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Based on interview, patient record review and a review of the Emergency Department log, hospital document "EMTALA - CW CR 500", registration documentation, "Nursing Disposition" documentation, hospital Emergency Department video, "Patient Triage, Assessment, Monitoring and Disposition" policy, "Safety Violence Risk Assessment (SVRA) Standard" policy, the facility failed to ensure that an individual who came to the emergency department was provided a medical screening examination to determine if an emergency medical condition existed for 1 of 22 sampled patients (#1). Refer to findings in Tag A-2406.

Based on interviews, patient record reviews and ae Emergency Department log, and Emergency registration document review, Medical Staff bylaws, and Rules and Regulations review, Police Department Incident/Investigation Report review, Educational training documents, and Policy and Procedure reviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided within the capability of the hospital's emergency department including ancillary services routinely available to determine whether or not an emergency medical condition exists for 1 (Patient #1) of 22 patients who presented to the emergency department complaining of suicidal ideations.

Findings:

1. Emergency Department (ED) Registration Document

A review of ED registration documentation for patient #1 of 12/22/19 at 1:55 PM entered by the Patient Access Representative revealed that following: "Visit reason: Thoughts of hurting self."

2. ED Log

A review of the Emergency Department (ED) log for 12/22/19 revealed that patient #1 presented in the ED on 12/22/19 at 1:55 PM and departed at 2:06 PM. The ED log read, "Left before triage."

3. Medical Record patient #1

A review of the medical record, titled "Nursing Disposition Entered On" of 12/22/19 at 2:05 PM, was reviewed. The section of the note labeled "Nurse Disposition" revealed in part, "Verbalizes Understanding of Info (information) given: Other: LWBS (left without being seen). Discharge Disposition: "Left before triage (LBT)."

4. Video Review

A review of video of patient #1's time in the ED was performed on 1/13/20 at 1:15 PM. A view from a camera which was positioned above and behind the Patient Access Representative, facing out towards the ED lobby on 12/22/19, revealed the following. Patient #1 was seen entering from screen left (not the ED walk-in door, seen to the right) at the time stamp of 1:54:56 PM. He went directly to the desk where the Patient Access Representative was seated at the timestamp of 1:54:59 PM. She had a computer screen on her desk. The patient was then seen interacting with the Patient Access Representative, almost immediately. He was then seen handing her some cards at the time stamp of 1:55:26 PM and more cards at the time stamp of 1:55:39 PM. During this time period, the Patient Access Representative remained seated and gave the appearance of performing some tasks. At the time stamp of 1:55:59 PM, the patient was seen reaching into the work area of the Patient Access Representative and grabbing back his cards off the desk. At the time stamp of 1:56:20 PM, he was observed beginning to leave the desk area, and at the time stamp of 1:56:28 PM, he was observed exiting the door of the ED, on screen right. Thus, the patient interacted with the Patient Access Representative from approximately 1:54:59 PM through approximately 1:55:59 PM, when he took back his cards. This was for one minute.

As to a view of the triage nurse calling into the area of the Patient Access Representative, on 1/14/20 at 4:10 PM, the Regional Director of Security Operations stated this was observed through a separate camera in the lobby. He stated that the calling by the triage nurse took place at the time stamp of 1:59:38. This was observed on the video on 4:10 PM on 1/14/20.

Further review of video on 1/13/20 at 1:15 PM involved video from a camera positioned outside of the hospital building which showed patient #1 going into a construction portable toilet at the time stamp of 1:58:11 PM on 12/22/19. This was just under two minutes after he was seen leaving the ED. Further review of video on 1/14/20 at 4:10 PM revealed that he left the portable toilet at the time stamp of 2:35 PM on 12/22/19 and returned at the time stamp of 5:57 PM on 12/22/19, not to leave again. Although the 5:57 PM view was not as clear, there were no further views of anyone leaving or entering the portable toilet until the arrival of the police. On 1/14/20 at 4:10 PM, the Regional Director of Security Operations stated that the last(and only entrant to the portable toilet at 5:57 PM on 12/22/19 did not exit it up until the time that the police approached the portable toilet at 7:56 PM on 12/22/19. He confirmed that the presence a deceased person, later identified as patient #1, was reported to facility staff at approximately 9:30 PM on 12/22/19 by the police as having been found in the portable toilet.

