HospitalInspections.org

Based on documentation review and interview, although during the first quarter of 2010 there were 71 elopements from the Hospital emergency department, the Governing Body of the Hospital failed to ensure that there was a policy or procedure in place for emergency department staff to follow in the event that a patient eloped from the emergency department and as a result when Patient #1 eloped from the emergency department at about 8:04 P.M., and hid in an examination room approximately 30 feet from the emergency department for over an hour, a thorough search of the Hospital was not completed and Patient #1 was discovered dead in bushes on Hospital property at approximately 6:00 A.M. the next morning.

The findings included:

An Emergency Nursing Record (Psychiatric Complaints/Suicide Attempt), dated 4/20/10, indicated Patient #1 arrived at the emergency department by ambulance and at 7:46 P.M. Patient #1 was triaged as urgent. The Emergency Nursing Record indicated Patient #1 was depressed, angry, hostile, had about 100 small cuts on the left arm, and Patient #1 complained of being manic for seven days. The Emergency Nursing Record indicated Patient #1 had a "6 pack" of alcohol today and had ingested 30 to 45 Wellbutrin at 7:20 P.M., but denied suicidal ideation and stated to Nurse #1 "just very angry". The Emergency Nursing Record indicated Patient #1 was was placed in the emergency department "code room". The Emergency Nursing Record indicated at 8:00 P.M. Poison Control was called and at 8:04 P.M. Patient #1 was not in the code room and was believed to have eloped, so Security was informed. The Emergency Nursing Record indicated that the local Police Department was notified at 8:10 P.M. to initiate a search of the area.

Nurse #1 was interviewed at 2:08 P.M. on 4/30/10. Nurse #1 said Patient #1 was placed in the code room, which had a cardiac monitor and Nurse #1's first priority was to contact Poison Control. Nurse #1 said at that time Nurse #1 did not think of a sitter with Patient #1 and Nurse #1 left the code room to call Poison Control. Nurse #1 said Nurse #1 was out of the code room for maybe 5 to 6 minutes, but when Nurse #1 returned to the code room, Patient #1 was not there.

Nurse #1 said after Patient #1 was missing from the code room, Nurse #1 went to Security and the video feed was up on the monitor, but while the security officer was checking the video tapes, there was a power surge and the monitor went black. Nurse #1 said security then started a search and Physician #1 was also notified that Patient #1 had eloped and the local police department was called. Nurse #1 said they initially believed Patient #1 walked out through the emergency department doors, so they checked the emergency department parking lot and then the police arrived and also checked the streets around the Hospital.

The Director of Engineering & Security was interviewed at 8:50 A.M. on 4/28/10. The Director of Engineering & Security said the Hospital had security cameras that covered most of the Hospital, but on 4/20/10 there was a power surge and the monitors went down. The Director of Engineering & Security said after Patient #1 eloped, the security guard attempted to view the cameras to determine where Patient #1 went, but the monitors were down; however, the cameras kept on taping, but it could not be seen on the monitors due to the power surge. The Director of Engineering & Security said it was asumed the cameras had stopped working, but the next morning he was able to bring up the tapes and observe Patient #1 leaving the emergency department via the rear door of the code room, which opened into a hallway in radiology. The Director of Engineering & Security said Patient #1 went across the hallway and entered an exam room, where Patient #1 remained for over an hour. The Director of Engineering & Security said Patient #1 then exited the exam room, walked throught radiology, followed the hallways to the other side of the Hospital, and exited the Hospital through the main entrance.

The Vice President of Patient Care Services was interviewed at 3:45 P.M. on 4/30/10. The Vice President of Patient Care Services said security did not complete an internal search of the Hospital, because they incorrectly assumed Patient #1 had left the Hospital. The Vice President of Patient Care Services said it was very unusual for the examination room, in which Patient #1 hid, to not be used for over an hour, so Patient #1 was not discovered. The Vice President of Patient Care Services said there was no current policy or procedure in place for elopement, so the Hospital was in the process of developing an elopement policy that had guidelines for completing an internal search of the Hospital in the event of an elopement.

A review of the Hospital's Intense Analysis, dated 4/21/10, indicated at approximately 6:00 A.M. on 4/21/10 a deceased person was found in bushes on the Hospital grounds and police were called. The Intense Analysis indicated the deceased person was identified as Patient #1. The Intense Analysis indicated the Hospital had no policy or procedure to guide staff during an elopement from the emergency department and currently the Hospital had no process for alerting all Hospital staff that an at-risk patient had eloped.

