HospitalInspections.org

Based on interviews, clinical record, administrative document, and video recording review, the hospital failed to protect patient rights when Patient 1 was wheeled out of the Emergency Department without being discharged or signing out Against Medical Advice (AMA) to a bus stop in front of the hospital at 51 minutes after midnight, which resulted in preventable events that may have contributed to Patient 1's death. (Refer to A 144)

The cumulative effect of this systemic problem resulted in the hospital's inability to protect patient rights.

Based on interviews, clinical record, administrative document and video recording review, the hospital failed to ensure 1 of 32 patients (Patient 1) was treated with respect and dignity in an emotionally safe environment when he was wheeled out to a bus stop at 12:51 a.m., prior to completion of his assessment, and without signing out Against Medical Advice (AMA) or being discharged.

This failure resulted in Patient 1 being left unattended near the hospital which resulted in preventable events that may have contributed to Patient 1's death.

Findings:

Patient 1's clinical record indicated he was a 40 year old male who was brought to the hospital's Emergency Department (ED) at 10:02 p.m., on 3/8/17. The ambulance Emergency Medical Service (EMS) report indicated Patient 1 had complained of heart palpitations and that he appeared moderately intoxicated. The EMS report indicated Patient 1 would not answer questions but kept repeating, "Just take me to the hospital". The EMS report indicated Patient 1's heart rate (HR) was 124 (normal is 60 to 100 beats per minute) and respiratory rate (how many times you breath in and out per minute, RR) was 28 (normal is 12 to 20). Patients 1's clinical record indicated his blood alcohol level was 454 mg/dl-milligrams per deciliter-normal is below 80 mg/dl).

The hospital's security video of the lobby and exterior of the building was viewed. The video runs from 10:03 p.m. On 3/8/17 when Patient 1 was brought into the hospital by EMS and then starts again at 11:36 p.m. on 3/8/17 through 1:10 a.m. on 3/9/17. There was no audio. Patient 1 was identified as the patient with a cap on and a jean jacket and pants. At the 12:41:13 reading on the video file identified as 0028 to 0050 Patient 1 had his head down on the arm of the chair. This was the waiting area of the main ED lobby. Security Guard (SG) 1 was seen approaching Patient 1. At 12:41:18 SG 1 stopped talking to Patient 1 and left. At 12:43:58 Registered Nurse (RN) 4 was seen approaching Patient 1. Patient 1 had his head down on the arm of the chair and appeared to be sleeping. At 12:44:03 RN 4 tapped and then grabbed hold of Patient 1 on the shoulder and shook his shoulder back and forth a couple of times. Patient 1 stood up with an unsteady stance, was very wobbly and appeared to attempt to follow RN 4. Patient 1 then bent over at the waist, straightened up slightly and turned around and sat back down. RN 4 walked back and spoke to Patient 1. Patient 1 didn't lift his head but had it face down. He leaned over and appeared to put his head on the arm of the chair. At 12:45:22, RN 4 left Patient 1. At 12:48:40 RN 3 was seen approaching Patient 1. RN 4 was a short distance from Patient 1 and RN 3. At 12:48:51 RN 3 was seen walking away from Patient 1 headed in the direction of the security desk. Patient 1 was still sitting in the chair. At 12:49:14 SG 1 and RN 3 approached Patient 1 with a wheelchair. At 12:49:52 Patient 1 was seen standing. He stood briefly at the chair, wobbly. He got into the wheelchair and SG 1 and RN 3 wheeled him out. On video labeled 0057 - 0112 ED Drive, SG 1 was seen returning to the hospital with the empty wheelchair at 12:57:06. At 12:57:31 Patient 1 was seen entering the image on the left corner walking into the intersection. At 12:57:38 Patient 1 was seen putting his belongings on the street in front of a vehicle and then laying down. At 12:57:59 the vehicle was seen running over Patient 1.

The ED clinical record for Patient 1 dated 3/8/17 indicated under "History of Present Illness ...Patient [1] was found face down on the ground at the bus stop at the front of the hospital. CPR was started and the patient was brought to the ED. Patient had two rounds of CPR with no palpable pulse noted or cardiac activity noted on the US [ultrasound]. Another round of CPR was done on the patient. Upon pulse check there was cardiac activity noted on the US but there was no palpable pulse so CPR was re-started. After the fourth round of CPR there was no palpable pulses or cardiac activity noted on the US. Patient was then pronounced expired [1:23 a.m. on 3/9/17]".

