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Based on record review and interview the facility failed to provide appropriate medical screening examination for a patient in the ER with behavioral proplems. A psychiatric evaluation was not conducted per facility policy to ensure the appropriate treatment was provided. This failed practice resulted in the patient returning to the ER less than 24 hours after discharge with psychotic behavior. Citing 1 of 1 patient named in a complaint. Patient # 2

Findings:

Patient #2

Review of complaint narrative revealed allegations that on 12/6/2013 in the early morning a medicated psychiatric patient was not being observed during a code blue, he wandered out of the ER and was hit and killed by a train. There was information the patient was handcuffed to his hospital bed prior to eloping from the hospital.

Investigation on 12/30/2013 -1/2/2014 revealed the following information:

Review of emergency room (ER) demographic record dated 12/4/2013 revealed Patient (# 2), 38 years old, arrived via ambulance to the emergency room at 22:01 with history of altered level of consciousness, he was found on the ground unresponsive. On arrival to the ER he was awake and shouting. His clothing was wet and dirty, he was barefoot and homeless. Patient # 2 had history of drug abuse. His breathing was unlabored.

The patient's acuity was classified as acuity 2, defined in the facility's policy as (urgent), high risk situation or confused/lethargic/disoriented or severe pain/distress, critical, requiring immediate lifesaving intervention.

Vitals signs recorded as BP 187/92, pulse 90, respirations 20, and temperature 98.3.

There was documentation that the patient was given Narcan 2mg IV push via a saline lock.

Review of physicians orders revealed no order for this medication.

Medical screen examination conducted by the nurse practitioner on 12/4/2013 at 22:01 in ER Room 2 revealed the patient had decreased mental status, confusion. He was aggressive, combative and disoriented.

The patient tested positive for PCP. Clinical impression: Drug Abuse, positive for PCP. There was a Physician's orders dated 12/4/2013 for Ativan 1 mg IM and, Haldol 5mg IM.

Review of medication administration record dated 12/4/2013 -12/5/2013 revealed in addition to the Haldol and Ativan Patient # 2 was given Geodon 20mg IM at 22:40, and Benadryl 50mg IM at 22:45.

(12/5/2013: Geodon 20 mg administered IM at 15:45, Benadryl 50mg IM at 15:46, Lorazepam 2mg IM at 15:47, Haloperidol 5 mg IM at 15:48. Lorazepam 2mg IM at 1800, Benadryl 50 mg IM at 1810, Ativan 2 mg IM at 21:50, Haldol 5 mg IM at 21:500).

Review of nurses' notes dated 12/4/2013 at 22:10 revealed documentation that a Foley catheter was inserted. There was documentation that the patient was screaming, that staff was trying to murder him by cutting off his penis. Review of nurses notes dated 12/4/2013 at 22: 46 documented the patient pulled the Foley out and was bleeding from his penis. Review of physician's orders revealed no orders or indication for a Foley catheter.

There was documentation that the patient was on combative restraints, 1:1 observation, Psych care for more than 4 hours.

Review of restraint order sheet dated 12/5/2013 at 00:00 revealed orders for bilateral soft wrist and ankle restraints due to violent and destructive behavior. The patient's behavior was documented every fifteen minutes for four (4) observations at 00:30, 00:45 and 01:00 and 01:15. There was documentation the patient's behavior was threatening to self and others.

Review of nurses' notes dated 12/5/2013 at 06:40 revealed notation "patient woken up oriented to time and place. For discharge, security at doorway." There was an aftercare instruction form with documentation the patient would not sign.

Review of physician's notes for patient #2 dated 12/4/2013 revealed the patient was placed in 4 point restraints. The patient was given medication to control his behavior. There was no documentation Patient # 2 had a psychiatric evaluation conducted by a physician to determine if he required inpatient psychiatric care.

Review of demographic information revealed the patient was discharged on 12/5/2013 at 07:00 am. There was no documentation the patient had a nursing assessment prior to discharge from the ER. His last assessment was at 03:15 on 12/5/2013.

Review of emergency room record for Patient # 2 dated 12/5/2013 revealed that in less than twelve (12) hours after his discharge from the ER, he was brought back to again to the ER and was diagnosed with psychosis.

Review of the emergency physician record dated 12/5/2013 at 15:29 showed that the patient had past history of psychotic behavior. The physician's clinical impression of the patient was documented as psychosis with substance abuse.The psychiatrist was consulted.

