HospitalInspections.org

Based on record review, observation, interviews, and review of the Incident Report from 12/03/22, the hospital failed to ensure for one of five Patients (P) 7 reviewed for elopement that care was provided in a safe setting, failed to ensure the patient did not elope from the facility, and failed to conduct a comprehensive investigation to ensure patient safety. This failure has the potential to put all psychiatric patients entering the Emergency Department (ED) at risk.

Findings include:

Review of the hospital's policy titled, "Violence, Self-Harm and Suicide Risk Assessment and Patient Management (Non- Psychiatric Units)" last revised 09/17/24 [Reviewed, added clarification on CTRS scoring, gave 2 RNs ability to reassess and upgrade risk level if Assessor not available, specified who can complete handoff checklist, clarified verbal report must be called to receiving RN for BH patients regardless of SBAR process] revealed, "The purpose of this procedure is to identify patients at risk for violence and/or suicide/self-harm and to guide implementation staff in of safety actions based on level of risk. Crisis Triage Rating Screening (CTRS) - An assessment tool used to determine and stratify the patient's risk for violence and/or suicidal behaviors assessments. ... Procedure: Identify patient(s) that need Performed by RN ... Complete the CTRS assessment if triggers are present. ... Select Risk Level identified in
assessment tool based on score. ... CTRS High Risk 3 - 8 points Moderate Risk 9 - 12 Low Risk 13-15 points. Implement Safety Actions based on risk level. High Risk. Keep direct 1:1 observation. Place in a "Safe Room." Notify physician of risk level. Notify psychiatric assessor. Document observations every 15 minutes. Reassess for risk every 4 hours and when changes in
behavior are noted."

Review of the hospital's policy titled, "Notification of Patient Rights and Responsibilities - Notice of Nondiscrimination" last revised 07/18/23 (noting "Minor grammatical updates) revealed, it does not include language to ensure patients receive care in a safe setting.

Review of the facility's policy titled, "Incident and Event Reporting" last reviewed 04/18/23 (noting no revisions had been made) revealed, " ...Sentara Healthcare shall maintain an electronic incident/event reporting system (ERS) for the collection of patient safety data, and other information surrounding events described below that are unrelated to the ordinary course of the patient's hospitalization. This system will provide reports to patient safety organizations, groups, quality management and peer review committees as defined in Va. code section 8.01-581 .17, and Fed 2008 Nov. 21;73(226):70732-814 in an effort to improve patient safety and health care outcomes, and additionally to assist in anticipation of litigation resulting from the events reported. ... Document Management - The contact listed shall be responsible for developing, communicating, and maintaining this policy and related procedures and job aids necessary for the implementation-n and continuance of the policy. This policy shall be reviewed at least every 3 years for repeal or amendment as appropriate. ..."

Review of P7's ED medical record revealed P7 presented to the ED with police escort on 12/01/22 at 3:42 PM, under an "Involuntary Commitment (IVC)" for "bizarre behavior" to receive a psychiatric screening and evaluation. Review of the IVC revealed the patient was "walking around with a scythe stating [he/she] was going to chop everyone's head off." The medical record indicated "P7 denies SI (suicidal ideations) and HI (homicidal ideations)."

Review of P7's ED medical record from 12/01/22 to elopement on 12/03/22 revealed P7 was assessed to have a CTRS score of "7" (High Risk) from 12/01/22 at 10:00 PM until 12/03/22 at 7:00 AM when P7's CTRS score was assessed as "6"(High Risk). Reassessments of P7's CTRS score was conducted every four hours while P7 was in the ED.

Review of the "ED Notes" dated 12:01/22 at 10:15 PM, documented by nursing staff revealed, Visual Checks: every 15 min (High Risk) 1:1 observation by: Safety Partner." There was no alteration or changes to P7's plan and a "Safety Partner" was assigned to P7 to provide one to one monitoring and to document "Precautions, Interventions, Patient Behaviors, and Patient Activity" every 15 minutes.

