HospitalInspections.org

Based on observation, review of policies & procedures, review of medical records, and interviews with staff, the Emergency Department (ED) staff failed to implement systems assuring a safe and functional environment for patients with psychiatric conditions. The ED census at the time of the incident was 10 patients with medical complaints and 1 patient (Patient#16) with a psychiatric complaint on arrival to the hospital ED.

The ED staff was aware the patient presented to the ED with his family with complaints of an altered mental state. The ED staff and security failed to protect Patient #16's safety by allowing him to walk out of the ED department and exit the hospital while barefoot and dressed in paper scrubs. At the time Patient #16 walked out of the ED, the outside temperature was 2 degrees Fahrenheit and the wind chill was -21 degrees Fahrenheit. Staff followed the patient down a corridor, into a lobby, and out the exit door without attempting to prevent the patient from exiting the building in paper scrubs and barefoot. Once the patient was outside the building, the security officer re-entered the hospital to get a coat and notify the police of the elopement. When staff went back outside the hospital, they followed the patient until losing sight of him.

The cumulative effect of these systemic failures and deficient practices resulted in the hospital's inability to ensure the safe care and monitoring of the psychiatric services for an ED patient and this resulted in the patient's death.

Refer to A 144.

Based on review of hospital policies & procedures, job descriptions, medical records, personnel records, video footage, documents, and staff interview, the Emergency Department (ED) Staff, and security staff failed to protect Patient #16's safety by allowing the patient to elope (walk away) from the ED and the hospital in frigid weather conditions while barefoot and wearing paper scrubs. The ED staff and security staff were aware that the patient had presented to the ED with psychiatric complaints.

Failure of the staff to attempt to intervene and prevent the patient from leaving or to bring the patient back in from the frigid weather conditions resulted in the patient dying from exposure to the extreme weather conditions. The patient's body was discovered by police 17 days after eloping from the hospital's ED. The patient's body was found covered by a tarp and laying between 2 storage sheds on private property approximately 300 feet from the hospital's east entrance.

The ED nurse manager reported the ED furnished care to an average of 93 patients daily with an average of 6 psychiatric/behavioral health patients daily.

Findings include:

1. Review of the following hospital policies and job descriptions revealed the following information applicable to the complaint investigation.

a. The hospital policy titled "Patient Rights" dated 3/19/12, revealed the following in part, ..."As a patient...you have the right to...Receive considerate and respectful care, consistent with sound medical and nursing practice, in a...safe and secure environment."

b. Review of "Charting policies" revised 4/14, revealed the following in part, ..."The chart is a continuous legal record of a patient's care. Documentation reflects the assessment of a patient...evaluation of the care being provided and the patient's response...individuals have access to those part of a patient's medical record which provide pertinent information needed to assess patient, develop a plan of care, deliver plan of care or measure outcomes."

c. Review of job description titled "Registered Nurse (RN)" revised 1/21/15, revealed the following in part, ..."The RN conducts an initial assessment to gather data...identifies patient problems and ...communicates relative information to the team...communicates relevant clinical information to physician's regarding the patient's condition....utilizes the Patient Care Policies and Procedure as references to guide nursing practice."

d. Review of job description titled "Security Officer" revised 1/14, revealed the following in part, ..."Secures patient...takes proactive steps to prevent problems...coordinates efforts to maintain/improve safety."

2. Review of video footage captured on the hospital's security cameras throughout the hospitals ED showed the elopement of Patient #16 from the inner core of the ED. He walked through the hospital to the parking lot.

The video showed the patient walking while a Physician's Assistant (PA), a registered nurse (RN) and a security officer watched him. The staff present did not intervene or attempt to bring the patient back when they saw he was barefoot and only dressed in paper scrubs. The weather conditions outside at the time of the elopement were frigid. The temperature was 2 degrees Fahrenheit with a wind chill of -21 degrees and there was still some snow on the ground.

