HospitalInspections.org

Based on record review and interview, the hospital governing body failed to ensure that the medical staff was accountable for the quality of care provided to each patient, in that,

1 of 1 Intensive Care Unit (ICU) patient (Patient #1) was not kept safe through stabilization of acute encephalopathy including psychosis and increased agitation. The Hospital failed to collaborate with the surrogate decision maker.

On 5/28/2024, the Hospital allowed the patient to sign out against medical advice (AMA), walk away from the hospital in a hospital gown, no phone, no identification, no means (money or card). The patient was in a delicate state and incapable of caring for himself. The patient was allowed to walk away from the hospital without means although there were 4 adult family members who could have safely picked him up. The patient wandered into an outpatient rehabilitation clinic near the edge of the hospital campus with a hospital gown and quite a bit of feces on him. The Rehab notified the Police. Police took him into custody and completed a detention order to protect him. The patient was taken to the county hospital and admitted on 5/28/2024 and treated for Altered Mental Status, Bipolar, severe mania with psychotic features. The patient was stabilized. The patient was discharged home on 6/09/2024 to his wife.

Findings

Patient #1 was allowed to AMA from ICU hours after being sedated for days for escalating agitation. The Hospital allowed the wife to sign consents throughout the admission and was consulted to make decisions up to and including the 5/27/2024 decision to re-sedate with Precedex. The Hospital did not consult the wife on 5/28/2024 when they allowed the patient to sign out AMA. The Hospital notified the wife after the patient left.

During a telephone interview on 6/17/2024 ending at 2:48 PM, the Grapevine Police Officer was asked about Patient #1 on 5/28/2024. The Grapevine Police Officer stated Officers went out to find him when they called us. They did not find him at that time. Later, we got another call from the Baylor Rehab in the hospital medical professional building. They called us for a welfare check not knowing what to do with him. He thought it was a hotel. The Grapevine Police Officer was asked if it was the building on the hospital grounds. Officer Hays stated it is right there in front of the hospital. The Grapevine Police Officer was asked what state the patient was in when she found him. The Grapevine Police Officer stated He had a hospital gown on and quite a bit of feces. He had a hospital arm band on. The Grapevine Police Officer was asked if he had socks or shoes on. The Grapevine Police Officer stated no ma'am. The Grapevine Police Officer was asked if he had a phone, wallet, his identification or means (money/card). The Grapevine Police Officer stated no, nothing. The Grapevine Police Officer was asked his mental state. The Grapevine Police Officer stated he was clearly not in the right state of mind. I was concerned he was able to leave the ICU in that state. I was able to talk to the wife. She said they let him AMA because he could state his name and the date. I have never heard of anyone AMAing from the ICU. She was not comfortable with him leaving the ICU in that state. She said he had a history of bipolar and he was off his medication. I EDO'd (Emergency Detention Order/Detention Warrant) him and took him to the county hospital.

The Hospital's record for Patient #1 documented his arrival on 5/18/2024 with severe back pain and was diagnosed with Acute encephalopathy. On 5/20/2024, he became over sedated/nonresponsive with worsening CKD. Narcan administration. Unexplained agitation and psychosis. From 5/24/2024 to 5/28/2024 patient was sedated on Precedex in the ICU due to progressive restlessness/agitation. During Precedex, Lithium was stopped. On 5/27/2024, Precedex stopped for a short time. Although alert and oriented, the patient did not know his own wife. He was agitated, volatile, and wanted to leave. His Lithium level was subtherapeutic. He was re-sedated with Precedex overnight after the physician asked the wife to agree. Precedex was stopped on 5/28/2024 at 8:00 AM. After waking up from Precedex, the hospital did not consult the family, but allowed the patient to sign out against medical advice and wander off.

