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Based on observation, interviews, the review of documentation, and the review of video surveillance it was determined that the hospital failed to protect and promote each patient's rights.

Findings:

The investigation of this complaint revealed that a Behavioral Health patient was admitted to the ED. While in the ED, the patient did not receive a face-to-face assessment from the physician or behavioral health personnel. The patient was placed on a psychiatric "hold" without this assessment being completed. In addition, while in the ED the patient had access to items that he/she used to simulate a gun and used to threaten hospital personnel. The patient eloped from the ED and was subsequently fatally shot by the police.

In addition, the hospital failed to clearly define the delegation of duties and responsibilities for placing patients on a hold and failed to execute written policies and procedures for the care of behavioral health patients in the ED.

Refer to the citation details at Tag 0144.

This Condition level deficiency substantially limits the capacity of the hospital to furnish services of an adequate level of quality.

Based on observation, interviews, the review of documentation, the review of video surveillance, and the review of 10 medical records for behavioral health patients admitted to the ED, it was determined that the facility had failed to ensure that all of the patients (Patient #3) had received care in a safe setting.

Findings:

Observation of the ED at 1215 on 2/25/13 revealed an area described by staff as the "secure area". This area was designated for BH patients and included 4 patient rooms (Room #'s 10, 11, 12, and 13). Access to these rooms was restricted by a locked door that closed all 4 rooms off from the rest of the ED. Observation revealed that the area behind the gurney in each room contained medical equipment and supplies, including but not limited to, resuscitation equipment, monitoring devices, supply carts, and telephones. This area could be closed off by a "garage door" that could be mechanically raised or lowered by ED staff. This allowed ED staff the ability to access this equipment if necessary for patient care, but if lowered, it prevented BH patients from having access to items that they could potentially use to harm themselves or others.

During an interview with Employee #8 at 1543 on 3/6/13 he/she stated that on 2/17/13 he/she was called on the ED cell phone by triage personnel requesting a bed in the secure area for a patient (Patient #3) who was "agitated and edgy". Employee #8 stated that triage personnel felt Patient #3 would calm down and the admitting assessment could be handled better if Patient #3 was not in the main triage area of the ED. Employee #8 stated that he/she "heard commotion in the background" on the cell phone so he/she went immediately to the secure area to expedite the process of getting a bed ready for Patient #3. In addition, Employee #8 stated that he/she observed Patient #3 as he/she was being escorted back to Room 12 by triage personnel and "[He/she] wasn't causing a ruckus, nothing alerted me to get involved".

An interview with Employee #6 at 1110 on 2/26/13 revealed that he/she was assigned to care for Patient #3 on 2/17/13 in the secure area of the ED. Employee #6 stated that he/she assessed Patient #3 as being "anxious and agitated" and "initially, [he/she] was cooperative and calm, but [he/she] was making hallucinatory statements about men in trench coats with guns." Employee #6 stated that Patient #3 was checked "every half hour to every hour". Employee #6 stated, "At some point I noticed that [he/she] [Patient #3] was no longer in Room 12 and the security guard wasn't in the hallway either".

Employee #6 stated that the "garage door" in Room 12 was in the raised position during the entire time that Patient #3 was in the ED. Employee #6 stated, "Anytime a patient is put on a hold, the garage door is lowered". Employee #6 stated during the interview that he/she was not aware that Patient #3 had been put on a hold at anytime during his/her stay in the ED. Employee #6 stated that if he/she had known Patient #3 had been placed on a hold, the "garage door" would have been lowered "immediately" to prevent Patient #3 from having access to any of the equipment in that area. Employee #6 stated that Patient #3 had not exhibited any behaviors that would warrant closing the "garage door".

Employee #6 stated there were several ways to communicate to staff when an ED patient had been placed on a hold. He/she stated that hold information could be written on the chart, given to the charge nurse, given to other ED staff, or given to security personnel. Employee #6 stated that the assigned nurse may also have already communicated with the MD about the need for a patient hold and could have heard directly from the MD that a patient had been placed on a hold.

