HospitalInspections.org

Based on document review, video surveillance review, and interview, it was determined that the Hospital failed to protect and promote patient's rights by failing to ensure appropriate interventions were provided to a patient with escalating, agitated behavior. This potentially places any patient with agitated behaviors requiring interventions in the ED at risk for harm, serious injury, or death. As a result, the Condition of Participation 42 CFR 482.13, was not in compliance.

Findings include:

1. The Hospital failed to provide care in a safe setting by failing to appropriately activate a response team to intervene and institute measures to address a patient's agitated behaviors. See deficiency at A-144.

The Immediate Jeopardy (IJ) began on 5/11/2022 due to the Hospital's failure to ensure appropriate actions and measures were provided to a patient with escalating, agitated behaviors while in the ED (emergency department). Immediately following the failure, the patient fell while while being escorted out of the ED, and sustained a brain hemorrhage. Subsequently, the patient died at another Hospital.

The IJ was identified on 5/26/2022 at 42 CFR 482.13, Patient Rights, and was annnounced on 5/26/2022 at 9:30 AM, during a meeting with the Executive Director of Quality, Chief Nursing Officer, Executive Director of Safety, Vice President of Ambulatory, Chief Opersting Officer, Quality Specialist, Chief Medical Officer, Assistant Chief Medical Officer, and Security Director. The IJ was not removed by the survey exit date of 5/26/2022.

Based on document review, video surveillance review, and interview, it was determined that for 1 of 4 (Pt. #2) clinical records reviewed for a patient with agitated behavior, the Hospital failed to provide care in a safe setting by failing to appropriately activate a response team to intervene and institute measures to address Pt. #2's agitated behaviors.

1. On 5/24/2022, the clinical record for Pt. #2 was reviewed. Pt. #2 was a 56-year-old male who came to the ED on 5/11/2022 due to anxiety. The clinical record included:

- The nurses triage note on 5/11/2022 at 7:13 PM indicated, " ... Arrival Mode: Ambulance ... (Pt. #2) to triage by (wheelchair), reports feeling anxious and pain all over (for two days) ... ESI (emergency severity index/triage algorithm) 3 (urgent [1 most urgent to 5 least urgent]) ..." Pt. #2's vital signs were as follows: blood pressure 146/100 (normal blood pressure less than 120 for systolic and less than 80 diastolic), respiration 18 per minute (normal), temperature 97.8 (/normal), pulse 70 beats per minute (normal), oxygen level 99% (normal).

- E #7's (physician assistant) progress notes on 5/11/2022 included, " ...past medical history of hypertension ... CVA (cerebrovascular accident/stroke) on Plavix (blood thinner) presenting for evaluation of "pain all over" and increased anxiety. ... (Pt. #2) states symptoms primarily due to the fact that he has not been able to sleep for the last couple of days ... History ...Anxiety ... Depression ... Medications ... Plavix ... Sertraline Hydrochloride (medication for depression or anxiety) ... Physical Exam ... alert, oriented to person ... place ... time. Speech clear ... Medical Decision Making ...Neurologically intact. No focal deficit on exam. (Pt. #2) states he has been increasingly anxious and requesting medication at this time ... Offered (Pt. #2) IV fluids and antianxiety medication, however, (Pt. #2) states if he is not being admitted to the Hospital, he would like to leave at this time ... Upon informing (Pt. #2) of plan for eventual discharge, (Pt. #2) became hostile and violent with staff. (Pt. #2) states he would like to leave the Hospital at this time. (Pt. #2) stating, "he is going to kill staff." We will plan for discharge home. Upon discharge, (Pt. #2) began throwing objects at staff and remained verbally aggressive. Security called at bedside. (Pt. #2) ambulatory and escorted off the premises by security. Per security, as (Pt. #2) was escorted out of the ED ... (Pt. #2) now endorsing pain to the facial area after falling to the ground. (Pt. #2) remains alert and oriented x 4 (person, time, place, and situation). (Pt. #2) placed in C-collar (cervical collar/used to stabilize neck injury) and brought back into the ED. Will order CT (computer tomography/detailed imaging of body organ) facial bone, cervical spine and brain for further evaluation. (Pt. #2) remains anxious and aggressive towards ED staff ... Per radiology, CT brain significant for subdural (part of the brain) bleed. We will plan for transfer to (Name of outside Hospital) for trauma evaluation ... Disposition ... Primary Impression: Anxiety. Secondary Impressions ... Subdural bleeding ..."

- E #8's (ED RN/emergency department registered nurse) progress notes on 5/11/2022 were as follows:

At 8:26 PM, "Provider at bedside."

At 9:36 PM, "(Pt. #2) becoming increasingly agitated towards staff. Unable to verbally redirect (Pt. #2). (Pt. #2) stating, 'I am going to kill you.' Security called to bedside."

At 9:40 PM, "(Pt. #2) throwing things at staff."

At 9:45 PM, "(Pt. #2) escorted out by security per provider. Ok to (discharge)."

At 9:45 PM, "MD called by security. States (Pt. #2) assisted out of ER ambulatory. Per report given, (Pt. #2) noted to have thrown himself to ground causing facial injury. (Pt. #2) presents back to (ED) room ... C-collar in place. (Pt. #2) demanding (medications at this time), continues to yell at staff ... Awaiting CT at this time."

- After Pt. #2 demonstrated threatening behavior towards staff, there was no documentation that Pt. #2 was re-evaluated by the physician assistant.