5. Police Department Incident/Investigation Report

The Police Department Incident/Investigation report dated 12/22/2019 at 1733 hours was reviewed. The section of the report titled "Reporting officer Narrative revealed in part, I was notified that Patient #1 went to Advent Health Kissimmee ...earlier today. Officer responded to Advent Health and were advised that Patient #1 arrived at the location around 1355 hours stated he was having suicidal thoughts, and was checking in. Shortly after 1356 hours patient #1 left the location as he was in process of registration. _______County Sheriff Officer K-9 units were contacted to conduct a K-9 tract, in an attempt to find patient #1. At around 2000 hours prior to K-9 arriving, Sargent (name) cancelled K-9 and requested Criminal Investigation Division (CID) to be called out. Patient #1 had been found deceased on the west side of the property belonging to Advent Health Kissimmee ...The Medical Director was requested and arrived on the scene."

5. Interviews

During interviews on 1/12/20 at 12:35 P.M., and at 12:40 P.M. the Risk Manager was asked a question by the surveyor. A question was asked by the surveyor was any security department or police notified by the ED staff once the ED staff knew Patient #1 had voiced thoughts of self-harm, then subsequently voiced an intent to leave, and finally left. At 12:40 P.M. the Risk Manager the Risk Manager stated that Patient Access Representative Personnel are not part of the ED and are not clinical personnel.

On 1/12/20 at 3:05 PM, the Risk Manager presented the policy "Workplace Violence Prevention", which she said applied to all employees. Educational materials associated with this policy, titled "Safety Violence Risk Assessment (SVRA) Standard" read, "Ask patient/guardian, 'Do you have anything that could be used to hurt yourself or others?... Ensure ANM (Assistant Nurse Manager)/CN (Charge Nurse) is briefed on observed behaviors of concern...." The review of the Safety Violence Risk Assessment revealed that ED staff to include all hospital employees would be obligated, through training, to report threats of self-harm to nursing manager or charge nurse. The facility produced evidence of training to staff in May of 2019 which stated that Patient Access staff were to "Call ANM (Assistant Nurse Manager) if patient in lobby states will be leaving.... not triage." The Educational training document provided revealed that the ED staff was educated on what to do in an incident such as what took place with patient #1 on 12/22/2019. This training did not exclude patients with suicidal ideations. There was no documented evidence that the Patient Access Representative took any steps to inform the triage nurse or other ED clinical staff of the presence of patient #1 presenting to the ED with suicidal thoughts on 12/22/2019.

On 1/13/20 at 3:07 PM, the Chief Nursing Officer stated that when a Patient Access Representative posts on the computer the patient's arrival time and chief complaint, it immediately shows up on the computer in the triage area and on any other device in the ED which is logged into the hospital's computer system "First Net".

