HospitalInspections.org

Based on document review and staff interviews, the critical access hospital's (CAH) administrative staff failed to ensure the emergency department staff followed the CAH's policies and provided adequate supervision to 1 of 16 reviewed emergency department patients reviewed (Patient #1). The CAH failed to provide an appropriate MSE, within its capabilities and capacity when Patient #1 presented to the ED seeking care on 3/29/22 and 4/6/22. On second presentation, Patient #1 was transported to another hospital for emergency psychiatric care approximately 37 miles away. The critical access hospital's administrative staff identified that approximately 130 patients per month presented to the CAH's ED and sought emergency medical care.

Findings include:

1. Review of the "EMTALA Policy", effective 11/2015, revealed in part "Emergency Medical Condition ... A medical condition manifesting itself by acute symptoms of sufficient severity (including ... psychiatric disturbances [such as suicidal thoughts] ...) such that the absence of immediate medical attention could reasonably be expected to result in ... placing the health of the individual ... in serious jeopardy ..." "If the individual has an emergency medical condition, further medical examination and treatment within the capabilities of the staff and facilities must be provided as required to stabilize the emergency medical condition..."

2. Review of the policy "Behavioral Health Sitter," effective 12/2019, revealed that if a patient presented to the CAH's ED with thoughts of killing themselves, the CAH staff should call in another staff member to provide continuous observation to the patient. The policy did not include instructions for the nursing staff to utilize the patient's family to provide continuous observation of the patient instead of calling in a CAH staff member.




2. Record review of Patient #1 revealed the following:


a. Patient #1 presented to the CAH's ED on 3/29/22 at 8:33 PM, complaining of abdominal pain after being physically assaulted by her brother. During the ED visit, Patient #1 refused medical care and later eloped from the CAH's ED. Further review of Patient #1's ED medical record from 3/29/22 revealed that the CAH ED staff failed to take any actions to keep Patient #1 (a 15-year-old patient) safe, de-escalate Patient #1, and ensure Patient #1 did not elope prior to the ED staff performing a medical screening examination or determining if Patient #1 had an emergency medical condition.

Patient #1 was noted to have blood in her urine (possibly showing kidney trauma) and was tenderness to her head and abdomen when examined. Patient #1 was noted to have old bruises on her upper arms. Patient #1 further was unable to void after being physically assaulted by her brother.

Patient #1 had reported that her brother had been arrested after the assault.

b. Patient #1 presented a second time to Community Memorial Hospital Medical Center (CMH) ED on 4/6/22 at 8:27 PM, complaining of wanting to kill herself. Prior to Patient #1's arrival at the ED, she had cut her arms and legs with a box cutter to intentionally hurt herself.

c. At 8:39 PM, RN A documented that Patient #1 was tearful and angry. Patient #1 was placed in the care of Patient #1's Foster Parent a few hours prior.

d. At 8:40 PM, nurse A documented that Patient #1 had made multiple cuts on both of Patient #1's arms and legs using a box cutter.

e. 8:48 PM, RN A assessed Patient #1 for their risk of committing suicide. RN A identified that Patient #1 was at "high" risk for committing suicide, that Patient #1 required continuous monitoring from a CAH staff member to ensure Patient #1 did not harm herself. Patient #1's history included physical and sexual abuse, and included multiple attempts by Patient #1 to kill themselves. Patient #1 was sad, depressed, and anxious. The CAH failed to provide the necessary supervision that Patient #1 needed due to her current emotional state and her increased risk for self-harm.

f. At 8:50 PM, RN A documented that Patient #1 was a danger to herself, had mental disorders, and impaired judgement.

g. At 10:20 PM, Patient #1 became angry and began yelling at ED staff. Patient #1 attempted to leave the ED.

h. At 10:38 PM, law enforcement deputies arrived at CMH ED.

i. At 11:40 PM, ED Physician B documented that Patient #1 and Patient #1's Foster Parent intended to leave the ED Against Medical Advice (AMA). Patient #1's Foster Parent informed ED Physician B that Patient #1's Foster Parent intended to take Patient #1 to Hospital #2 (approximately 37 miles away), as the ED staff at CMH could not provide adequate supervision to Patient #1, especially as Patient #1 continued to attempt to leave the CAH's ED.

j. At 11:58 PM, RN A documented that Patient #1 left the ED AMA, so that Patient #1 could receive psychiatric care at Hospital #2. Law Enforcement Deputies escorted Patient #1 out of the CAH's ED.