On 5/10/17 at 07:54 a.m., during an interview, RN 3 stated Patient 1 arrived to the ED that evening, and was seen briefly by the triage nurse. Patient 1 was considered stable, so he was sent to the waiting room to wait to be assessed by a qualified medical provider (QMP). RN 3 stated he received a call from RN 4 informing him that Patient 1 was cursing and being disruptive in the waiting room. RN 3 stated he asked SG 1 to speak with Patient 1 to see if SG 1 could calm him down, but SG 1 was unsuccessful. RN 3 stated he knew Patient 1 from a previous visit the night before when Patient 1 displayed similar disruptive behaviors. RN 3 stated the previous night, he was able to calm Patient 1 down, but on this night, Patient 1 continued to curse and be disruptive in front of women and children. RN 3 stated Patient 1 kept repeating that he wanted to go home. RN 3 was asked why it shows on the video that he tapped Patient 1 on shoulder and made him get up, when it appeared Patient 1 was falling asleep. RN 3 stated Patient 1 wasn't sleeping, he had his head down but continued to curse. RN 3 stated he was concerned Patient 1's behavior would "escalate" so he made the decision to put Patient 1 in a wheelchair and take him to the bus stop. RN 3 stated he did not inform the QMP of this decision. RN 3 stated he did not discharge Patient 1 from the hospital, nor did he have him sign AMA papers. RN 3 stated the normal process would have been for him to have Patient 1 be evaluated by the QMP before leaving the hospital. RN 3 stated he did not follow this process. RN 3 also stated the normal process for any patient that wants to leave the hospital before they have been medically cleared to do so, would be to have the patient sign AMA papers. RN 3 stated he did not follow this process. RN 3 stated he felt he had built a rapport with Patient 1 so he and SG 1 wheeled him outside and thought they would be able to calm him down while walking him outside. RN 3 stated at one point, while being wheeled outside, Patient 1 apologized for cursing in the waiting room and he considered bringing Patient 1 back in to the waiting room, but then he started cursing again. RN 3 stated he and SG 1 continued wheeling Patient 1 to the bus stop . RN 3 stated when they arrived at the bus stop, Patient 1 got out of the wheel chair and they left him at the bus stop. RN 3 stated he knew the buses were not running at that time of night (01:00 a.m.). RN 3 stated he did not consider offering Patient 1 a taxi voucher, or another way home. RN 3 was asked if he would do the same thing if this situation occurred again. RN 3 stated, "No, I would notify the QMP and let them make the decision to let the patient go." RN 3 also stated he would have patient sign AMA papers before leaving.

On 5/10/17 at 09:12 a.m., during an interview, RN 4 stated he was the triage (the sorting of patients-as in an emergency room, according to the urgency of their need for care.) nurse the night of 3/8/17 when Patient 1 was brought into the ED. RN 4 stated Patient 1 kept going in and out of the department to smoke,was cursing, and was just being "difficult." RN 4 stated Patient 1 was yelling and cursing, demanding the hospital staff provide with him transportation home, and being generally disruptive to the department. RN 4 stated he called his charge nurse (RN 3) to come assess the situation. RN 4 stated RN 3 and SG 1 came to the waiting room to talk to Patient 1, but he continued cursing. RN 4 stated RN 3 and SG 1 asked Patient 1 to get into a wheelchair and they wheeled him outside. RN 4 was asked what the normal process would be if a patient wanted to go home. RN 4 stated he would try to put them in a room and notify the QMP. RN 4 was asked if it was normal process to take a patient to the bus stop at 01:00 a.m., when the buses aren't running. RN 4 stated, "I don't know, but the homeless are manipulative, they are resourceful and resilient, so I wasn't really worried."

On 5/10/17 at 09:28 a.m., during an interview, SG 1 stated he was working the night of 3/8/17 when Patient 1 was brought into the ED. SG 1 stated Patient 1 was in the waiting room and was very disruptive. SG 1 stated, "This guy was being disruptive, wanting to go home, cursing. There was a family with kids across from him. He kept going in and out (of the ED) smoking. I told him there was no smoking on the property. He kept saying he wanted a ride home by ambulance." SG 1 stated RN 3 was called to the waiting room. RN 3 tried to talk to Patient 1, but he wasn't cooperating, so RN 3 said to, "Get him out of here." SG 1 stated he and RN 3 got Patient 1 a wheelchair and escorted him to the bus stop. SG 1 was asked if it is a normal practice to take a patient to the bus stop in the middle of the night when no buses were running, SG 1 stated, "Yes, it is not an unusual practice." SG 1 was asked if this practice is still going on. SG 1 stated, "Yes, not every night, but it still happens."