At 8:46 AM, Patient #16 exited the hospital, Staff H, RN, and Staff F, Security Officer watched the patient exit. They did not attempt to intercede on behalf of the patient's well-being or safety. Staff F followed the patient outside but returned to the hospital to get his coat, hat, and gloves. When Staff F returned to the exit the patient had already reached a street front of the parking lot. Patient #16 lived with family on this street in an apartment complex located 3 blocks from the parking lot. The security officer lost sight of the patient after he crossed the street. The patient had reached the street and was no longer in plain view of the cameras. The approximate distance from the time the patient started walking down the inner core of the ED to the end of the parking lot was 1,125 feet or approximately 2 blocks. The video showed the patient was walking, not running at any time as he left the hospital campus.

3. Observations by the surveyor on 3/16/15 at approximately 3:00 PM, of the route Patient #16 walked from the behavioral examination room to the street on 2/22/15 revealed: The patient walked down the inner core of the ED, approximately 100 feet to the lobby exit doors. The patient walked 15 feet out into the lobby having opened 2 large doors. The patient walked 15 feet through the lobby and another 110 feet down a hallway to the main entrance doors where he exited to the outside. The patient walked down the hospital's parking lot another 200 feet to the street.

At the time of the observation Staff D, RN/ED Nurse Manager, said the patient lived in an apartment building located on the street he crossed that day approximately 2-3 blocks from the entrance to the hospital's parking lot.

4. On 3/17/15 at 11:32 AM, Staff P Plant Operations, provided an exact total distance traveled by Patient #16 from the time he walked out into the inner core and the area where Staff F, Security Officer lost sight of the patient, was 1,175 feet or approximately 2 blocks. He also provided an exact total distance from the hospital where the patient's body was discovered 17 days later, was 300 feet from the east side of the hospital campus.

5. During an interview on 3/23/15 at 10:35 AM, the State Climatologist reported the following frigid weather conditions at the Waterloo airport on 2/22/14: The last snow event: 2/3/15. At 8:54 AM - Actual temperature was 2 degrees Fehrenheit. The winds that day were out of the North Northwest (NNW) at 24 miles per hour (mph) creating a wind chill of -21 degrees Fehrenheit.

6. Review of Patient #16's medical record revealed:

A triage nursing note, at 6:56 AM, completed by Staff J, RN lacked information regarding the patient's condition upon arrival to the ED, nursing observations of the patient's behavior or symptoms demonstrated by the patient and information reported to the nurse by the patient and/or family regarding recent changes in the patient's behavior.

A nursing note documented care transferred from Staff J to Staff H, RN at 7:20 AM. The note lacked documentation of change-of-shift reporting and patient information handoff. Staff H documented the patient was changed into paper scrubs. The note lacked specific observations of the patient's behavior or any information that may have been reported to Staff H by family members.

A nursing note, at 8:35 AM, completed by Staff H, documented Patient #16 requested to go home, the Physician Assistant (PA), Practitioner C informed the patient he was free to go and staff would discharge the patient. Patient #16 started walking out of the ER into the lobby and exited the hospital dressed in paper scrubs and barefoot. The note documented the patient avoided staff and then started running.

A Clinical History or Present Illness summary, at 7:53 AM, completed by Practitioner C, PA , documented the following in part, ... " Presents to ED today for psych eval ...speaks English ...accent very difficult to understand ...states for past week ...mind disturbed and is forgetting things ...have reviewed and agreed with RN note ...history comes from patient ...slight language barrier exits during history ...therefore difficult to obtain a good history ...Mood and affect normal. "

A progress note, at 8:01 AM, completed by Practitioner C, documented the patient wanted to go home, refused discharge papers, and eloped. Prior to the patient leaving the practitioner documented the patient denied suicidal or homicidal thoughts or hallucinations and he felt the patient was free to leave. Practitioner C noted the patient walked out into single degree weather wearing only paper scrubs and that behavior demonstrated concern for the patient safety. Practitioner C documented any attempts by staff to stop the patient from eloping were unsuccessful and the patient ran. Police were notified and Practitioner C contacted the magistrate's court to obtain an order for committal. Practitioner C documented a primary diagnosis at 9:08 AM of Delusional Disorder.


