HospitalInspections.org

Based on observation, document review and interviews, on November 21, 2016 and November 30, 2016, it was determined that the Governing Body failed to ensure that Hospital Policies and Procedures regarding patient care and safety were adhered to appropriately.
The finding includes:
The Hospital failed to assure that a patient received care in an environment that promoted and protected the physical and emotional safety through compliance with Hospital Policies and Procedures. See Condition of Participation Patient Rights, Tag A-0144, for further information.
The Hospital failed to ensure that adequate nursing staff was assigned to monitor and provide patient safety. See Emergency Services Tag A-1112, for further information.
The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on record reviews and interviews, it was determined that the Condition of Participation (CoP) for Patient Rights was not met. The facility failed to ensure that patient safety assessments required by Hospital Policy were conducted, and failed to ensure that patients were monitored and assessed consistent with facility policy regarding patients who present seeking psychiatric care.

The finding includes:

This facility has failed to comply with the CoP for Patient Rights as evidenced by the deficiency identified as follows:

§482.13(c) Standard: Privacy and Safety, also known as A-0142: Based on record review, policy review, and interview, the facility failed to ensure that patient safety requirements were met. See A-0142 for details.

§482.13(c)(2) Element: The patient has the right to receive care in a safe setting, also known as A-1044: Based on record review, policy review, and interview, the facility failed to ensure that Hospital Policies pertaining to patient safety and monitoring were followed. See A-0144 for details.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on observations, document review and interviews with key personnel on November 17, 2016 and November 30, 2016, it was determined that the facility failed to ensure patient safety requirements were met.

The finding includes:

Patient A entered the hospital Emergency Department (ED) on transfer from another facility seeking assessment to be admitted to an inpatient psychiatric facility/unit to treat a reported exacerbation of his/her mental health symptoms. Patient A was reported as not responding as intended to treatment at the sending facility.

While in the ED, the facility failed to provide safety assessments and close monitoring as required by Hospital Policy. The result of this failure allowed the patient to elope undetected from the ED and later the same patient was found in cardiac arrest in the ED from an apparent suicide. See tag A-0144 for additional details.

Based on observations, document review and interviews with key personnel on November 17, 2016 and November 30, 2016, it was determined that the facility failed to follow hospital policy regarding required safety assessments and close observation/monitoring of psychiatric patients presenting in the Emergency Department and failed to provide interventions necessary to assure patient safety.

The finding includes:

Patient A entered the hospital Emergency Department (ED) on transfer from another facility seeking assessment to be admitted to an inpatient psychiatric facility/unit to treat a reported exacerbation of his/her mental health symptoms, which reportedly was not responding as intended to treatment at the sending facility. While awaiting a psychiatric assessment, the patient eloped from the ED without detection and was absent from the ED approximately 1.5 hours and was unaccounted for. The patient later returned to the ED on his/her own accord was eventually placed in a treatment room without ongoing/frequent supervision and was found in the adjoining restroom in cardiac arrest from an apparent suicide.

A review of the patient record and transcript of security video monitoring provided the following evidence:

Hospital policy 20.071 titled "Screening for risk of suicide Ideation/Attempt and providing Close Observation", issued 10/2016, states:

"EMMC Emergency Department:
A. Patients who present following a suicide attempt, who are displaying suicidal ideation or present with a primary psychiatric complaint will have a suicide risk assessment completed by an RN and placed on close observation until seen by the Acadia physician/licensed independent practitioner (LIP) who dictates otherwise...
D. Patients will be placed in the "Blue" assignment of the Emergency Department under close observation by security and assigned staff RN, ...and a psychiatric consult will be obtained to assist with safe discharge planning from the Emergency Department or until the patient becomes an inpatient."

Patient A was transferred to Eastern Maine Medical Center ED on November 10, 2016. Patient A arrived by ambulance at approximately 4:50 PM for the documented purpose of obtaining a psychiatric evaluation to access an inpatient psychiatric hospital admission.

