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Based on medical records reviews, policy and procedure reviews, document reviews, staff interviews and reviews of the video surveillance tapes, it was determined the hospital, including emergency room staff, failed to provide emergency care consistent with prevailing standards of practice; and the hospital failed to ensure that patients received care in a safe setting. Specifically: The hospital did not ensure that patients received care in a safe setting to minimize the risks of harm to the patients - a patient was abused when she presented to the emergency department (ED) for care. This was found in 1 of 50 medical records reviewed. This was found for patient #1 (MR #1). Furthermore, psychiatric patients that pose risks of harm to themselves and others were not monitored continuously according to the hospital's practice. This was found in 4 of 10 patients that were on constant observations, medical records #6, #24, #45 and #54.


Findings include:

Staff #3's foot made contact with patient #1's head while patient #1 was in the ED for emergency care. See detailed findings at A 145.

Patient #6, #24, #45 and #54 eloped from the ED. See detailed findings at A 144.

Based on medical record reviews, staff interviews and policy reviews, it was determined the facility failed to ensure that patients received care in a safe setting. Specifically, psychiatric patients that pose risks of harm to themselves and others were not monitored continuously according to the facility's practice - patients eloped from the Emergency Department (ED). This was found in 4 of 10 patients that were on constant observations, patient #6, #24, #45 and #54.


Findings include:



1. Patient #6 is a twenty-one year old patient who was brought into the ED on June 4, 2014 at 12:02 PM by the Police Department after they found him on the Interstate 95 (I-95) overpass attempting to jump from the overpass and in an attempt to kill himself. Upon arrival the patient was agitated, yelling and cursing and would not answers question.


Review of the medical record (#6) on December 3, 2014 revealed the patient had a previous history of frequent entanglement with the police and he had a prior medical history of Substance Induced Mood Disorder, Anti-social Disorder and Borderline Personality Disorder. A security officer was assigned to provide 1:1 constant observations. The patient's global assessment of functioning (GAF) was 11-25 [which indicates some danger of hurting self or others, or occasionally fails to maintain minimal personal hygiene, or gross impairment in communication // the numeric scale is: 0 inadequate information, 1 to 10 persistent danger of severely hurting self or others, or persistent inability to maintain personal hygiene, up to 91 to 100 no symptoms - superior functioning in a wide range of activities] and he was diagnosed with Depressive Disorder. At 6:10 AM on June 5, 2014 the patient eloped from the ED while he was under 1:1 constant observation of a security officer.



A review of medical record #24 on December 3, 2014 revealed this is a forty-one year old patient who presented to the ED on September 7, 2014 at 1:14 PM. According to the triage nurse the patient had bizarre behavior and had been running on the streets without clothing. The patient was guarded, paranoid, disorganized and screaming at his mother. The patient's previous medical history included Chronic Schizophrenia, was acutely decompensated, acutely psychotic and he had not been taking his medications. A security officer was assigned to continuously (1:1) watch the patient. The patient was given multiple doses (4) of chemical restraints of Haldol and Ativan because he tried to elope. However, at 5:50 AM on September 8, 2014 the patient walked out of the ED while he was on 1:1 constant observation.


Reviews of facility documents on December 3, 2014 revealed 1 security officer was assigned to 1:1 constant observations of 2 patients, 1 of whom was patient #6 when he eloped on June 5, 2014. The patient's elopements are unsafe because these psychiatric patients are at risk to harm themselves.


A review of medical record #54 (patient #54) on 01/07/15 revealed this is a forty-nine year old patient who presented to the ED on January 18, 2014 at 12:04 PM because of a suicide attempt with an overdose of Depakote and Trazodone. The patient had persistent thoughts of death and she had many chaotic family, social, medical and financial stressors. The patient's previous medical history was significant for Bipolar Disorder and Depression. The patient was placed on continuous 1:1 observation, however the patient eloped from the ED at 6:55 PM that day.



A review of medical record #45 on January 7, 2015 revealed this is a twenty-eight year old patient who presented to the ED on December 2, 2014 at 9:19 PM and told the triage nurse that the FBI had been watching him, was taking information off his lines and putting it on the TV. The nurse documented that the patient was at risk for self-harm and that he had paranoid thoughts. The patient's previous medical history was Schizophrenia. The patient was placed on continuous 1:1 observations however, that night at 9:57 PM the patient eloped from the ED.



During an interview these findings were confirmed with Staff #4, the Director of Quality Management on January 3, 2015 at approximately 11:10 AM. Staff #4 also stated the facility's policy allows security officers to perform continuous monitoring of patients with behavioral concerns in the ED.



