HospitalInspections.org

Based on record review and interview the facility failed to meet the Conditions of Participation to ensure stabilizing treatment for 1 patient (P (patient) 2). This deficient practice of failing to provide stabilizing treatment to a suicidal patient led to the patients death.

These findings are:

A. The facility failed to provide stabilizing treatment - Refer to Tag A-2407

Based on record review and interview the facility failed to provide necessary stabilizing treatment for 1 (P (patient) 2) of 20 (P1-P20) patients reviewed for stabilizing treatment in the emergency department. This deficient practice of failing to provide stabilizing treatment for a suicidal patient led to the patients death.

These findings are:

A. Record review of facility's policy titled "Patient Suicide Risk Prevention" dated 06/26/23 under section 2.5.4 titled "Risk level high" under 2.5.4.2 explained high risk suicide patients should be placed on 1:1 observation (1 observation attendant to one patient). Under section 5.5 it is stated the Patient Observation Attendant (individual providing 1 on 1 observation) ". . . must maintain direct line of sight with the patient at all times."

B. Record review of P2's medical record revealed:

1. P2 arrived to the emergency department on 01/29/24, at 7:28 AM, and a Suicide Screen (screening to determine if an individual is suicidal) was completed on 01/29/24, at 7:43 AM. Stated under "risk of suicide" was marked "high risk" (patient is at high risk for attempting and/or committing suicide).
2. Under the section "Quick updates" at 4:20 PM stated "pt (patient) (P2) is medically cleared, BH consult placed, pt upset that he is here in ER [emergency room] wants to leave AMA, male charge RN [registered nurse] at pt bedside to explain BH process". Indicating that P2 made facility staff aware that P2 wanted to leave.
3. P2 had a psychiatric evaluation and under the section "Risk level" states "High - Risk factors are highly prominent and need to be managed intensely". Indicating that the patient is high risk and requiring management.
4. Under the section "Disposition" states "Unable to determine" under the section "Rationale for Disposition" states "As this CL [clinician] was consulting with the psychiatrist [Name of Dr], I was informed by the ED [emergency department] provider and the ED RN that the pt had eloped from the ED. No final disposition was able to be given"

C. Record review of video footage of outside P2's emergency department (ED) room and ED hallways on 01/29/24, at 6:09 PM, revealed S(staff)4, Patient Observation Attendant did not have the patient in their direct line of sight and was helping a different patient, in the room next to the patients assigned room.

D. Record review of the facility's incident log on 01/29/24, at 7:13 PM, revealed "Patient under suicide hold with sitter at bedside. Despite having sitter at bedside patient eloped from our emergency department" and ". . . the patient was struck by a motor vehicle while outside of the emergency department"

E. During an interview with S6, Security manager, on 02/12/24, at 9:15 AM. S6 confirmed that P2 had been hit by a motor vehicle after elopement from the emergency department.

F. During a confirmation interview with S5, Patient Observation Attendant, on 02/13/24, at 9:00 AM. S5 confirmed that eyes should be kept on the patient, "At all times."

G. During an interview with S2, Emergency Department Manager, on 02/14/24, at 9:10 AM. S2 confirmed that P2 was out of the direct line of sight of S4 (patient observation attendant) for 4 minutes and 55 seconds. S2 also confirmed that P2 eloped from the emergency department at 6:12 PM, on 01/29/24. S2 stated the expectation of the sitter is, "to be keeping an eye on the patient."

H. Record review of the patients medical record from the outside hospital revealed the patient had presented to the outside hospital Emergency Department on 01/29/24, at 7:31 PM. Under the section titled "History and Physical" explains the patient presented for "peds [pedestrian] vs auto [automobile]". Under the section titled "History of Present Illness" stated "The patient was transported by EMS [Emergency Medical Services], to [name of outside hospital] where they arrived in critical condition." Under the section titled "Discharge Summary " stated the patient was pronounced deceased at 11:02 PM.