MHT by grabbing her breast and butt.
- On 02/22/24, he got into a physical altercation with a peer. Later he charged at and attempted to hit his 1:1 observer.
- On 02/26/24, he charged at a male peer.
- On 02/27/24, he charged at a male peer. When talking to the RN he grabbed the RN and had his arm around her neck and took her down to her knees and onto the ground. Later he charged at a female RN in the hallway. An observation order for 1:1 was written with room door closed while the patient was in the room. Continue every 15-minute checks. Staff were not to enter his room alone at any time.
- On 03/03/24, he charged at and hit a peer in the hallway.
- On 03/07/24, he grabbed a nurse walking down the hallway and began to choke him. He later exited his room and attacked a MHT. Later he ran out of his room towards a nurse with his hands up in a double hand choke stance. He contacted the nurse's neck with both hands.
- On 03/11/24, his observation did not follow the 1:1 order, he was on every 15-minute checks.
- On 03/22/24, he voluntarily walked to the quiet area and, unprovoked, he hit a male peer three times in the face.
- On 03/27/24, he was discharged into police custody.

During a telephone interview on 05/08/24 at 10:00 AM, Staff XX, Physician, stated that a provider order was required to change a patient's level of observation. Patient #47 was mostly observed by LOS or 1:1. With increased violence he was placed on 1:1 observation. His activity was restricted because of his behavior. Any modification in his activity required a provider order. Review of Patient #47's medical record showed inconsistent documentation.

During an interview on 05/27/24 at 2:10 PM and 05/28/24 at 9:00 AM, Staff LL, CNO, stated that a physician order was required for LOS and 1:1 observation. Every 15-minute rounding was a standard in the BHU. The hospital did not have a policy for the management of patient to peer and/or staff abuse.

During an interview on 05/07/24 at 3:07 PM, Staff QQ, Assistant CNO, stated that a provider order was required for 1:1 observation. Extra staff members were assigned to 1:1 observation of Patient #47 without a provider order for 1:1 observation.

During an interview on 05/07/24 at 3:25 PM, Staff RR, Nurse Manager, stated that a provider order was required for 1:1 observation.

During a telephone interview on 05/07/24 at 5:30 PM, Staff SS, Licensed Practical Nurse (LPN), stated that observation orders change per the provider orders. Staff followed the current observation order; observation frequency was shared in report. Patient #47 was "completely unpredictable."



48359