Based on documentation review, interview, and observation the Hospital failed to ensure the safety of one of nine sampled Patients (Patient #1) who was brought to the emergency department (ED) after an attempted suicide. Specifically, Patient #1, who had ingested alcohol and two handfuls of Wellbutrin (anti-depressant), arrived by ambulance, was placed in the ED code room, which had an unsecured rear door, and Patient #1 was left unsupervised. While unsupervised and out of the direct line of vision of staff, due to temporary construction in the ED, Patient #1 left the code room via the rear door, hid in an examination room that was diagonally across the hallway, for over an hour (per the Hospital's security tapes), then exited the Hospital through the main entrance, and was discovered lying dead in bushes on the Hospital grounds at approximately 6:00 A.M. the next morning.

The findings included:

A review of a Partial Hospitalization Evaluation, dated 3/22/10, indicated Patient #1 had a past medical history that included a suicide attempt, severe depression, insomnia, diabetes, migraine headaches, and a differential diagnosis that included bipolar disorder and ADHD (Attention Deficit hyperactivity Disorder). The Partial Hospitalization Evaluation indicated Patient #1 was alert, oriented, and cooperative, but was depressed, tearful, moderately anxious, and severely depressed. The Partial Hospitalization Evaluation indicated Patient #1 denied suicidal feelings. The Partial Hospitalization Evaluation indicated Patient #1 was on Wellbutrin (antidepressant) 300 mg (milligram), which would be tapered and discontinued and Patient #1 was started on Effexor (antidepressant).

The Hospital's Partial Hospitalization Program consisted of Patient #1 coming to the Hospital from 9:00 A.M. to 2:45 P.M. daily Monday thru Friday for community meeting/problem solving, goals, activity/occupational therapy, group psychotherapy, psychoeducation, and interpersonal review. The plan was to educate Patient #1 related to coping skills, structure, and medications. The progress notes indicated Patient #1 attended the Partial Hospitalization Program from 3/22/10 to 3/31/10.

A review of a physician's progress note, dated 3/29/10, indicated Patient #1 struggled to not cut self on a daily basis and it was always in the back of Patient #1's mind. The progress note indicated Patient #1 had self destructive impulses since the age of 12 years, which had been kept a secret for Patient #1's whole life. The progress note indicated Patient #1 was off the Wellbutrin today and today was the first day that Patient #1 took Effexor 75 mg.

A Partial Hospitalization Program progress note, dated 3/31/10, indicated Patient #1 reported having a hard time and had thoughts of hurting self on Sunday and Monday and Patient #1's goal was to make it through today and make it through the night safely.

A review of an Admission Psychiatric Evaluation, dated 3/31/10, indicated Patient #1 was on the Partial Hospitalization Program and Partial Hospitalization Program staff grew concerned about Patient #1's safety, so Patient #1 was admitted to the Hospital's inpatient psychiatric unit for treatment of depression, anxiety, suicidal ideation, and self injurious behavior. The Evaluation indicated this was Patient #1's second admission to the Hospital's inpatient psychiatric unit. The Evaluation indicated Patient #1 had numerous superficial lacerations on the left forearm. The Evaluation indicated Patient #1 attempted suicide at age 16 by overdose and eight years ago Patient #1 was hospitalized for planning another overdose. The Evaluation indicated Patient #1 endorsed suicidal and self injurious ideations and Patient #1 was admitted for safety and stabilization.

A review of a Medication Reconciliation, dated 3/31/10, indicated Patient #1 was no longer taking Wellbutrin 300 mg and was taking Effexor 37.5 mg two tablets each morning and one tablet at bedtime daily, and Ambien 10 mg at bedtime each night.

A review of a Hospital Discharge Summary, dated 4/6/10, indicated Patient #1 struggled with severely depressed mood, anxiety, urges to cut self, and more recently the thought of overdosing. The Hospital Discharge Summary indicated Patient #1 was started on Ativan (anxiolytic) 1 mg three times daily, which was dramatically helpful in reducing Patient #1's anxiety and Patient #1 became more engaged in treatment. The Hospital Discharge Summary indicated Patient #1's Effexor was increased to 75 mg twice daily and Patient #1's thoughts of hurting self resolved entirely. The Hospital Discharge Summary indicated that by the end of Patient #1's stay, Patient #1 did not appear, in the team's evaluation, to be an immediate danger to self or others and Patient #1 could be safely discharged back to the Partial Hospitalization Program.