The 5/28/2024 10:07 Telepsychiatry Consult Note reflected Primary Diagnosis: Acute encephalopathy Reason for Consultation: Bipolar disorder...Communicated with ICU Physician through Secure chat. Provided update about patient's participation when Tele psych consult started. "no worries. please let me know about your recommendations especially regarding his decisional capacity as he wants to sign out AMA." Per Patient...He was being hyperverbal. He did not allow to ask questions for conducting the psychiatric assessment. He was being increasingly goal-directed talked about his wife and how he was brought to the hospital. He talked about the implant. He stated, "massive breach of trust, you put my wife against me, your hospital abused me, I am signing out AMA right now". Patient's nurse was available bedside who attempted multiple times to engage the patient and participate in the psychiatric interview. Patient continued to remain uncooperative and not wanting to participate...Mental Status Evaluation: Patient being alert, awake. He is aware that he is currently in the hospital. No acute distress observed. Patient's appearance was inappropriate, he had limited coping. His eye contact was fair. His behavior was selective, guarded difficult to engage and not cooperative. His speech was hyperverbal but clear. His mood and affect appeared irritable. His thought processes were increasingly goal-directed, he was talking about going AMA, about his wife. He appeared to have paranoid delusions. Could not assess the patient for experience of suicidal or homicidal ideations. Could not assess the patient for experience of auditory and visual hallucinations. His cognition appeared limited. His insight is limited. Impulse control is limited. His judgment is poor. His attention is impaired ...Patient was undergone psychiatric initial assessment on 5/24. At that time, patient was given diagnostic impression of delirium of multifocal origin, rule out serotonin syndrome, rule out neuro septic medically syndrome. Disposition recommendation was deferred until patient was medically stable. Patient was recommended Zyprexa p.r.n. for controlling severe agitation ...Patient was being hyperverbal, increasingly goal-directed and appeared paranoid. At this time, patient is showing limited factual understanding of his current health condition, he appears not able to appreciate his current situation and possible consequences of his request for against medical advice. Patient appears not to have ability to rationally manipulate the information presented to him. He did not participate in the psychiatric assessment even after repeated attempts made by the nurse. Based on the limited information available, it appears that patient does not have the capacity to make an informed decision regarding his treatment choices to his treatment team. If a patient is found to lack capacity, the next step is to determine the urgency of the medical intervention. If a health care proxy exists, it should be invoked at this point in time, and medical decisions should be deferred to that person. If no health care proxy exists, the family/hospital should attempt to locate a surrogate decision maker by contacting next of kin ...Continue Seroquel 25 mg p.o. B.i.d. for mood stabilization, psychosis. Consider Zyprexa 2.5-5 mg PO/IM q.8 hours p.r.n. for acute agitation/psychosis control...Due to concerns of serotonin syndrome and neuroleptic malignant syndrome, Continue hold lithium and Zoloft...Regarding Patient's bipolar medications at home, reviewed those medications. At this time, recommend to discontinue Xanax due to the concerns of paradoxical agitation...

The 5/28/2024 1:40 PM ICU Physician Note reflected Discharge Summary...During the course of his hospital stay he is developed acute encephalopathy and is very restless/agitated. Does not follow commands or answer questions for evaluating physicians...Due to progressive restlessness/agitation, ICU transfer was requested for initiation of Precedex as well as continuous EEG monitoring...He was initially on lithium but given the fact that the patient was having more hypernatremia and his renal function was deteriorating it was stopped. The patient remained on Seroquel...subsequently, the patient was noted to be alert and oriented x3. As per our evaluation and as per the tele psychiatrist evaluation the patient was not deemed to have any decisional capacity but as per the hospital policy it was noticed that since the patient is alert and oriented x3 the patient has the right to sign out against medical advice. The patient was provided the papers and he signed and left against medical advice knowing the risks of this decision. The case management service is aware. The Baylor Grapevine PD determined that the patient does not meet the criteria for EDO. The patient did not have any homicidal or suicidal ideations. The Grapevine Police Department was made aware as well...Physical Exam: Agitated. Oriented x 3.

The 5/28/2024 2:29 PM ICU physician note reflected Patient seen and evaluated by the case management team. As per the hospital policy the patient can sign out AMA as the patient is alert and oriented x3. He is denying any suicidal or homicidal ideations. He does not qualify for EDO as per Baylor Grapevine PD. CM has informed the Grapevine PD. Patient understands the risks of AMA as he has been informed about this many times. Also, family updated by the RN. So, based on the hospital policy the patient was discharged against medical advice.

During a telephone interview on 6/14/2024 at 9:07 AM, Personnel #7 called and was asked about the psych eval stating no decision-making capacity. Personnel #7 stated I felt he was not willing to talk. Refusing to answer or cooperative is a choice. If a patient is unwilling, it does not mean they don't have capacity to decide. He did not want to answer the questions versus capacity to answer. Personnel #7 was asked what treatment was provided for agitation. Personnel #7 stated we sedated him on a Precedex drip in the ICU. At that time, he was determined to not have mental capacity for decisions due to the sedating affects. Upon my last evaluation, he was off the drip, and it was not limiting us from making that decision. When he came off the drip, his capacity came back. He was not wanting care, wanting to leave against advice. Personnel #7 was asked about restarting lithium for bipolar symptoms. Personnel #7 stated that would have been the plan if he had stayed. Personnel #7 was asked about the treatment for psychosis. Personnel #7 stated time. We are not sure of the cause. We did an extensive work up and found no exact id of the cause of it. When we stopped Precedex he was calm, and no other meds were needed for control. Personnel #7 was asked if he was party to him trying to leave AMA on 5/27/2024. Personnel #7 stated yes, I spoke to him and the wife. We restarted the Precedex. On 5/28, the next day he came off the Precedex. I was able to assess him. He was awake and oriented with no suicide or homicidal ideations. At this point, I determined he could make decisions and allowed his decision to AMA. When he went AMA, I did not agree with him leaving AMA.