7. During interviews with the ED nursing staff reported the following information.

a. On 3/16/15 at 2:30 PM, Staff R, RN reported the following information. Patients received their rights and responsibilities from the registrar clerks when they present to their hospital for care and services. The hospital educated nursing staff in orientation training on how to access hospital policies readily available for staff at any time on the intranet. The hospital educated nursing staff to place patients in paper scrubs for the patient and staff safety when they are admitted to the ED with psychiatric complaints .

b. On 3/19/15 at 7:30 AM, Staff L, RN reported the following information. The hospital educated nursing staff to assess psychiatric patients for any changes in mood or behaviors, conduct interviews with the patient and family to get their input of the patient's condition, and report this information to the provider. The hospital educated nursing staff to document all information in the patient's record. Staff L said this was critical so the provider can assess the patient to determine if the patient's needs are being met ultimately providing the appropriate care and treatment the patient may require.

c. On 3/19/15 at 8:10 AM, Staff M, RN reported the following information. If a patient is admitted to the ED with a chief complaint of psychiatric evaluation, they are placed in paper scrubs for their safety. The nursing staff are to inform the provider of any comments the patient or family members make during the nursing assessment to ensure the patient is evaluated as soon as possible by the physician. The reason for this was any delays in treatment may result in the patient becoming increasingly anxious. The staff received education in the use of the electronic medical record and were instructed in the free text tab nurses could document whatever the family says or anything any observations or feelings about a patient. Staff M added if a nurse failed to put critical information in the patient's medical record it wasn't done and this is standard nursing practice.

8. The following interviews were consistent with the events related to the arrival and elopement of Patient #16 from the hospital and the failure of the hospital staff to comply with the Patient Rights requirements as directed by hospital policy.

a. During an interview on 3/17/15 at 8:05 AM, Staff F, Security Officer, reported the following information. Their office received a call on 2/22/15 at 8:25 AM, requesting security staff come to the ED to watch a patient. Then the call was canceled minutes later. At 8:45 AM Staff F went to the ED. Upon arrival to the ED, Staff H, an ED RN, told him a patient had just left. At that time he noticed Patient #16 barefoot and dressed in paper scrubs exiting the hospital. Staff H said the patient was free to go. Staff F reported he called out to the patient, the patient paused and looked at him but continued walking. He was concerned for the patient's well-being because it was so bitter cold outside and there was snow on the ground. He went outside and called out to the patient. The patient paused and looked at him but continued walking down the parking lot.

Staff F went back inside to get his hat, coat and gloves and then went back outside. By the time he got back outside the patient had walked approximately 300 feet across the parking lot and a street running parallel to the parking lot. Staff F continued walking towards the patient and at one point the patient turned and looked back at him again. At that point the patient was a "big" distance ahead of him and he lost sight of the patient. He said he turned and walked back to the hospital and called the police to inform them a patient had left the hospital and was not dressed to be out in the type of weather conditions that existed. He went back to the security office at 10:00 AM and contacted the house supervisor. Staff F reported they had a security policy directing security staff if a patient is "free to go" they did not have the authority to detain them. Staff F denied any attempts to intervene or redirect the patient physically while he observed the patient walking away from the hospital because the patient was "free to go."

b. During an interview on 3/17/15 at 9:15 AM, Staff G, Security Officer, provided the following information. He confirmed their office received a call on 2/22/15 at 8:25 AM requesting assistance to watch a patient. Staff G said shortly after the call was canceled. Staff G said he went to the ED at 8:35 AM and observed Patient #16 exiting a bathroom in the ED outer core, walking toward a behavior health exam room accompanied by Staff H, RN. He assumed this was the reason for the call to assist. Staff G spoke with Staff H and she told him there were communication issues with Patient #16's family. He said she told him they didn't speak English very well. Staff G left the area and he received a call from Staff F, approximately 5 minutes later, informing him a patient had eloped form the ED and was walking outside. He did not respond to the call. At 8:47 AM, he made a non-emergent call to the local police to alert them a patient had eloped from the hospital because at that point they were concerned the patient was not dressed properly for the bitter cold temperatures. Staff F said security did not have the authority to detain Patient #16 because the patient was "free to go" and was being discharged.

c. During an interview on 3/17/15 at 1:35 PM, Staff J, RN reported the following information. He triaged Patient #16 on 2/22/15. There were 2 family members with the patient. He took the patient and 2 family members (an aunt and uncle) to a regular exam room. The uncle said they were very concerned with recent changes in the patient's behavior. Staff J said the patient's chief complaint sounded like anxiety but after spending some time with the patient he felt there may be something else going on. It was the change of shift so he gave report to Staff H, RN. When Staff J left, Patient #16 was wearing street clothes and shoes.

