HospitalInspections.org

Based on a review of facility documents, medical records (MR), and interviews with staff (EMP), it was determined that the facility failed to follow their policy for incident report documentation after police were notified of a patient making homicidal threats to an identified individual in one of one medical records reviewed (MR1), by failing to document behavioral health patients were wanded upon admission to the Emergency Department (ED) in 12 of 21 medical records (MR1, MR3, MR4, MR6, MR7, MR8, MR9, MR12, MR13, MR17, MR20 and MR21), by failing to document behavioral health patient belongings were removed and secured in 10 of 21 medical records (MR1, MR3, MR4, MR6, MR8, MR9, MR13, MR17, MR20 and MR21), and by failing to document that the behavioral health patient was admitted to a ligature free environment in 14 of 21 medical records (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR12, MR13, MR17, MR20 and MR21).



Findings Include:

Review of Policy "Patient Rights and Responsibilities" Policy Number SB-5/ADM-39 dated February 2023, revealed, "... I. Scope: Applies to patients, patients legally responsibility party, and employees. I. Purpose: As a patient or the patient's legally responsible party at Penn Highlands Huntingdon, the patient should have certain basic rights. III. Text: Patient Rights and Responsibilities ... Your rights: ... As our patient, you have the right to safe, respectful, and dignified care at all times. You will receive services and care that are medically suggested and within the hospital's services, its stated mission, and required law and regulation. ... Care Delivery: You have the right to: Expect emergency procedures to be implemented without unnecessary delay. Receive care in a safe setting free from any form of abuse, harassment, and neglect. Receive kind, respectful, safe, quality care delivered by skilled staff. ... ."

Review of facility policy L-12, "Elopement" dated March 2023, revealed Procedure: Elopement: ... 5. If patient is 201, notification of police needs to be in form of written order from physician. If patient is 302, police will need to be contacted. A physical description of patient and clothing worn is to be given to police. In addition, if patient has made suicidal or homicidal threats, that information along with name of person homicidal threats were made about should be given to police. 6. Detailed documentation including an incident report will need done. ... ."

Review of Policy "Intake of the Behavioral Health Patients" Policy P-79, last reviewed February 2023, revealed, "... All Emotionally Ill Patients: 1. Patient presents to ED registration and is placed in the Quiet Room alerting the ED nurses of patient's arrival and security to perform metal detector wanding. 2. Patient wanded and taken to ED treatment room [preferably [sic] room 14 if medically able] and changed into paper scrubs/hospital gown and slipper socks. 3. Patient's belongings obtained and secured by security and patient wanded a second time. ... ."


Review of Policy "Guidelines to Follow for Behavioral Health Patients Who Refuse Care" Policy Number: P-78 dated February 2023, revealed, "... Policy Special consideration should be given if the patient meets criteria for 302 commitment. ... The following are criteria to determine appropriateness for a 302 petition based on MH783 'Application for Involuntary Emergency Examination and Treatment-Mental Health Procedures Act of 1976, Section 302'. ... Clear and present danger to others shall be shown by establishing that within the past 30 days the person has inflicted or attempted to inflict serious bodily harm on another and that there is reasonable probability that such conduct will be repeated. A clear and present danger of harm to others may be demonstrated by proof that the person has made threats of harm and has committed acts in furtherance of the threat to commit harm: ... ."



1. Review of MR1 dated August 15, 2023, at 8:15 PM revealed that the patient was psychotic, a threat to self, severely mentally disabled and was admitted as an involuntary commitment and the patient's "MH-783 Application for Involuntary Emergency Examination and Treatment-Mental Health Procedures Act of 1976, Section 302" was upheld by the ED physician.

Continued review of MR1 dated August 15, 2023, revealed the homicidal patient eloped from the ED at 8:38 PM and failed to reveal documented evidence that a detailed incident report was completed after the police were notified of a patient who made homicidal threats about an identified person.

2. Interview with EMP6 on September 12, 2023 at 2:15 PM, confirmed that a detailed event report was not completed after the police were contacted regarding a patient who made homicidal threats about an identified individual.


3. Additional review of MR1 dated August 15, 2023, at 7:46 PM revealed, prior to the Emergency Department (ED) visit the patient smashed a windshield and apartment buildings circuit box causing the power to go out. MR1 revealed during the ED visit the patient was very paranoid and would not answer questions directly, had scattered thoughts and stated that he wanted to kill three people.

Continued review of MR1 dated August 15, 2023, at 8:41 PM revealed, that the patient has had ongoing psychosis with anger, aggression, homicidal and suicidal threats.


4. Tour of the Emergency Department on September 14, 2023, conducted with EMP1 and EMP2, revealed Room 14, with ligatures that included a patient bed, recliner and overbed table.

Interview with EMP3 on September 14, 2023, confirmed Room 14 is utilized for behavioral health patients when available, that MR1 was admitted to this room and that the overbed table was allowed to remain in the room with the patient.

5. Review of MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR12, MR13, MR17, MR20, MR21 failed to reveal documented evidence of patient's being admitted in a ligature free room.

Interview with EMP5 on September 14, 2023, at 11:20 AM confirmed the above findings.

6. Review of MR1, MR3, MR4, MR6, MR8, MR9, MR13, MR17, MR20, MR21 failed to reveal documented evidence of personal belongings should have been removed by staff and secured at the nurse's station.

Interview with EMP5 on September 14, 2023, at 11:20 AM confirmed the above findings.

7. Review of MR1, MR3, MR4, MR6, MR7, MR8, MR9, MR12, MR13, MR 17, MR20, MR21 failed to reveal documented evidence that patient's were wanded prior to changing into hospital gown per hospital policy.

Interview with EMP5 on September 14, 2023, at 11:20 AM confirmed the above findings.

8. Interview with EMP2 on September 14, 2023, confirmed the expectation for nursing would be to document behavioral health patients are wanded on admission to the ED, changed into hospital gown, with belongings collected by staff and secured at the nurse's station, and admitted to a ligature free room.