Review of the facility's policy titled "Eye Contact Record" which was last reviewed in November 2013 states the standard of care is "the patient on one to one observation can expect to have a safe environment." The policy also lists security officers as members of staff who can perform this task.

Based on reviews of the video surveillance tapes, reviews of medical records, reviews of policies and procedures, document reviews and staff interviews, it was determined the emergency room staff failed to provide emergency care consistent with prevailing standard of practice. Specifically, the hospital did not ensure that patients received care in a safe setting to minimize the risks of harm to the patients - a patient was subject to physical and verbal abuse. This was found in 1 of 50 medical records reviewed MR #1.

Findings include:


1. Review of the facility's video tape on December 2, 2014 at revealed that on September 26, 2014 Staff #3, a Security Officer/Psychiatric Technician II, kicked a patient while he was assisting other members of the hospital staff to provide a safe environment for patient #1. During the process of kicking Staff #3's security officer shoe came in contact with patient #1's head.

The regimen for this psychotic patient were not consistent with prevailing standards of practice.

An interview was conducted with the Staff #1, the Administrative Nurse Coordinator (ANC) on November 20, 2014 at 10:00 AM. Staff #1 stated when she entered the patient's room the patient complained that Staff #3, a security officer, kicked her (the patient) in the head and he "said I'm not going to deal with this s... today." The Administrative Nurse Coordinator also confirmed that the security officer, Staff # 3, was assigned to perform the 1:1 observation (constant observation) for patient #1 that day and that patient #1 pointed at Staff #3 to indicate that he had kicked her. This interviewee stated she asked Staff #3 to be removed from the patient at that point.

Review of the medical record on November 21, 2014 revealed the Emergency Department (ED) physician documented his notes at 7:54 PM that night, approximately ½ hour prior to the patient's discharge from the ED. The physician noted that he immediately saw the patient upon her arrival and that the patient's normal behavior was "paranoid/psychotic." He also noted the patient's symptoms were severe and the onset of her symptoms was sudden. According to the medical record she was "now screaming, throwing herself on the floor and thrashing with staff." The patient's global assessment of functioning (GAF) was 10 [the numeric scale is: 0 inadequate information, 1 to 10 persistent danger of severely hurting self or others, or persistent inability to maintain personal hygiene, up to 91 to 100 no symptoms - superior functioning in a wide range of activities].

A review of medical record #1 on November 21, 2014 revealed the patient presented to the emergency department (ED) on September 26, 2014 at 1:15 PM and she told the triage nurse that she was sick.

Review of the medical record on November 21, 2014 revealed the patient had a previous history of Post-Traumatic Stress Disorder due to Sexual Abuse which occurred in her childhood and adolescence, Cannabis Abuse, Psychosis and Seizure Disorder. The patient had visited the ED approximately 38 occasions since September 7, 2013 with similar symptoms and complaints. According to the nursing staff the patient was unable to follow re-direction or be reasoned with. The patient appeared frightened, disoriented and confused. During this visit she vomited then proceeded to drink some water from a water fountain in the ED.

A review of the facility's video surveillance tapes on December 2, 2014 at 10:15 AM with Staff #2, the Manager of the Security Department, revealed that on September 26, 2014 at 1:17:39 PM the patient was seen entering the ED from the rear entrance with a sheet wrapped around her waist. The patient walked to the front of the ED at 1:19:11 PM.

The review of the video surveillance tapes revealed a nurse escorted the patient to a psychiatric room (B1). The staff removed 2 chairs from the room, turned off the lights in the room and shut the door at 1:20:37 PM.

The review of the video surveillance tapes revealed that at 1:20:44 PM the patient's door was reopened, the patient was lying on the floor in the room with the patient's head at the entrance of the doorway. Staff #3 was seen standing at the doorway. Two other security officers were seen in the corridor in front of the doorway.

During the review of the facility's video surveillance tapes the Manager of the Security Department (Staff #2) stated that Staff #3 prevented the patient from leaving the room.

The review of the video surveillance tapes revealed that at 1:20:47 PM Staff #3's right foot was seen kicking the patient's head which was now outside of the doorway. At 1:20:56 PM the patient was seen holding onto Staff #3's left foot.

The light in the room was turned on at 1:21:06 PM and at 1:21:17 PM Staff #3 kicked patient #1's head again with his right leg. At 1:21:38 PM, another nurse was seen lifting the patient's left arm and the patient was pulled back into the room at 1:22:45 PM. Staff #1, the Administrative Nurse Coordinator (ANC) of the ED and Behavioral Health Unit arrived in the ED at 1:23:20 PM and entered the patient's room.

