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Based on observation, record review, and interview, the facility failed to ensure that patients recieve care in a safe setting.


A patient was diagnosed with "acute psychosis" and deemed to be a "substantial risk of serious harm to self or others" but was not placed on a 1:1 observation;


The facility failed to have systems in place to effectively monitor a sedated psychiatric patient in the emergency room (ER)to ensure the patient's safety was maintained;


The patient was able to leave his room in the ER undetected.


The facility failed to ensure surveillance camera used in patient's room as an observation device, was positioned to visualize the patient's room;


The cameras were not seeing activities in patient rooms with surveillance cameras.


The facility failed to ensure a patient in the ER on suicide precautions was monitored every 15 minutes according to their "Standard of Care for Behavioral Health Patient in the Emergency Department" policy/procedure dated September 2016.


This failed practice lead to the patient's escape from his room in the ER, went outside, carjacked a visitor's vehicle, drove away from the facility, ran a red light causing a fatal crash, killing one person and seriously injuring himself. Citing one (1) patient named in a complaint (Patient #1).



Ref to A 144 ( 482.13 (c )(2) for details.

Based on observation, record review, and interview, the facility failed to ensure that patients recieve care in a safe setting.


The patient was diagnosed with "acute psychosis" and deemed to be a "substantial risk of serious harm to self or others" but was not placed on a 1:1 observation;


The facility failed to have systems in place to effectively monitor a sedated psychiatric patient in the emergency room (ER) to ensure the patient's safety was maintained;


The patient was able to leave his room in the ER undetected.


The facility failed to ensure surveillance camera used in patient's room as an observation device, was positioned to visualize the patient's room;


The cameras were not seeing activities in patient rooms with surveillance cameras.


The facility failed to ensure a patient in the ER on suicide precautions was monitored every 15 minutes according to their "Standard of Care for Behavioral Health Patient in the Emergency Department" policy/procedure dated September 2016.


This failed practice lead to the patient's escape from his room in the ER, went outside, car jacked a visitor's vehicle, drove away from the facility, ran a red light causing a fatal crash, killing one person and seriously injuring himself. Citing one (1) patient named in a complaint Patient (#1).



Findings:


Facility Policy Review


Review of the facility's Policy titled "Standards of Care for the Behavior Health Patient in the Emergency Room" dated September 2016, revealed the following information:


"If the ED Physician determines that the patient cannot safely be released from the hospital because of an emergency psychiatric condition in which the patient presents a danger to him/her self or to others, or is gravely disabled [unable to provide for his or her basic personal needs, of food, clothing, or shelter],


The ED Physician may involuntarily detain the patient for assessment by the BH clinician in accordance with (State and or Local) Mental Health Laws.


The ED Physician will document this assessment in the medical record, including the reason[s] that the patient cannot safely released from the hospital and the time involuntary detention began.


The patient will be assessed for degree of physical impairment and behavioral changes such as confusion, disorientation, anger, depression, and verbalized intent for suicide and/or elopement.


Staff will utilize the Hospital Suicide Risk Screening and Behavioral Close Observation/ Sitter Policy for patients identified with suicide risk.


The staff observation of the patient's location, activities, and behavior will be documented on the patient's Observation Record every 15 minutes. Each observation is charted as performed by the person assigned, assuring the accuracy of documentation at all times.


Due to the duration awaiting Psychiatric Hospital placement, care activity may also include support for showering, meals and toileting.


All staff will be vigilant in regard to changes in patient behavior and will report to the nurse immediately".



Medical Record Review Patient (# 1)


Review of emergency room record revealed a 26 year old individual (Patient # 1) arrived at the Emergency Room (ER) on 6/4/2017 at 18:22 accompanied by his wife. His wife gave history the patient had altered mental status, aggressive and the family was concerned with his behavior. He was triaged as Emergent.


Review of nurses' assessment notes dated 6/4/2017 at 18:27 revealed documentation there were no verbal or physical threats from the patient. He was irritable and confused.


Violent/aggression Assessment Checklist (VAAC) was completed scoring risk type of two (2) moderate at 19:12.


There was documentation that the patient required moderate intervention which included:


Precaution rounds every 15 minutes,


applicable non-crisis intervention,


observe for escalating behaviors during interactions.


Notify Charge Nurse of any marked escalation in behavior. Spouse at bedside.


The patient denied suicidal or homicidal ideation.


There was documentation that the patient's wife was educated on safety, medication and was encouraged to give input and participate.