Review of the psychiatric screen evaluation dated 12/5/2013 at 4:00 pm documented clinical impression diagnosis as: Schizoaffective, Borderline Intellect, and positive for substance abuse.

His cognition was documented as Borderline intellect, impared insight and judgement. The patient was having auditory and visual hallucination active arguing with himself, he was not suicidal.

The recommendation from the Psych evaluation was that the patient be transferred to an inpatient psychiatric facility for further evaluation. An available bed was secured in a state psychiatric hospital.

Further review of the nurses notes revealed the patient was secluded in the room by the presence of Hospital Security Officer posted at the patient's door.

Review of the facility's video surveillance for room 5 where the patient was located revealed the patient was also in handcuff restraint from 3:30 pm on 12/5/2013 until 03:37 am on 12/6/2013.

Review of the surveillance video revealed at 04:44 am on 12/6/2013 Patient (# 2) got out of bed, he was seen stumbling around in the room , unsteady on his feet, he appeared disoriented. There was no audio to tell if the patient was saying anything. He wandered to the door of his room and was brought back by a security officer.

Further review of video surviellance revealed on 12/6/2013 at 05:12 Patient (# 2) was seen going through the opened back doors of the hospital.

There was no evidence on the video surveillance that Patient( # 2) was contineously monitored by a qualified medical personnel while he was in restraint and seclusion. There was no staff seen on the surveillance doing 1:1 observation in the patient's room.

There was one (1) documentation on the nurses notes on 12/5/2013 at 23:30 that the patient was seen on the video surveillance at the nurses station. The last documentation on the patient was at 03:58 when the patient was medicated with psych drugs for attempting to leave the room. There was documentation that hospital security was at the patient's bedside.(not a trained medical personnel).

Review of ER Physician record for Patient # 2 dated 12/6/2013 revealed information the patient was seen in the ER at 05:30 am with injury to his trunk. There was documentation that "psych patient escaped from ER and got hit by a train".Trauma activation level 1 was called. There was documentation the patient was taken to the OR at 07:03 the patient was pronounced dead at 07:24.

Review of the facility's Behavioral Emergency Policy/procedure dated September 2012 gave the following information:

"To provide appropriate treatment and safety for patients experiencing behavioral emergencies, while ensuring a safe envirioment for patients, public and employees.
Patients experiencing behavioral emergencies will be placed in a treatment room that has been cleared of all unsafe objects and will be observed at all times". The policy documented that this is the responsibility of the nursing Staff.

Psych Response Team should be notified as soon as appropriate,
Emergency Center Physician is responsible to evaluate and treat the patient in conjunction with the Psych Response Team.

If the patient is a danger to self or others the physician may have to order chemical or physical restraints to maintain a safe environment. "

Review of the facility's policy/procedure on patient assessment in the ER dated 2/2012 gave the following information:

Reassessment of vital signs in a treatment room should occur as following:
Emergent Patients/Level One and Level Two: Every one hour or more frequently as needed, based on patient ' s condition. Every one hour or more frequently as needed, based on patient ' s condition.

Non-Urgent Patients/Level Three to Five: Every four hours or more frequently as needed, based on patient ' s condition.

Patients who are experiencing a life-threatening or emergent condition should be assessed a minimum of every fifteen to thirty minutes, a set of vital signs should also be obtained during these times increments, until the conditions stabilizes. Patients who are not experiencing a life-threatening or emergent condition should be reassessed every four (4) hours

All patients will receive a set of vital signs 30 minutes prior to discharge and within thirty (30) minutes before any admission.

During an interview on 12/31/2013 at 1:35 pm at the facility with Staff ( #9) QA Director, he stated the patient should have been given a psychiatric evaluation on 12/4/2013 when he first came to the emergency room. Staff (#9) stated security Officers are not considered trained nursing personnel and should not be observing patients in restraints.

Based on record review and interview the facility failed to provide stabilizing treatment in a safe setting for a patient with psychiatric emergency condition in the ER while he awaited transfer.

This failed practice resulted in the patient wandering out of the hospital unobserved and was hit and killed by a train. Citing 1 of 1 patient named in a complaint.(#2).

Findings:

Review of complaint narrative revealed allegations that on 12/6/2013 in the early morning a medicated psychiatric patient was not being observed during a code blue, he wandered out of the ER and was hit and killed by a train.