The review of documentation in Record #3 revealed a CareMark Behavioral Health Services Intake Data Sheet. Documentation reflected that Patient #3 arrived at the ED on 2/17/13 at 1915 with a documented complaint of "anxiety". Documentation reflected that this intake sheet had been completed by Employee #11.

During an interview with Employee #11 at 1730 on 3/6/13, he/she stated that Patient #3 "had admitted to methamphetamine and cocaine use prior to coming to the ED" and that a urinalysis for drug screening had been ordered. Employee #11 stated during the interview that the information he/she had entered on the CareMark Behavioral Health Services Intake form was obtained from a "conversation" he/she had in his/her office with the nurse assigned to Patient #3 (Employee #6), from information he/she received from Employee #8, and from what he/she (Employee #11) had "overheard" and "observed" when Patient #3 "walked past him/her in the hallway. Employee #11 stated, "[He/she] [Patient #3] appeared under the influence".

Employee #11 stated during the interview that he/she did not conduct a face-to-face evaluation of Patient #3 while Patient #3 was in the ED. Employee #11 stated that "[Patient #3's] record was on Employee #12's desk, so I assumed [he/she] was on [his/her] way to see [him/her] [Patient #3]."

Employee #11 stated that after completing the Intake Data Sheet and attempting to find other medical records for Patient #3 he/she then left the department and went to dinner. He/she stated that when he/she returned from dinner the urine drug screen results for Patient #3 were back and she simultaneously heard a "Code Silver" being announced on the overhead PA system.

Observation of video surveillance of the secure area and Patient #3 on 2/17/13 revealed that he/she had been left in his/her clothes throughout the time he/she was in the ED. Employee #6 stated during interview "it's left up to Security to wand [use of a metal detection device] a patient."

The review of documentation, video surveillance, and interviews revealed that when Patient #3 was placed in Room 12 a security officer was already present in the secure area. Interviews with Employees #6, #8, #10,and #11 during the investigation and the review of video surveillance revealed the door to Room 12 remained open and the main door to the secure area was locked throughout Patient #3's stay in the ED.

An interview with Employee #10 on 3/6/13 at 1700 revealed that he/she was already in the secure area of the ED when Patient #3 was escorted to Room 12 by triage personnel. Employee #10 stated during the interview that Patient #3 was "edgy" and "doing a lot of walking around the room" and "I could hear [him/her] talking to [him/herself]".

Employee #10 stated that "at some point, I don't remember the exact time, [Patient #3] came out of the room and lifted [his/her] shirt and I saw something black in [his/her] pants. I remember thinking, 'I'm going to get shot and I'm glad I have my vest on'". Employee #10 also stated, "[He/she] [Patient #3] said [he/she] wanted to leave and [he/she] had a gun. [He/she] told me [he/she] would shoot me if I didn't do what I was told. [He/she] said, 'It's a good night to die, isn't it?'".

The review of video surveillance for 2/17/2013 revealed Patient #3 exiting Room 12 at 21:21:46 and approaching Employee #10. Further surveillance images show Patient #3 and Employee #10 starting to exit the secure area at 21:22:14.

Employee #10 stated, "[He/she] told me where to go the whole time". The review of video surveillance reflected that Employee #10 and Patient #3 walked past the nursing station and exited the ED. Employee #10 stated that while escorting Patient #3 from the ED he/she "Tried to lock eyes with someone to let them know what was happening. I finally locked eyes with [ED nurse] and mouthed to [him/her] 'help me' and 'call a Code Gray'".

Employee #10 stated that he/she had not been told that Patient #3 had ever been placed on a psychiatric hold during his/her ED stay.

Interviews with Employees #1, #2, #3, #4, and #5 during the investigation revealed that it was determined that Patient #3 had removed the black handset from the telephone in Room 12 and this was the item seen in the waistband of Patient #3's pants and that Patient #3 had used to indicate to Employee #10 that he/she had a gun. During an interview with Employee #1 at 1336 on 2/25/13, he/she stated, "We were very fortunate it wasn't a real gun".

