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Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to provide an appropriate medical screening examination for 1 of 30 sampled Emergency Department (ED) patients (Patient #5), with medical records dated between 5/1/14 to 11/12/14, selected for review. Please see C-2406 for additional information.

Based on document review and staff interviews, the CAH staff failed to provide all appropriate stabilizing treatment for 1 of 30 sampled ED patients (Patient #5), with medical records dated between 5/1/14 and 11/12/14, selected for review. Please see C-2407 for additional information.

Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to provide an appropriate medical screening examination for 1 of 30 sampled Emergency Department (ED) patients with medical records dated between 5/1/14 to 11/12/14, selected for review (Patients #5). The CAH's administrative staff identified an average of 347 patients per month requesting emergency medical care at the CAH.

Failure to provide an appropriate medical screening exam resulted in the ED staff failing to detect changes in a patient's emergency medical condition that led to an actively suicidal patient eloping from the ED without the knowledge of the ED staff.

Findings include:

1. Review of the policy "COBRA - EMTALA," effective 4/2/12, revealed in part, "This hospital will provide an appropriate medical screening examination ... for all patients with emergency medical conditions..."

2. Review of Patient #5's medical record revealed Patient #5 presented to the ED on 11/5/14 at 8:31 AM with thoughts of committing suicide. Patient #5 reported a recent broken-up relationship, a debilitating back injury preventing Patient #5 from working, and a family member that committed suicide in the last year. Patient #5 had a plan to commit suicide by hanging using a belt. The patient had access to a belt at home and had placed the belt around his neck as a test the prior day. The patient did not have a belt in the ED.

ED Physician A documented Patient #5 required inpatient mental health care at a hospital and arranged a transfer to the receiving hospital A. Registered Nurse (RN) A documented Receiving Hospital A accepted the transfer of Patient #5 at 11:30 AM. RN A documented that the patient expressed increased anxiety and desired to walk into a local river in a suicide attempt after RN A informed the patient of the transfer to Receiving Hospital A at 12:21 PM. RN A documented she contacted Patient #5's emergency contact person with Patient #5's permission at 1:05 PM.

At 1:37 PM, RN A documented she discovered Patient #5 left the ED when the ambulance arrived to take the patient to Receiving Hospital A. Patient #5 had changed from the CAH's paper scrubs back into the clothes he presented in and left the CAH's property. Patient #5 left the ED but RN A did not identify the patient left the CAH's property until the arrival of the ambulance.

RN A documented Patient #5 called and notified the ED registration staff member that he had chosen to go to Receiving Hospital A in a personal car instead of the ambulance. ED Physician B documented Patient #5 wanted to obtain his cell phone prior to transferring to Receiving Hospital A.

RN A and ED Physician B did not document any additional assessment of Patient #5's increased anxiety regarding the transfer or the patient's desire to obtain his cell phone prior to the transfer. RN A and ED Physician B did not document if Patient #5 arrived at Receiving Hospital A.

3. During an interview on 11/13/14 at 1:45 PM, RN A stated Patient #5 expressed anxiety regarding the transfer to Receiving Hospital A and expressed a desire to walk into a river instead of seeking help at the CAH. Patient #5 expressed additional anxiety since he did not have his cell phone and asked if the ambulance staff members could stop to pick up Patient #5's cell phone on the way to Receiving Hospital A. RN A informed Patient #5 the ambulance staff members could not stop and had to take Patient #5 directly to Receiving Hospital A. RN A did not recognize Patient #5 was at increased risk for elopement due to the anxiety over the transfer and lack of his cell phone.

4. Review of Patient #5's medical record from Receiving Hospital A revealed Patient #5 presented to Receiving Hospital A's ED on 11/5/14 at 3:37 PM (2 hours after RN A discovered Patient #5 had eloped and twice the drive time to Receiving Hospital A). Patient #5 presented to the receiving hospital's ED with active suicidal thoughts and a suicide plan with the potential for self-harm.

Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to provide appropriate supervision of an actively suicidal patient for 1 of 30 sampled Emergency Department (ED) patients with medical records dated between 5/1/14 to 11/12/14, selected for review (Patient #5). The CAH's administrative staff identified an average of 347 patients per month requesting emergency medical care in the ED at the CAH.

Failure to provide appropriate supervision resulted in the staff failing to ensure an actively suicidal patient did not elope from the CAH.

Findings include:

1. Review of the policy "COBRA - EMTALA," effective 4/2/12, revealed in part, "This hospital will provide ... necessary stabilizing treatment for all patients with emergency medical conditions..."