Subsequent Hospitalization on 5/28/2024 through stabilization and discharge on 6/09/2024
The 5/28/2024 County Hospital's Emergency Department Provider note reflected presents to the ED via EMS under DW with PD for altered mental status. Per PD, patient was found walking around outside Baylor Grapevine where he'd left AMA from the ICU. He was reportedly found to be altered and placed under DW...He states that there was some confusion about his wife coming to pick him up and he did not like the way he was being treated at the other hospital, so he left AMA...Physical Exam...Comments: Dried feces on legs bilaterally Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Thought Content: Thought content is not paranoid. Thought content does not include homicidal or suicidal ideation. Comments: He appears mostly logical aside from occasional incomprehension regarding physical exam. For example, when I asked him multiple times to follow my finger with his gaze, he continued to stare straight ahead at me while telling me that he was doing as asked.

The 5/29/2024 10:16 AM County Hospital's Psychiatry Consult...flight risk...fall precautions...Psychosis...bipolar disorder Consult received for "confusion, on DW." The patient presents delusional, paranoid. His symptoms are likely multifactorial...He has been on lithium for 30 years. Per his wife, he has never exhibited symptoms of psychosis or mania before. His altered mentation/psychotic symptoms began during a recent hospitalization at Baylor Grapevine ...admitted ...altered mental status ... He is awake, alert, oriented to person and place but not time...illogical...difficult to follow...delusional thinking. He does not appear overtly manic, however. He reports that he's in the hospital because his wife and the doctor "had a miscommunication." He seems irritated when asked if he can elaborate and does not provide a logical response...He denies a past psychiatric history and says "I have no concerns for my well-being, I'm not a psychiatric patient...Spoke to patient's wife...She reports "...he got himself checked out AMA and they said that it was because he was able to tell them his full name and the date. Grapevine police called and said that they had found him in a professional building across from the hospital building. He was in a hospital gown in his own feces...Social history: He and his wife have been married x 30 years. He works as an IT engineer, has had stable jobs his entire adulthood. They have 3 (adult) children...Speech is tangential...Judgment: Judgment is impulsive and inappropriate...Hallucinations: Suspected...Suicide Risk: no expressed suicide risk. not ideating. Aggression risk: no aggression risk demonstrated. not ideating. Insight: Into mental illness: Poor. Patient does not understand need for treatment. Judgement: concerning everyday activities and social situations is: Poor...His initial DW has expired, but the primary team has documented that the patient currently lacks medical decision-making capacity. Patients that lack capacity cannot leave AMA and do not need a DW (Detention Warrant) to be kept in the hospital. JPS policy allows for the least restrictive means necessary to keep the patient safely in the hospital (including chemical and physical restraints, if appropriate).

The 6/07/2024 County Hospital's Physician Progress Note reflected Bipolar I disorder...pressured speech...Suspect that he may be minimizing symptoms with the goal of discharge. Patient's presentation is likely consistent with manic episode...Due to risk for impulsive behavior and risk of potential harm to himself or others. Recommend continued inpatient hospitalization for symptom stabilization and medication management, and safe discharge planning.

Policy
Multiple care staff documented per hospital policy the alert and oriented patient can sign out AMA. There was no hospital policy provided that stated Alert and Oriented patients could sign out AMA.

The 1/03/2022 Last reviewed/revised "Patient Abuse and Neglect " policy required "Neglect - a form of abuse and the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..."

The facility's 8/17/2022, last reviewed/revision "Patient Leaving (Leaving the Floor/Against Medical Advice/Elopement)" policy required "Surrogate decision makers for adult patients not involving life-sustaining treatment...If there is no legal guardian and no agent under a medical power of attorney , then an adult from the following list...the patient's spouse...the patient's reasonably available adult children...Surrogate decision makers for adult patient who lack decision making capacity...If the physician believes that discharge of an adult patient is not medically advisable at the time, the physician may evaluate the patient to determine if the patient has decision making capacity. Mental health professional consultation may be requested...Adult patient lacking decisional making capacity - notify Surrogate Decision Maker...(the AMA policy further allows:) Adult patients with Decisional-making capacity who are neither suicidal nor a threat to others, may leave AMA, even if doing so may lead to serious harm up to and including death..."

Based on record review and interview, the facility failed to ensure each patient's rights, in that,

1 of 1 Intensive Care Unit (ICU) patient (Patient #1) was not kept safe through stabilization of acute encephalopathy including psychosis and increased agitation. The Hospital failed to collaborate with the surrogate decision maker.

On 5/28/2024, the Hospital allowed the patient to sign out against medical advice (AMA), walk away from the hospital in a hospital gown, no phone, no identification, no means (money or card). The patient was in a delicate state and incapable of caring for himself. The patient wandered into an outpatient rehabilitation clinic near the edge of the hospital campus with a hospital gown and quite a bit of feces on him. The Rehab notified the Police. Police took him into custody and completed a detention order to protect him. The patient was taken to the county hospital and admitted on 5/28/2024 and treated for Altered Mental Status, Bipolar, severe mania with psychotic features. The patient was stabilized. The patient was discharged home on 6/09/2024 to his wife.