A review of progress notes from the Partial Hospitalization Program indicated Patient #1 attended five days of programs from 4/8/10 to 4/20/10. A group progress note, dated 4/20/10, indicated Patient #1 attended the Partial Hospitalization Program from 9:00 A.M. to 2:50 P.M. on 4/20/10 and had a "good day".

A review of a Fire Department Ambulance Report, dated 4/20/10, indicated at 7:24 P.M. a call came in for ingestion/poisoning and an ambulance was dispatched to Patient #1's residence. The Ambulance Report indicated the ambulance arrived at Patient #1's residence at 7:29 P.M. and Patient #1 had been drinking alcohol, had cut self on the left forearm over 50 times and the wounds were superficial, but were bandaged with a dry sterile dressing and secured with kling. The Ambulance Report also indicated Patient #1 had ingested two handfuls of Wellbutrin 15 minutes prior to the ambulance's arrival. The Ambulance Report indicated Patient #1 refused oxygen and intravenous access, but allowed an EKG to be obtained and Patient #1 was in sinus rhythm with a pulse rate of 88. The Ambulance Report indicated Patient #1's blood pressure was 130/80, respiratory rate was 18, and oxygen saturation level was 97 %. The Ambulance Report indicated the ambulance left Patient #1's residence at 7:38 P.M., arrived at the Hospital emergency department at 7:42 P.M., and report was given to Nurse #1.

An Emergency Nursing Record (Psychiatric Complaints/Suicide Attempt), dated 4/20/10, indicated Patient #1 arrived at the emergency department by ambulance and at 7:46 P.M. Patient #1 was triaged as urgent. The Emergency Nursing Record indicated Patient #1 was depressed, angry, and hostile, but denied suicidal thoughts. The Emergency Nursing Record indicated Patient #1 had about 100 small cuts on the left arm and Patient #1 complained of being manic for seven days. The Emergency Nursing Record indicated Patient #1 had a "6 pack" of alcohol today and had ingested 30 to 45 Wellbutrin at 7:20 P.M., but denied suicidal ideation and stated to Nurse #1 "just very angry". The Emergency Nursing Record indicated Patient #1's Wellbutrin bottle was brought to the emergency department by the ambulance crew and upon examination of the bottle, 35 tablets were missing from the Wellbutrin bottle. The Emergency Nursing Record indicated Patient #1 was alert, oriented to person, place, and time, and was placed in the emergency department "code room". The Emergency Nursing Record indicated at 7:55 P.M. an EKG was completed and at 8:00 P.M. Poison Control was called and their recommendations were reported to Physician #1. The Emergency Nursing Record indicated at 8:04 P.M. Patient #1 was not in the code room and was believed to have eloped, so Security was informed. The Emergency Nursing Record indicated that the local Police Department was notified at 8:10 P.M. to initiate a search of the area.

Nurse #1 was interviewed at 2:08 P.M. on 4/30/10. Nurse #1 said Nurse #1 was not familiar with Patient #1, but Patient #1 arrived at the emergency department by ambulance at about 7:45 P.M. and Patient #1 had self-inflicted multiple lacerations on the left arm, had ingested alcohol, and had ingested medication. Nurse #1 said Patient #1 was lethargic and did not really respond until Patient #1 was woken up, but then Patient #1 kind of nodded in and out. Nurse #1 said that during the triage of Patient #1, Nurse #1 had to use ammonia salts twice to wake Patient #1 up. Nurse #1 said Patient #1 stated that Patient #1 had a "6 pack" and had ingested two handfuls of Wellbutrin. Nurse #1 said the ambulance crew had brought Patient #1's Wellbutrin bottle to the emergency department, but based on the date of the refill, the regular daily dose, and the number of Wellbutrin left in the bottle, they were unable to determined exactly how many Wellbutrin Patient #1 had taken. Nurse #1 said Patient #1 had said two handfuls of Wellbutrin had been ingested, so they treated Patient #1 as if a large amount of Wellbutrin had been ingested. Nurse #1 said Nurse #1 asked Patient #1 if she was trying to kill Patient #1 and Patient #1 denied that and said Patient #1 was just angry, so after taking the Wellbutrin, Patient #1 called the ambulance. Nurse #1 said that comment did bring Nurse #1's guard down a bit. Nurse #1 said Patient #1 expressed to Nurse #1 that Patient #1 did not want to die and that made Nurse #1 drop Nurse #1's guard, because Nurse #1 believed that downgraded the risk, although that was apparently was an incorrect assumption. Nurse #1 said usually if a patient made a physical attempt at suicide, the Security guard would sit with the patient, but Nurse #1 did not believe Patient #1 was a high risk for elopement, because Patient #1 had done a self-rescue by calling the ambulance.