During a follow up interview on 3/18/15 at 11:00 AM, Staff J acknowledged failing to document a complete triage assessment including the patient's anxiety level and the concerns expressed by the patient's family members. He acknowledged he failed to inform Practitioner C of the patient's status prior to leaving that morning. Staff J admitted he should have documented more information in the patient's medical record stating "I dropped the ball."

d. During an interview on 3/17/15 at 2:10 PM, Staff H, RN reported the following information. On 2/22/15, she took charge of Patient #16 from Staff J, RN. The patient and 2 family members were waiting in a regular exam room. She was informed by the family that Patient #16 wasn't sleeping, was stating people were watching him, hiding from the family, and peeking out windows. Staff H acknowledged she failed to document this information in the patient's medical record but remembered thinking there was obviously something out of the ordinary going on with Patient #16.

She said the patient was quiet, and she got a "funny feeling" from what she was observing and hearing from the family, so she decided to move the patient to one of the behavior rooms. As they made their way to the room she instructed the patient to go to the bathroom remove his coat, clothes, and shoes and put on the paper scrubs she gave him. After the patient undressed and put the paper scrubs on, the patient's belongings were put in a clear plastic bag and she placed them in a file cabinet in the ED's central core. Staff H acknowledged she failed to document this information in the patient's medical record at the time it occurred. At that point she viewed the patient as a psychiatric patient although he was cooperative and did not appear to be a threat to himself or others.

After they got to the behavior room, the patient said he felt confused in his head. The patient's affect was flat, a severe reduction in emotional expressiveness. The patient responded to questions but did not initiate conversation. Staff H said her first thought as a nurse showed the patient was exhibiting schizophrenic behaviors and the direction would be admitting him to the hospital's behavior unit for psychiatric evaluation and observation. She said she based her opinion of the situation on an instinct and her "gut" feelings. Staff H acknowledged she failed to document this information in the patient's medical record at the time it occurred and she failed to communicate any information to Practitioner C, the PA on duty.

Staff H reported she had contact with Patient #16 and his family three times while they were in the behavior room but failed to document this in the patient's medical record. She said at some point she realized the family was gone and the patient was alone. She said she was under the impression Patient #16 was going to be admitted and thought this was why the family members left.

At approximately 8:30 AM, she saw the patient approach Practitioner C in the inner core and heard the patient say, "I want to go home." She said she watched the patient walk down the inner core toward the lobby exit doors. Staff H said she called out to the patient, the patient turned to look at her, but continued walking. She said she saw the patient walk across the lobby to the visitors exit doors and go outside. Staff H said she opened the lobby exit doors and called out the patient's name again. The patient turned to look at her but continued walking. She said Staff F, joined her at the door and Staff F went outside to watch the patient.

Staff H denied attempting to intervene or redirect the patient while she observed the patient eloping because it was "bitterly cold" outside. Staff F was watching the patient, and ultimately the patient was "free to go" even if he was only barefoot and dressed in paper scrubs.

During a follow up interview on 3/18/15 at 9:30 AM, Staff H acknowledged Patient #16's medical record failed to give a clear picture of what was happening. She admitted if they had searched his belongings after the patientand found the wooden handled utility knife with a 5 inch serrated blade, things may have gone differently but did not feel this would have changed the course of events.

Staff H acknowledged critical information should have been documented in the patient's medical record prior to Practitioner C's medical assessment, in order for them to provide appropriate care and services for Patient #16.

e. During an interview on 3/17/15 at 9:30 AM, Staff I, Behavior Health Director, provided the following information although she was not involved with Pateint #16's care.

Hospital policy directs staff to put patients in paper scrubs for their safety and limiting access to contraband or objects that could be used as weapons. When a patient presents to the ED with behaviors that are unusual or out of the ordinary this may indicate the patient is on "edge" and staff should consider mental health issues and immediate safety concerns. Insomnia, a lack of sleep, exacerbates paranoid or psychotic behaviors.