Review of the "Visual Checks Flowsheet" dated 12/01/22 through 12/3/22 based on the every 15-minute behavior and activity documentation by the Patient Safety Partner revealed four columns: Precautions (#1-#9), Interventions (#10-#16), Patient Behavior (#17-#27), and Patient Activity (#17-#31). Under the section for "Interventions" #14 was 1:1. The following was documented:

On 12/01/22 from 3:45 PM to 12/02/22 at 6:45 AM staff documented every 15 minutes that P7 under Precautions #4 indicated "close watch." Under Interventions #10 indicated "observation," Under Behaviors varied from #24 (calm), Under Patient Activity was #18 (restless), #20 (throwing objects), #22 (verbal threats) and #27 and (other-handwritten in was "Disorganized/Illogical Speech Grandiosity."

Review of the medical record from 12/01/22 at 3:45 PM to 12/02/22 at 6:45 AM did not reveal documentation the Patient Safety Partner provided one to one observation of P7.

On 12/02/22 from 7:00 AM to 12/03/22 at 6:30 AM, staff documented every 15 minutes that P7 was #4 indicated "close watch" and #10 indicated "observation." Behaviors from 12/2/22 at 5:45 AM were documented as #24 (calm), on 12/03/22 at 6:00 AM P7s behavior was documented as #17 (agitated) until 6:30 AM. From 12/02/22 at 7:00 AM to 12/03/22 at 6:30 AM the Patient Safety Partner did not document that P7 was being observed one to one and missed the 15-minute check at 6:45 AM on 12/03/22.

On 12/03/22 from 7:00 AM until the time P7 eloped from the hospital at 9:58 AM, staff documented every 15 minutes that P7 was #4 indicated "close watch" and #10 indicated "observation." Behavior from 7:00 AM until elopement was documented as #24 (calm) from 9:15 AM until elopement also #23 (escalating behavior). Activity from 7:00 AM until time of elopement varied from #18 (in bathroom), #25 (cross off "day room" wrote in "loitering") #31 (Pacing), #21 (Quiet-Awake), #23 (watching TV), #22 (in Room), and to #29 (RN visit). Although ED staff indicated they were observing, P7 eloped through an emergency exit door out of the ED.

Review of P7's "Visual Checks Flowsheet" did not reveal the Patient Safety Partner assigned to P7 was providing one to one monitoring.

Review of the ED "Psychiatric Evaluation" screening conducted by the ED provider dated 12/02/22 at 7:18 AM revealed, "43-year-old [gender] presents with IVC Per the IVC paperwork patient has a history of drug use and was walking on the street yesterday holding a sickled will sing with quintuple pupils had because God told him/her to and that he/she was Jesus. Patient is denying the story and says he/she was chopping some bushes. He/she will not answer the question of whether he/she is Jesus, but he/she does speak with religious overtones. He/she denies any homicidal ideation or suicide ideation. No suicidal history reported. Denies any current drug use or alcohol abuse. [He/she] denies any known psychiatric disorders." There were no documented concerns about elopement. However, the medical record confirmed there was "No past medical history on file. No past surgical history on file. No family history on file." The "ED Plan for P7 was to medically clear patient and "Continue to monitor for safety. Awaiting Placement [at a psychiatric facility]."

During an observation on the psychiatric section of the Emergency Department (ED) on 10/31/24 at 1:48 PM of the seven rooms and a triage area psychiatric bay, revealed there was an Emergency Exit door #300-106 with large red sign "Emergency Exit Only Alarm Will Sound."

During an interview on 10/31/24 at 1:48 PM with Senior Director of Facilities (SDF) and the Director of ED (DOED) also present, the SDF stated the hospital could not validate that the alarm on the door in 2022 was working with this incident occurred on 12/03/22. SDF stated there was no preventative maintenance (PM) log or alarm testing available for the time frame.