On 1/13/20 at 3:12 PM, the Patient Access Representative (PAR) stated that when patient #1 came to her desk, he first stated that he wanted counseling. He then stated that he had thoughts of hurting himself. She stated that she further questioned the patient and he stated that he wanted to kill himself. She stated that she then obtained identification cards from the patient and processed them. After she was done, the patient stated to her: "I don't think this is a good idea.... I don't want to be seen anymore." She stated that she tried to engage him in conversation to urge him to stay and told him that he was next in line. She stated that he still refused to continue in the ED and then left. When the Patient Access Representative was asked what the facility's expectation was for any steps to take with the departure of pre-triage patients who voiced suicidal ideation prior to the presentation of patient #1 on 12/22/19, she stated that Patient Access Representatives were not required to notify anyone. She also stated that she did not initiate any telephone call, verbal request or other distinct form of communication to the triage nurse or other ED staff before or after the patient left the ED. She stated that when the triage nurse eventually called for patient #1, she was already involved with another patient. She stated that in response to an inquiry by him at this time regarding patient #1's whereabouts, she motioned to him in a manner which indicated that the patient had left. She stated that shortly after the patient left, she spoke to the Assistant Manager of Patient Access in person, while remaining at her station. She stated that she told him of the encounter with patient #1 and his final decision to not pursue treatment. She stated that the Assistant Manager told her that she did nothing wrong and did not violate any policy. She stated that he did not ask if she told the triage nurse or other ED staff about what had happened concerning patient #1. She stated that prior to this incident, she had not received any training on how to handle situations where a person with suicidal ideation voices or attempts a desire to leave while in the pre-triage stage of admission to the ED.

On 1/13/20 at 3:38 PM, the triage RN stated that on 12/22/19, before he became aware of patient #1, he had just finished with another patient. He refreshed his computer screen and immediately saw patient #1 and his chief complaint posted on it. At that point he looked into the lobby and called for the patient (Patient #1); he stated that there was no response. He stated that since there was no response, he went to the door of his room and called to the Patient Access Representative to inquire of patient #1's whereabouts. She (Patient Access Representative) indicated in response to him that patient #1 had just left. He stated that in response to this news he left the patient tracker (computer screen) on for a while, in case the patient returned. He stated that he did not return promptly and, as a result, he signed him (Patient #1) out at 2:06 PM. He stated that after step this he took no further action concerning patient #1.

During an interview with the Assistant Manager-Patient Access on 1/14/2020 at 12:13 P.M, he stated that he recalled interacting with the Patient Access Representative (PAR) about patient #1 on 12/22/2019. He also stated the PAR asked whether or not the patient (#1) should still be registered on the computer since he had left and he and he replied "yes." He stated that he did not recall whether or not there was any discussion regarding the circumstances of the patient's arrival or departure, He continued to state that could not recall if self-harm ideations were included in training for the position prior to the incident date on 12/22/2019, but he stated that such training is now including.

An interview was performed on 1/14/2020 at approxiamtely 6 PM with the ED physician (One of the ED physicians on duty in the ED of 12/22/2019). The ED physician stated that if a patient with suicidal ideations who expressed a desire to leave he would expect that nursing addresses it immediately, and urge the patient to stay. Such a patient would be at relatively high risk for harm if his concerns are not properly addressed. He stated that he became aware of the event with Patient #1 late in the evening of 12/22/2019, and that the patient had initially come to the ED and left. He stated that he is confident that is now fully aware of what to do should a similar occurrence take place again.

An interview was conducted with the Regional Director of Security Operations on 1/14/2020 at 4:10 P.M. He confirmed that the presence of a deceased person (Later identified as Patient #1) had been reported to them at 9:30 P.M. on 1/22/2019 by the police as having been found in Portable toilet.

On 1/15/20 at 10:50 AM, the Risk Manager stated the registration process involves asking the reason for coming to the ED: chief complaint, presenting condition, etc., obtaining two forms of identification, and placing this information into the computer.


Medical Staff Bylaws, Rules and Regulations and Policies

The Adventhealth Orlando Medical Staff Bylaws, Rules and Regulations and policies, Approved September 30, 2011 was reviewed. The section Article 2, Patient Management in the Emergency Department specified in part, "2.3 Medical Screening Examination every patient who comes to the Emergency Department requesting examination and treatment must be provided with a medical screening examination. 2.3.1 The Medical Screening Examination must be performed by the ED physician or other qualified practitioner." The facility failed to ensure that their Medical Staff Bylaws, Rules and Regulations, and Policies were followed as evidenced by failing to ensure that on 12/22/2019, patient #1, who came to the hospital's ED, received an appropriate medical screening examination by a physician or qualified practitioner.


