HospitalInspections.org

Based on review of facility documents, medical records (MR1), and staff interview (EMP), it was determined that the facility failed to ensure the Emergency Department (ED) physician ordered a continuous 1:1 sitter after discussing the recommendations with the tele-health psychiatrist after consultation was completed (A0144). This failure resulted in an Immediate Jeopardy (IJ), posing a serious risk of harm to the patient. The IJ was identified on October 16, 2024, at 2:03 PM.

On October 16, 2024, the survey team reviewed that all staff in the ED, ED providers, Nursing Supervisors, Nursing Managers, and Senior administration were immediately educated when a Tele-psych consult is performed and recommendations are communicated verbally and/or in writing, the recommendations will be immediately communicated by the receiver to the care team (Physicians, Mid-level provider, Primary nurse, etc.) Orders will be entered into the Medical Record based on the Attending Provider's discretion. If there is a disagreement between the tele-psych Provider and the Attending Provider, the Attending Provider shall immediately address, document in the Medical Record and communicate to care team the reasons why he/she is choosing not to follow the tele-psych recommendation(s). The immediate education sign-in sheets were reviewed to determine compliance for the removal of the immediate jeopardy.

The survey team verified these immediate interventions were implemented and confirmed the facility's IJ was removed October 16, 2024, at 6:18 PM.

Cross reference

482.13(b)-Exercise Use Of Rights

482.13 (c)(2)-The patient has the right to receive care in a safe setting

482.13(e)-Use of Restraint Or Seclusion

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure adequate nutrition to patients who are in the Emergency Department (ED) for a prolonged period of time for four of 11 applicable medical records reviewed (MR4, MR5, MR6 and MR11).

Findings include:

A request was made of EMP1, EMP2 and EMP3 on October 17, 2024, for a facility policy / procedure / protocol / guideline facility staff follow regarding ensuring patients who are in the ED for a prolonged period of time are provided with adequate nutrition. None was provided.

Interview with EMP1, EMP2 and EMP3 revealed the facility does not have a policy / procedure / protocol / guideline for facility staff to follow regarding ensuring patients who are in the ED for a prolonged period of time are provided with adequate nutrition.

Review of MR4 on October 17, 2024, revealed this patient presented to the ED on October 4, 2024, at 12:13 PM for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on October 5, 2024, at 5:35 PM.

There was no documentation in MR4 indicating the facility provided this patient with a meal tray or any nutrition on October 4, 2024, for the lunch meal or on October 5, 2024, for the breakfast, lunch, and evening meal.

Review of MR5 on October 17, 2024, revealed this patient presented to the ED on September 30, 2024, at 11:23 AM for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on October 1, 2024, at 12:46 PM.

There was no documentation in MR5 indicating the facility provided this patient with a meal tray or any nutrition on September 30, 2024, for the lunch and dinner meals.

Review of MR6 on October 17, 2024, revealed this patient presented to the ED on October 1, 2024, at 3:03 PM for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on October 3, 2024, at 7:51 AM.

There was no documentation in MR6 indicating the facility provided this patient with a meal tray or any nutrition on October 1, 2024, for the lunch meal; on October 2, 2024, for the lunch meal or on October 3, 2024, for the breakfast meal.

Review of MR11 on October 17, 2024, revealed this patient presented to the ED on September 14, 2024, at 00:29 AM for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on September 16, 2024, at 9:07 PM.

There was no documentation in MR11 indicating the facility provided this patient with a meal tray or any nutrition on September 14 and 16, 2024, for the breakfast or lunch meals or on September 16, 2024, for the breakfast meal.

Interview with EMP2 and EMP3 on October 17, 2024 confirmed the above findings.