- There was no documentation that a code BERT (Behavioral Response Team) was activated nor documentation that elements of the code BERT was provided to Pt. #2 when Pt. #2 demonstrated potentially harmful behavior to others and when Pt. #2 did not respond to verbal redirection.

- The clinical record indicated that Pt. #2 was given Ativan (medication for agitation) on 5/11/2022 at 10:09 PM in ED. This medication was administered when Pt. #2 was returned to the ED for medical evaluation after it was reported that Pt. #2 sustained an injury while being escorted outside of the ED.

- The transfer form on 5/11/2022 at 11:00 PM indicated, " ... Diagnosis: Brain hemorrhage (status post) fall ..."

2. On 5/24/2022, the Hospital's policy and procedure titled, "Code BERT (Behavioral Emergency Response Team) (dated 1/2021) was reviewed. The code BERT was one of the processes used in the ED to address patients with agitated behaviors. The policy required, " ...The purpose of this policy is to give guidance regarding ... activation of the response team for the agitated person ... B ... Code BERT is utilized on inpatient care areas ... D. Procedure. 1. The Response Team May Be Activated When: a. Any behavior that is escalating or potentially escalating and potentially harmful to self, others ... or b. The patient does not respond to verbal redirection and the behavior continues to be threatening and/or escalating, or c. The Code BERT response can be activated for patients on inpatient units that exhibit the following aggressive/agitated behavior ... Anxiety ... E. Members of the Code BERT; 1. De-Escalation Lead: a. Behavioral Health Staff Member and/or the Nursing Supervisor ... 2. Medical Lead: Hospitalist/Resident ... 3. Primary Members: a. Primary nurse caring for the patient. b. Security officer(s) ... G. Medical Leader Responsibilities: 1. The Medical Leader will provide a focused clinical assessment of the situation at hand to identify if there are any acute medical issues that may be causing or contributing to the current presentation. 2. The Medical Leader will guide the team to gather additional clinical information as well as determine if pharmacologic interventions are indicated and if so will provide the necessary orders to implement such interventions..."

3. On 5/24/2022 at approximately 2:00 PM, E #11 (Executive Director of Quality) stated that code BERT is used by the Hospital's ED as one of the processes to address agitated behaviors of patients in the ED.

4. On 5/24/2022 at approximately 11:45 AM, video surveillance review was conducted with E #11 (Executive Director of Quality), E #13 (VP of Ambulatory and Hospitality), and E #14, (Manager of Public Safety).
The video footage had a stamped date of 5/11/2022 at 21:41:21 (hour/minutes/seconds) showing views from the outside of the emergency room exit (by the ER waiting room) between the north and south ED:

- At 21:41:23, the ER exit door opened.

- At 21:41:27, three people (patient safety officers/E #15 and E #16) and Pt #2 were seen coming out of the ED. Pt. #2 was only wearing shorts with no shirt or shoes on. E #16's left hand was on Pt. #2's back. Two security officers followed (E #17 and E #18).

- At approximately 21:41:28, Pt. #2 was seen being shoved by E #16. Momentarily, Pt. #2 was seen falling to the ground.

- During the video surveillance review, E #14 stated that E #16 pushed Pt. #2.

5. On 5/24/2022 at approximately 3:00 PM, during the tour of the Emergency Department, interviews were conducted with four registered nurses/RNs (E #2, E #3, E #4, and E #5). All four RNs stated that they have not received any in-service on how to handle agitated patients since January 2022.

6. On 5/25/2022 at approximately 9:15 AM, a telephone interview was conducted with E #7 (physician assistant). E #7 stated, "I spoke with my attending that Pt. #2 came in for restlessness and the plan. Upon offering intravenous fluid and antianxiety medications, (Pt. #2) became irate and wanted to be discharged if he is not going to be admitted. I gave the discharge paper to the nurse and explained the plan to (Pt. #2). After that, I was seeing other patients, I could hear Pt. #2 began screaming and threatening staff." At the time when Pt. #2 was verbalizing that he is going to kill staff, E #7 stated, "I don't think he needed medication. There is no need for Pt. #2 to be reevaluated and it is ok for Pt. #2 to be discharged." E #7 stated that he did not discuss with the attending physician regarding Pt. #2's threatening behavior. E #7 stated that he continues to work in the ED and has not received re-education on how to handle patients with agitated behavior in the ED.

7. On 5/25/2022 at approximately 10:00 AM, an interview was conducted with the ED medical director (MD #2). MD #2 stated that when a patient's condition changes in the ED, it is appropriate to reevaluate the patient's condition. MD #2 stated, "I would ask more questions what the patient needs? If he wants to speak with a psychiatrist." MD #2 stated that the ED also uses the elements of the (Code) BERT on how to handle agitated patients. MD #2 could not provide documentation on the clinical record that Pt. #2's threatening behavior was re-evaluated, if need for pharmacologic intervention was necessary, or if additional information was gathered from Pt. #2. MD #2 stated that the elements of the code BERT are also followed in the ED.

8. On 5/25/2022 at approximately 10:50 AM, an interview was conducted with E #12 (Executive Director of patient Safety and Regulatory). E #12 stated that the Hospital has not completed the root cause analysis and investigation regarding Pt. #2's incident. Therefore, education and training has not been fully implemented.

9. On 5/25/2022, the Hospital's self-reported incident was reviewed and indicated that Pt. #2 subsequently died at another Hospital on 5/13/2022.