HospitalInspections.org

Based on interview, record review, policy review, and review of video surveillance, the hospital failed to follow their policies and provide stabilizing treatment within the hospital's capability and capacity, when one patient (#26) presented to the hospital's Emergency Department (ED) seeking care for an emergency psychiatric (relating to mental illness) condition, out of a sample of 40 records selected for review from 6/01/20 to 12/01/20. The hospital failed to initiate measures to prevent the patient, who was considered high-risk for suicide (to cause one's own death), from elopement (when a patient makes an intentional, unauthorized departure from a medical facility). The hospital's ED had an average of 2,534 emergency visits per month over the past six months.

This failure by the hospital had the potential to affect the care and treatment for all psychiatric patients who presented to the hospital's ED seeking medical care/treatment.

Based on interview, record review, policy review, and review of video surveillance, the hospital failed to stabilize one patient (#26) within the hospital's capacity and capability, when the patient presented to the Emergency Department (ED) with a psychiatric (relating to mental illness) emergency. The hospital failed to initiate measures available to prevent a high-risk suicidal (displays an inclination to attempt/commit suicide) patient from elopement (when a patient makes an intentional, unauthorized departure from a medical facility). A total of 40 patient ED records were reviewed out of a sample selected from 6/01/20 through 12/01/20. The ED had an average of 2,534 emergency visits per month over the past six months.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act," dated 11/19/19, showed that in the event an individual presents with an emergency medical condition (EMC), the hospital will provide stabilizing treatment to the extent of the hospital's capability and capacity and, if indicated, provide an appropriate transfer to another hospital with the capability and capacity to stabilize the individual. An EMC is a medical condition with acute (sudden onset) symptoms of severity, including psychiatric disturbances, and substance abuse. Capability of the hospital included services routinely available to the ED, such as on-call personal to provide treatment necessary for stabilization of an EMC.

Review of the hospital's policy titled, "Suicide Prevention for Patients in the Emergency Department," dated 12/03/19, showed that:
- A high risk patient is one that had active suicidal ideation (SI, thoughts of causing one's own death) with intent to act without a specific plan or expresses intent with a plan.
- Suicide precaution patients were to have one-to-one (1:1, continuous visual contact with close physical proximity) observation with trained and competent staff members in reasonable proximity to the patient, so that the staff member was immediately available to provide appropriate interventions to prevent harm, including but not limited to episodes of toileting, bathing, sleeping, and, if indicated, testing/procedures conducted in areas outside of the patient's room.
- Patients with serious suicidal risk must be placed under demonstrably reliable monitoring within line of sight (LOS, continuous visual contact with the patient) allowing for 360 degree (full circle) viewing.
- Continuous visual observation must be done by a staff member who is trained and competent in managing patients with suicidal thoughts, and must be provided at all times, including while the patient uses the bathroom or is sleeping.
- When continuous video monitoring is utilized, a staff member shall be solely dedicated to monitor the patient via video and must be immediately available to provide appropriate interventions to prevent harm.
- All patients on suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) were to have their belongings secured.

Review of the hospital's policy titled, "Abduction and Elopement of Patients," dated 10/10/20, showed that the nurse's assessment was to include communication regarding the patient's high risk for elopement, to nursing and/or social work, the administrative supervisor, and security, and that current instances of wandering behavior can affect the patient's ability to make safe choices.

Review of the hospital's policy titled, "Safety Search of Patient and Belongings," dated 03/07/18, showed that a patient who had expressed suicidal ideation should have their belongings bag secured, placed in a safe location outside of the patient's room, and the patient made aware that they would be returned to them upon discharge.

Review of the ambulance report dated 07/22/20 at 3:47 PM, showed that the patient had attempted suicide with an intentional (on purpose) overdose, and was found on the floor of her kitchen.

Review of an affidavit (a written statement confirmed by oath, for use as evidence in court) dated 07/22/20, and included in the patient's medical record, showed that Police Officer A documented that the patient reported that she took six Xanax (a medication used in the treatment of mild to moderate anxiety) laced (adding a substance to another) with Fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use) because she wanted to kill herself, and that she had cut her wrists and legs earlier in the week for the same reason.