During an interview on 10/31/24 at 12:41 PM, the Registered Nurse (RN) on duty (ED-RN4) at the time of P7's elopement stated staff were aware of the elopement, but the hospital had a "hands off" protocol when patients run or elope. Their protocol was to call the police department, which "we did," and I ran after P7, but he/she was really fast and ran into the wooded area near the river and I lost sight of P7, so I return to the ED to ensure police were notified. When asked if ED-RN4 stated "We do have the County Ambulance Service on an adjacent property and P7 found an ambulance and fled via ambulance." ED-RN4 confirmed he/she did complete an incident report on 12/03/24 after returning to the ED.

On 10/31/24 at 1:00 PM, the Patient Safety Partner (SP) assigned to P7 on 13/03/22 from 9:15 AM until P7 eloped at 9:58 AM, stated he/she was in the corridor when P7 eloped from the hospital.

On 10/31/24 at 2:51 PM, a telephone interview with Chief of Pasquotank Emergency Medical Services (EMS) confirmed he was not on duty 12/3/22 but did receive the notification as soon as staff realized the Ambulance had been taken. The Chief of Pasquotank EMS stated his staff were preparing the ambulance for a local race "motocross stand-by" and had the ambulance running and were in the building getting the last of the supplies "5 minutes from leaving for the event" and when they went back out the ambulance was gone, and I was called and also the police. P7 was on the ambulance radio rambling. The Chief of Pasquotank EMS stated that all their ambulances have a CAD-GPS (computerized aided design-global positioning system) tracking device, so we were monitoring P7 location during this event. P7 pulled off into a desolate area in the State of Virgina, where P7 was apprehended and taken into police custody and was threatening that we were going to go to DC and run the ambulance into the White House.

A review of the requested Incident Report entered by ED-RN4 for P7's elopement on 12/03/22 at 12:05 PM revealed an SBAR (Situation, Background, Assessment, and Recommendations) assessment was completed. The following was documented on the elopement incident, " ... Situation: Patient (7) ran out of the hospital and took an ambulance. Background: ED patient (7) ran out of the emergency exit into the parking lot. Nurse followed but lost him/her. Police arrived finding patient (7) had taken an ambulance and left [hospital] property. Assessment: Concerns about patient (7) access to emergency exit. Also access to an emergency vehicle.
Recommendations: Security follow-up. Address safety and accessibility concerns."

During an interview on 10/31/24 at 2:17 PM, the DOED confirmed that the hospital's investigation for the elopement of P7 and the theft of an EMS vehicle did not include staff interview, a review of P7s medical records, and evaluation of the current policies and procedures related to the Psychiatric ED unit, verification of whether the emergency door alarmed or not, or the outcome of the investigation, and plan to prevent IVC elopement. The DOED stated the facility did not have a comprehensive investigation for incident in 2022. DOED confirmed the hospital did not have evidence of a root cause analysis or deep dive into the incident where P7 eloped while on a 1:1 and stole an EMS vehicle and drove into another State. DOED (also present) SDF stated as a result of the elopement and vehicle theft on 12/03/22 the hospital did implement environmental safety rounding to find areas within the hospital that could be made safer, and the ED nursing desk was relocated so there would be no blind spots. However, DOED confirmed the areas they provided for improvement were not included in the incident report as outcomes related to their findings.

Review of the facility's "Patient Rights" brochure provided to patients titled, "Let's Talk about Patient Rights and Responsibilities," dated 09/23 revealed, " ...Express concerns about your care or safety and get a prompt response."

During an interview on 10/31/24 at 2:17 PM, DOED and the Accreditation & Regulatory/Quality (AR/Q) confirmed the hospital did not have a complete investigation on the 12/03/22 related to P7's elopement and theft of the adjacent County EMS ambulance. After conducting an ED query AR/Q confirmed that in 2023 the ED had 497 patients elope and from January 1, 2024, until October 31, 2024, there have been 448 patients that eloped from the hospital.