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Based on review of facility documents, medical records (MR) and interviews with staff (EMP), it was determined that Holy Spirit Hospital failed to provide and maintain care in a safe setting (A144) for one of 27 medical records reviewed (MR1).

Findings:

A review on April 25, 2012 of facility policy Patient-Rights, dated January 2012, revealed "...Your Rights ... As our patient, you have the right to safe, respectful, and dignified care at all times ... Care Delivery ... Receive care in a safe setting free from ay form of abuse, harassment, and neglect ... ."

A review on April 23, 2012, of Policy/Procedure for Display/Distribution of Patients Rights, reviewed January 2012, revealed, " ... Appendix A ... Care Delivery: You have the right to: expect emergency procedures to be implemented without delay. ... Receive efficient and quality care with high professional standards that are continually maintained and reviewed. ... ."

A review on April 26, 2012 of MR1 revealed the patient presented to the Emergency Department by ambulance on April 17, 2012, at 9:20 PM.

The review of the Triage documentation revealed 9:29 PM, "Pt (patient) presents to ER via BLS from home c/o suicidal attempts. Per BLS patient was stopped from jumping out of 2nd story window at home by Police. Pt has history of depression and suicidal attempts ... ."

The review of nursing documentation revealed:
"21:30 See triage. Pt here due to 81. Pt c/o pain 'everywhere.' Await eval.
"21:55 Protocol initiated."
"22:20 pt still actively suicidal. stating '... wishes they would have let [me] jump.' Blood obtained by EDT"
"22:20 pt made previous statement to EDT"
"22:35 pt given OJ, resting in bed. w/o complaints"
"22:45 pt still resting on bed."
"22:45 cont' d: pt cooperative and appropriate with staff, suicidal ideations not verbalized to RN, patient content in RM, curtain open. Still awaiting physician evaluation."
"23:05 pt not in RM when checked by RN, Security notified, staff and security searching premises."
"23:13 pt not found on premises, police notified of patient elopement"

The ED videotape was reviewed and revealed the patient arrived by ambulance on April 17, 2012, at 9:23 PM. It showed the patient at 10:47 PM walking through the ED Discharge Lounge, dressed in paper scrubs and wearing only socks, and then walking through the ED entry doors into the parking lot in the direction of the helicopter-pad. The patient exited the parking lot in a wooded area and was no longer visible.

An interview was conducted with EMP2 on April 26, 2012, at 10:45 AM. EMP2 confirmed that they had received notification on April 17, 2012, that MR1 had eloped from the ED and was deceased. Further interview confirmed that the Coroner ruled the patient's (MR1) death as a suicide, on April 19, 2012.

Cross Reference with:
482.21 QAPI
482.23(b) Staffing and Delivery of Care

Based on a review of facility documents, medical records (MR) and interview with staff (EMP) it was determined that Holy Spirit Hospital failed to initiate Quality Improvement activities for problem prone areas which could affect health outcomes and patient safety (A285), and failed to monitor the number of mental health patients that presented to the Emergency Department (ED) and eloped before receiving an evaluation by Crisis (A275) for nine of nine MR reviewed (MR1, MR12, MR13, MR15, MR16, MR17, MR18, MR20 and MR21).

Findings include:

A review on April 25, 2012, of the Holy Spirit Hospital Quality Improvement Plan, reviewed August 29, 2011, revealed, " ... The goals of Holy Spirit Hospital Quality Improvement Plan are: ... Programs designed for safety, and excellence in clinical practice ... While the primary goal of the Quality Plan is to improve the performance of Holy Spirit's clinical outcomes and operational efficiencies, high volume, high risk, problem prone areas ... (High Risk is defined as the probability of injury or loss to patients ...Quality Improvement goals are accomplished through the coordinated efforts of the leadership and by the involvement of physicians and staff in the Performance Improvement Initiatives. ... ."

A review of the Unit Based Effectiveness Dashboard for the period July 2011 through April 2012, revealed that volumes of mental health patients, minutes held till placement and boarder minutes per patient were evaluated. There was no monitoring/tracking of mental health patients who presented to the ED and eloped before receiving a Crisis Intervention consultation.