Nurse #1 said the emergency department had three rooms (room #1, room #2, and the code room) with built in cardiac monitors, but there was construction in the emergency department and room #1 and room #2 were both closed for renovation, so the only other room with a cardiac monitor was the code room. Nurse #1 said the nurses' station was also being renovated and, so the nurses' station was temporarily located in the hallway outside rooms #1 and #2. Nurse #1 said because of the renovations, there was no line of sight from the nurses' station to the code room. Nurse #1 said Nurse #1's first priority was to contact Poison Control and at that time Nurse #1 did not think of a sitter with Patient #1. Nurse #1 said considering a sitter was probably the next thing Nurse #1 would have considered. Nurse #1 said Nurse #1 left the code room to call Poison Control, then Nurse #1 spoke to Physician #1 about Poison Control's recommendations, then Nurse went to the Pixus (medication storage vending system) to get charcoal, then Nurse #1 returned to the code room. Nurse #1 said Nurse #1 was out of the code room for maybe 5 to 6 minutes, but when Nurse #1 returned to the code room, Patient #1 was not there. Nurse #1 said Patient #1 was in a hospital gown, but still had stretch type pants on. When asked if the code room had a telephone, Nurse #1 replied yes, but that telephone did not get used very often and Nurse #1 did not think of using that telephone. Nurse #1 said looking back on the incident, Nurse #1 should have called Poison Control from the code room. Nurse #1 said that prior to the construction, the code room would have been visible from the nurses' station and also from the Pixus machine.

Nurse #1 said after Patient #1 was missing from the code room, Nurse #1 went to Security and the video feed was up on the monitor, but while the security officer was checking the video tapes, there was a power surge and the monitor went black. Nurse #1 said security then started a search. Nurse #1 said Physician #1 was also notified that Patient #1 had eloped and the local police department was called. Nurse #1 said they initially believed Patient #1 walked out through the emergency department doors, so they checked the emergency department parking lot and then the police arrived and also checked the streets around the Hospital. Nurse #1 said that while the police were there, the Hospital Operator called and told them Patient #1 had just left the Hospital through the front door. Nurse #1 said they rushed there and checked the area around the front door and the parking lot, but did not find Patient #1. Nurse #1 said that Nurse #1 could still justify Nurse #1's presumption that Patient #1 was not a risk, but that was obviously wrong and Nurse #1 would not be leaving that type of patient alone again.

A review of Nurse #1's personal file, indicated that Nurse #1 was currently licensed as a Registered Nurse and Nurse #1 had meet Hospital expectations in all areas in the most recent performance appraisal. Inservice records indicated that Nurse #1 attended a 90 minute presentation on Suicide Assessment on 4/8/10.

A review of the Suicide Assessment inservice indicated the following points: suicide ideation was the process of contemplating suicide or the methods used without taking action; suicidal gestures included taking a few pills or making superficial cuts on the wrist and suggested the person was ambivalent about dying, had not planned to die, had the will to live, and wanted to be rescued. Suicidal gestures were often a cry for help; and a suicide attempt such as taking a potentially lethal dose of medication, indicated that the person wanted to die and had no wish to be rescued. The inservices indicated that key points to remember was that ideation + plan + intent + means = active suicidal crisis. The inservice also indicated that because a nonpsychiatric hospital environment was loaded with potentially dangerous items, it could not be made completely safe for a patient at risk for suicide, so one-to-one observation status should be initiated according to the facility's policy.