5/11/17 at 10:47 a.m., during a concurrent interview with the Medical Director of the ED (EDMD), the Director of the ED (ED Dir), and Risk Manager (RM), EDMD stated his expectation in his department is that there is collaboration between staff and medical providers with every patient. When asked specifically about patients that say they want to leave, EDMD stated there should be communication between nursing staff and medical providers. It should be discussed at length to make sure patient is safe to leave, and if they aren't safe to leave they should consider doing something else like possibly getting social services involved. EDMD stated there needs to be better documentation by nursing staff . EDMD stated he thinks the mistake made in the case of Patient 1 was an error in judgement by RN 3, because RN 3 did not discuss the situation with the medical provider before escorting him outside. When asked if it is still acceptable to discharge a patient to the bus stop at 01:00 a.m. when buses aren't running, EDMD stated it would be ok on a "case by case basis."

The hospital's Policy and Procedure titled "Against Medical Advice (AMA): Left Without Being Seen (LWBS)" dated April 2015, indicated, "...Policy: 1. Reasonable efforts will be made to avoid having patient leave the hospital AMA or LWBS. 2. The risks and consequences of leaving the hospital will be explained to the patient. 3. Every effort will be made by nursing personnel to have the patient sign the "Leaving Hospital against Medical Advice" form (see Appendix A) prior to leaving the hospital. Procedure:...1. Assess the patient's ability to understand their condition and the risks of leaving the hospital (vital signs, mental status, language. etc.). 2. Notify the attending physician, the manager/designee and/or Administrative Director of Nursing immediately of patient's intent to leave the hospital. 3. Inform the patient their physician is aware of their desire to leave. 4. Explain the patient's diagnosis/condition to the patient. 5. Explain the risks and consequences of leaving the hospital to the patient and family...7. Involve available resources in an attempt to dissuade the patient from leaving, including the physician, social worker, chaplain, family or friends, etc. 8. Complete "Leaving Hospital Against Medical Advice" form (see Appendix 1) when the patient (or responsible person) persists in wanting to leave the hospital prior to completion of treatment by the attending physician... 12. If requested, assist the patient in arranging transportation..."

The hospital's policy and procedure titled, "Emergency Medical Treatment and Active Labor Act (EMTALA). transfer Protocol, "dated January 2015, indicated, "...B. Patient refusal to accept treatment or transfer against medical advice. 1) If an individual refuses treatment against medical advice, the risks and benefits of treatment must be explained. The patient is asked to sign the patient Refusal to Accept Examination and/or Treatment Against Medical Advice form...If the individual refuses to sign the form, document the risks and benefits explained and the effort taken to have the individual sign, and the individual's refusal."

The hospital's "Patient Bill of Rights and Responsibilities," undated, indicated, "As a patient, you have the right to... 2. Considerate and respectful care, and to be made comfortable...9. Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate courses of treatment or nontreatment and the risks involved with each... 17. Receive care in a safe setting..."

Based on interviews, clinical record, and administrative document review, the hospital failed to ensure medical staff operated under current by laws, rules, and policies approved by the governing body when 49 of 58 sampled patients (Patients 2-50) nonstress tests (NST-The nonstress test measures the fetal heart rate in response to fetal movement over time, done to ensure fetal well being. The term "nonstress" means that during the test, nothing is done to place stress on the fetus.) had not been read by a doctor within 24 hours period after completion of NST.

This failure had the potential for fetal distress to go unnoticed and possibly lead to fetal death before delivery.

Findings:

On 5/10/17 at 10:54 a.m., during a concurrent interview and record review, no documentation could be found in the Electronic Medical Record (EMR) that a doctor had read the results of an NST. Registered Nurse (RN) 1 stated the hospital had no way to document the test had been read by a doctor. Informatics Technician (IT) stated, "Right now, we have no way for the doctors to view the strip in the EMR and sign off that it has been read, we are working on that."

On 5/10/17 at 11:00 a.m., during an interview, the Director of Obstetrics (DOB) stated, there is currently no way for the doctors to view the NST's and sign off on them in the EMR. The DOB stated the NST's are placed in a file in the doctors' lounge and the doctors are responsible to read and sign off on them. DOB stated there is no system in place to ensure the NST's are viewed within the required 24 hours.

