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Based on medical record review, review of the Medical Staff Rules and Regulations, and interview, the facility failed to ensure one patient (Patient #1) was free from seclusion. The facility ED evaluates approximately 3,753 patients per month.


Findings include:

The medical record of Patient #1 was reviewed. The record revealed Patient #1 was admitted to the facility's emergency department on 04/20/16 at 1:55 PM with a chief complaint of "out of control". Patient #1 had been furloughed to the emergency department for a mental evaluation. The medical record contained an order for restraints on 04/21/16 at 9:00 AM. The order was for "locking/locking alternative". Patient #1 was discharged from the emergency department on 04/22/16 at 10:26 AM. Patient #1 was discharged to police custody.

An observation of the facility's emergency department was conducted from 8:40 AM through 9:00 AM on 04/21/16. On 04/21/16 at 8:53 AM, Patient #1 was observed exiting the emergency department, leaving the main entrance of the facility and jumping into a parked car. The facility's staff followed Patient #1 and were able to accompany Patient #1 from the car back into the emergency department. Once Patient #1 was placed back into the emergency department room, the facility staff locked Patient #1 in the room. Patient #1 was locked in the room without anyone else present in the room.

The Staff D was interviewed on 04/21/16 at 8:59 AM. Staff D confirmed Patient #1 was locked in the room and was unable to leave the room.

Staff A was interviewed on 04/22/16 at 8:48 AM. Staff A reported Staff E was taking Patient #1 to the bathroom when Patient #1 bolted and ran.

Staff E, who was accompanying Patient #1 to the bathroom, was interviewed on 04/22/16 at 2:59 PM. Staff E reported Patient #1's room door was not locked prior to Patient #1 attempting to leave the emergency department.

The facility's Medical Staff Rules and Regulations were reviewed. The rules and regulations stated "Seclusion is not available at" the facility.

Based on medical record review, policy review and interview, the facility failed to monitor one Patient (Patient #18) every 60 minutes in accordance with the facility's policy. This had the potential to affect every patient that presents to the facility's emergency department. The facility evaluates approximately 3,753 patients per month.

Findings include:

The medical record of Patient #18 was reviewed and revealed Patient #18 arrived at the facility's emergency department on 04/14/16 at 5:16 PM with a chief complaint of a fever for two to six days. Patient #18's vital signs were obtained during triage and were as follows: temperature - 99.1 degrees Fahrenheit, blood pressure - 121/80, respiratory rate - 24, pulse oximetry - 93% on room air and heart rate - 129 beats per minute. Patient #18 complained of left groin pain as eight out of ten. The pain was described as constant and aching. Patient #18 reported the pain began a few days ago. Patient #18 was triaged at a level three. Patient #18's height was five feet three inches and weighed 260 pounds. Patient #18's blood glucose level was checked in the emergency department at 5:35 PM and the result was 243 mg/dL. A Triage Note from 04/14/16 at 5:26 PM stated Patient #18 had a fever and shortness of breath for four days at home. The fever at home was reported as 101 degrees Fahrenheit and treated with Tylenol and Ibuprofen. Patient #18's pulse oximetry was 84 % at doctor's office. Patient #18 is clammy and diaphoretic with a history of Diabetes Mellitus. Patient #18 has not had anything to eat today and is able to drink and urinate. Patient #18 reported Patient #18's urine had a foul odor. Patient #18 denied nausea, vomiting or diarrhea. The medical record stated Patient #18 was discharged on 04/14/16 at 8:13 PM and contained documentation of Patient #18 leaving without being seen. The medical record did not contain documentation of Patient #18 complaining of chest pain. The medical record did not contain evidence of the facility assessing/monitoring Patient #18's vital signs after the initial triage.

The facility's Triage Acuity Systems/Triage Codes policy (#ES-32) was reviewed. The policy stated patients triaged as a level three should be monitored every 60 minutes for changes in condition while in the waiting room or as needed.

Staff B, who triaged Patient #18 on 04/14/16, was interviewed on 04/22/16 at 9:10 AM. Staff B reported remembering Patient #18's visit. Staff B reported not being aware if anyone reassessed Patient #18 in the waiting room. Staff B reported patients triaged at level two have their vital signs reassessed in one hour if they are still waiting and patients triaged at level three have their vital signs reassessed in two hours.

Staff C's review of Patient #18's emergency department visit on 04/14/16 was reviewed. The review was completed on 04/21/16 and stated Patient #18 met criteria for Sepsis, but was stable. Staff C documented ESI level two is reserved for patients who are unstable within 30 minutes. Staff C reported three hours was too long for Patient #18 to have waited (if accurate). Staff C stated the facility should have had resources to get Patient #18's work up started from the waiting room.