A review of MR1 on April 19, 2012, revealed the patient presented to the Emergency Department by ambulance on April 17, 2012, at 9:20 PM. Further review of the "PA EMS Report" revealed the patient had been stopped from jumping from the second floor window of their home by Police. The patient had superficial lacerations on their forearms that the patient stated were self inflicted. There was no evidence in the MR that Crisis Intervention had been consulted.

A review of MR1 Nursing documentation revealed, " ... 11:13 PM pt not found on premises, Police notified of patient elopement ... ."

A review on April 26, 2012, of MR1, MR12, MR13, MR15, MR16, MR17, MR18, MR20, and MR21 revealed that the patients had presented to the ED for mental health related complaints and then eloped. There was no documentation that the patients had been evaluated by Crisis Intervention.

An interview was conducted with EMP12 on April 19, 2012, at 2:55 PM. EMP12 confirmed that suicide assessment training had not been provided to the ED nurses.

An interview was conducted with EMP14 on April 25, 2012, at 2:30 PM. EMP14 confirmed that the facility does not track elopements of the patients who present with mental health related complaints. (A275)

Cross Reference with:
482.13(c)(2) Patient Rights
482.55 Emergency Services

Based on a review of facility policy, medical records (MR), and interviews with staff (EMP) it was determined that Holy Spirit Hospital failed to ensure the immediate availability of Nursing supervision to a suicidal patient.

Findings include:

A review on April 19, 2012, of the Holy Spirit Hospital Clinical Nurse Practice entitled Suicide Precautions, last revised December 2011 revealed, " ... safety of the suicidal patients in the Emergency Center is maintained from Triage to Disposition. ... ."

A review on April 19, 2012, of the Holy Spirit Hospital Clinical Nurse Practice revealed, " ... Assigned RN responsibility ... If Secure room not available, prepares Exam room so that it is as free as possible of harmful objects. Monitors with close observation 1:1 ... Completes Nursing Assessment form ... with special emphasis on self harm risks and factors ... ."
The policy did not include a definition for close observation or 1:1.

A review on April 19, 2012, of the Holy Spirit Hospital Clinical Nurse Practice entitled ED Protocols revealed, " ... ED Depression a. Obtain vital signs and medical records b. Assess Suicidal Risk c. STAT labs; ... d. Consult Crisis e. Additional Lab and Radiology studies may be added at the Physician/RN discretion as per ED Order Sets ... ."

A review on April 26, 2012, of the Holy Spirit Hospital policy entitled, Crisis Intervention, Walk-ins to the ECU, reviewed March 18, 2011, revealed, " ... Patient presents to ... Triage Nurse and does not request Crisis Intervention. ... Triage Nurse assesses the patient and determines the order of care based on severity of symptoms. ... . "


A review on April 23, 2012, of Holy Spirit Hospital policy entitled Suicide Precautions, revised April 2012, revealed: " ... IV. Procedure ... 1. Assigned RN responsibility: a. Assess patient; b. Places patient in the Secure room (room 17 or 21); c. Notifies Security for additional assistance; d. Monitors room, i.e. camera, continuously, or with continuous observation; e. If Secure room not available, prepares Exam room so that it is as free as possible of harmful objects. Monitors with continuous observation. ... . "

A review on April 19, 2012, of MR1 revealed that the patient was brought to the ED on April 17, 2012 at 9:29 PM by ambulance. A review of the PA EMS Report revealed, "Pt was trying to jump from second floor window as a suicide attempt ... Pt has superficial lacerations on their forearms that they said were self inflicted a few days ago." ... The patient was triaged at 9:30 PM and protocols for depression were initiated at 9:55 PM by the Registered Nurse (RN). A review of the Nursing documentation revealed that the patient was not in the room at 11:05 PM. Security was notified and a search of the premises ensued. Local Police were notified at 11:13 PM.