Based on review of facility documents, medical records (MR), observation, security footage and staff interview (EMP), it was determined the facility failed to ensure the Emergency Department (ED) physician ordered a continuous 1:1 sitter after discussing the recommendations with the tele-health psychiatrist after consultation was completed for one of one medical records reviewed (MR1); failed to ensure a patient admitted for a psychiatric evaluation was placed in paper scrubs as per hospital policy for 2 of 12 applicable medical records reviewed (MR1 and MR2) and the facility failed to identify a 25 second delay in the first set of ED exit doors contributing to an ED patient admitted for a psychiatric evaluation to elope from the ED (MR1).

Findings include:

Review on October 16, 2024, of the facility policy, "Patient's Rights and Responsibilities," reviewed November 28, 2023, revealed "Policy: It is the policy of Wayne Memorial Hospital to inform each patient (inpatient and outpatient), or when appropriate, the patient's representative, of their rights and responsibilities, in advance of furnishing or discontinuing patient care, whenever possible. ...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 .... "

Review on October 16, 2024, of the facility's "Psychiatric Emergencies: Voluntary/Involuntary Commitment 201/302 Policy: P6" , last revised September 2024, revealed "Policy: it is the policy of Wayne Memorial Hospital to evaluate and stabilize patients suffering from a psychiatric emergency by addressing immediate medical needs and providing a safe environment that reduces potential harm to both the patient and others in conjunction with available county resources ...Purpose: To ensure a safe and secure environment for patient, staff and visitors ...Definitions: ...Voluntary Commitment (201): Agreement by patient to consent to inpatient psychiatric care. Involuntary Commitment (302): Completion of warrant for patient in crisis who does not voluntarily consent to treatment ... Guidelines of Practice For Emergency Department Care of Patients With Psychiatric Disorders And/Or Behavioral Issues: At the time of triage, if the patient is found to be a threat to themselves or others, or is under a 302 warrant, the patient will be placed in a designated area in ED where he/she can be continually observed ...Patients will change into disposable clothing and all clothing (including socks, belt, underwear, and cell phone) valuables, medications and potentially dangerous equipment/items are removed from the room ..."

Review on October 16, 2024, of facility, "Standard Of Care Violence, Potential For, Self-Directed Or Directed At Others (Suicidal Or Homicidal)" revised October 2018, revealed " ...Nursing Directives Emergency Department Management ...Continuous Observations-Requires a staff/patient ratio where one person can continuously view a patient, or group of patients and alert staff if patient(s) in danger. 1:1/Arm's length observation-(for immediate violent/self-destructive behavior)-Requires 1 to 1 staff to patient ratio where the staff person is at the bedside (or just outside the room) and is only monitoring 1 patient. ...Special Circumstances: One to One (1:1) observation may be implemented in situations where there is no immediate violent/self-destructive behavior identified, but neither close or continuous observation are adequate to protect the patient from harm. Examples may include, but are not limited to, high fall risk, at risk to wander, disorientation, etc. ..."


1.Review on October 16, 2024, of MR1, revealed MR1 presented to the Emergency Department (ED) on October 12, 2024, at 12:20 PM, for a mental health examination. MR1 revealed a tele-psychiatry consult note dated October 13, 2024, at 3:44 AM from CF1 that revealed history of anxiety disorder, TBI, cluster B personality disorder, bipolar disorder, schizophrenia, depressive disorder, schizoaffective disorder, ADHD, current cannabis use, history of suicide attempt(s), disruptive behavior, poor self-care, history of psychiatric hospitalization, self-referred via walk-in for psychosis. Clearly psychotic and in need of inpatient psychatric admission again for safety and stabilization.-unclear if patient has been compliant with medications or not, talking about wanting/needing to die, and maintains no insight into severity of mental illness or need for treatment. Though patient intermittently agreeable to voluntary admission, recommend involuntary admission on the grounds of gravely poor insight/judgment that is impairing MR1's capacity to make decisions about treatment (unable to maintain a consistent decision). Patient is at elevated risk of danger to self, danger due to grave disability/poor self-care. Patient presently meets criteria for inpatient psychiatric hospitalization. Plan disposition: Involuntary admission when medically stable. Observation level - Psychiatric 1:1 needed. Continue psych 1:1. Discussed plan with onsite team member: Yes-OTH2.

