HospitalInspections.org

Based on record reviews and interviews, the facility failed to provide an appropriate medical screening for one of eleven patients reviewed (Patient #1) who eloped from the facility after an initial medical screening and then arrived back at the facility's dedicated emergency department two hours and twenty-five minutes after the initial medical screening needing another medical screening.

Findings included:

Review of Patient #1's emergency department medical record revealed the following: Patient #1 was brought to the facility emergency department by a family member on 02/11/2023 at 1927, triaged at 1958, and a medical screening was documented by Physician #1 at 2007 to 2017 but patient left after medical screening at 2045 by eloping thru the back door after going to the restroom. She was given a diagnosis of Bipolar Disorder, current mixed, severe with psychotic features. Patient #1 returned to the facility emergency department on her own on 02/11/2023 at 2310 and another medical screening was being attempted at 2356 by Physician #2. Patient #1 was documented as "being verbally uncooperative, screaming at the top of her lungs as she was very manic". Physician #2 "attempted to complete a medical screening but patient was screaming at the top of her lungs". A Code Gray (violent patient/visitor) was called by Registered Nurse #1 and then Registered Nurse #2 asked security to escort the patient off of the premises because she was a "voluntary" patient. Security escorted Patient #1 off of the hospital campus. A medical screening was not completed during the second visit to the emergency room due to Registered Nurse #2 asking Security to escort Patient #1 off of the premises.

Review of email, dated 02/13/2023 at 9:53 AM sent to Director of Nursing for the Emergency Department by Registered Nurse #1 revealed but was not limited to the following: "Patient (Patient #1) was dropped off by father for psychiatric evaluation. Patient was obviously manic but oriented times three, following commands and redirectable. Patient had obvious internal stimuli but denied suicidal/homicidal ideation and/or audio/visual halluciantions during triage. Patient eloped from emergency department after being manic, in obvious unstable state, after receiving medications by mouth. Patient returned. Patient was taken straight back to hallway 45 where patient became manic in obvious state of psychosis. This RN (Registered Nurse #1) called a Code Gray and requested charge (nurse) to lateral patient over so she could go into room 21 and have direct supervision and be safely treated. Emergency Room Charge Nurse (Registered Nurse #2) then said, "Oh she is here voluntary and she needs to get out with all that screaming". She then proceeded to ask security to escort patient out. Security Officer screamed "get out"' at unstable manic patient who is now only alert to self, has no idea where she is at and is expression persecutory hallucinations, uncorrelated flight of ideas, and has agitated motor skills. Patient fell back as she was frightened. In addition patient was mentally retarded and her father should have been notified. Patient's behavior was disruptive but not violent towards others or staff. Patient was obviously not in her right state of mind. This RN made primary RN (Registered Nurse #3) call the police to locate patient as the patient was unstable and an immediate danger to herself."

Interview on the afternoon of 03/27/2023 with facility administrative staff confirmed the facility self reported this incident to the state survey agency as a potential EMTALA violation. The administrative staff stated Registered Nurse #2 was given written disciplinary action and was retrained on EMTALA policies and procedures. Administrative staff reported that Registered Nurse #2 resigned on 03/15/2023.

Interview by phone on the morning of 03/28/2023 with Registered Nurse #1 confirmed the information in the email that she had sent to the Director of Nursing for the Emergency Department was accurrate. She indicated she had witnessed security guards escort Patient #1 off the premises. She recalled telling other staff that "they can't do that" to Patient #1. She further indicated that Patient #1 was "worse" from her first time in the Emergency Department to coming back the second time. She stated that during the first visit, Patient #1 was able to answer questions but that on the second visit, she could not answer questions and seemed to have no idea where she was.