Staff I acknowledged Patient #16 met the criteria for 23 hour observation to their behavior health unit. After reviewing call logs for the behavior unit on the morning of 2/22/15, Staff I confirmed they did not receive notice from the ED for a psychiatric evaluation for Patient #16. She acknowledged if the ED staff had searched the patient's belongings and found the knife it would warrant additional investigation. ED Staff should ask the patient why they're carrying a knife and what they intend to do with this. Staff I said this clearly indicated Patient #16 exhibited poor judgement.

During a follow up interview on 3/18/15 at 10:35 AM, Staff I emphasized the importance of documenting anything a patient may say or a family's story of what is happening in the medical record because it is going to be vital in how a physician provides care and treatment to the patient.

Staff I said if a patient exhibiting poor judgement leaves the hospital, this places them at risk for their own personal safety and well-being. Staff I said she would follow the patient, call 911, approach them and attempt to redirect them back to safety. If nursing staff had documented Patient #16's behaviors in his medical record, an Access Nurse in the behavior health unit would have been contacted for an admission to their unit. She confirmed there were 5 adult behavioral health beds available for patient admission on the morning of 2/22/15 . Staff I said the hospital had a policy/procedure containing criteria guidelines for admission of patients to the behavior health unit.

Review of policy titled "Admission Criteria" for Psychiatric patients that is accessible by all departments through the intranet policy manuals revealed the following in part, ..."Admission Criteria - inpatient adult...imminently dangerous to self...severe depression...decreased level of function...fixed delusions...hallucinations." Review of documentation from Staff I, on the policy, revealed: "20/20 hindsight, could he Patient #16 been admitted - yes."

f. During an interview on 3/17/15 at 12:30 PM, Practitioner C, PA, reported the following information. He assessed Patient #16 on 2/22/15 at 7:53 AM. He did not recall speaking with Staff H prior to seeing the patient but confirmed he reviewed the patient's medical record. Practitioner C said the patient's demeanor was calm and his face expressionless. He said although the patient's accent was thick the patient insisted on speaking to him in English. He verified the patient arrived to their ED for psychiatric evaluation and screening to determine if the patient was an immediate harm to himself or others. He said the plan was to discharge the patient with a referral for outpatient psychiatric services. Practitioner C said he asked Patient #16' s aunt if she had any concerns and she told him "no."

Practitioner C said when the patient said he wanted to go home, he advised the patient to wait for discharge instructions. The patient started walking down the inner core of the ED towards the lobby. Practitioner C reported he did not attempt to intervene or redirect Patient #16 physically, because the patient was "free to go." and they were not able to physically hold the patient. Patient #16 did not demonstrate psychotic indicators or impaired judgement up until when he walked away from their hospital. When the patient decided to leave and go outside exposing himself to winter weather conditions in 2 degree temperature while dressed only in paper scrubs, the patient demonstrated impaired judgement.

Practitioner C said when the patient eloped he ordered Staff H to call the police and contacted the magistrate to obtain a legal hold to admit the patient when he returned to their hospital. Practitioner C admitted when the family left around 8:30 AM, in hindsight, this very well could have been the precipitating factor for Patient #16's leaving.

During a follow up phone interview on 3/18/15 at 12:30 PM, Practitioner C stated if Staff H had informed him of the patient's behaviors reported to her by the family or any other concerns, this information would have been critical for the patient's psychiatric assessment. Practitioner C said if hospital staff had searched Patient #16's belongings and found a knife, he would have consulted a psychiatrist to seek their opinion for possible admission to the hospital. Practitioner C said at that point the patient may have met the criteria for possible admission to their behavior unit for further psychiatric evaluation.


g. During an interview on 3/18/15 at 9:15 AM, Staff N, RN/House Supervisor said she was in the ED on the morning of 2/22/15 around 8:30 AM. Staff N said she observed Patient #16 walking out into the inner core and talking with Practitioner C. She said she recalled Practitioner C telling her the patient came in with a known history of schizophrenia but was not suicidal. Practitioner C was planning on discharging the patient. Staff N said, Staff H called her minutes later reporting a patient had eloped. Staff N said upon returning to the ED, Staff H reported when evaluating the patient he seemed paranoid and had a known history of paranoia. Staff N instructed nursing and security staff to complete an incident report. She contacted the Risk Management/Quality Director and the ED nurse manager. Staff N said she spoke with the police approximately 2 hours after Patient #16 eloped and they said a missing persons report had been filed.