Vital sign Pulse 120, Respiration 17, Blood Pressure 147/76, oxygenation on room air 99%.



Review of ER physician notes dated 6/4/2017 at 18:46 revealed the following information:


Twenty six (26) year old presents to the ER with wife for paranoia and aggressive behavior since yesterday (6/3/2017.


Patient's wife said, she took the patient to Hospital (S 77) yesterday for chest pain and headache, onset two weeks ago.


The wife said the patient started to act bizarre so a psych evaluation was done at Hospital S 77 and the patient was given Ativan.


The patient was evaluated at a Health Center for bizarre behavior today (6/4/2017) and now the wife states the patient is convinced his medications are being tampered with.


The wife reported he had not been eating and he smoked marijuana last weekend. He had a history of Hypertension.


The history was limited due to AMS and uncooperativeness. The Patient was becoming more agitated, paranoid, combative, and aggressive at home. Not sleeping or eating for days, history of mental illness in family, wife states he does not drink, he smokes marijuana but no other drugs.


Risk Stratification: Suicide


Altered mental status and uncooperativeness.


Clinical Impression: Acute psychosis.


Secondary Impression: Dehydration, Delusion, Hypertension, Hyponatremia, Insomnia, Marijuana abuse, paranoia Tachycardia.


Review of Physician orders dated 6/4/2017 at 18:43 were as follows laboratory tests for comprehensive metabolic panel (CMP),


Drug screen, complete blood count (CBC).


Suicide Precautions,

Geodon 10 mg, IM, EKG,
Benadryl 25 mg.

Cardiac Enzyme Profile, Troponin, Sodium Chloride IV.



Review of Medical record for Patient (#1) revealed an Emergency Detention Order dated 6/4/2017 at 19:07 with the following information:

(2). I have reason to believe and do believe that the above named person evidences a substantial risk of serious harm to himself/herself or others Based upon the following:

Subjects statements and actions towards others. Subject has been aggressive with family and believes T. V is talking to him. This information was reported to me by Dr. (Q64).

The statement was signed by a Peace Officer( R 76).


The physician documented on the Detention Order that Patient (#1) was evaluated on 6/4/2017 at 1900 PM which was within the 24 hours of the time the person was apprehended. On the basis of the preliminary examination I am of the opinion:He/She is mentally ill, the nature of which the disorder is as follows:


The physician described the "disorder" as "He/She evidence a substantial risk of serious harm to self or others, which is described as follows:
Patient with insomnia for three (3) days, aggressive with family, delusional, hallucination.

This information was signed and dated by the examining physician,( Physician Q64).


Review of medication administration record revealed on 6/4/2017 Patient (# 1) was administered Geodon 10 mg intramuscularly in left arm at 19:08.

There was documentation that most common side effect of the medication was drowsiness and weight gain and was reviewed with the patient.


Benadryl 25 mg was also administered at 19:08 in left arm. Common effects of the medication was documented as drowsiness, dizziness and fatigue and was discussed with the patient.

There was documentation the Benadryl was not administered for an adverse drug reaction.


At 21:15 there was a behavior health related assessment documented as "no change" this activity was recorded at 22:46.


At 22:15 there was nursing documentation as follows: Suicide Precautions.


Eloped, AMA, left to home unaccompanied ambulatory via private vehicle.



Medical Record for Patient (# 1) Hospital T 78(after the crash)


Review of Emergency Room record from Hospital T 78 revealed the following information:


The patient arrived at the hospital's ER on 6/4/2017 at 22:56 via EMS with reason for visit as motor vehicle accident unknown speed and loss of consciousness. He rear ended another car and both cars went up in flames.


The patient sustained Liver laceration, Nasal Bone Fracture, Subarachnoid Hemorrhage and 6% TBSA(Total Body Surface Area) 2nd degree burns, Rib


Fracture, Pulmonary Contusion and essential Hypertension. He was admitted to the Intensive Care Unit (ICU) for continued care. He was discharged from the hospital on 6/12/2017 into Police to a State Correctional Facility.


Review of Emergency Department (ED) Surveillance Video Recording


Review of the ED video #1 from 6/4/2017 revealed 1813 Patient (# 1), enters the ED with his wife and appears reluctant to enter.


Video #2- on 6/4/2017 at 1829 the patient was taken to room 4, accompanied by wife and was in the room for approximately three(3) hours .


Video #3 on 6/4/2017 at 2140 the patient's wife left the room.


The unit secretary at the nurses station is on the phone. Three(3) people at the nurses station.