An interview was conducted with EMP7 on April 19, 2012. EMP7 stated that "on the night of the incident, both Seclusion rooms were occupied by other patients and the decision was made to place this patient (MR1) into room #4, as it was directly across from the Nurse's Station. The patient should have been within the Charge Nurse's view at all times. Close observation or 1:1, means that the staff seated at the desk (the Unit Secretary and/or the Charge Nurse) would frequently watch the patient. It doesn't mean staff can't take their eyes off of the person. ... We do not assess intent for suicidal patients nor do we have a lengthy suicide assessment. Crisis would evaluate the patient after their medical screening exam (MSE). Crisis had not been called on this patient because they were already in the Department evaluating other patients. The patient eloped during change of shift. The patient appeared calm and was not expressing any suicidal ideations. No commitment papers had been requested at the time of the elopement. EMP8 told me that they had to transport another patient out of the Department. EMP8 claimed that they made eye contact with the patient in room #4 as they transported the other patient and when they returned from the transport, approximately 12 minutes later, the patient had eloped. Security was immediately called and they searched the property and notified the Police but were unable to locate the patient."

An interview was conducted with EMP8 on April 19, 2012. EMP8 stated, " I visited the patient, introduced myself, explained what will happen and exited the room. I returned to the room shortly after and offered something to eat/drink. MR1 accepted orange juice. The ED Tech obtained blood-work and MR1 whispered under their breath that they wished they would have let them jump. The Tech informed me, and I immediately returned to room #4 to assess the patient. The patient told me that they didn't have a plan anymore. I was required to transport a monitored patient to the Eighth floor and reported to my Charge nurse that I was going. MR1 eloped while I was transporting another patient."

Based on a review of facility policy, facility documents and interview with staff (EMP), it was determined that the facility failed to ensure that the Emergency Department (ED) services were provided to meet the emergency needs of patients presenting with mental health related complaints in accordance with acceptable standards of practice for nine of nine patients records reviewed (MR1, MR12, MR13, MR16, MR17, MR18, MR20, MR21 and MR22).

Findings include:

A review on April 23, 2012, of the facility's policy ED Protocols, reviewed March 2012, revealed: " ... III. Purpose: ... B. To enhance timely care in the Emergency Room setting. ... IV. Procedure: ... B. Order sets: ... 3. ED Depression. A. Obtain vital signs; b. Assess Suicidal Risk; c. STAT labs ... d. Consult Crisis ... " The policy failed to address those patients seeking Crisis Intervention or overt behaviors.

A review on April 23, 2012, of the facility's policy Triage, revised March 2012, revealed, " ... III. Purpose: ... B. To quickly identify those patients with urgent, life threatening conditions. "

A review on April 23, 2012, of the facility's policy Management of the Acutely Disturbed Patient, reviewed August 2011, revealed, " ... II. Policy: The Emergency Center physician provides a medical screening and Crisis Intervention is called to assess the ability of an acutely disturbed individual. Hospital personnel monitor the patient with a severe dysfunction of behavior, mood, thinking, or perception that may create a threat to life, adequate functioning, or psychological integrity at all times. ... IV. Procedure: ... E. Notify Crisis Intervention. ... V. Guidelines/Precautions: ... B. Maintain continuous evaluation of potential for dangerousness. C. Maintain a safe environment for the patient, i.e.. camera monitoring of seclusion room, 1:1 monitoring by staff/security. ... ."

A review on April 23, 2012, of the facility's policy ECU Seclusion Room, reviewed February 2012, revealed, " ... Policy: The following procedures for secluding patients should be adhered to by ECU and Safety, Security and Emergency Management staff to ensure the safety of all Emergency Room patients, staff and visitors. Procedure: 1. The Seclusion Room will be given priority to these patients that pose a threat to themselves, other patients, staff and/or visitors or are an elopement risk. ... ."

A review on April 25, 2012 of MR1 revealed the patient was a 30 year old female who arrived in the ED via Basic Life Support Unit (BLS) on April 17, 2012, following a suicide attempt. The patient arrived at 9:27 PM and was triaged at 9:29 PM and eloped from the ED at 11:05 PM. The MR revealed that the patient was not placed in a secure room. There was no documentation in the MR to indicate that Crisis had been consulted or that Crisis had evaluated the patient prior to elopement.
MR1 contained an EMS report, " ... Police greet EMS. Officer advised EMS that they just pulled patient from the window. Officer states that patient was trying to jump from the second floor window as a suicide attempt. Entered residence to find a second officer with patient. Patient was sitting in living room, handcuffed. Patient was dressed in street clothes and was being verbally agressive. Patient states has been suicidal and wanted to end their life. Patient states they wish the officers had not stopped them from jumping out of the window. Patient states that they have been suicidal for a long time and denies any recent events leading up to today's attempt. Officers state that patient will be a 302, involuntary committment. Patient then states that they will not be a 302 and that they wish to go as a voluntary commitment. Patient states that they will cooperate with EMS. ... has superficial lacerations on forearms ... self inflicted ... Patient states they are tired of the physical and emtional pain. ... ." (A1104)