Interview with EMP2 on October 16, 2024, confirmed the above findings.

Continued review on October 16, 2024, of MR1, revealed there was no documentation from OTH2 that a continuous 1:1 sitter was ordered after discussing the consultation with CF1. Nursing documentation revealed MR1 eloped (unauthorized leaving of the hospital's emergency department independently and without notifying staff) on October 13, 2024, at 5:09 AM. MR1 was returned to the ED on October 13, 2024, at 8:25 AM via state police.

Interview with EMP 2 on October 16, 2024, confirmed the above findings.
Review on October 16, 2024, of the facility provided security footage dated October 13, 2024, at 5:09 AM revealed MR1 exiting the ambulance entrance doors wearing a dark t-shirt, paper scrub bottoms and socks.

Interview with EMP2, EMP4 and EMP5 on October 16, 2024, at the time of review confirmed MR1 eloped from the ED though the ambulance entrance doors wearing a dark t-shirt, paper scrub bottoms and socks. EMP2 and EMP4 confirmed MR1 was not wearing a required hospital paper scrub top as per hospital policy.

2. Interview with EMP2 and EMP4 on October 16, 2024, revealed disposable clothing included paper scrub tops and pants.

Review of MR1 on October 16, 2024, revealed this patient was admitted to the ED on October 12, 2024, for evaluation and treatment of a psychiatric disorder and was discharged to an inpatient psychiatric facility on October 13, 2024. During MR1's ED admission, the facility initiated a 302 (Involuntary Commitment) warrant on MR1 after consultation with the Tele-Psychiatrist who determined this patient had gravely poor insight and judgement that was impairing the capacity to make decisions about treatment and was unable to maintain a consistent decision.

Review on October 16, 2024, of MR1's nursing documentation dated October 12, 2024, at 1248 revealed EMP7 documented this patient changed into paper scrubs and non-skid socks.

Further review on October 16, 2024, of MR1 revealed this patient eloped from the ED on October 13, 2024, through the side hallway doors of the ED and through the ambulance entrance doors.

Review on October 16, 2024, of the facility provided security footage dated October 13, 2024, at 0509 revealed MR1 exiting the ambulance entrance doors wearing a dark t-shirt, paper scrub bottoms and socks.

Interview with EMP2, EMP4 and EMP5 on October 16, 2024, at the time of review confirmed MR1 eloped from the ED though the ambulance entrance doors wearing a dark t-shirt, paper scrub bottoms and socks. EMP2 and EMP4 confirmed MR1 was not wearing a required hospital paper scrub top as per hospital policy.

Review of MR2 on October 16, 2024, revealed this patient was admitted to the ED on October 7, 2024, for evaluation and treatment of a psychiatric disorder. MR2 was brought to the ED accompanied by police and on a 302 warrant.

Review of MR2 on October 16, 2024, revealed no documentation nursing staff provided this patient with paper scrubs and non-skid socks on admission to the ED.

Interview with EMP2 on October 16, 2024, confirmed the above findings at the time of the medical record review.

3. Observation tour on October 16, 2024, revealed a set of doors that were employee only badge activated to exit from the ED to a second set of doors leading to the ambulance bay. EMP2 activated these doors with the employee badge; this surveyor, EMP2 and EMP5 exited through the first set of doors and proceeded to the second set of doors to the ambulance bay. It was noted there was a 25 second delay in the closure and securing of the first set of doors.

Interview with EMP2 and EMP5 on October 16, 2024, confirmed the above findings. EMP2 revealed this was not reviewed as part of MR1's elopement investigation.

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure a staff member maintained constant one-to-one visual observation of a pediatric patient (MR3) and the facility failed to ensure staff assigned to function as a one-to-one sitter for behavioral health patients had training for seven of 14 personnel files reviewed (PF1, PF2, PF3, PF4, PF6, PF7 and PF10).