Findings

Patient #1 was allowed to AMA from ICU hours after being sedated for days for escalating agitation. The Hospital allowed the wife to sign consents throughout the admission and was consulted to make decisions up to and including the 5/27/2024 decision to re-sedate with Precedex. The Hospital did not consult the wife on 5/28/2024 when they allowed the patient to sign out AMA. The patient was allowed to walk away from the hospital without means although there were 4 adult family members who could have safely picked him up. The Hospital notified the wife after the patient left.

During a telephone interview on 6/17/2024 ending at 2:48 PM, the Grapevine Police Officer was asked about Patient #1 on 5/28/2024. The Grapevine Police Officer stated Officers went out to find him when they called us. They did not find him at that time. Later, we got another call from the Baylor Rehab in the hospital medical professional building. They called us for a welfare check not knowing what to do with him. He thought it was a hotel. The Grapevine Police Officer was asked if it was the building on the hospital grounds. Officer Hays stated it is right there in front of the hospital. The Grapevine Police Officer was asked what state the patient was in when she found him. The Grapevine Police Officer stated He had a hospital gown on and quite a bit of feces. He had a hospital arm band on. The Grapevine Police Officer was asked if he had socks or shoes on. The Grapevine Police Officer stated no ma'am. The Grapevine Police Officer was asked if he had a phone, wallet, his identification or means (money/card). The Grapevine Police Officer stated no, nothing. The Grapevine Police Officer was asked his mental state. The Grapevine Police Officer stated he was clearly not in the right state of mind. I was concerned he was able to leave the ICU in that state. I was able to talk to the wife. She said they let him AMA because he could state his name and the date. I have never heard of anyone AMAing from the ICU. She was not comfortable with him leaving the ICU in that state. She said he had a history of bipolar and he was off his medication. I EDO'd (Emergency Detention Order/Detention Warrant) him and took him to the county hospital.

The Hospital's record for Patient #1 documented his arrival on 5/18/2024 with severe back pain and was diagnosed with Acute encephalopathy. On 5/20/2024, he became over sedated/nonresponsive with worsening CKD. Narcan administration. Unexplained agitation and psychosis. The first mention of psychosis was 5/22/2024. The 5/22/2024 EEG showed the presence of a moderate encephalopathy and bilateral independent interictal epileptiform sharps. (An EEG - electroencephalogram is a test that measures your brain activity. Healthcare providers order EEGs to diagnose conditions that affect your brain.) From 5/24/2024 to 5/28/2024 patient was sedated on Precedex in the ICU due to progressive restlessness/agitation. During Precedex, Lithium was stopped. On 5/27/2024, Precedex stopped for a short time. Although alert and oriented, the patient did not know his own wife. He was agitated, volatile, and wanted to leave. His Lithium level was subtherapeutic. He was re-sedated with Precedex overnight after the physician asked the wife to agree. Precedex was stopped on 5/28/2024 at 8:00 AM. After waking up from Precedex, the hospital did not consult the family, but allowed the patient to sign out against medical advice and wander off.

The physician order reflected Sitter at bedside 5/20/2024 3:17 PM through 5/28/2024 4:48 PM.

5/27/2024

Lithium 0.4 low (0.6 to 1.2)

The 12:30 PM Nurse note reflected approximately 12:30 pt. Abruptly became very belligerent with his wife, myself, and sitter at bedside. His wife left during this time to "let him cool off". I called Dr...to the bedside to discuss his concerns, but the patient was unable to answer orientation questions (place/time/situation) and clearly was unable to form cohesive thoughts. The physician, charge nurse and house supervisor were all at bedside and it was determined the patient lacked decision making capability. Dr...spoke with the patient's wife via phone, and she agreed the patient is not able to make decisions for himself and wants him to continue to receive care here until he improves.

The 2:28 PM ICU Physician Note reflected patient is quite upset, the nursing staff informed me. At the patient's bedside, I assessed him. When speaking with the medical staff, the patient was using derogatory words. In addition, his wife left the room before I could assess him because she was unhappy with the way the patient was acting. The patient persisted in wanting to sign out in defiance of medical advice. After conducting an evaluation, I came to the conclusion that the patient lacked decisional capacity because during the encounter, the patient was unable to respond to any of my questions that were relevant to orientation, was thinking incoherently, and could not provide me with a valid or trustworthy response. The patient lacks decisional capacity, as the other members of the medical team concurred. For a more thorough assessment, I have asked the staff to confer with the telepsychiatry team. Additionally, we are unable to administer any more antipsychotic medicine to the patient at this time due to their abnormally prolonged QT interval. If necessary, we will instead employ benzodiazepines. And wean the Precedex drip as tolerated, if at all possible.