Investigation on 12/30/2013 -1/2/2014 revealed the following information:

Review of emergency room (ER) demographic record dated 12/5/2013 revealed Patient (# 2), 38 years old, arrived via ambulance to the emergency room at 3:29 pm with history of bizzare/paranoid behavior.

The patient's acuity was classified as acuity1, defined in the facility's policy as critical, requiring immediate lifesaving intervention.

Review of emergency physician record dated 12/5/2013 at 1529 documented the patient had past history of psychotic behavior.The physicians clinical impression of the patient was documented as psychosis with substance abuse.The psychiatrist was consulted.

Review of the psychiatric screen evaluation dated 12/5/2013 at 4:00 pm documented clinical impression diagnosis as: Schizoaffective, borderline intellect, and positive for substance abuse.

His cognition was documented as borderline intellect, impared insight and judgement. The patient was having auditory and visual hallucination active arguing with himself, he was not suicidal.

The reccommendation from the psychiatric evaluation was that the patient be transferred to an inpatient psychiatric facility for further evaluation. An available bed was secured in a state psychiatric hospital. There was documentation the patient was unable to sign patient rights form because due to restraints. There was documentation the patient was cleared for transfer at 1640.

Review of ER nurses notes dated 12/5/2013 through 12/6/2013 revealed documentation Patient ( #2) was treated with chemical restraint of Geondon, Benadryl and Lorazepam intramuscular(IM) on 12/5/2013 at 3:48 pm, Lorazapam and Benadryl IM on 12/5/2013 at 6:10 pm and Ativan and Haldol IM at 9:50 pm.

On 12/6/2013 Geodon and haldol IM was administered at 01:00 and Lorazepam IM was administered at 03:58 am. There was no standing order for the medication and was administered for behavioral problems.

Further review of the nurses notes revealed the patient was secluded in the room by the presence of Hospital Security Officer posted at the patient's door.

Review of the facility's video surveillance for room 5 where the patient was located revealed the patient was also in handcuff restraint from 3:30 pm on 12/5/2013 until 03:37 am on 12/6/2013.

Review of the surveillance video revealed at 04:44 am on 12/6/2013, Patient (# 2) got out of bed, he was seen stumbling around in the room , unsteady on his feet, he appeared disoriented. There was no audio to tell if the patient was saying anything. He wandered to the door of his room and was brought back by a security officer.

Further review of video surviellance revealed on 12/6/2013, at 05:12, Patient (# 2) was seen going through the opened back doors of the hospital.

There was no evidence on the video surveillance that Patient( # 2) was continuously monitored by a qualified medical personnel while he was in restraint and seclusion. There was no staff seen on the surveillance doing 1:1 observation in the patient's room.

There was one (1) documentation on the nurses notes on 12/5/2013, at 23:30, that the patient was seen on the video surveillance at the nurses station. The last documentation on the patient was at 03:58 when the patient was medicated for attempting to leave the room. There was documentation that the hospital security officer was at the patient's bedside.(not a trained medical personnel).

Review of ER Physician record for Patient # 2 dated 12/6/2013, revealed information that the patient was seen in the ER at 05:30 am with injury to his trunk. There was documentation that "psych patient escaped from ER and got hit by a train." Trauma activation level 1 was called. There was documentation that the patient was taken to the operating room at 07:03 the patient was pronounced dead at 07:24.

Review of the facility's Behavioral Emergency Policy/procedure dated September 2012 gave the following information:

"To provide appropriate treatment and safety for patients experiencing behavioral emergencies, while ensuring a safe envirioment for patients, public and employees.
Patients experiencing behavioral emergencies will be placed in a treatment room that has been cleared of all unsafe objects and will be observed at all times." The policy documented that this is the responsibility of the nursing Staff.

"To provide appropriate treatment and safety for patients experiencing behavioral emergencies, while ensuring a safe envirioment for patients, public and employees.
Patients experiencing behavioral emergencies will be placed in a treatment room that has been cleared of all unsafe objects and will be observed at all times." The policy documented that this is the responsibility of the nursing Staff.

Psychiatric Response Team should be notified as soon as appropriate, Emergency Center Physician is responsible to evaluate and treat the patient in conjunction with the Psychiatric Response Team. If the patient is a danger to self or others the physician may have to order chemical or physical restraints to maintain a safe environment.

Review of the facility's restraint Policy/procedure dated February 2012 gave the following information:

"The patient who is simultaneously restrained and secluded must be continually (ongoing without interruption) monitored by trained staff either in person or through the use of BOTH video and audio equipment".