At 21:55 six (6) people are at the desk at the nurses station, the unit secretary/monitor Technician is busy. The patient is undetected until he walks by the nurses station.


Staff # B 52, RN Charge Nurse identifies the patient and verbally confronts the patient who did not stop walking. She follows him out of the ED. The patient did not appear aggressive.


Video # 4- (Alternative camera angle) on 6/4/207 at 21:57 the Patient (#1) reaches the main ED doors and attempts to leave the ED, realizing the door is locked, he turns around and left through a side exit door.


Charge nurse walking behind the patient speaking on her phone. None of the other staff attempted to intervene. Both nurse and patient exited the Emergency Department.


Video #5- (Exterior view of the parking lot towards the ambulance bay) on 6/4/2017 at 21:58 Patient # 1 tried the door to a car it is locked.


Video #6 and 7- Exterior view facing ED parking lot. At 21:58 shows black Lexus in process of exiting the parking lot, two nurses watching and vehicle occupants in the vacated parking spot. An individual was lying on the ground being assisted by the nurse. The car sped away.



Observation in the Emergency Room


Observation rounds in emergency room on 6/8/2017 between the hours of 0900 and 11:32 am revealed there were adequate staff for a 23-bed emergency department (ED).


Room two (2) located near the nurses station had two beds and this room is dedicated for patients with a psychiatric problems.


Rooms three (3) and four(4) also located close to the nurses station are used for patients with psychiatric problems when room two is full.


The three(3) rooms had a sign on the rooms which state these rooms are monitored by surveillance cameras at all times. There was a video monitor located on the desk at the Nurses station.


During an interview on 6/8/2017 at 9:45 am with Staff D 54, RN Director of the Emergency Room, she stated the video monitoring is done by the Unit Secretary or Charge Nurse and if they are not at the desk any staff can monitor.


The Surveyor asked Staff D 54 why was the Patient (#1) able to leave his room without being detected when there were cameras located in the rooms? she stated the cameras were not positioned so they could see into the rooms.


She further stated the patient did not have a sitter, his wife who was in the room with him had left to get food and did not tell staff she was leaving.
She stated the 15 minute monitoring was not done.


During a telephone interview on 6/8/2017 at 9:30 PM with Staff B 52, Charge Nurse on duty when Patient (# 1) eloped, she stated usually she was not assigned patients but on 6/4/2017 there were two other patients with psychiatric problems in the ER.


She stated the Primary Care Nurse assigned to Patient(#1) was attending to a patient with trauma condition so she had to take over four patients and also assisted him with the trauma case. Staff B52 stated it was difficult to monitor psych patients and see to all the other patients in the ER.


She stated she realized the patient had left his room when he was walking past the nurses station. She tried to encourage him to return to his room but he kept going.


She was following him to see if he would stop. He only spoke to her once saying "get the hell out of my way" when he reached the exit door which lead to the passage way leading to the ambulance entrance she called security, however, as they passed by the security station she heard the phone ringing in the station and realized security was not in there so she called the operator for security.


According to Staff D 54, she did not call a "Code Gray"(used for aggressive patients) because the patient was not aggressive. She followed him out into the parking lot and by the time security arrived, the patient had carjacked a car from some visitors and drove away from the facility.


Within a few minutes he ran into an oncoming car causing an accident which killed the other driver and he sustained severe burns and was taken to a Trauma 1 Emergency Room for care.


During an interview on 6/8/2017 at 11:50 am with Staff H58, hospital Security Manager he stated when he received the call on his radio that he was needed in the ER he was there within two(2) minutes. He stated ER staff initially were not aware why he was called and he did not see any activities in the ER that required his attention.


He went outside but did not see anything, it was only when he went back into the ER that a staff told him Staff B 52 was gone after a patient. When he went outside he was just in time to see the patient reversed a car hitting down a lady, then driving away from the parking lot.


Before he could call 911, there was the sound of sirens and police and ambulance speeding by. He later went to the scene and saw a fiery crash.


Staff H58 stated a Code Gray should have been called initially. Usually when a Code Gray is called several persons would respond. He stated staffing was limited. Only two security personnel to serve the entire hospital during the day and one at nights. He was responding to another call when security was initially called.


During an interview on 6/9/2017 at 9:15 am with the Chief Nursing Officer she stated going forward family members will not have the sole responsibility to monitor patients in the ER.


She stated all staff present in the ER including physicians were educated and were given an opportunity to participate in the root Cause analysis.