The 3:39 PM Social Work note reflected acute encephalopathy. Pt moved to ICU due to increased delirium and agitation. Pt noted to be doing better today and more verbal, however agitation increased this afternoon.

5/28/2024

The 4:47 AM ICU Physician Assistant Note reflected 5/28: Yesterday, the patient became very agitated. He was noted to have a rational and tandem thoughts. He would not answer questions. He kept on saying that he would want to sign out against medical advice but was deemed to have no medical capacity. He was kept off the Precedex then started to become more agitated, so it was restarted. Overnight, there were no events. This morning, the patient was noted to be oriented x3 but was very hostile. He kept using derogatory comments. This was noticed by the Neurology team as well. Once again, he was not able to provide me with evaluate or trustworthy response...General appearance - Very agitated and hostile...Neurological - Alert, moves all extremities, very restless, does not answer questions and keeps talking...based on my evaluation and based on the recommendations of the tele psychiatrist the patient has no decisional capacity...He fails to understand. He does not let any of the providers talk and keeps talking himself. Additionally, he seems to have a flight of ideas at this point and with the limited information that is available to us based on the encounter I do feel that he has not decisional capacity. I have also updated his wife who is the MPOA (Medical Power of Attorney) and all decision-making process will be deferred to her from now onwards till the patient is deemed stable enough to make decisions. (signed by the ICU Physician at 11:42 AM)

The 8:00 AM and 9:00 AM Nurse Assessment stated alert, agitated, illogical, restless...fecal incontinence...precautions: High Fall Risk...Very High to moderate violence risk (confused, irritable, Boisterous, verbal threats)...2 person assist...

There was no further nursing assessment or change to the plan of care prior to the AMA.

The 9:08 AM Neurology Note reflected seen...830 AM...late entry...sitter at bedside...During this hospitalization on 5/20 an RRT code was called for worsening mental status. His agitation was suspected initially to be related to metabolic disturbances or polypharmacy given narcotics + baclofen + steroids, however he has also been having elevated WBC counts and low-grade fevers and an EEG was also very abnormal...He was awake and conversing. He was speaking a lot, and not allowing me to participate in conversations. Wants to leave AMA. Was increasingly hostile when I attempted to redirect him to my examination and when I did not want to engage in his AMA discussion. Was more hostile when I tried to explain that I was not part of the issue he had with his wife yesterday and so was not able to opine on it. He went on accusing us ( medial team) of lying to him that his wife didn't want him to leave when in fact he said she did want him to leave. I requested him to talk with primary team (ICU) in the room with me as they were directly related to his issues at hand regarding events of yesterday and AMA etc. He refused several times and was increasingly hostile. He openly stated distrust of all medical professionals I finally had to leave the room after telling him that I was not comfortable carrying on this conversation MENTAL STATUS: alert, awake; speaks fluently. Refused to cooperate with orientation questions. Tangential speech and somewhat verbose. Appeared mistrustful of medical personnel and angry/hostile of his situation...SPEECH: fluent, spontaneous speech. Was able to talk in complete sentences but with paranoia. Some tangential, speech, hostile...Acute Encephalopathy Etiology not clear...is bipolar and his presentation today appears consistent with his primary psychiatric diagnosis. His lithium levels are low, would need to consider restarting given his improving renal function vs have tele psychiatry assist with medication management...Problem complexity: Acute or chronic illness or injury posing a threat to life or bodily function. (high)...Education was not able to be provided due to: Impaired medical decision-making capacity of the patient.

The 10:00 AM Occupational Therapy note reflected Patient being hostile towards staff. Waiting for tele psych to assess for capacity. Patient wanting to leave AMA.