Review of Patient #26's ED record dated 07/22/20 through 07/23/20, showed the following:
- Staff II, Physician Assistant (PA), documented on 07/22/20 at 4:51 PM, that the patient was a 21-year-old female with a history of attention deficit hyperactivity disorder (ADHD, characterized by the inability to sit still and maintain self-control), depression (extreme sadness that doesn't go away), oppositional defiant disorder (ODD, defiant and disobedient behavior to authority figures) and post traumatic stress disorder (PTSD, persistent mental and emotional stress occurring as a result of trauma that was witnessed or experienced) who arrived by ambulance after an intentional overdose. The patient had slurred speech, did not answer questions related to orientation (awareness of person, place, time, etc.), appeared "significantly intoxicated," and admitted she had consumed Xanax, Fentanyl and alcohol (increases the effects of the Xanax and Fentanyl when taken in combination), and was too somnolent (sleepy/drowsy) for Staff II to obtain the patient's history.
- Staff JJ, Physician, documented on 07/22/20 at 5:36 PM, that the patient stated that, "She wanted to go to sleep and not wake up," and was to be monitored closely because of the overdose.
- Staff AA, Physician, documented on 07/23/20 at 3:32 AM, that the patient ran out of the ED and down the street, and the Registered Nurse (RN) was unable to stop her.

Review of Patient #26's ED medical record on 07/23/20 at 2:52 AM, showed that Staff P, Clinical Psychiatric Nurse Practitioner, documented that the patient:
- Stated that she wanted to go to sleep and not wake up.
- Had multiple bruises, abrasions, and lacerations in various stages of healing.
- Was suicidal with an intentional overdose.
- Asked to leave multiple times and attempted to elope.
- Was placed on elopement precautions.
- Was to be processed for placement for involuntary admission.
- Was medically cleared and would be transferred to an inpatient psychiatric unit when a bed was available.
- Was high risk for suicide.

During an interview on 12/02/20 at 1:25 PM, Staff P stated that she expected the patient to have a sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) placed outside of her door because the patient had intentionally overdosed.

During an interview on 12/07/20 at 12:25 PM, Staff BB, Housekeeper, stated that she remembered the patient being mad about being transferred to another facility, and the patient stated several times that she wanted to leave.

Review of the "Observation Flowsheet for Patient Safety," showed that on 07/23/20, Staff X, Monitor Technician (person responsible for monitoring the patient's safety through video), documented at 3:00 AM, that the patient was observed talking on the phone, and at 3:15 AM, documentation showed the patient's observation was "eloped."

Observation on 12/07/20 at 12:10 PM of the nurse's station, showed that the monitor technician area was approximately 20 feet away (not close physical proximity), not directly outside of the patient's room to assist with interventions, and did not provide a 360 degree view of patient rooms.

During an interview on 12/08/20 at 9:15 AM, Staff X, Monitor Technician, stated that the patient was sedate (quiet, sleepy) early in the visit, and later when she woke up, the patient was cursing, wandering in the hall, wanted her cell phone and wanted to leave. She stated that Staff S, RN, then called security and asked them to bring the patient's personal belongings bag.

During an interview on 12/08/20 at 10:50 AM, Staff V, RN, stated that all personal belongings were to be locked up with security.

During an interview on 12/02/20 at 3:34 PM, Staff S, RN, stated that the patient wanted to speak with her boyfriend and was upset about not having her cell phone. Staff S then called security and asked them to bring the patient's belongings bag back, but could not remember if she returned the belongings to the patient.

Review of the "Case Report," dated 07/23/20 at 3:58 AM, showed Staff Z, Security Officer, documented that Staff S called her on 07/23/20 at 2:58 AM, and told her to return Patient #26's belongings. She stated that she had Staff S sign for the belongings, and left them at the nurse's station with Staff S.

Review of the document titled, "Belongings Have Been Secured," showed that the patient's secured belongings were released to, and signed by, Staff S on 07/23/20 at 3:16 AM.

During an interview on 12/08/20 at 1:40 PM, Staff Z, Security Officer, stated that when Staff S called her for Patient #26's belongings, she brought them to the nurse's station and Staff S then took custody of the belongings.

During an interview on 12/02/20 at 1:25 PM, Staff P, Psychiatric Nurse Practitioner, stated that the patient's personal belongings should not have been returned to a patient when they were suicidal and on elopement precautions.

During an interview on 12/02/20 at 1:10 PM, Staff R, RN, ED Charge Nurse, stated that Patient #26's personal belongings should not have been returned.

Review of video surveillance of the ED hall outside of Patient #26's room, dated 07/23/20 showed that at 3:19 AM, the patient entered the hall with her belongings bag in her hand, visibly upset, speaking to a person (not visible on the video) at the nurse's station, and at 3:20 AM, the patient left down the ED hall toward the exit.