A review of the Hospital's Suicidal Patients in the Emergency Department Policy indicated the elements of practice included: a physical examination by a physician or mid-level practitioner to determine current state of health; assessing the expression of intent, duration of desire, duration of plan, intensity of thoughts, specific plan, availability of plan, lethality of plan, preparation for death, and past attempts; assessing the state of the patients mind to determine if hopeless, intoxicated (impulsive), manipulative, angry, or psychotic and watch for a "calm before the storm" to see if the decision to die was made and the patient was at peace; being nonjudgmental; and do not leave the patient alone.

The Hospital had a second Policy for Suicide Precautions in the Emergency Department, which indicated patients would be assessed for suicidal risk upon admission to the emergency department and staff would intervene accordingly to protect the patient through initiation of the appropriate suicide precaution and through removal of environmental dangers. The Policy indicated Level 1 included those patients determined to be at immediate risk to act on suicidal impulses and were unpredictable. Level 1 included a patient who verbalized a clear intent to suicide, a patient who exhibited high impulsivity, or a patient who was psychotic and the nursing intervention included one-to-one observation, restriction to assigned treatment room and bathroom only to ensure safety of environment, and the patient was to have continuous one-to-one even when leaving the department for diagnostic tests or inter-hospital admission. Level 2 included patients at significant, but not immediate risk such as patients with recent suicidal behavior, patients who were withdrawn, or patients with impaired reality testing. Nursing interventions for Level 2 included visual observation every 5 minutes while awake or asleep, provision of safe environment, restriction from use of sharps or other potentially dangerous objects, restriction to assigned treatment room and bathroom, and if the patient left the unit for diagnostic testing or admission the patient must be accompanied by a staff member.

A review of the Emergency Physician Record, dated 4/20/10, indicated Patient #1 arrived by ambulance after an intentional drug overdose with alcohol and Wellbutrin. The Emergency Physician Record indicated Patient #1 had no answer related to intent. The Emergency Physician Record indicated Patient #1 was seen briefly on arrival and treatment (charcoal with sorbitol) was ordered, but Patient #1 eloped shortly thereafter.

Physician #1 was interviewed at 2:55 P.M. on 4/30/10. Physician #1 said Patient #1 arrived by ambulance and he observed Patient #1 go by with the ambulance crew. but had not examined Patient #1 yet. Physician #1 said Nurse #1 made the determination of which room to put Patient #1 in and triaged Patient #1. Physician #1 said one-to-one observation would not be implemented just based on an attempted suicide and sometimes the nurse made the decision to implement a one-to-one and sometimes the physician made the determination. Physician #1 said Patient #1 was cooperative with the ambulance crew, the Nurse, and agreed to allow an EKG. Physician #1 said Nurse #1 brought Physician #1 the EKG report and the recommendation for charcoal made by Poison Control. Physician #1 said about one minute after speaking to Nurse #1, Patient #1 was discovered missing. Physician #1 said a section 12 was completed so the local Police could pick up and detain Patient #1. Physician #1 said Wellbutrin was a "nasty" drug to overdose on, because it caused severe seizures. Physician #1 said this was no a suicidal gesture, this was a potentially serious attempts. Physician #1 said there was no doubt Patient #1 was not acting in Patient #1's best interest. Physician #1 said within 10 minutes of Patient #1's arrival, Poison Control was called and an EKG was obtained. Physician #1 said the EKG showed sinus tachycardia, which was common with anti-depressant overdose. Physician #1 said the emergency department was usually a very safe ED, because a patient could be seen from the nurses' station, but with the current construction that was not the case. Physician #1 said from what he knew of Patient #1, a one-to-one sitter was not needed, but Physician #1 had not yet assessed Patient #1.

A review of Physician #1's credential/privilege file indicated Physician #1 was currently licensed by the State as a physician and Physician #1 was board certified in emergency medicine. The file indicated the Hospital had appointed Physician #1 to associate medical staff with clinical admitting privileges in emergency medicine.

Nurse #2 was interviewed at 10:05 A.M. on 4/28/10. Nurse #1 (the ED Charge Nurse) said Patient #1 arrived by ambulance and the only contact Nurse #2 had with Patient #1 was when Nurse #2 poked Nurse #2's head in the code room to get a piece of equipment. Nurse #2 said at that time Patient #1 was in a fetal position on the stretcher and was being transferred onto the hospital bed. Nurse #2 said the decision to implement a one-to-one would depend on the patient and the situation.