h. During an interview on 5/11/22 at 4:00 PM, RN F recalled Patient #1 leaving the CAH ED department and walking out the CAH door but didn't know who Patient #1 was nor did RN F feel it was RN F's place to know. RN F revealed that RN F had received training to stay away from unruly patients that present to the CAH ED.

f. During an interview on 5/11/22 at 4:30 PM, the Director of Nursing (DON), indicated that the CAH ED staff contacted the DON on 4/6/2022 to inform the DON that Patient #1 and Patient #1's Foster Parent attempted to leave the ED, despite Patient #1 having attempted to commit suicide earlier that night. The DON left their home and started to drive into the CAH to provide additional supervision to Patient #1, as the ED staff could not provide adequate supervision to Patient #1 with the CAH staff on-duty.

The ED staff informed the DON that the Law Enforcement Deputies were already at the ED. The DON instructed the ED staff to attempt to obtain an involuntary court committal to prevent Patient #1 from leaving the ED, especially since Patient #1 was placed in the care of Patient #1's Foster Parent a few hours prior. The ED staff informed the DON that Patient #1's Foster Parent wanted to leave the ED, due to the ED staff's inability to supervise Patient #1.

The DON revealed the CAH uses the one call now on the computer that has built in calls if the CAH needs additional staff. The CAH uses an MCI mash call list (master list of employees call list) or the DON will receive calls and the DON will makes calls to staff if needed. The ED staff failed to follow their "Behavioral Health Sitter" policy on both presentations, 3/29/2022 and 4/6/2022 for Patient #1.

The DON revealed each employee receives Crisis Prevention Intervention (CPI) training (training to de-escalation techniques and behavioral management strategies).

g. On 3/29/2022, the CAH had a total census of 5 patients with 2 being in the ED department at the time of Patient #1's ED visit. On 4/6/2022 the CAH had a total census of 7 patients with 2 being in the ED department. The CAH staffs with 3 RNs and 1 ED Physician to cover inpatient and ED department.


Please refer to C-2406 for additional information.

Based on document review and staff interviews, the Critical Access Hosptial's (CAH) administrative staff failed to ensure the CAH's emergency department failed to provide necessary medical screening exam (MSE) to 1 of 16 reviewed emergency department patients (patient #1) on two presentations. Failure to provide an MSE resulting in Patient #1 leaving the emergency department with a possible kidney injury on visit #1 on 3/29/2022 and Patient #1 leaving without performing a medical screening examination (MSE) or determining if Patient #1 had an emergency medical condition on visit #2 on 4/6/2022, which resulted in Patient #1 leaving the ED department on both visits with a potential life-threatening medical condition, potentially placing Patient #1 at an elevated risk for death. The CAH administrative staff identified an average of approximately 130 patients per month who presented to the emergency department requesting an emergency medical screening examination.

Findings include:

1. Review of Patient #1 medical record revealed the following:

Patient #1 (15 years old) presented to the ED on 3/29/2022 at 8:33 PM after being assaulted and complaining of rib and hip pain on the left side, and abdominal pain. At 8:53 PM, ED physician D documented the patient had a history of depression, and cutting (self-injurious behavior as a mechanism to cope with emotional pain/distress), and having been assaulted at around 2:00 PM by "older brother" and hit in the back of the head and kicked in the abdomen, "pain has worsened since assault." Further documentation showed the "older brother" became the patient's legal guardian in November 2021 after parents were incarcerated and the patient had been repeatedly assaulted - "only ever enough to leave bruises, no previous evaluation or significant injury." The patient reported inappropriate touching by brother at 10 years of age, "but nothing since - specifically denies rape." "No LMP (last menstrual period) recorded, she thinks 2/5/2022." "She is sexually active, last 3/3/2022." Further documentation showed patient # 1 did not have a primary care provider on file. ED physician D documented the patient "has been unable to urinate since assault", is "nervous/anxious", and had generalized "abdominal tenderness", and "guarding" on examination.

Blood and urine were obtained for testing. The urinalysis showed 1+ Ketones (normal is none), 2+ blood (normal is none), and 1+ protein (normal is none) in the patient's urine (indicating possible injury to the kidneys).