Patient A was placed in a "Rapid Medical Exam" (RME) room, which was located in the ED waiting room, at approximately 4:55 PM, following initial assessment by the Emergency Department triage nurse. [Nurse responsible for initial rapid assessment to determine severity of patient need and assigns a priority level based on pre-approved standards]. Triage nurse note states; "in from [sending facility] outpatient group, + [positive] paranoid, denies SI?HI [suicidal or homicidal thoughts], recent med [medication] changes". Although the note states the patient denied suicidal ideation (SI), there is no evidence that a patient safety risk assessment was completed or the patient placed on close observation consistent with facility policy.

Based on security video transcript, patient A was allowed to leave the ED waiting area without detection and was absent from the ED for approximately 1.5 hours (7:56 PM - 9:25 PM). A review of the nurses notes and entries in the medical record for Patient A demonstrated that the triage nurse had made a brief triage nurse note at 4:55 PM and then a nurse entered a note that stated, "2040-2105: Pt [patient] called in WRx2 [waiting room twice], no answer. Search in department, no results. Charge and MD made aware." Based on interviews it was determined that no staff was assigned to specifically monitor the patients in the waiting room area.

Patient A re-entered the ED waiting room at approximately 9:29 PM and remained in the waiting room until approximately 9:46 PM, when patient A was taken to ED room 18. [Located adjacent to the psychiatric ED treatment area]. A nurse note in the medical record at 9:50 PM indicated that Patient A had a diagnosis of bipolar disorder, and that Patient A was "afraid and doesn't know why. Patient is notably anxious and denied SI." There was no indication that a patient suicide risk/safety assessment was completed by this nurse consistent with the hospital policy.

Security video transcript documents that at approximately 10:25 PM a staff member was observed leaving room 18 and the adjoining bathroom and noted to be walking towards the nursing station. No other staff is reported as observed on the video transcript entering/monitoring the patient in room 18.

Security video transcript documents that at approximately 10:30 PM Patient A exited room 18 and went into the restroom adjacent to room 18.

At approximately 11:07 PM the video transcript documents that a housekeeping staff member attempted to open the door to the restroom adjacent to room 18 and notified the nurse of an obstruction.

Nursing documentation dated November 10, 2016 at 2350 (11:50 PM) indicated that the nurse who was assigned to observe the psychiatric patients at the end of the hallway [identified as not assigned to patient A] responded at 11:08 PM, to a request for help by the housekeeper and found the patient inside the bathroom "sitting on the floor against door with blood pressure cord wrapped around neck and over top of door."

A code [resuscitation response for individual in cardio/respiratory arrest] was called and CPR (Cardiopulmonary resuscitation) was initiated. Documentation indicates that patient A was declared deceased at 11:37 PM, and resuscitation efforts were ended.

There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility.

Based on document review, observation and interview on November 21, 2016 and November 30, 2016, it was determined that Eastern Maine Medical Center failed to ensure that adequate nursing staff was assigned to monitor and provide patient safety.
The finding includes:
Eastern Maine Medical Center (EMMC) Emergency Depart. Departmental Directive (DD) Safety and Care of Mental Health/Behavioral Patients in the Emergency Department No. 10.5772 states, in part, "A Suicide Risk Assessment will be completed upon presentation to the ED and every 24 hours... for all patients who present: a. With a primary psychiatric complaint;" and "H. Patient Care Considerations 2. An initial Psychiatric Assessment will be performed by nursing staff and updated every shift/ with each change in caregiver on all mental health/behavioral patients."
EMMC Interdepartmental Directive Screening for Risk of Suicide Ideation/Attempt and Providing Close Observation No. 20.071 states, in part, "EMMC Emergency Department: A. Patients who present following a suicide attempt, who are displaying suicidal ideation or present with a primary psychiatric complaint will have a suicide risk assessment completed by an RN and placed on close observation until seen by the Acadia physician/Licensed Independent Practitioner (LIP) who dictates otherwise...", and, "D. Patients will be placed in the 'Blue' assignment of the Emergency Department under close observation by security and an assigned staff RN, will be medically evaluated and treated and a psychiatric consult will be obtained to assist with safe discharge planning from the Emergency Department or until patient becomes an inpatient."
Patient A's Emergency Department (ED) medical record failed to contain documentation of a Suicide Risk Assessment, Nursing Psychiatric Assessment, or documentation of the patient being placed in the Blue Assignment of the Emergency Department under close observation and an assigned staff RN, as required by EMMC Directive.
A nurses note dated November 10, 2016 at 7:42 PM stated, "1942 (7:42 PM) presented to Acadia. To be moved to chair room."