At 1:00 P.M. on 4/28/10, the Surveyor and the Hospital Director of Continuous Quality Improvement (CQI) observed Patient #1's Wellbutrin bottle, which was still in the Hospital's possession. The Wellbutrin 300 mg prescription was filled on 3/17/10 and 90 Wellbutrin were dispensed by the pharmacy. The Director of CQI and the Surveyor counted the number of Wellbutrin tablets left in the bottle and it was determined that there were 55 Wellbutrin left in the bottle, which indicated that 35 Wellbutrin were missing from the bottle.

A physician's progress note, dated 3/29/10, indicated Patient #1 was off the Wellbutrin today, so if Patient #1 took the Wellbutrin from 3/17/10 to 3/29/10 that would account for 12 tablets; however, it was unknown if Patient #1 took the Wellbutrin as ordered or if Patient #1 had some Wellbutrin left from the previous prescription, which was taken after Patient #1 filled the prescription on 3/17/10. Therefore, the Surveyor determined that Patient #1 could have ingested from 23 to 35 Wellbutrin 300 mg tablets on 4/20/10, based on the amount left in the bottle.

The Director of Engineering & Security was interviewed at 8:50 A.M. on 4/28/10. The Director of Engineering & Security said the Hospital had security cameras that covered most of the Hospital, but on 4/20/10 there was a power surge and the monitors went down. The Director of Engineering & Security said after Patient #1 eloped, the security guard attempted to view the cameras to determine where Patient #1 went, but the monitors were down; however, the cameras kept on taping, but it could not be seen on the monitors due to the power surge. The Director of Engineering & Security said it was assumed the cameras had stopped working, but the next morning he was able to bring up the tapes and observe Patient #1 leaving the emergency department via the rear door of the code room, which opened into a hallway in radiology. The Director of Engineering & Security said Patient #1 went across the hallway and entered an exam room, where Patient #1 remained for over an hour. The Director of Engineering & Security said Patient #1 then exited the exam room, walked through radiology, followed the hallways to the other side of the Hospital, and exited the Hospital through the main entrance. The Director of Engineering & Security said the switchboard operator observed Patient #1 leave the Hospital and called security, but by the time security arrived at the main entrance, Patient #1 was nowhere in sight.

Physician #2 was interviewed at 2:45 P.M. on 4/28/10. Physician #2 said he heard that there was someone outside in the grass, so Physician #2 went outside to see what was going on. Physician #2 was unable to recall the exact time, but said it was approximately 6:00 A.M. or so. Physician #2 said there was a body lying kind of face down, half under the hedge to the left of the Hospital main entrance. Physician #2 said the body was approximately 20 yards down the hedge and could be seen from the Hospital main entrance. Physician #2 said it was obvious that the person was dead (autopsy pending) and Physician #2 did not touch or assess the body, because the person was not technically an ED patient. Physician #2 said it was the patient that had eloped from the emergency department the night before (Patient #1).

The Vice President of Medical Affairs was interviewed at 1:20 P.M. on 4/28/10. The Vice President of Medical Affairs, who was also an emergency department physician, said Patient #1 was only in the ED briefly before eloping and the emergency department staff were unaware of Patient #1's history at that time. When asked if it would have been prudent to place a one-to-one staff member with Patient #1, the Vice President of Medical Affairs replied, hell yes, but it would not have been practical, because this was a nine bed unit with a limited number of staff.

Based on documentation review, the Hospital failed to identify all opportunities for improvement.

Findings included:

An Intense Analysis of Patient #1's death was conducted on 4/21/2010. The Hospital's investigation identified the following process deficiencies: that there was equipment breakdown because the Hospital experienced a power surge that disrupted several computer functions; that there was human error because after Patient #1 eloped from the emergency department, security staff attempted to view the Hospital security tapes, but were unable to view the tapes due to a power surge that shut down the monitors, and security staff incorrectly assumed that the security video tapes had been destroyed by the power surge, so no further attempt was made to retrieve the tapes, but the next morning the Director of Engineering and Security was able to retrieve the video which showed how Patient #1 left the emergency department; that there was no policy or procedure to guide staff in the event of a patient elopement from the emergency department; that a controllable environmental facter existed, because Patient #1 had eloped through a "back door" in the emergency department examination room; that environmental management issues existed, because
visibility into Patient #1's examination room was slightly more restricted by a temporary wall constructed for the current renovation project; that there was communication issues, because emergency department staff were unsure whether Patient #1 summoned the ambulance or whether someone else summoned the ambulance for Patient #1; and that there was a human resource issue, because for Patient #1 a one-to-one situation would have been optimal, but currently the Hospital did not have the capability of timely access to an additional person to monitor an at risk patient.