A review of the medical record (#1) on December 3, 2014 revealed there was no documented evidence in the medical record of the patient's allegations. There was no documented evidence in the medical record that the patient was examined for any physical trauma after this incident occurred. Furthermore, there was no evidence that the patient was offered counseling regarding this incident. The patient was discharged at 8:38 PM that night.

Given the severity of the patient's agitation, paranoia and psychotic behavior and low GAF, the assignment of the security officer to monitor the patient was not appropriate or safe. Furthermore, there was inadequate documentation to indicate that the nursing staff conducted periodic assessments of the patient.

The policy titled "Eye Contact Record" which was last reviewed 11/2013 revealed the "standard of care" states "the patient on one to one observation can expect to have a safe environment." For patient #1 a safe environment was not provided on September 26, 2014.

Based on medical records reviews, policy reviews and staff interviews, it was determined the hospital failed to provide emergency care consistent with prevailing standards of practice. Specifically, (1) consultations were not comprehensive and (2) reassessments of patients were not performed. This was found in 9 of 50 medical records that were reviewed. This was found for patients MR #1, MR #2, MR #5, MR #6, MR #15, MR #24, MR #29, MR #38, and MR #41.


Findings include:


1. Review of the facility's electronic database on November 21, 2014 revealed patient #1 (MR #1) made 38 visits to the facility from September 2013 - November 19, 2014. The patient was only admitted on 1 occasion to the behavioral health unit since September 2013. There was no documentation found in the medical record that a comprehensive psychiatric consultation was conducted on each of the patient's visits to the emergency department.

Review of medical record #1 on November 21, 2014 revealed on the September 30, 2014 Emergency Department (ED) visit, the psychiatrist's evaluation/consultation states "formal mental status exam is not practical as she is severely agitated, screaming, inconsolable and unapproachable. Recommend give Haldol 5 milligrams (mg) intramuscularly for her own safety and release when episode is resolved and refer back to outpatient psychiatrist." A comprehensive psychiatric consultation was not done for this visit.

Review of medical record #1 on December 3, 2014 revealed the patient was given Haldol, Ativan and Cogentin at 4:26 PM. The psychiatrist documented at 6:34 PM that the patient had a good response to the medications that were administered and that her "presentation on arrival was not as severely disturbed as on prior visits." The psychiatrist also noted that pending medical clearance the patient may return home with outpatient follow-up appointments. However, the ED physician documented at 8:12 PM that night that the patient was awake and distraught and she was requesting additional medication to calm her. The patient was again given Haldol, Ativan and Cogentin at 8:31 PM that night. There was no documented evidence in the medical record that the patient was re-evaluated by a psychiatrist after the second doses of medications were administered. The patient was discharged approximately 9 hours after she arrived at the facility.

Review of another ED visit for patient #1 on December 3, 2014, revealed the emergency medical service (EMS) brought the patient to the ED on November 19, 2014 as an "emotionally disturbed person" at 10:24 AM. According to the psychiatrist note documented at 11:41 AM the patient stated "leave me alone, mommy help me. I'll be a good girl." The psychiatrist also noted at that point that after the usual medications (Haldol, Ativan and Cogentin) were given the patient "calmed down and was able to interact normally with staff while drowsy and without fear of dozing off and that he would re-evaluate the patient when she awakes from her medication induced slumber." The GAF was listed as 25/60. The patient was discharged at 3:15 PM after 3 hours of sleep. A comprehensive psychiatric evaluation was not conducted.

Patient #1's other ED visits, also included, but were not limited to a November 23, 2014 ED visit, which revealed the patient did not receive a comprehensive psychiatric evaluation to determine the patient's appearance, behavior, agitation, grooming/hygiene, eye contact, attitude, psychomotor activity, mood, affect, speech/language, thought process and/or thought content.

Reviews of medical record #1 on November 21, 2014 revealed the patient returned to this ED on September 30, 2014, October 7, 24 and October 26, 2014, November 9, 12, 19, 23, 2014 and December 18, 2014 with similar complaints and was seen and discharged home after each visit.

2 (a) Reassessments were not conducted prior to the discharge of patients from the ED.

During a review of the medical record (#1) on December 3, 2014 it was revealed that at 4:33 PM on November 12, 2014 the patient presented to the ED "crying, scared and verbalizing fear." The patient admitted to seeing scary things but she did not elaborate on her hallucinations. Her mood was depressed and she had impaired insight, judgment and impulse control. The patient was also noted to be cognitively impaired due to her psychotic break and she needed 1:1 observation according to the psychiatrist. This record also indicates the patient had an order of protection against her husband.

b. Medical screening examinations were not performed prior to the psychiatric consultations to ensure that all patients were medically cleared for these consultations. According to current standards of practice, a medical screening examination must be conducted prior to a psychiatric consultation. The following finding includes, but is not limited to patient #1.