The 10:07 Telepsychiatry Consult Note reflected Primary Diagnosis: Acute encephalopathy Reason for Consultation: Bipolar disorder...Communicated with ICU Physician through Secure chat. Provided update about patient's participation when Tele psych consult started. "no worries. please let me know about your recommendations especially regarding his decisional capacity as he wants to sign out AMA." Per Patient...He was being hyperverbal. He did not allow to ask questions for conducting the psychiatric assessment. He was being increasingly goal-directed talked about his wife and how he was brought to the hospital. He talked about the implant. He stated, "massive breach of trust, you put my wife against me, your hospital abused me, I am signing out AMA right now". Patient's nurse was available bedside who attempted multiple times to engage the patient and participate in the psychiatric interview. Patient continued to remain uncooperative and not wanting to participate...Mental Status Evaluation: Patient being alert, awake. He is aware that he is currently in the hospital. No acute distress observed. Patient's appearance was inappropriate, he had limited coping. His eye contact was fair. His behavior was selective, guarded difficult to engage and not cooperative. His speech was hyperverbal but clear. His mood and affect appeared irritable. His thought processes were increasingly goal-directed, he was talking about going AMA, about his wife. He appeared to have paranoid delusions. Could not assess the patient for experience of suicidal or homicidal ideations. Could not assess the patient for experience of auditory and visual hallucinations. His cognition appeared limited. His insight is limited. Impulse control is limited. His judgment is poor. His attention is impaired...Patient was undergone psychiatric initial assessment on 5/24. At that time, patient was given diagnostic impression of delirium of multifocal origin, rule out serotonin syndrome, rule out neuro septic medically syndrome. Disposition recommendation was deferred until patient was medically stable. Patient was recommended Zyprexa p.r.n. for controlling severe agitation...Patient was being hyperverbal, increasingly goal-directed and appeared paranoid. At this time, patient is showing limited factual understanding of his current health condition, he appears not able to appreciate his current situation and possible consequences of his request for against medical advice. Patient appears not to have ability to rationally manipulate the information presented to him. He did not participate in the psychiatric assessment even after repeated attempts made by the nurse. Based on the limited information available, it appears that patient does not have the capacity to make an informed decision regarding his treatment choices to his treatment team. If a patient is found to lack capacity, the next step is to determine the urgency of the medical intervention. If a health care proxy exists, it should be invoked at this point in time, and medical decisions should be deferred to that person. If no health care proxy exists, the family/hospital should attempt to locate a surrogate decision maker by contacting next of kin...Continue Seroquel 25 mg p.o. B.i.d. for mood stabilization, psychosis. Consider Zyprexa 2.5-5 mg PO/IM q.8 hours p.r.n. for acute agitation/psychosis control...Due to concerns of serotonin syndrome and neuroleptic malignant syndrome, Continue hold lithium and Zoloft...Regarding Patient's bipolar medications at home, reviewed those medications. At this time, recommend to discontinue Xanax due to the concerns of paradoxical agitation...

The 11:03 AM Nephrology Note reflected Remain on Precedex...Limited neuro assessment...Not in acute distress...Foley catheter in place NG tube in place...

There was no documented change in condition for the patient from 11:03 AM to 1:04 PM.

The 1:04 PM Physical Therapy Note reflected pt being hostile towards staff. Hold PT until pt is cooperative with staff and appropriate for therapy session.

The Hospital police did not complete an EDO (emergency detention order). There was no hospital police report documented.

The 1:40 PM ICU Physician Note reflected Discharge Summary...During the course of his hospital stay he is developed acute encephalopathy and is very restless/agitated. Does not follow commands or answer questions for evaluating physicians... Due to progressive restlessness/agitation, ICU transfer was requested for initiation of Precedex as well as continuous EEG monitoring... He was initially on lithium but given the fact that the patient was having more hypernatremia and his renal function was deteriorating it was stopped. The patient remained on Seroquel...subsequently, the patient was noted to be alert and oriented x3. As per our evaluation and as per the tele psychiatrist evaluation the patient was not deemed to have any decisional capacity but as per the hospital policy it was noticed that since the patient is alert and oriented x3 the patient has the right to sign out against medical advice. The patient was provided the papers and he signed and left against medical advice knowing the risks of this decision. The case management service is aware. The Baylor Grapevine PD determined that the patient does not meet the criteria for EDO. The patient did not have any homicidal or suicidal ideations. The Grapevine Police Department was made aware as well...Physical Exam: Agitated. Oriented x 3.

The 1:43 PM Nurse Note reflected Pt refusing care, pt axo3 ( person, place, and situation) . Pt refused to answer orientation question for time. Pt refusing treatment and getting up to leave. Education and reorientation attempted, pt refuses. Provider notified, NP came to bedside, Pt refused to answer orientation question of time as well for provider. Foley, NGT, and IV removed. Security to beside and escorted out. Wife notified.

The 1:53 PM Social Work Note reflected SW case finding for dc planning; pt requesting to leave AMA. Pt seen by tele psych this morning with recommendations for pt to remain in hospital until psychosis resolved. Pt does not have EDO, continues to refuse care and a&ox3. Staff attempted to redirect pt multiple times but pt continues to refuse to answer questions and getting up to leave. Baylor Grapevine security at bedside to escort pt out. Baylor Gpvn security share pt does not meet criteria for EDO at this time, and therefore can leave AMA. RN called pt's wife to notify. Grapevine PD notified. Copy of company policy provided to staff by CCM...Pt escorted out.

The 2:29 PM ICU physician note reflected Patient seen and evaluated by the case management team. As per the hospital policy the patient can sign out AMA as the patient is alert and oriented x3. He is denying any suicidal or homicidal ideations. He does not qualify for EDO as per Baylor Grapevine PD. CM has informed the Grapevine PD. Patient understands the risks of AMA as he has been informed about this many times. Also, family updated by the RN. So, based on the hospital policy the patient was discharged against medical advice.