The Hospital did not identify an additional human error issue. Patient #1, who had just carried out what Physician #1 said was not a suicidal gesture, but a potentially serious attempt at suicide, was left unattended by Nurse #1, even though the Hospital's Suicidal Patients in the Emergency Department Policy indicated the elements of practice included "do not leave the patient alone".

Based on record review, interview, and observation the Hospital failed to ensure that a safe environment was maintained in the Hospital's emergency department due to construction, which obstructed vision and closed certain examination rooms, and due to an unsecured rear exit form the code room.

The findings included:

An Emergency Nursing Record (Psychiatric Complaints/Suicide Attempt), dated 4/20/10, indicated Patient #1 arrived at the emergency department by ambulance and at 7:46 P.M. Patient #1 was triaged as urgent. The Emergency Nursing Record indicated Patient #1 was depressed, angry, hostile, and complained of being manic for seven days. The Emergency Nursing Record indicated Patient #1 had ingested a "6 pack" of alcohol today and had ingested 30 to 45 Wellbutrin. The Emergency Nursing Record indicated Patient #1 was alert, oriented to person, place, and time, and was placed in the emergency department "code room". The Emergency Nursing Record indicated at 8:04 P.M. Patient #1 was not in the code room and was believed to have eloped, so Security was informed.

Nurse #1 was interviewed at 2:08 P.M. on 4/30/10. Nurse #1 said the emergency department had three rooms (room #1, room #2, and the code room) with built in cardiac monitors, but there was construction in the emergency department and room #1 and room #2 were both closed for renovation, so the only other room with a cardiac monitor was the code room. Nurse #1 said room #2 had a window and would have been the room of choice for this type of patient, but room #2 was closed for renovation. Nurse #1 said the nurses' station was also being renovated, so the nurses' station was temporarily located in the hallway outside rooms #1 and #2. Nurse #1 said because of the renovations, there was no line of sight from the nurses' station to the code room. Nurse #1 said Nurse #1 was not aware of any pre-planning about which room should be used for suicide patients during the construction period in the emergency department. Nurse #1 said Patient #1 was only left alone for maybe 5 to 6 minutes and when Nurse #1 returned ot the code room, Patient #1 was missing.

Physician #1 was interviewed at 2:55 P.M. on 4/30/10. Physician #1 said the emergency department was usually a very safe ED, because a patient could be seen from the nurses' station, but with the current construction that was not the case.

The Director of Engineering & Security was interviewed at 8:50 A.M. on 4/28/10. The Director of Engineering & Security said the on 4/20/10 there was a power surge and the monitors went down, but the cameras located throughout the Hospital continued to record. The Director of Engineering & Security said the next morning he was able to bring up the tapes and observe Patient #1 leaving the emergency department via the rear door of the code room, which opened into a hallway in radiology.

The Vice President of Patient Care Services was interviewed at 3:45 P.M. on 4/30/10. The Vice President of Patient Care Services said the construction in the emergency department was more like on-going maintenance and consisted of painting, new flooring, countertops, and that sort of this, but did not involve taking out or moving walls. The Vice President of Patient Care Services said the maintenance started in February 2010 and was expected to be completed in two months. The Vice President of Patient Care Services said during the construction period there were meetings every Tuesday with the construction team and it was determined that the code room would be the room of choice if a patient required cardiac monitoring.

Observations made by the Surveyor on 4/28/10 indicated the nurses' station was located in the center of the emergency department with rooms located around the outside walls of the emergency department, which was in the shape of a square. The Surveyor observed that sheetrock panels had been placed to somewhat enclose the nurses' station during construction. The Surveyor observed the temporary nurses' station was set up in the hallway outside rooms #1 and #2, which was also closed off for renovation. The Surveyor observed that due to the temporary sheetrock panels, there was no line of sight from the temporary nurses' station to the code room. The Surveyor observed the code room had an unsecured rear door that opened into a hallway in the radiology area.

Please refer to 0144.