At 8:55 PM ED physician D documented that Patient #1 did not appear in acute distress and vital signs were stable, "but abdominal exam is limited due to pain" and the patient "is requesting something to help the pain." The ED physician D ordered insertion of a peripheral IV for injection of the dye used when performing CT scans (type of special x-ray) and for pain medication, "fentanyl."

At 9:08 PM Nurse E documented that the radiology tech came to the triage room and reported that Patient #1 had dressed and left the CAH.

At 9:16 PM ED Physician D ordered a renal (kidney) function panel and a pregnancy test, which were not performed.

At 9:30 PM ED Physician D documented the patient's "symptoms are more severe than indicated" by exam findings. Further documentation showed "per nurse" the patient is now refusing any further examination without the presence of the male friend who accompanied the patient to the ED. ED Physician D documented they went out to the parking lot to locate the patient's male friend but could not locate him, and when the physician returned inside the ED, Patient #1 was missing.

At 10:18 PM Nurse F documented that Patient #1's male friend called the ED and reported that he and Patient #1 were together and he was taking the patient to another unspecified hospital ED.

The evidence in the medical record showed the CAH had the capabilities to prevent the patient's elopement (a teen with a volatile social, emotional and family history) and provide an appropriate medical screening examination that included a mental health evaluation, pregnancy testing given the presence of blood in her urine, CT scan of the head and abdomen to assess for internal injuries after blunt abdominal and head trauma from an assault, and re-evaluation by a physician including assessment of the need for mandatory child abuse reporting to the appropriate authorities.


During an interview on 5/12/2022 at 9:30 AM, ED Physician D revealed that Patient #1 complained of abdominal pain and rated the pain 10 out of 10, on a 1-10 pain scale (where 1 was little to no pain and 10 was the worst pain they ever felt).

ED Physician D additionally stated that when Patient #1 presented to the ED, "she cooperated" with the ED staff. However, during the ED visit, Patient #1 began to panic and requested that the ED staff allow her male friend to stay with her in the ED. ED Physician D left the ED to look for Patient#1's male friend in the parking lot. When ED Physician D and Patient #1's male friend returned to the ED, Patient #1 had was gone.

During an interview on 5/11/2022 at 2:30 PM, Nurse H stated if a patient is a danger to harm themselves, a staff member is to stay with that patient at all times.

During an interview on 5/11/2022 at 3:33 PM, Nurse G revealed that Nurse G helped Nurse E escort Patient #1 to an ED exam room. Patient #1 was tearful upon arrival to the room. Patient #1 stated that her older brother had assaulted her earlier that afternoon. With no where to go, she went to her male friend's house who brought her to the ED. Nurse G stated that Patient #1 left the ED when staff was not with her.

During an interview on 5/11/2022 at 9:00 AM, Nurse E stated Patient #1 came to the nurses station asking where her male friend was at, appearing upset. At some point soon after, Patient #1 removed her peripheral IV site and while the radology tech left patient #1's room, Patient #1 left. Nurse E did not see her leave.

Nurse E recalled Nurse F received a phone call from Patient #1's male friend who stated Patient #1 was fine and he would be taking her to another ED for treatment as she felt it took "too long" for treatment. Nurse E confirmed that Nurse F did not attempt to have ED Phyiscian D talk to Patient #1 about her lab results or medical concerns. Nurse F failed to record a number to reach Patient #1.

Further review of Patient #1's medical record revealed that Patient #1 presented a second time to CMH on 4/6/2022 at 8:27 PM with suicial ideation. Patient #1 had cut her upper arms and thighs with a box cutter earlier that evening. Patient #1 had been placed in foster care that evening due to the previous assault by her older brother and having a questionable relationship with her male friend who she had been staying with. At 8:39 PM, Nurse A documented Patient #1 was tearful and angry. Patient #1 has history of psychiatic ward treatment at age 10 for a month, and a history of depression, but denied taking antidepressants. ED Physician D documented Patient #1 expressed feeling hopeless and helpless. Patient #1 admitted to wanting to kill herself and stated she had access to the method she planned to use to kill herself. Patient #1 admits to being sexually active 2 months ago with a boy her age and did not know when her last menstrual period was (potentially indicating Patient #1 was pregnant). On assessment, completed by Nurse A, Patient #1 was "sad, depressed, and anxious" and a "high" risk for committing suicide, which required continous monitoring from a CMH staff member for safety.

At 8:30 PM, ED Physician B documented Patient #1 is in a distressed state with loud crying. Her mood showed intense feelings of depression with flat affact (uncaring or unresponsive). Her eye contact is poor and she repeatedly stated "she wishes to die".