A nurses note in the medical record which was dated November 10, 2016 at 9:02 PM stated that between 8:40 PM and 9:05 PM, staff called in the waiting room twice for Patient A and received no answer or response from the patient, so a search of the ED was performed. They were unable to locate the patient and the charge nurse and physician were made aware of this.

At 9:50 PM on November 10, 2016, there was a nurse's note that stated, "Assumed patient's care. On assessment, patient stated that he/she has been going to IOP (Intensive Outpatient Program) at [the sending facility]. He/She has a diagnosis of bipolar disorder. Patient stated he/she is afraid and doesn't know why. Patient notably anxious and denied SI (suicidal Ideation) and HI (Homicidal Ideation)." In addition to this nurse's note there was an entry in the electronic medical record titled, "ED Triage Part-2 Adult form" that was documented as being completed on November 10, 2016 at 9:50 PM. In this nursing assessment, the chief complaint is documented as "In from [sending facility] Outpatient Group, positive paranoid, denies SI?HI, recent med changes." This assessment also documented under Behavioral Health Concern "No" with no impaired judgement/safety awareness, no agitation. Additionally, this 9:50 PM nurse assessment documented that Patient A had no fears or worries despite the nurses note documentation for the same time period stating that Patient A, "stated he/she was afraid and doesn't know why."

During an interview conducted on November 30, 2016 at approximately 5:00 PM, ED Triage Nurse 1 stated, "I had a "run sheet" (An EMS document completed by the ambulance crew transporting the patient) that he/she came from an outpatient group session and some sort of statement that he/she was paranoid and he/she denied suicidal or homicidal ideation. I asked him/her if he/she was having any visual or auditory hallucinations and he/she denied any. It's kind of a funny thing that he/she is sent here from [sending facility] to get a medical clearance and a psych eval. [evaluation] to go back to [sending facility]...", and, "I didn't do a suicide Risk Assessment ... I asked if he/she was suicidal or homicidal and he/she denied it. It wasn't needed."

During an interview conducted on November 30, 2016 at approximately 5:00 PM, when asked if a Suicide Risk Assessment was done for this patient, the Director of Nursing Systems stated, "No. You see the suicide risk assessment didn't fire because this box wasn't checked "yes" (the check box is located on the electronic "ED Triage Part 2 General Assessment" form labeled "Behavioral Health Concern") the suicide Risk Assessment didn't open up and so they didn't need to do it. The initial triage assessment said he/she didn't have suicidality."
During an interview conducted on November 30, 2016 at approximately 1:45 PM, the Emergency Department Nurse Manager stated, "The triage nurse in triage 2 is responsible for monitoring the patient in the waiting area...", and, "I don't think there is a policy for that. It is part of the training for the triage nurse."
During an interview conducted on November 30, 2016 at approximately 5:15 PM, when asked, when she found out Patient A was missing and what she did, Triage Nurse 2 stated, "I went out in twenty minutes to bring him/her back to the chair room. I told the charge nurse he/she was missing. I said I would go back in twenty minutes and try again. That's our policy. We do that a lot because patients go out to smoke or something and we will wait for a while for them to get back."
On November 30, 2016 at approximately 4:50 PM a review of the 2016 triage nurse training slides was conducted. The ESI (Emergency Severity Index) Triage training slide titled "RME [Rapid Medical Exam] Nurse Responsibilities" stated "Monitor lobby patients/re-checks".
During an interview conducted on November 30, 2016 at approximately 5:18 PM, the Emergency Department Nurse Manager stated, "There is no RME nurse. It is the triage nurses responsibility to monitor the patients in the waiting area."
A review of the security camera transcript for November 10, 2016, provided by security staff denoted that the patient was not on " observation" by security.