Policies and Procedures

The facility's policy titled "Company- wide "EMTALA" CWCR 500", origination date 6/22/1999, Last approved 7/24/2019 was reviewed. The policy revealed in part, "Emergency Stabilization: when a patient arrives to the Emergency Department (including situations where the patient is on the property ....)...and a request is made on the patient's behalf for examination or treatment of a medical condition, the hospital must provide for an appropriate medical screening examination to determine if an emergency medical exists.

A review of triage policy "Patient Triage, Assessment, Monitoring and Disposition" read, "Triage assessment is based on the Emergency Severity Index (ESI), a tool to determine initial acuity; ED nurses use the ESI algorithm to categorize patients according to the following....Level 2 - High-risk situations which may include, but are not limited to....suicidal, have homicidal ideations...." Patient #1's presenting complaint of Suicidal thoughts on 12/22/2019, would have met the qualification of a Level 2 patient unless eventually proven otherwise with an assessment, due to the fact that he expressed "thought of hurting self".

The facility's "Work Place Violence Prevention" Policy # SOP (Standard Operating Procedure) #646.000, effective 10/16/2015, and review date4/25/2019 was reviewed. The Policy revealed in part, the purpose of the policy was establish guidelines and procedures to mitigate, prevent or respond to a workplace violence situation. The policy further indicated the policy applied to all advent health employees. Further review of the policy revealed in part, Disruptive Conduct: Patient's and visitors on Advent health Premises are expected to conduct themselves in a manner that does not disrupt the hospital operations cause injury to themselves or others. Reporting, Restraining Orders and threat Management: A. Reporting threats or incidents of workplace violence. If any employee, contractor, vendor, or medical or threats of violence, whether vague, direct or indirect, the person shall notify one or more of the following: Security, their Supervisor or Human Resources. Advent Health maintains a corporate compliance hotline that can also be used as an alternate means to report non-emergent threats or incidents of workplace violence."

In Summary, on 12/22/2019 Patient #1 presented to the ED voicing complaints of "though of hurting self" to the Patient Access Representative. The facility failed to have an effective system in place to ensure that when patients presenting to the hospital's ED complaining of "thoughts of hurting self" (suicidal thoughts), suicidal ideations, or exhibiting signs and symptoms of behavioral disorders, all ED staff should be required to immediately contact/report it to a physician or qualified medical personnel to ensure that an appropriate medical screening examination is provided. This resulted in the facility's failure of the ED staff not contacting and/or not reporting to a Physician or Qualified Medical Personnel that an appropriate medical screening examination was needed immediately for patient #1 on 12/22/2019 (because of his presenting complaint), which was within the capability of the hospital's ED, to include ancillary services which were available to determine whether or not an emergency medical condition existed for patient #1.

Based on medical record reviews, Policy and Procedure review, ED Registration Department document review, Police Report and staff interviews the facility failed to ensure that an individual who did not consent to treatment was informed of the risks and benefits of the individual of the examination and treatment prior to leaving the ED for 1 (Patient #1) of 22 sampled patients who presented to the ED with complaints of hurting self. Additionally, the facility also failed to ensure the medical record contained a description of the examination, treatment, or both if applicable was refused by patient #1.


Findings were:

1. Emergency Department (ED) Registration Document

A review of ED registration documentation for patient #1 of 12/22/19 at 1:55 PM entered by the Patient Access Representative revealed that following: "Visit reason: Thoughts of hurting self."

2. ED Log

A review of the Emergency Department (ED) log for 12/22/19 revealed that patient #1 presented in the ED on 12/22/19 at 1:55 PM and departed at 2:06 PM. The ED log read, "Left before triage."

3. Medical Record patient #1

A review of the medical record, titled "Nursing Disposition Entered On" of 12/22/19 at 2:05 PM, was reviewed. The section of the note labeled "Nurse Disposition" revealed in part, "Verbalizes Understanding of Info (information) given: Other: LWBS (left without being seen). Discharge Disposition: "Left before triage (LBT)."