Review of the policy "Suicide Precautions," effective 5/30/14, revealed in part, "A [nurse] shall initiate suicide precautions if a patient is determined to be at risk of self-harm.... If a patient is determined to be at immediate risk for self-harm ... a staff member shall remain with the patient at all times..." "Hazardous objects, including hazardous patient belongings, will be removed from the patient's room."

2. Review of Patient #5's medical record revealed Patient #5 presented to the ED on 11/5/14 at 8:31 AM with thoughts of committing suicide. Patient #5 reported a recent broken relationship, a debilitating back injury that prevented him from working, and a family member who committed suicide in the last year. The patient had a plan to commit suicide by hanging using a belt and he reported placing a belt around his neck as a test the prior day.

ED Physician A documented Patient #5 required inpatient mental health care at Receiving Hospital A. Registered Nurse (RN) A documented Receiving Hospital A accepted the transfer of Patient #5 at 11:30 AM. RN A documented at 12:21 that Patient #5 expressed increased anxiety and a desire to walk into a local river in a suicide attempt after RN A informed the patient of the transfer to Receiving Hospital A.

At 1:37 PM, RN A documented she discovered Patient #5 had left the ED when the ambulance arrived to transport Patient #5. Patient #5 had changed from the CAH's paper scrubs into his clothes and left the CAH's property. Patient #5 left the ED but RN A did not identify Patient #5 had left the CAH's property until the arrival of the ambulance.

RN A documented Patient #5 called and notified the ED registration staff member that he had chosen to go to Receiving Hospital A in a personal car instead of an ambulance. ED Physician B documented Patient #5 wanted to obtain his cell phone prior to transferring to Receiving Hospital A.

3. Review of Patient #5's medical record from Receiving Hospital A revealed Patient #5 presented to Receiving Hospital A's ED on 11/5/14 at 3:37 PM. This was 2 hours after RN A discovered Patient #5 had eloped from the CAH ED and twice the drive time to Receiving Hospital A. Patient #5 presented to the receiving hospital's ED with active suicidal thoughts and a suicide plan with the potential for self-harm. Patient #5 was admitted to Receiving Hospital A for 3 days while receiving inpatient mental health care with suicide precautions in place.

4. During an interview on 11/13/14 at 1:45 PM, RN A stated she had Patient #5 change out of his clothes and into CAH provided paper scrubs. RN A placed Patient #5's clothes into a plastic bag and left the bag in Patient #5's ED room. The patient was not wearing a belt. RN A did not secure Patient #5's clothes away from his access. Patient #5 was in an ED room where the nursing staff could not provide continuous visual observation of the patient.

Patient #5 experienced increased anxiety after RN A notified Patient #5 about the transfer to Receiving Hospital A. RN A did not provide any additional monitoring of Patient #5 despite the increase in Patient #5's anxiety regarding the upcoming transfer and Patient #5's desire to obtain his cell phone.

RN A stated the ED staff normally placed patients with suicidal thoughts in a room close to the nurses' station. The room had a window to allow the CAH staff to directly observe the patient. The ED staff normally had the patients change out of their clothes and into CAH provided scrubs. The ED staff normally removed the patient's clothes from the ED room and stored the clothes in the nurses' station.

RN A stated she and ED Physician B discussed moving Patient #5 into the ED room where they could provide continuous visual observation of Patient #5. RN A and ED Physician B did not want to place Patient #5 in the room due to the possibility a patient with a life-threatening illness would require the room where they considered placing Patient #5. RN A verified she could easily move patients between ED rooms and had frequently moved patients between ED rooms to accommodate the needs of new patients in the ED in the past.

RN A stated she normally requested a paramedic to sit with suicidal patients if needed. A paramedic was not available at the time Patient #5 presented to the ED, but the ED staff could request a nurse from another part of the CAH sit with a patient or request an on-call nurse come to the CAH to sit with a patient. RN A stated the ED staff had used all of the other options before to provide continuous observation for suicidal patients.

RN A acknowledged allowing Patient #5 access to his clothes could allow Patient #5 to hang himself with his clothing in the ED room, especially since the ED staff did not provide continuous visual observation of Patient #5.

5. During an interview on 11/14/14 at 3:00 PM, the ED Medical Director stated "we did not follow our policy" for suicidal patients. The ED Medical Director stated the ED staff should have changed Patient #5 into CAH provided paper scrubs and removed his belongings from the ED room. The ED staff should have either arranged for a staff member to provide continuous visual observation of Patient #5 or the ED staff should have moved Patient #5 into a room where the ED staff could continuously monitor the patient through the window from the nurses' station. The ED staff could have easily moved Patient #5 in the event another patient needed the room. The ED Medical Director stated, "we are in emergency medicine. If we focus on the 'what if' scenarios, we will never get anything done."