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Based on interview, record review of Emergency Department (ED) Logs, 72 Hour Return Logs, Medical Records, Staffing and Physician On-Call Schedules, the facility failed to appropriately complete a medical screening exam (MSE) within its capacity and capability for one Patient (#28) of 28 patient's records reviewed, when the facility failed to notify the patient's guardian of his imminent discharge, and allowed the patient to leave unattended after information was obtained that the patient was an elopement risk. The emergency department average daily census was 137. The facility census was 330.


The facility had the capability and capacity to complete an appropriate MSE to determine whether the patient had a guardian, and that he required supervision prior to discharge due to a significant history of mental illness and traumatic brain injury (a brain dysfunction caused by a mechanical force), and who also resided in a locked unit at a skilled nursing facility.

Please refer to A2406 for details.

Based on interview, record review, and policy review the facility failed to provide an appropriate medical screening exam (MSE) sufficient to determine whether a patient had a guardian, or that he required supervision and was an elopement risk for one Patient (#28) of 28 patient records reviewed. Patient #28's guardian was not notified prior to, or at the time of discharge, from the Emergency Department (ED). Facility nursing staff was made aware prior to discharge that the patient posed a significant elopement risk. Before being transported back to the skilled nursing facility where he resided, the patient independently left the ED without staff knowledge. Approximately three days later the local police found Patient #28 in front of a hotel and transported him back to this facility for treatment, and the patient was subsequently admitted. The facility's failure to provide a complete examination within its capabilities and capacity had the potential to increase the risk for a negative outcome for all individuals seeking treatment within the ED. The emergency department average daily census was 137. The facility census was 330.

1. Record review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) MSE Policy," dated 02/01/16, showed the following:
-An MSE shall be provided to determine whether or not the individual is experiencing an Emergency Medical Condition (EMC) or a pregnant woman is in labor.
-The MSE must be appropriate to the individual's presenting signs and symptoms and the capability and capacity of the hospital.
-The extent of the MSE is an ongoing process. The individual shall be continuously monitored according to the individual's needs until it is determined whether or not the individual has an EMC, and if he or she does, until he or she is stabilized or appropriately admitted or transferred.
-The responsibility of the MSE remains with the ED physician until the individual's private physician or an on-call specialist assumes that responsibility, or the individual is discharged.
-If an individual leaves the facility without notifying facility personnel, this must be documented upon discovery.

2. Review of Patient #28's ED record showed:
-The patient arrived at the facility per Emergency Medical Services (EMS) on 07/23/16 at 3:49 AM.
-The physician's notes showed that the patient's chief complaint was chest pain.
-Demographic sheet from the patient's skilled nursing facility, received by the ED upon arrival of the patient and scanned into the ED record, showed that the patient had a Public Administrator, who served as his guardian.
-The physician had contact with the patient at 4:20 AM. She noted the patient was cooperative, oriented, and that speech was within normal limits. She also noted his mood and affect were within normal limits and he was not suicidal.
-Past medical history included:
-Schizophrenia (a long-term mental disorder that is a break down in the relation between thought, emotion, and behavior which leads to faulty perception, inappropriate actions and feelings, and withdrawal from reality);
-Traumatic Brain Injury (a brain dysfunction caused by a mechanical force);
-Chronic Renal Failure (a slow progressive loss of kidney function over a period of several years);
-Hypertension (chronic elevated blood pressure);
-Hyperlipidemia (chronic elevated cholesterol levels);
-Dementia (a chronic mental disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning);
-Diabetes (a disease in which the body's inability to produce any or enough insulin causes elevated levels of glucose (sugar) in the blood);
-Angina (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart); and
-Hypothyroidism (abnormally low activity of the thyroid gland).
-The patient had an electrocardiogram (a machine that measures electrical activity all over the heart), laboratory blood tests, oxygen, cardiac monitoring, chest x-ray, and medication administration of a Gastrointestinal Cocktail (generic term for a mixture of three liquid medications primarily used to treat acid reflux, which is a condition in which acid travels up from the stomach to the esophagus causing a burning sensation or pain).
-There were no notations in the record by the physician or nursing that the patient had a guardian or was an elopement risk, and no evidence of any contact made with the guardian.
-There was no documentation that the patient eloped from the facility.
-The physician documented a disposition decision and discharge to home at 6:02 AM on 07/23/16. There is no further documentation from this physician regarding any events after 6:02 AM.
-Nursing note recorded on 07/23/16 at 6:25 AM showed the following,"Patient found smoking in the room, patient educated on hospital policy and risk of possible injury with oxygen in the room."
-Nursing note recorded on 07/23/16 at 6:30 AM showed the following,"Report called to the skilled nursing facility, Logisticare (a company that transported patients from the ED to their home or other facility and utilized cab drivers or ambulances dependent on the patient and circumstances of transfer) notified for transport."
-No further notes from nursing staff.
Disposition indicated that the patient was discharged, and the time noted in the chart by nursing was 7:30 AM on 7/23/16.