Review of medical record #1 on December 3, 2014 revealed the psychiatrist documented that pending medical clearance the patient may return home with an outpatient follow-up on the November 12, 2014 ED visit.

The facility's policy titled "Emergency Room Psychiatric Evaluation" last revised 5/14 states "the medical evaluation may proceed in concert with the psychiatric evaluation." However, this is not consistent with prevailing standards of practice where all medical conditions and emergencies should be ruled out before psychiatric consultations can be performed.

(c) A review of patient #29 (MR #29) on January 8, 2015 at 7:07 AM revealed this is a fifty-three year old patient that presented to the ED on September 26, 2014 with a complaint of eye trauma that had occurred the previous day. The patient was alert and oriented and reported a pain level of 9 on a scale of 0 (no pain) to 10 (most severe pain). A telephone eye consultation was done and the patient was discharged from the ED at 8:12 AM that morning for an eye consultation at another location. The patient returned to the ED at 9:56 AM that morning where it was noted that the patient had a dislocated lens in the left eye. The patient was transferred to another offsite location at 1:30 PM that day for further management. The patient's discharge from the hospital at 8:12 AM for an eye consultation at another location was inappropriate given the nature and location of the patient's trauma.

(d) A review of medical record #38 on January 7, 2015 revealed this twenty-two year old patient presented to the ED on April 12, 2014 at 7:50 PM with complaints of nausea, vomiting and abdominal cramping. The patient also reported diarrhea and that he was not eating. The physician noted that the patient had bilious coffee ground vomitus for 1 day which was of sudden onset. The patient was anxious and grimacing, but there was no documentation of a pain score. According to the physician the patient did not have pain. The physician's notes did not indicate the time that the patient was seen. The physician noted that the patient reported that the patient stated that this was his second episode, but the physician did not identify any precipitating factors, frequency of this episode and what specific location (quadrant) that the patient had the pain.

Review of the electronic database revealed the patient had 4 prior episodes of these symptoms and that he was admitted in April 24, 2013 where he had undergone an EGD (esophagogastroduodenoscopy) which revealed the patient had a Mallory Weiss Tear, Gastritis and Reflux. The physician's review of the patient's abdomen revealed there was no abdominal pain which was inaccurate. The patient was given intravenous fluids, Zofran and Esomeprazole intravenously.

A review of the medical record on January 7, 2015 revealed the nurse's notes documented at 9:53 PM revealed the patient had tenderness in the epigastric area and that the nausea and vomiting had not resolved. The physician's recheck notes indicated the patient was improving with treatment and that he was stable. The patient was discharged at 1:44 AM on April 13, 2014 without the benefit of a gastrology or surgical consultation and there was no documentation that the patient's pain score was evaluated throughout his visit.

(e) Review of medical record #5 on January 7, 2015 revealed this is a thirty-five year old patient who presented to the ED on January 1, 2015 at 1:13 AM with a complaint of vaginal bleeding and vaginal cramps. The patient was 8 weeks pregnant. There was no documentation in the medical record of the patient's pain score. She was discharged at 3:43 AM that morning with a diagnosis of threatened abortion without any physician or nursing documentation of the patient's level of pain during her ED stay.

The facility's policy titled "Pain Management" last revised 12/14 states "The Numerical Rating Scale (0= no pain to 10= worst pain imaginable) should be the first scale utilized."

(f) A review of medical record #15 on January 9, 2015 revealed this patient presented to the ED on December 2, 2014 at 3:38 PM for an evaluation of a syncopal episode. The patient reported shortness of breath after walking up 2 flight of stairs then he got dizzy and passed out. The patient was given oxygen and intravenous fluids prior to arrival in the ED. The patient's previous medical history included Deep Vein Thrombosis and Diabetes Mellitus. Diagnostic tests results were consistent with severe cardiac ischemia. At 4:40 PM the Blood Pressure (B/P) was 146/106, at 6:09 PM it was 140/100, and at 8:27 PM it was 142/101. There was no documentation in the medical record that a physician was notified of these elevated blood pressure readings. The next B/P check was conducted at 6:00 AM on December 3, 2014 when it was still elevated at 134/89. This 10 hour gap between the 8:27 PM and 6:00 AM B/P assessments were not consistent with the facility's policy and current standard of practice.

A review of the policy title "Vital Signs Monitoring" which was last revised 2/14 states blood pressures should be taken at least every four hours if the blood pressure is unstable. The patient's blood pressure was elevated, therefore, it should have been rechecked in a more timely manner in keeping with this policy.