During an interview on 6/13/2024 ending at 12:00 PM, Personnel #9 was asked about the tele psych eval. Personnel #9 stated I could see he was becoming more agitated. The patient said that was far enough and did not want to continue. Personnel #9 was asked what the patient was wearing when he left. Personnel #9 stated a regular gown, a second gown from behind. He was agreeable to the second gown. I think we gave him socks. We asked if he had stuff here. He was not aware of stuff, not aware of any belongings. He was becoming very aggressive. I was trying to appease him. I told him he could go when Security could come to the room. He wanted to go right now. He was escalated. He was not volatile to me. Personnel #9 was asked who called the wife. Personnel #9 stated I did at the start of my shift about 9 when I charted my 2nd neuro check. Then before security came up and after he left. I told her I can't hold him down against his will. He could answer the 3 orientation questions and he was escorted out. She thanked me. I thought security would hold him downstairs. I don't know if family picked him up. This was my first encounter with a situation like this. Personnel #9 was asked if she refused to come get him. Personnel #9 stated I did not ask her. Personnel #9 was asked if he was aware the patient was off his lithium. Personnel #9 stated I don't know if I was aware. Personnel #9 was asked if the patient belongings were found after he left. Personnel #9 stated Later, the son came by and said they were missing those things. The Charge Nurse gave them to the son. I was not party to conversation. I think they found them when cleaning the room.

During an interview on 6/13/2024 ending at 12:46 PM, Personnel #5 and #6 were present. Personnel #6 stated I got called to escort and AMA patient out. When I got to the unit the Social Worker was there and I think the Director. They (social work) told me he does not meet criteria for an EDO. He was calm, not agitated, and talkative. He spoke to his Son. The call got escalated and he hung up. I took him to the Lobby to wait. I called cab on the desk phone. I informed visitor management He was nice to me. When he walked away, Visitor Management alerted us.

During an interview on 6/13/2024 at 2:13 PM, Personnel #1 was asked about the documentation. Personnel #1 stated I am not going to speak to someone else's note. I can have you talk to legal. Personnel #1 was told Legal should not have to speak to the policy. Someone at the hospital should understand the policy. If leaders do not understand the policy, then how can an employee act in a manner to comply with the policy. Personnel #1 stated I can have the CNO come back in. We can't hold them (patients) against their will. Personnel #1 was reminded the hospital documented psychosis, lacking decisional capacity, agitated, illogical. These each could constitute an unsafe discharge. They skipped past capacity and allowed the AMA due to alert and oriented although he was alert and oriented the previous day and they did not allow his desire to AMA and sedated him. The policy required the surrogate decision, and the wife was not involved with letting him leave AMA. There were 3 adult children. They (employees) called the wife 4 times and did not ask her to pick him up. They notified her after they let him leave. Personnel #1 stated the physician documented return of capacity in his last note.

During an interview on 6/13/2024 at 3:50 PM 4:07 PM, Personnel #13 stated she recalled the patient events. He had been in multiple units and in the ICU that day. I did not know the patient. We round every morning. They said he had been threatening to leave. The ICU MD/NP were involved. There was no EDO. Personnel #12 was working on getting Baylor security/PD up then she called Grapevine PD after they left. We could not keep him against his will. I provided the policy. An AMA that police will not give a detention warrant for. We can't hostage a person here. The physician mase the decision to let him AMA. The nurse said he would answer some questions clearly then some he did not want to answer. Personnel #13 was asked if she was aware the physician and psych consult documented the patient did not have decision making capacity. Personnel #13 stated no I was not aware. Our practice would be the same though.

During a telephone interview on 6/14/2024 at 9:07 AM, Personnel #7 called and was asked about the psych eval stating no decision-making capacity. Personnel #7 stated I felt he was not willing to talk. Refusing to answer or cooperative is a choice. If a patient is unwilling, it does not mean they don't have capacity to decide. He did not want to answer the questions versus capacity to answer. Personnel #7 was asked what treatment was provided for agitation. Personnel #7 stated we sedated him on a Precedex drip in the ICU. At that time, he was determined to not have mental capacity for decisions due to the sedating affects. Upon my last evaluation, he was off the drip, and it was not limiting us from making that decision. When he came off the drip, his capacity came back. He was not wanting care, wanting to leave against advice. Personnel #7 was asked about restarting lithium for bipolar symptoms. Personnel #7 stated that would have been the plan if he had stayed. Personnel #7 was asked about the treatment for psychosis. Personnel #7 stated time. We are not sure of the cause. We did an extensive work up and found no exact id of the cause of it. When we stopped Precedex he was calm, and no other meds were needed for control. Personnel #7 was asked if he was party to him trying to leave AMA on 5/27/2024. Personnel #7 stated yes, I spoke to him and the wife. We restarted the Precedex. On 5/28, the next day he came off the Precedex. I was able to assess him. He was awake and oriented with no suicide or homicidal ideations. At this point, I determined he could make decisions and allowed his decision to AMA. When he went AMA, I did not agree with him leaving AMA.