Mulitple requests were made to interview Employee #12 as part of the complaint investigation. An interview with Employee #12 with his/her attorney present was conducted on 3/14/13 at 0800. Employee #12 revealed that he/she had assumed responsibility for the medical care of Patient #3 after he/she was admitted to the ED. Documentation on the "Emergency Department Record" revealed a written physician's order that included, "UDS, [trident symbol] hold, preemptive admit, [trident symbol]". Employee #12 acknowledged during the interview that he/she had written this order. This order was not dated or timed.
Employee #12 stated that he/she could not remember at what point during Patient #3's ED stay he/she had determined that Patient #3 needed to be placed on a psychiatric hold. Employee #12 stated that he/she "assumed" that CareMark personnel had completed a face-to-face assessment of Patient #3. Employee #12 stated that his/her decision to place Patient #3 on a psychiatric hold was based on the information that he/she had received from CareMark and nursing personnel. Employee #12 stated that he/she did not complete a face-to-face assessment of Patient #3 prior to him/her being placed on a "psych hold" or at any time during Patient #3's stay in the ED.
Documentation in Record #3 in the "Reexamination/Reevaluation" section reflected that a physical examination of Patient #3 had been completed. During the interview with Employee #12 on 3/14/13 at 0800, documentation of an amendment to Record #3 was presented by Employee #5. This documentation had been completed on 3/13/13 at 19:01 and reflected that Patient #3 had not received a physical examination by Employee #12 during the time he/she was in the ED.
During an interview with Employee #9 on 3/6/13 at 1645 he/she stated, "I would expect that a face-to-face assessment would be done with any patient and a physician before they're [the patient] is put on any kind of a hold".
The review of documentation revealed "Adventist Medical Center Psychiatric Patient Protocol (Emergency Department) Policy/Procedure Sec 820 Effective 10/28/2010." Documentation revealed, "Procedure: II. Search patient's belongings for:......B. Sharps, i.e. needles, knives, scissors, fingernail clippers" and "F. Other potential weapons".

None of the employees interviewed during the investigation were able to articulate if Patient #3 had been searched or wanded according to the policy and procedure. The review of video surveillance of Patient #3 while he/she was in the ED failed to reflect that Patient #3 had been searched or wanded while he/she was in the ED.

The hospital had failed to design, implement, monitor and evaluate a clearly defined mechanism to disperse critical information regarding the hold status of behavioral health patients. This failure resulted in a behavioral health patient having access to items in a secure room that he/she used to threaten hospital personnel.

In addition, the hospital failed to follow their written policy and procedure for wanding behavioral health patients who were allowed to remain in their clothes. Failure to wand patients posed a risk of weapons being brought into the ED and a threat to the safety of other patients, staff, and the public.

NOTE: Interviews, the review of video surveillance, and the review of documentation revealed that after Patient #3 exited the ED he/she confronted police officers. Patient #3 verbally taunted the officers and simulated that he/she had a gun. Patient #3 ran toward the police officers and was subsequently shot and killed by the police. The review of documentation revealed that after this confrontation and during the police investigation, the handset was found on the ground adjacent to Patient #3.

Based on interviews and the review of documentation, and the review of documentation in 12 ED records, it was determined that in 1 record (Record #3) the hospital had failed to ensure that all orders, including verbal orders, had been dated, timed, and authenticated promptly by the ordering practitioner.

Findings:

Record #3: The review of documentatation revealed that Patient #3 was admitted to the ED on 2/17/13 with a diagnosis of "agitated".

Additional review of documentation in the medical record and interviews with Employees #6, #8, and #11 on 3/6/13 revealed that Patient #3 was placed on a "hold". Information obtained during these interviews and the review of documentation in the medical records failed to reflect at what point during his/her stay in the ED Patient #3 was actually placed on the hold.

An interview with Employee #12 with his/her attorney present on 3/14/13 at 0800 revealed that he/she had assumed responsibility for the medical care of Patient #3 after he/she was admitted to the ED. Documentation on the "Emergency Department Record" revealed a written physician's order that included, "UDS, [trident symbol] hold, preemptive admit, [trident symbol]". Employee #12 acknowledged during the interview that he/she had written this order. This order was not dated or timed.