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Based on record review and expert psychiatric review, the governing body did not ensure that the medical staff was accountable to the governing body for the quality of care provided to Patient #1.

Findings Include:

Review of the Emergency Department (ED) record dated 10/16/10 at 0026 revealed Patient #1 was triaged in the ED by nursing as severity index level 3 after being brought to the facility by Emergency Medical Services (EMS) after he jumped out of a car because "God told him to". At 0054 drug toxicology results return as negative. At 0130 Patient #1 is referred to the behavioral health ED and assessed by nursing. At 0220 the medical nurse practitioner conducted a physical assessment and review of the drug toxicology results. At 0224 the medical nurse practitioner documents that the patient is psychotic and will be admitted as he feels he is an angel. God is talking to him and telling him to jump out of the car. Abnormal findings include bilateral abrasions to knees, hallucinations and pressured speech. Symptoms are classified as moderate. Patient #1 has no previous medical, surgical or psychiatric history. At 0245 he is admitted on a 9.39 status for psychosis.

Review of the emergency admission sections I and II of the 9.39 form dated 10/16/10 at 0209 revealed Patient #1 jumped out of a car going 60 mph and stated God told him to. God also stated to him to bring everyone to heaven. The document was signed by the ED medical physician.

Review of admission orders dated 10/16/10, time illegible, revealed telephone orders by the psychiatrist were received.

Review of the medical consult dictated 10/16/10 at 1213 revealed a general physical exam of Patient #1 documenting no serious medical problems. No new orders are noted.

Review of the emergency admission sections III and IV of the 9.39 form dated 10/16/10 at 1000 revealed an assessment by the psychiatrist which is illegible.

Review of the psych history form dictated 10/16/10 at 10:25 revealed the initial assessment by the psychiatrist. The assessment lacked collateral contact with the family, evaluation of impulse control, evaluation of suicidal and homicidal ideation, evaluation of potential risks as identified by presenting symptoms and complete diagnosis on all 5 axis.

Review of psychiatry progress note dated 10/17/10 at 0845 revealed sections of the assessment are incomplete in the areas of subjective, objective, diagnosis and medications and the hand written subjective documentation is illegible.

Review of nursing note dated 10/17/10 at 11:35 revealed Patient #1 was walking in hallway and suddenly hit the fire alarm twice. He pushed open the fire door and ran out. Rapid response and code gray were called. Level 3 observations maintained. At 11:45 administration and the psychiatrist are notified.

Review of the physician progress note dated 10/17/10 at 1315 revealed he answered a call that a patient had jumped out of a hospital window. Two nurses, an aide and the physician responded to the scene. The paramedics were present and providing treatment to Patient #1. Patient #1 was assessed and taken to the ambulance. He was reassessed and judged safe for transfer to the closest trauma center for continued care. At 1500 report from the EMS personnel who transferred Patient #1 stated they were greeted by the trauma team and Patient #1 was safely transported to the Trauma Center's ED. Patient #1 remained unconscious throughout.

There was no evidence of communication between the ED staff physician and the on call psychiatrist. A complete medical assessment was not conducted in the ED or after admission, which would have included routine blood work to rule out an organic etiology for the psychosis and imaging to assess for internal injuries.

There was no evidence of the psychiatrist's assessment of this sentinel event/emergency transfer in the medical record.

There was no evidence of communication between the facility staff and the receiving trauma center, nor was there any evidence that Patient #1's family was contacted.




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Based on medical record review and facility documentation, the facility did not ensure care was provided in a safe setting, specifically, there was a delay in intervention and lack of communication by staff during and after Patient #1's elopement from the unit.

Findings include:

-Review of nursing note dated 10/17/10 at 11:35 revealed Patient #1 was walking in the hallway and suddenly hit the fire alarm twice. He pushed open the fire door and ran out. A rapid response code and a code gray were called.

-Review of the surveillance video dated 10/17/10 from 11:37 to 11:40 revealed staff are intermittently seen in the hallway, coming in and out of rooms. At 11:40 AM Patient #1 punches the fire alarm x 3 and proceeds out of the fire exit door into the stairwell. Two staff approached the fire exit door and looked at the alarm box. They continued walking down the hall. At 11:42 two staff members proceeded through the fire exit door. At 11:43 AM another staff member and a security officer went through the fire exit door.

-Review by a Board Certified Physician in Psychiatry dated 11/18/10 revealed the charge nurse should have activated the internal alarm systems in addition to the external rapid response and code gray (elopement) to expedite immediate intervention from all staff present on the unit. Altogether, three staff exited through the fire exit about 2 1/2 minutes after the sounding of the fire alarm and almost two minutes after the charge nurse made the alerts. The staff should have responded promptly when the charge nurse shouted for Patient #1 to stop after witnessing him punch the fire alarm and leave through the fire exit. The staff should have attempted to run out promptly after the charge nurse shouted, and followed Patient #1 in the direction of the fire exit to catch him. There was a 2 1/2 minute delay in following Patient #1, hence visual contact with Patient #1 may have been lost. All three staff exited the fire door and proceeded downwards in the same direction instead of dividing search in both directions (upwards and downwards). The staff had lost contact with Patient #1 and there was a delay in finding him.

Based on record review and expert psychiatric review, the medical staff did not ensure that quality care was provided to Patient #1.

Findings Include:

See Findings under Tag # A 049

Based on record review, nursing staff failed to evaluate the care needs for Patient #1.

Findings Include:

Review of the emergency department behavioral health nursing assessment dated 10/16/10 at 0130 revealed the patient was brought to the emergency department by the police due to jumping out of a moving vehicle going 60 mph. The patient feels the world is ending and God told him to bring people to heaven. He has bilateral abrasions to knees. The patient has no previous medical or psychiatric history. The patient is anxious, euphoric, hyperactive, elevated mood, delusional, poor insight and poor judgement. He denies suicidal or homicidal ideation.

The suicide lethality assessment completed by the mental health nurse rates the patient as a low suicide risk and does not reflect the new onset psychosis, dangerous/impulsive behaviors and overall clinical presentation.