Subsequent Hospitalization on 5/28/2024 through stabilization and discharge on 6/09/2024
The 5/28/2024 County Hospital's Emergency Department Provider note reflected presents to the ED via EMS under DW with PD for altered mental status. Per PD, patient was found walking around outside Baylor Grapevine where he'd left AMA from the ICU. He was reportedly found to be altered and placed under DW... He states that there was some confusion about his wife coming to pick him up and he did not like the way he was being treated at the other hospital, so he left AMA...Physical Exam...Comments: Dried feces on legs bilaterally Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Thought Content: Thought content is not paranoid. Thought content does not include homicidal or suicidal ideation. Comments: He appears mostly logical aside from occasional incomprehension regarding physical exam. For example, when I asked him multiple times to follow my finger with his gaze, he continued to stare straight ahead at me while telling me that he was doing as asked.

The 5/29/2024 10:16 AM County Hospital's Psychiatry Consult...flight risk...fall precautions...Psychosis...bipolar disorder Consult received for "confusion, on DW." The patient presents delusional, paranoid. His symptoms are likely multifactorial...He has been on lithium for 30 years. Per his wife, he has never exhibited symptoms of psychosis or mania before. His altered mentation/psychotic symptoms began during a recent hospitalization at Baylor Grapevine...admitted...altered mental status... He is awake, alert, oriented to person and place but not time...illogical...difficult to follow...delusional thinking. He does not appear overtly manic, however. He reports that he's in the hospital because his wife and the doctor "had a miscommunication." He seems irritated when asked if he can elaborate and does not provide a logical response...He denies a past psychiatric history and says "I have no concerns for my well-being, I'm not a psychiatric patient...Spoke to patient's wife...She reports "...he got himself checked out AMA and they said that it was because he was able to tell them his full name and the date. Grapevine police called and said that they had found him in a professional building across from the hospital building. He was in a hospital gown in his own feces...Social history: He and his wife have been married x 30 years. He works as an IT engineer, has had stable jobs his entire adulthood. They have 3 (adult) children..Speech is tangential...Judgment: Judgment is impulsive and inappropriate...Hallucinations: Suspected...Suicide Risk: no expressed suicide risk. not ideating. Aggression risk: no aggression risk demonstrated. not ideating. Insight: Into mental illness: Poor. Patient does not understand need for treatment. Judgement: concerning everyday activities and social situations is: Poor...His initial DW has expired, but the primary team has documented that the patient currently lacks medical decision-making capacity. Patients that lack capacity cannot leave AMA and do not need a DW (Detention Warrant) to be kept in the hospital. JPS policy allows for the least restrictive means necessary to keep the patient safely in the hospital (including chemical and physical restraints, if appropriate).

The 6/07/2024 County Hospital's Physician Progress Note reflected Bipolar I disorder...pressured speech...Suspect that he may be minimizing symptoms with the goal of discharge. Patient's presentation is likely consistent with manic episode...Due to risk for impulsive behavior and risk of potential harm to himself or others. Recommend continued inpatient hospitalization for symptom stabilization and medication management, and safe discharge planning.

Policy
Multiple care staff documented per hospital policy the alert and oriented patient can sign out AMA. There was no hospital policy provided that stated Alert and Oriented patients could sign out AMA.

The 1/03/2022 Last reviewed/revised "Patient Abuse and Neglect " policy required, "Neglect - a form of abuse and the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..."

The facility's 8/17/2022, last reviewed/revision "Patient Leaving (Leaving the Floor/Against Medical Advice/Elopement)" policy required, "Surrogate decision makers for adult patients not involving life-sustaining treatment...If there is no legal guardian and no agent under a medical power of attorney , then an adult from the following list...the patient's spouse...the patient's reasonably available adult children...Surrogate decision makers for adult patient who lack decision making capacity...If the physician believes that discharge of an adult patient is not medically advisable at the time, the physician may evaluate the patient to determine if the patient has decision making capacity. Mental health professional consultation may be requested...Adult patient lacking decisional making capacity - notify Surrogate Decision Maker...(the AMA policy further allows:) Adult patients with Decisional-making capacity who are neither suicidal nor a threat to others, may leave AMA, even if doing so may lead to serious harm up to and including death..."

The 12/14/2021 last reviewed/revised "Patient Rights and Responsibilities" policy required, "respect the rights of patients and their surrogate decision makers...collaborate with patient's and their surrogate decision makers to promote patient health and welfare...treat all with dignity, compassion, and respect...responsibilities...If a patient is unwilling to do so, we will consider the patient responsible for the consequences..."

The 12/09/2022 last reviewed/revised "Discharge Planning" policy required "optimize patient's health and recovery and minimize the potential for post discharge adverse health consequences and readmission..."