A review on April 25, 2012, of MR12 revealed the patient was a 48 year old male who arrived in the ED on February 24, 2012, with a complaint of Crisis. The patient arrived at 6:36 PM and eloped at 8:00 PM. There was no documentation in the MR to indicate that Crisis had been consulted or that Crisis had evaluated the patient prior to elopement. (A1104)

A review on April 25, 2012, of MR13 revealed the patient was a 21 year old male who arrived in the ED on March 21, 2012, with a complaint of Crisis. The patient arrived at 8:12 PM, was triaged at 9:36 PM and eloped at 10:48 PM. There was no documentation in the MR to indicate that Crisis had been consulted or that Crisis had evaluated the patient prior to elopement. A review of ancillary Crisis Intervention documentation from previous and subsequent ED visits for Crisis revealed that the patient had presented to the ED for Crisis Intervention on March 20, 2012, and again on March 22, and 23, 2012. A review of the March 22, 2012 Crisis Intervention documentation revealed that there had been repeated visits within a 72 hour period. (A1104)

A review on April 25, 2012, of MR16 revealed the patient was a 26 year old male who arrived in the ED on March 2, 2012, with a complaint of Crisis. The patient arrived at 3:12 PM and eloped at 3:45 PM. The review of the MR revealed that a Crisis consult had been ordered at 3:30 PM. There was no documentation in the MR to indicate that Crisis had evaluated the patient prior to elopement. (A1104)


A review on April 25, 2012, of MR17 revealed the patient was a 12 year old male who arrived in the ED on February 2, 2012, with suicidal ideation. The patient arrived at 12:00 PM, was triaged at 1:10 PM and eloped at 2:20 PM. There was no documentation in the MR to indicate that Crisis had been consulted or that Crisis had evaluated the patient prior to elopement. (A1104)


A review on April 25, 2012, of MR18 revealed the patient was a 19 year old male who arrived in the ED on January 25, 2012, with a complaint of Crisis. The Arrival and Triage time were not documented on the MR. The patient eloped at 11:00 PM. There was no documentation in the MR to indicate that Crisis had been consulted or that Crisis had evaluated the patient prior to elopement. (A1104)


A review on April 25, 2012, of MR20 revealed the patient was a 12 year old male who arrived in the ED on March 23, 2012, with a complaint of Crisis. The patient arrived at 12:00 PM and eloped. The time of the elopement was not documented in the MR. There was no documentation in the MR to indicate that Crisis had been consulted or that Crisis had evaluated the patient prior to elopement. (A1104)


A review on April 25, 2012, of MR21 revealed the patient was a 35 year old female who arrived in the ED on February 2, 2012, with a complaint of Crisis. The patient arrived at 8:13 PM and eloped. The time of the elopement was not documented in the MR. There was no documentation in the MR to indicate that Crisis had been consulted or that Crisis had evaluated the patient prior to elopement. (A1104)


A review on April 25, 2012, of MR22 revealed the patient was a 41 year old male who arrived in the ED on January 4, 2012, with homicidal ideations. The patient arrived at 4:45 PM and eloped. The time of the elopement was not documented in the MR. There was no documentation in the MR to indicate that Crisis had been consulted or that Crisis had evaluated the patient prior to elopement. (A1104)

An interview was conducted with EMP4 on April 25, 2012, at 10:00 AM. EMP4 confirmed there was no documentation that these patients had been evaluated by Crisis Intervention. (A1104)

Cross Reference
482.13 Patient Rights
482.21 QAPI
482.23(b) Staffing and Delivery of Care