Findings include:

Review on October 16, 2024, of the facility's "Behavioral Health Emergency Care Competency" last reviewed September 2024, revealed "Wayne Memorial Hospital (WMH) routinely provides services to those in the community in need of mental health crisis services. Those that have been identified as an increased risk for potential harm to self (Moderate / high risk) or others require a care provider with a specific skill set to ensure safety. Though training, established policies, standards of care, guidance, and educational materials staff are able to provide safe, quality care for those with behavioral health needs. [space for the name of the employee], has shown the ability to: Maintain the dignity and respect of the patient at all times. Follow Primary nurses [sic] direction for level of observation required for each patient. Can differentiate between the variation of 1:1 observation: 1 to 1 observation - (for immediate violent/self-destructive behavior) - Requires 1 to 1 staff to patient ratio where the staff person is in close proximity and facing the patient at all times and is only monitoring 1 patient. This level of observation is also required (regardless of order) when the patients is: Secluded and restrained. Exhibiting immediate violent or self-destructive behavior until behavior is controlled ...Ordered by the Provider regardless of risk assessment, that must be maintained until discontinued by Provider ...Exhibiting no immediate violent/self-destructive behavior identified but neither close or continuous observation are adequate to protect the patient from harm ...Requiring arm's length 1:1. This is when the patient requires protection from injury that cannot be done from a distance ...Understands the Importance / rational of maintaining a one to one observation of a patient. Ensure for room safety (free from any potentially harmful objects such as but not limited to): sharp, heavy objects, cords, wires, medications, clothing, cleaning solutions, or contraband (which includes cell phones) etc. Focus is on patient and free of distraction such as cell phone, games, electronics, etc. Recognizes that the patient is never to be left unattended (this includes bathroom use). Implements appropriate safety precautions with meals: finger food only, paper or foam dinnerware, no plastic ware, not water bottles, or any drinks in plastic bottles. Communicate using nonjudgemental words and behaviors. Maintains appropriate boundaries with patient at all times. [space for Employee Signature and date] [space for Primary Nurse/instructor signature and date] [space for Education Manager Signature and date]."

1. Review of MR3 on October 16, 2024, revealed this patient presented to the Emergency Department (ED) on October 15, 2024, for evaluation of behavioral problems.

Interview with EMP4 on October 16, 2024, revealed MR3 required a 1 to 1 sitter as this patient was pediatric.

Observation of the ED on October 16, 2024, at approximately 10:50 AM revealed PF1 sitting in MR3's room. Further observation revealed MR3, and this patient's parent, reclined in the recliner next to the bed with their eyes closed. PF1 was facing away from MR3; PF1 was facing the wall with the wall mounted television and watching the Tom and Jerry cartoon show. PF1's vision and attention were on the television and not on MR3.

Interview with EMP2 and EMP4 on October 16, 2024, confirmed the findings noted above at the time of the observation.

2. A request was made of EMP2, EMP3 and EMP4 on October 16, 2024, for PF1's Behavioral Health Emergency Care Competency. None was provided.

Interview with EMP2, EMP3 and EMP4 on October 16, 2024, revealed PF1 did not receive the required Behavioral Health Emergency Care Competency prior to performing this job.

A request was made of EMP2, EMP3 and EMP4 on October 16, 2024, for PF2, PF3, PF4, PF6, PF7 and PF10's Behavioral Health Emergency Care Competency. None was provided.

Interview with EMP2, EMP3 and EMP4 on October 16, 2024, revealed PF2, PF3, PF4, PF6, PF7 and PF10 did not receive the required Behavioral Health Emergency Care Competency.

Interview with EMP2 on October 16, 2024, revealed any staff member can function as a 1:1 sitter and must have the Behavioral Health Emergency Care Competency completed in order to perform this job.