Observation on 12/30/2013, at 11:45 am, in the Emergency Room revealed there were 16 patient rooms and one nurses' station. Room 5, where Patient (#2) was admitted on 12/5/2013, is located at the end of the 16 room ER unit. The room is not in view of the Nurses station and is about ten (10) regular steps away from a back door that opens automatically to the outside of the facility when the door is approached. Once the door closes it cannot be opened from the outside, reentry is not allowed.

Patients placed in ER room 5 with emergency condition require constant monitoring to ensure patient safety. There was no treatment plan for the patient as a result safe treatment was not implemented.

During an interview on 12/30/2013, at 2:40 pm, at the facility with Staff (12) Security Officer he gave the following information:

he came on duty at 11:00 pm on the night Patient (#2) absconded and took over watching him from another Officer. Staff (12) stated his responsibility was to watch the patient from 11:00 PM until 07:00 am the next morning to ensure he did not leave the room. According to the Officer he was told that the patient was not cooperative and was a flight risk. The patient's both hands were handcuffed to the bed rails.

Staff (12) stated the patient was sleeping on and off for short periods. At around 03:00 am on 12/6/2013, the ER Nurse Supervisor told him to remove the cuffs from the patient who was hand cuffed to both bed side rails . He told the nurse the patient would walk if the cuffs were removed because he only slept for short periods.

Staff (12) stated at 5:00 am he had to open the hospital doors so he told the nurse to watch the patient. While he was off the ER there was an overhead code blue paged so he returned to the ER and found the patient was not in his room.

The Officer stated he went outside the back door but it was cold and dark and he did not see the patient. He concentrated his search inside because he did not think the patient would be out in the cold. Shortly after his search began a man came into the ER stating he was a train conductor and had just struck a man on the train lines. Staff (12) stated he went out with the conductor to look for the individual. It was Patient(#2), he was alive and was trying to get up, shortly after that the ambulance came and the patient was transported to the hospital emergency room and died shortly after.

During an interview on 12/30/2013, at 12:00 pm, at the facility with Staff (5) he stated he was the Manager of Security the main duties of the security officers is to provide security for patients, visitors and staff by ensuring they are safe from harm. He stated the officers make rounds to help deter crime. He stated in addition to those duties the officers provide 1:1 monitoring for the psych patients to ensure they do not harm themselves or others. According to Staff (5) the officers are trained in non violent Crisis Intervention but not trained in patient's rights or in the care of psychiatric patients. He stated 1:1 moniotering was not in their job description but it was a task they were assigned at least 20 times per month for Psych patients.

During a telephone interview on 12/31/2013, at 11: 25, am with Staff (#13) Security Officer, he stated he was assigned the care of Patient # 2 on the afternoon of 12/5/2013. According to the Officer after the police officer left and took the handcuffs the Security Chief at the hospital decided that because the patient was combative he would put hand cuff on the patient. Staff (#13) stated the patient was in handcuffs for all of his shift and he never released the cuffs on the patient. He handed over the patient to the oncoming officer with cuffs on. He stated the officers rarely use handcuffs but it is the Chief's decision whether or not to use them on the patient. Staff # 13 stated Nursing staff in the ER were aware the patient had handcuffs on. Staff (#13) stated he was not trained to provide restraint care or patient's rights protocol.

During an interview on 1/2/2013, at 8:35 am, with Staff (#11) RN Educator at the facility, she stated she gives training to staff on restraints use and patient rights during orientation for nurses and annually for other health care providers. According to Staff (#11) the security officers were not included in the staff for training. With regards to the use of handcuffs on patients or patients in seclusion she stated these areas were not covered in the teaching because it is not the hospital's policy to use restraint or seclusion. She further stated documentation and patient assessment while in restraints is extensively covered in the training.

During interview on 12/31/2013, at 11:45 am with Staff (# 1) RN, she stated she was assigned the care of Patient # 2 from admission until her shift ended at 11:00 pm. She stated she did not document the assessments that were done on the patient but she did observe the patient. Staff (# 16) stated she did ask for orders from the Nurse Practitioner but did not write the orders on the patient's medical record. She stated she did not know the patient should not be handcuffed.

During an interview on 12/31/2013, at 1:35 pm at the facility with Staff ( #9) QA Director, he stated the patient should have been given a psychiatric evaluation on 12/4/2013 when he first came to the emergency room. Staff (#9) stated security Officers are not considered trained nursing personnel and should not be observing patients in restraints.