On 5/10/17 at 11:02 a.m., during an interview in the doctors lounge, OB 1 stated he was aware the hospital policy is to read the NST's within 24 hours. OB 1 stated, "They (NST's) can go longer than 24 hours without being read. If a doctor isn't on call or doesn't come back to the hospital for a delivery, it could be days or weeks before it (NST) gets read. " OB 1 stated once the NST is read, the doctor signs it and places it in a bin for medical records to come pick up.

On 5/10/17 at 2:30 p.m., during a record review of completed NST's in the doctors lounge, 49 NST's with dates ranging from 4/12/17 to 5/9/17 were found. These 49 NST's had no evidence that they had been read by a doctor within 24 hours.

On 5/10/17 at 3:00 p.m., during a telephone interview, the Medical Director of Obstetrics (MDOB) stated it is his expectation that the doctors in the department read the NST's within 24 hours of the test being done, and it is not an acceptable practice to read them after the 24 hour time frame. MDOB stated the NST is a test to check for fetal well being and according to the American Congress of Obstetricians and Gynecologists (ACOG) the test should be read as soon as possible, within 24 hours. The MDOB stated it is the hospital's policy to read the NST's within 24 hours. The MDOB stated he has been aware since he took over as director in January, that the doctors in the department have not been reading the NST's within 24 hours, but has been unable to get them to comply with the hospital policy.

On 5/11/17 at 08:05 a.m., during a telephone interview, OB 2 stated he was aware of the hospital policy that an NST is to be read within 24 hours. OB 1 stated he attempts to read them daily, but is often unable to do so and feels this policy is too stringent.

The hospital's Policy and Procedure titled, "Non-Stress Tests (NST) Protocol" dated March 2016, indicated, "...7. the physician will review the NST within 24 hours..."

The hospital's Bylaws dated March 28, 2014, indicated, "...13.1-3 Policies and Procedures (a)...The policies and Procedures Manual will be maintained in the Medical Staff Office...Applicants and Members of the medical Staff shall be governed by these policies and procedures..."

Based on observation, staff interview and administrative document review, the hospital failed to ensure a registered nurse supervised the nursing care in the endoscopy area when an endoscopy technician (ET) 2 transported a colonoscope (slender, tubular optical instruments used as a viewing system for examining an inner part of the body) in a manner that did not safeguard the highly disinfected status of the scope. ET 2 was observed transporting a colonscope without wearing clean gloves and with the scope wrapped around his arm and shoulder. ET 2 transported the colonoscope from the storage cabinet area (where the scopes were dated for disinfection) to the point of use procedure room located 7 feet away.

This failure resulted in the potential risk of utilizing a cross contaminated endoscope when the standard is to use a highly disinfected endoscope for the intended procedure.

Findings:

On 5/8/17 at 10:05 a.m., during a concurrent interview and tour of the endoscopy department, ET 1 stated all scopes are transported from the storage area to the procedure room in a bag.

On 5/9/17 at 11:34 a.m., during an observation, ET 2 was observed coming out of the clean storage area of the endoscopy department, with a colonoscope wrapped around his upper right shoulder area. ET 2 was not wearing gloves while carrying the scope. ET 2 carried the scope wrapped around his shoulder and in his ungloved hands, across the hallway, into Procedure Room 1 where he prepared to use it for a scheduled procedure.

On 5/9/17 at 11:36 a.m., during an interview, ET 2 stated he did not transport scopes within the department in any kind of bag and that this was the way he has always transported them .

On 5/9/17 at 1:34 p.m., during an interivew, ET 3 stated she did not transport scopes in a bag, but, "I at least wear gloves when transporting them (scopes)."

On 5/9/17 at 1:50 p.m., during an interview, the Director of Surgical Services (DSS), stated she was unsure of how the scopes were supposed to be transported in the department. The DSS stated this issue has never been brought up before and as far she was aware, the scopes have always been transported this way. The DSS stated when the scopes are taken outside of the department for a procedure, they are transported in tote bags.

On 5/9/17 at 3:08 p.m., during an interview, the Infection Control Nurse (ICN) stated she wouldn't expect the scopes to be carried against the body, but she would expect them to be carried with gloves on, away from the body.

On 5/10/17 at 10:14 a.m., during an interview, ET 1 stated all clean scopes should be handled with clean gloves.

The hospital's Policy and Procedure titled, "Endoscope Cleaning, Disinfectant Through the Use of the Automatic Reprocessor/Sterilizer", dated January 2017, did not provide any guidance on how the scopes are to be transported once disinfected.