HospitalInspections.org

Based on observation and interview, the facility failed to post required signage in 2 of 2 treatment rooms (regular treatment room and trauma room) observed.

Findings included:

On the afternoon of 1-26-2021, a tour of the Emergency Department was made. During a tour of the patient treatment rooms (regular treatment room and trauma room), the surveyor observed that required signage specifying the rights of persons with emergency medical conditions and women in labor was not present. This was confirmed by Staff #3 and Staff #4. Staff #4 confirmed that, at times, patients were transported by ambulance and would go directly from the ambulance to the patient treatment room.

This process would not allow patients the opportunity to observe signage that had been posted elsewhere in the Emergency Department. Patients arriving in this manner would not have the opportunity to view their rights while waiting in the treatment room.

Based on review of records and interview, the facility failed to ensure the Central Log contained complete information in 5 patient entries (Patient #19, #20, #21, #22, and #23) out of 1055 entries on the Central Log for the month of January and 2 patient entries (Patient #10 and Patient #18) out of 10 patients identified as leaving Against Medical Advice (AMA) for their disposition had the incorrect disposition identified.

Findings included:

Records for patient who left the Emergency Department Against Medical Advice (AMA) were reviewed on the morning of 1-26-2021 with Staff #15 in the conference room. Central Log entries without discharge/disposition information were reviewed on the afternoon of 1-26-2021 with Staff #15 in the conference room.

Review of the Central Log showed that Patient #10 left the Emergency Department Against Medical Advice (AMA). Review of Patient #10's medical record was showed that Patient #10 was admitted to the hospital as an inpatient. Staff #15 confirmed the information on the Central Log was incorrect.

Review of the Central Log showed that Patient #18 had left AMA. Review of Patient #18's medical record indicated that Patient #18 had eloped after the Medical Screen. The record did not contain documentation of the risks of leaving AMA as explained to the patient or a copy of the completed AMA form. Staff #15 confirmed that documentation in the record showed the patient had eloped and had not been discharged AMA.

Review of the Central Log showed that 5 patient entries for the month of January were missing discharge dates, discharge diagnosis, and/or disposition information. Staff #15 reviewed the entries in the computer and determined the 5 patients had left the ED prior to care being completed. Staff #15 explained that there appeared to be a problem with the way the patients were being removed from the ED record in the computer that was creating the incomplete record on the Central Log.

Based on review of records and interview, 2 (Patient #1 and Patient #2) of 2 psychiatric patients were allowed to leave the Emergency Department without completion of a psychiatric assessment as part of the medical screening examination to ensure the patient was safe to leave. Patient #1 and Patient #2 had been identified as being a danger to themselves and/or others upon initial assessment but had not been held involuntarily until a psychiatric evaluation was performed and the patient had been evaluated as not being a danger to self and/or others.

Findings included:

A review of the Central Logs for August 2020 through January 25th, 2021 was made on 1-25-2021. There were 24 patients identified with psychiatric complaints/diagnosis. All were either transferred to another facility or discharged home. No psychiatric patients were found on the log as having left the Emergency Department Against Medical Advice (AMA).

In January 2021, there were 5 psychiatric patients identified as transfers and 2 psychiatric patients (Patient #1 and Patient #2) identified as leaving AMA.

Patient #1

Review of Patient #1's chart was made on 1-26-2021. The record showed that Patient #1 arrived at the Emergency Department on 1-11-2021 at 9:24 AM. On 1-11-2021 at 1:34 PM, the patient was evaluated by a Qualified Mental Health Professional (QHMP) from the local mental health authority. The QMHP faxed the report to the Emergency Department on 1-11-2021 at 2:18 PM with the following evaluation/recommendations:

"In my clinical opinion, (Patient #1) does appear to be in imminent risk of harm to self or others due to apparent functional impairment evidenced by his level of delusions, disorientation, reckless behavior, & refusal of treatment."

"Higher level of care recommended. Due to level of disorientation, a MHW (mental health warrant) or EPOW (Emergency Peace Officer Warrant) must be obtained."

On 1-11-2021 at 4:34 PM, Staff #8 documented, "Pt walked out of department, Dr. (Staff #6) encouraged pt to remain for continued treatment, Pt continued to walk out without response." Staff #8 did not document the notification of the local mental health authority staff or notification of the police.
Staff #6 documented in the physician's comments, "Most consistent with psychosis and/or schizophrenia. No documented history of mental health disorder presently. Evaluated by (local mental health authority) and they recommend admission. Patient eloped from the ER after completion of the ER evaluation but prior to finding a bed. Police notified."

During pre-survey preparation, the local police department had been contacted on 1-21-2021 at 4:00 PM. The local police department reviewed the call logs for 1-11-2021. No record of a call advising of Patient #1 leaving the hospital emergency department was found during the review.