h. During an interview on 3/18/15 at 2:45 PM, Staff K, RN/Director of Nursing Operations for the ED said when Patient #16 presented to the ED the morning of 2/22/15 it was "unusually busy". Staff K acknowledged Staff J, RN completed and documented a "limited assessment" of the patient. Staff K said Staff H, RN failed to document a more "descriptive assessment" of the patient's behaviors, what she had observed and felt, and what the patient's family told her.

i. On 3/19/15, at approximately 8:30 AM, the Chief Nursing Officer documented, "The expectation of all nurses in the ED would be to complete and accurately document all information obtained in assessment in the patient's electronic health record."

9. Review of document titled "Patient event summary" dated 3/18/15 at 10:30 AM and signed by Staff C, Risk Management/Quality, revealed the following in part, ..."On Sunday, 2/22/15, I noted, via media, that there had been a missing person's report released for Patient #16. It was noted he had left...Covenant Medical Center...Per Staff O, RN/House Supervisor, although he was not present during the event...he told me that the patient had been demonstrating some behaviors that were concerning to family - that someone wanted to "get him". He stated he thought there was a history of Schizophrenia that had been mentioned but could not confirm this. I had asked him where this information had originated - he noted that this was what he had been told. He also told me that the patient had been placed into a Behavioral Health room and changed into paper scrubs/slipper socks for his safety, while the staff continued to examine and evaluate him. At some point, the patient indicated he wanted to go home and left the building, still in paper scrubs..."

10. During an interview on 3/24/15 at 3:00 PM, Patient #16's family member stated the patient lived with them in an apartment complex located approximately 3 blocks from the hospital's parking lot. The patient had moved from another country about 5 weeks earlier.

Patient #16's family member and a close friend said they took him to the hospital because his behaviors in the past weeks had changed. He was confused, agitated, hearing voices, not eating, not sleeping, and was afraid people were after him. Patient #16's family member said the close friend; "Auntie" who stayed with him at the hospital understood English very well but could she could not speak English.

They also said Patient #16 understood English but at times his accent was thick and it could be difficult to understand. They said earlier that morning they found him outside dressed in a T shirt and pants without a coat around 3:00 AM. Family became concerned because the patient had just moved to the US and was unfamiliar with winter weather. Previously, he lived in another country, where the weather is rarely cooler than 70 degrees Fahrenheit all year long. The family decided it was time to take him to the hospital because they thought he was depressed and were concerned with changes in his behavior.

Patient #16's close family member said he told the staff at the front desk that Patient #16 was running away, acting confused, and he thought someone was trying to kill him. They said while in the ED Patient #16 kept sighing, breathing deep, and kept touching his head. The close family member said a male nurse came out to take Patient #16 back to a room and they went with them. They told [Staff J] they thought Patient #16 was having anxiety or depression and that he was hearing voices and thought someone was going to kill him.

The close family member said at 7:45 AM nursing staff said they were going to put Patient #16 in another room. Auntie stayed with the patient and the close family member left the hospital. At that point in the interview, the close family member interpreted for Auntie. Auntie said a nurse took Patient #16 to a bathroom, changed him into paper scrubs and the nurse put his clothes in a bag. Auntie said Patient #16 told the same nurse, who was female, he was running away, wasn't familiar with this country, wasn't eating or sleeping, and was confused.

Auntie said although no one told her Patient #16 was going to be admitted to the hospital, she thought when they undressed him and put Patient #16 in a paper gown this meant they were admitting him to the hospital. She said because it was taking so long and she needed to return home to take her medicine she left around 8:30 AM. When she left the hospital Patient #16 was still in the examination room waiting for blood and urine test results, dressed in the paper gown.

Patient #16's close family member said when they got back to the hospital a nurse told them the patient had left the hospital. The nurse said the patient had the right to walk out even if he only had on paper scrubs.