At 9:20 PM, blood, urine, throat/nose swabbing were obtained for testing. Urinalysis showed 2+ Ketones (normal is none), Protein 3+ (normal is none) in the patient's urine (indicating possible injury to the kidneys from assualt on 3/29/22). Urine pregnacy test performed (negative). Two rapid strep tests were performed (negative).

Around 10:09 PM, Nurse A4 documented Patient #1 became angry and started yelling at the ED staff and then attempted to leave the ED. The CMH hospital did not have a staff member to stay 1:1 with Patient #1 and she began to run through the ED and into the inpatient area, yelling and trying to leave. Patient #1's Foster Parent became very upset, expressing concern to the ED staff regarding keeping Patient #1 safe while waiting for treatment. At 10:12 PM, law enforcement deputies were contacted for assistance.

At 10:22 PM, Nurse A documented information was sent to ITP for a new patient assessment. When Nurse A inquired about the wait time, Nurse A was told it wouldn't be until after midnight for Patient #1 to be seen.

At 10:38 PM, law enforcement deputies arrived at the ED who informed ED Physician D, Patient #1's male friend (adult) had been arrested for inappropriate sexual activity with Patient #1(15 years old). Deputies further state Patient #1 had been questioned about this at another hosptial locally, even though she had not disclosed this information to her foster parent or ED staff. Patient #1 is unaware of her male friend's arrest and voices her plans to go back to her male friend's house.

At 11:40 PM, ED Physician B documented that Patient #1 and Patient #1's Foster Parent intended to leave the ED Against Medical Advice (AMA). Patient #1's Foster Parent informed ED Physician B that they intended to take Patient #1 to Hospital #2 (approximately 37 miles away), as the ED staff at CMH could not provide adequate supervision to Patient #1, especially as Patient #1 continued to attempt to leave the CAH's ED.

At 11:58 PM, Nurse A documented that Patient #1 left the ED AMA, so that Patient #1 could receive psychiatric care at Hospital #2. Law enforcement deputies escorted Patient #1 out of the CAH's ED and Patient #1's Foster Parent followed.

ED Physician B documented on final disopostion on Patient #1 after she left the CAH ED, "the patient does have physical signs of pharyngitis, but denies symptoms currently. Two rapid strep tests have been negative in the past week, and Mono testing also negative tonight. Now that I am aware of the alleged inapproproiate sexual contact between the patient and the adult male friend, I feel she warrants testing for sexual transmitted infection (STI) as a cause of the exudative apparance of the tonsils." ED Physician B failed to perform an STI screening on Patient #1 or to ensure the information was communicated to Hospital #2 for the testing to be performed on Patient #1.

Review of patient #1's medical record from hospital #2 revealed that patient #1 presented to hospital #2's ED on 4/7/2022 at 12:45 AM, needing a psychiatric evaluation. Patient #1 received an evaluation from a psychiatric trained nurse practitioner on 4/7/2022 at 7:06 AM. The ED staff at Hospital #2 discharged Patient #1 to the care of her Foster Parent.

The evidence in the medical record supports the CAH had the capabilities to address the patient's complaints of scuicidal ideation and provide appropirate medical screening examination that included a mental health evaluation.

During interview on 5/11/2022 at 2:00 PM, Nurse A revealed that Patient #1 presented to the CAH's ED after she cut herself with a box cutter at her foster parent's house. The Iowa Department of Human Services (DHS) staff placed Patient #1 in the care of Patient #1's Foster Parent earlier that day, as the DHS staff discovered that Patient #1 was living in a inappropriate situation with her male friend. Patient #1 initially cooperated with the nursing staff to change in the CAH's scrubs and gave the nursing staff her cell phone for safety.

Nurse A stated she informed Patient #1's foster parent about the concern with Patient #1 and they would need to wait several hours before a tele-psychiatrist could see Patient #1. When Patient #1 heard this, she became angry and stormed out of the ED room, threatening ED staff. Nurse A could not control Patient #1's behavior, and Patient #1 ran into the inpatient area, while screaming. Nurse E then called the sheriff's department when Patient #1 left through the ED doors. ED staff followed her outside and attempted to calm her down. Patient #1 sat on the bench outside the ED and Patient #1 spoke to ED Physician B. Her foster parent became overwhelmed attempting to provide supervision and help keep her safe.