During an interview on 12/08/20 at 10:50 AM, Staff V, RN, stated that she witnessed the patient in the doorway of her room visibly upset and then witnessed her running to the exit. She then ran after the patient, and attempted to stop her with no success, so she reported the elopement to the local police department. Staff V added that all high-risk behavioral health patients were supposed to have an elopement band (a wristband that the hospital placed on patients so if they were close to the exit door, an alarm would sound), but there was no alarm when Patient #26 eloped.

During an interview on 12/07/20 at 3:34 PM, Staff S, RN, stated that she could not remember if the patient had an elopement band on.

During an interview on 12/07/20 at 12:06 PM, Staff W, RN, stated that the hospital had a shortage of elopement bands and staff had to prioritize their use due to limited availability.

During an interview on 12/08/20 at 2:15 PM, Staff AA, Physician, stated that Patient #26 was a suicide risk and should have had an elopement band on.

Review of video surveillance of the ED driveway, dated 07/23/20, showed that:
- At 3:20 AM, the patient ran with her belongings bag out of the ED entrance.
- At 3:20 AM, Staff S, RN, was seen following after the patient and then turned back.
- At 3:21 AM, Staff Z, Security Officer, stood at the door, and there was no indication that she attempted to prevent the patient's elopement.

During an interview on 12/08/20 at 1:40 PM, Staff Z, Security Officer, stated that when she arrived to the ED upon the emergency elopement call, the patient had already eloped and was off of hospital property.

Observation on 12/02/20 at 12:40 PM, showed that the ED parking lot was approximately 50 feet from the ED door (that Patient #26 exited from) to the street (off of hospital property).

During a telephone interview on 12/10/20 at 11:40 AM, Staff KK, ED Medical Director, stated that for a high-risk suicidal patient:
- He expected the patient to be placed on 1:1 observation.
- He expected staff to place an elopement wrist-band on the patient so that when she was near an exit, an alarm would have sounded and delayed the door from opening.
- He expected security to have secured the patient's personal belongings until the patient was discharged.

Review of the police report dated 07/23/20, after Patient #26's elopement, showed that at 3:23 AM, law enforcement received a call from hospital staff, informing them of the patient's elopement. At 8:23 AM, they located the patient and transported her to Hospital B's (nearby hospital) ED for a psychiatric evaluation.

Review of the ambulance report on 07/23/20 at 8:10 AM, showed that they were contacted by law enforcement to transport Patient #26 to Hospital B, due to the patient banging her head against their car window and stating that she wanted to commit suicide.

Review of an affidavit dated 07/23/20, showed that Police Officer A documented that the patient told him she wanted to kill herself numerous times and still planed on it after she left Hospital A. He stated that the patient's grandmother and boyfriend reported to him that the patient said she planned to drive off of a cliff.

Review of Patient #26's ED medical record from Hospital B, dated 07/23/20, showed that:
- At 8:38 AM, the patient presented to the ED with law enforcement and emergency medical services (EMS) after attempted drug overdose, elopement from Hospital A, and with aggressive suicidal behavior.
- At 9:43 AM, the patient was screaming and threatening to kill herself.
- At 10:30 AM, the patient was placed in four point (restraints placed on all four limbs) restraints (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) with a sitter at the bedside.
- At 1:18 PM, the patient was removed from the four point restraints.
- At 4:17 PM, Staff LL, Licensed Clinical Social Worker (LCSW), documented the recommendation to admit the patient involuntarily (for psychiatric services).
- At 4:22 PM, Staff MM, Physician, ordered the patient to be admitted involuntarily.
- At 6:54 PM, the patient was transferred to Hospital C (Hospital A's off-site inpatient psychiatric hospital).

Review of Patient #26's ED medical record from Hospital C, dated 07/23/20, showed that Staff NN, RN, documented that the patient arrived at 7:20 PM, was aggressive, threatened to hang herself in the shower if she was admitted, was placed on suicide and elopement precautions and involuntarily admitted.

Hospital A failed to ensure Patient #26 was provided stabilizing treatment within their capabilities, when the patient presented with an emergency psychiatric condition. She was reported to have mixed drugs and alcohol and with the desire to "go to sleep and not wake up." While in the ED, the patient indicated that she was high-risk for elopement when she became mad, began cursing, and stated repeatedly that she wanted to leave. The hospital failed to place an elopement band on the patient, the patient was not monitored within close proximity by staff, and the patient was allowed to wander in the ED. Her personal belongings, which were previously secured, were returned to her, and the patient was allowed to elope when she was high-risk for suicide.