4. Policy and Procedure

The facility's policy titled, "Patient Left Without Seeing a Physician- Emergency Department", SOP (Standard Operating Procedure) #155.176, Effective Date 06/15/2013, Review date 03/26/2019 was reviewed. The policy stated in part, "Form Emergency Department: Left Without Seeing Doctor:
A. If "Patient chooses to withdraw his/her request for examination or treatment at the Advent Health Orlando Emergency (ED), and if if the ED Registered Nurse or Physician should take the following steps:

1. Encourage the patient to remain for any necessary stabilization treatment that the patient may require for an emergency medical condition.
2. Inform the patient of the benefits of such examinations and treatment, and the risks of withdrawal prior to receiving such examination and treatment.
3. Take all reasonable steps to secure patient's written Informed consent to refuse such examination and treatment using the form, "Emergency Department: Left Without Seeing Doctor."
4. Documents the disposition as 'Left Without Seeing Doctor" on the Nurse Disposition Form."
B. If the patient leaves without notifying hospital personnel, the medical record must contain at least the following:
1.) Documentation of the patient leaving the ED without notifying staff.
2.) Documentation of the time the ED staff discovered the patient was no linger in the ED
3.) All triage notes, and additional records, if any.
4.) Documentation of the disposition as "Left Without Seeing Doctor" on the nurse disposition Form."



5. Interviews


On 1/13/20 at 3:12 PM, the Patient Access Representative stated that when patient #1 came to her desk, he first stated that he wanted counseling. He then stated that he had thoughts of hurting himself. She stated that she further questioned the patient and he stated that he wanted to kill himself. She stated that she then obtained identification cards from the patient and processed them. After she was done, the patient stated to her: "I don't think this is a good idea.... I don't want to be seen anymore." She stated that she tried to engage him in conversation to urge him to stay and told him that he was next in line. She stated that he still refused to continue in the ED and then left. When the Patient Access Representative was asked what the facility's expectation was for any steps to take with the departure of pre-triage patients who voiced suicidal ideation prior to the presentation of patient #1 on 12/22/19, she stated that Patient Access Representatives were not required to notify anyone. She also stated that she did not initiate any telephone call, verbal request or other distinct form of communication to the triage nurse or other ED staff before or after the patient left the ED. She stated that when the triage nurse eventually called for patient #1, she was already involved with another patient. She stated that in response to an inquiry by him at this time regarding patient #1's whereabouts, she motioned to him in a manner which indicated that the patient had left. She stated that shortly after the patient left, she spoke to the Assistant Manager of Patient Access in person, while remaining at her station. She stated that she told him of the encounter with patient #1 and his final decision to not pursue treatment. She stated that the Assistant Manager told her that she did nothing wrong and did not violate any policy. She stated that he did not ask if she told the triage nurse or other ED staff about what had happened concerning patient #1. She stated that prior to this incident, she had not received any training on how to handle situations where a person with suicidal ideation voices or attempts a desire to leave while in the pre-triage stage of admission to the ED.


On 1/13/19 at 3:38 PM, the triage RN stated that on 12/22/19, before he became aware of patient #1, he had just finished with another patient. He refreshed his computer screen and immediately saw patient #1 and his chief complaint posted on it. At that point he looked into the lobby and called for the patient; he stated that there was no response. He stated that since there was no response, he went to the door of his room and called to the Patient Access Representative to inquire of patient #1's whereabouts. She (Patient Access Representative) indicated in response to him that patient #1 had just left.



The Patient Access Representative failed to notify any ED clinical staff that on 12/22/2019 that Patient #1 presented to the ED complaining of "Thoughts of hurting self. " Patient #1 was not stable and experiencing ineffective thinking and coping abilities, and required immediate attention by any ED clinical staff on 12/22/2019. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that Patient #1 was offered the risks and benefits of receiving further medical screening examination and treatment of the medical screening examination when the patient had voiced the intent to leave or actual departure.