The law enforcement deputies arrived around 10:30 PM. The Law Enforcement Deputies told the nursing staff that the nursing staff could not adequately supervise Patient #1 and that Patient #1 needed to go to a facility where the nursing staff could provide adequate supervision for Patient #1. The Law Enforcement Deputies informed Patient #1's Foster Parent that, due to the CAH ED's inability to provide adequate supervision for Patient #1, that the Law Enforcement Deputies normally transport all patients in the city who require mental health care to Hospital #2. The Law Enforcement Deputies informed Patient #1's Foster Parent that the Law Enforcement Deputies could only provide on-site supervision to Patient #1 for approximately 4 more hours, and after 2:30 AM the next morning, the Law Enforcement Deputies had to rely on the CAH's ED staff to provide adequate supervision to Patient #1.

ED Physician B had patient #1's foster parent sign a form indicating Patient #1 was leaving the hospital AMA, as Patient #1's foster parent wanted to take her to Hospital #2, so Patient #1 could receive adequate supervision.

During an interview on 5/11/2022 at 4:30 PM, the DON indicated that the ED staff contacted the DON to inform the DON that Patient #1 and her foster parent attempted to leave the ED, despite Patient #1's attempt to hurt herself using a box cutter earlier that evening. The DON left their home and started to drive into the CAH to provide additional supervision to Patient #1, as the ED staff could not provide adequate supervision to her with the staff on-duty.

The ED staff informed the DON that the deputies were already at the ED. The DON instructed the ED staff to attempt to obtain an involuntary court committal to prevent Patient #1 from leaving the ED, especially since she was placed in the care of her foster parent a few hours prior. The ED staff informed the DON that her foster parent wanted to leave the ED, due to the ED staff's inability to supervise Patient #1 and keep her safe.

During an interview on 5/12/2022 at 8:30 PM, ED Physician B stated they assessed Patient #1 and identified that she had thoughts of killing herself. At the time Patient #1 presented to the ED, the CAH only had 2 nurses working that evening. The 2 nurses floated between providing care to patients in the inpatient Medical/Surgical unit and patients in the Emergency Department. The CAH's nursing staff only had 1 nurse who could provide care to patients in the ED, as the other nurse on duty had to provide supervision and care to the inpatients. Due to the CAH only staffing 2 nurses and ED Physician B at the CAH overnight, the ED staff could not provide sufficient supervision to keep Patient #1 safe or to prevent her from leaving the ED.

During interview on 5/12/2022 at 1130 AM, Patient #1's Foster Parent stated that they took Patient #1 to the CAH ED several hours after the Iowa DHS placed Patient #1 with the foster parent. Patient #1 had attempted self-mutilation (cutting herself with the box cutter), and her foster parent was seeking assistance for Patient #1's self-harming behaviors.

While at the CAH's ED, the ED staff examined Patient #1 and informed Patient #1's Foster Parent that her Foster Parent would need to provide supervision for Patient #1 for at least several hours, before the CAH staff could arrange for a tele-psychiatrist to evaluate Patient #1 and for the tele-psychiatrist to determine the appropriate treatment plan for Patient #1.

During Patient #1's admission in the CAH ED, she became more agitated and upset. The ED staff did not provide additional nursing staff to provide supervision to Patient #1, but instead expected her foster parent to supervise Patient #1. Due to Patient #1's behavior, the ED staff contacted law enforcement and 3 law enforcement deputies arrived at the ED around 10:30 PM. The law enforcement deputies informed her foster parent that the law enforcement deputies could stay at the ED for another 4 hours and provide assistance to supervise Patient #1 but the law enforcement deputies may have to leave at 2:30 AM (4 hours later), resulting in her foster parent needing to resume providing supervision to Patient #1 in the ED.

Since her foster parent was exhausted from attempting to provide supervision to Patient #1 and the law enforcement deputies could not guarantee they could provide supervision to Patient #1 for more than 4 hours, her foster parent followed the suggestion of the law enforcement deputies and contacted Hospital #2 to verify Hospital #2 had a locked ED unit where her foster parent would not need to provide supervision to Patient #1 while she awaited assessment by a tele-psychiatrist. The law enforcement deputies transported Patient #1 to Hospital #2 for further evaluation and treatment.

Following Patient #1's discharge from Hospital #2, Patient #1 ran away, which ultimately resulted in Patient #1 requiring inpatient mental health treatment.