Interview with Staff #8 was conducted on the afternoon of 1-26-2021. Staff #8 stated that she did not call the police department. Interview with Staff #6 was conducted on the afternoon of 1-26-2021. Staff #6 stated that he did not call the police department but would have asked the nursing staff to call. No record was found documenting that the nursing staff called the police department.

Staff #6 was asked why an order to hold the patient involuntarily and an Emergency Detention Warrant through the local magistrate was not requested. Staff #6 stated that the patient had been cooperative up until the time he decided to leave. When asked why he was involuntarily detained at that time, Staff #6 stated that the nursing staff would be place at risk of harm trying to prevent a patient from leaving. Staff #6 stated that the staff were mostly women and could not be put in a position where they may be harmed. When asked, Staff #6 confirmed that there was not a set process or plan to prevent psychiatric patients from leaving the ER.

Interview with Staff #3, Staff #4, Staff #7 and Staff #8 conducted at separate times revealed that all four believed that they could not hold the patient against their will. If a patient stated they wanted to leave, they had to let that patient leave.

Review of the Restraint and Seclusion log showed that the only restraints used since March 2020 were nonviolent restraints for medical patients.

Patient #2

Review of Patient #2's chart was as follows:

Patient #2 arrived at the Emergency Department on 1-14-2021 at 11:27 PM. Under "Visit Information: Reason for Visit" the nurse documented, "Spoke with a counselor Tues. who recommended in patient treatment for detox Pt drinks daily and vomits when he has no alcohol". The patient was assessed using the Patient Health Questionnaire. Patient indicated that he felt like hurting himself "nearly all the time". The patient scored a 23 overall on the questionnaire, Moderate or Severe, with an observation level of one-to-one (one staff member to one patient) due to the risk.

The physician notes were as follows:
"Patient presents requesting to get "alcohol detox" ... Earlier today he was frustrated and angry and he punched a truck, suffering abrasions to the knuckles of his left hand. He states that he frequently has suicidal thoughts, almost on a daily basis, and the past has occasionally acted on them but only in nonlethal ways. Earlier today he told his wife he was thinking of suicide by cop, but currently was not suicidal."

The nurse's notes from 1-15-2021 at 12:39 AM documented that the patient asked if was on an involuntary hold. When told he was not, he stated he was leaving. He was given his clothes back and left the Emergency Department prior to signing an AMA form. The nurse charted, "Went outside and spoke to wife. Informed her that he was a voluntary pt and we could not keep him here against his will. Informed her I had let the Jasper PD know about him. Explained that she could go to a judge and get a warrant for 72 hr evaluation if she was concerned bout his safety or to the safety of others. Pt was sitting in car in parking lot at this time."

Despite having a suicide screening tool that indicated Moderate to Severe risk and the patient stating he had suicidal thoughts almost daily with thoughts earlier in the day of suicide by cop, the physician documented:
"Patient is not suicidal and was getting a voluntary psychiatric clearance screen work-up and was preparing to talk to the remote psychiatric assessment team regarding whether or not he could get inpatient placement for alcohol detox. During this time, while I was in bed 1 suturing a stabbing victim, the patient decided he no longer wanted to pursue this course of action and eloped. As he was not actively suicidal I do not feel it necessary to send the police to find him right now."

Other than the documented patient statement that he wasn't currently thinking of suicide, no objective information that the risk of suicide had lessened from the original moderate to high risk identified on the original Patient Health Questionnaire completed upon admission. The patient was allowed to leave before the remote psychiatric team could evaluate the patient and make recommendations for treatment.

Staff #6 was interviewed on the afternoon of 1-26-2021. After reviewing the notes, Staff #6 stated that since the patient was seeking voluntary treatment for alcohol abuse, the physician had to let the patient go. Despite the screening that indicated the patient had thoughts of harming himself daily, had acted on those thoughts in the past in non-lethal ways, had considered suicide-by-cop earlier in the day, had injured his hand earlier in the day by punching a truck, the physician did not order an involuntary hold and request an emergency detention warrant through the local magistrate so that a full mental health assessment could be completed to ensure that the patient was not a harm to self or others.

Review of the policy titled "Care of the Suicidal Patient"; Policy Number: 3.082; revised/reviewed 3/2020 was as follows:

"IV. DEFINITIONS:

A. Suicide Screening Tool: The Patient Health Questionnaire 9 (PHQ9) is an appropriate suicide-screening too for individuals twelve years of age and older as well as postpartum individuals. The PHQ9 screening tools for adults and teens have both been validated for use with the targeted age groups. The PHQ9 tool is a multipurpose instrument for screening, monitoring, and measuring the severity of depression. The PHQ9 tool also identifies those who are expressing thoughts of death or self-injury (question number 9).

...

V. PROCESS/PROCEDURE
...
6. Patients will be considered at "Severe" risk for suicide when they meet one of the following conditions:
a. Have a total PHQ9 score of twenty or more OR
b. Present with treatment related to a suicide attempt"