During an interview on 08/03/16 at 2:15 PM, Staff O, ED Registered Nurse (RN), stated that:
-She met Patient #28 in the ED when he arrived via Emergency Medical Services.
-Her role was to triage the patient, but that was her only contact with him.
-They did not receive any report that he had a guardian or that he was an elopement risk, nor did she ask the patient.
-The normal practice is to review the paperwork sent from the skilled care or nursing facility, but she did not recall if she reviewed the paperwork for this patient.
-There is no prompt in their electronic medical record that required nursing to document whether patient had a guardian or durable power of attorney.

During a telephone interview on 08/02/16 at 4:15 PM, Staff F, ED RN, stated that:
-She was the primary nurse for Patient #28 after he was triaged.
-The patient never attempted to leave the department, or gave any indication he would be an elopement risk. He also never mentioned he had a guardian.
-She contacted the skilled nursing facility once the physician indicated he would be discharged, and had planned to send him back in a cab. The skilled nursing facility informed her that he was not able to come back by cab because he was a high elopement risk and had come from a locked unit.
-After she received that information, she ordered an ambulance to transport the patient through Logisticare. She did not implement any action to prevent the patient from leaving the ED prior to transport arriving.
-Staff F stated, "I didn't have any issues with him, so I didn't expect he would leave, and we are a locked unit so someone would have had to let him out."

During a telephone interview on 08/02/16 at 2:10 PM, Staff E, ED RN, stated that:
-She took report from Staff F at 7:00 AM on Patient #28.
-Staff F relayed to her that she had ordered transport for the patient due to the skilled nursing facility's report that the patient was an elopement risk and resided on a locked unit.
-She did not put any interventions in place to prevent the patient from eloping prior to transport.
-At approximately 7:30 AM she noticed the patient was no longer in his room. She immediately searched the department for the patient. She called Security and gave them a description of the patient and they were asked to watch out for him (the security office was a glassed area that had full view of the ED waiting room and triage area, as well as the main ED entrance). She made the Charge Nurse aware of the situation, and no further action was taken.
-Staff E stated,"I had three other patients so I went back to caring for them."
-She did not document any of the situation in the patient's medical record.
-She was not aware the patient had a guardian until later in the day, and after he had eloped.

During an interview on 08/02/16 at 10:15 AM, Staff J, Team Lead Registration, stated that she collected information from patients and their families regarding durable power of attorney (DPOA) or guardians, and they would then contact the guardian or DPOA and obtain consent. She noted that if the patient had a guardian, the guardian would normally ask to be transferred to the nurse to be updated on the medical condition of the patient. She stated that the situations which would prompt her to ask whether the patient had a guardian or DPOA, would be "if they are older or from a nursing home."

Record review of the facility's policy titled, "Advance Directive Administrative Process-The Patient Determination Act," dated 08/2013, showed no directive for staff to obtain information regarding guardianship for patient's admitted to the ED.

During an interview on 08/03/16 at 3:15 PM, Staff D, Assistant Director of the ED, stated that:
-The facility did have a policy titled,"Code Purple," that directed staff throughout the hospital how to respond when a patient eloped.
-Staff D stated, "We don't usually call Code Purple's in the ED because our unit is secure and we usually are able to find them."
-She confirmed that if a Code Purple had been called when Patient #28 eloped, the staff would have had heightened awareness and they would have probably caught him prior to leaving the ED.
-There was no documentation prompt in the electronic medical record for staff to ask about a guardian or DPOA.
-Since the event with Patient #28, staff had been educated in the ED Daily Huddles (meetings done at the beginning of each shift where updates are given verbally to staff) that all patients who are an elopement risk but be a one to one ([1:1] an intervention where a staff member remains with the patient at all times), and that this included patients from nursing homes that had locked units.
-She reported that she had ordered new forms from the print shop that will prompt staff when taking report from another facility, to ask if the patient had a guardian or was from a locked unit. The forms would be ready in the next week and staff would be educated on their use.
-There is no prompt in the nursing assessment to inquire about a guardian or DPOA.

During a telephone interview on 08/04/16 at 9:30 AM, Staff N, ED Physician, stated that she had been the physician for Patient #28. She was not aware he had a guardian, nor that he was an elopement risk and had come from a locked unit.

During an interview on 08/03/16 at 10:55 AM, Staff M, ED Medical Director, stated that he had been made aware of the situation with Patient #28. He felt that the physician's at the facility did not take chances if there was a risk of elopement. He stated that in regards to whether or not a patient had a guardian, the physicians were often "the last to know." He stated that his expectation was that if a guardian or DPOA was established for the patient, the physician would communicate with them and find out their expectations for care.

Review of a 2nd medical record showed that patient # 28 presented to the ED by ambulance on 7/26/16 at 2:20 AM, approximately 72 hours after eloping on 7/23/16. The ED physician documented the patient had been missing for three days "until he was found tonight." Further documentation showed the patient was under legal guardianship and resided in a locked psychiatric unit at a nursing home due to his mental illness, dementia, and previous traumatic brain injury. Lab tests revealed patient # 28 had an elevated blood glucose of 289 (normal is 70 - 99 mg/dl) and a creatine kinase (CK) elevated at 2,965 units/liter (CK is an enzyme that is released when skeletal muscles are damaged, normal level is 26 - 308 units/liter). Patient # 28 was subsequently admitted to Research Medical Center for treatment of Rhabdomyolysis (a serious syndrome in which damaged skeletal muscle breaks down and an enzyme harmful to the kidneys is released into the blood stream).