HospitalInspections.org

Based on review of State Hotline Intake Information Form, the facility's Hotline Call Detail Report, policy review, and staff interview, the facility failed to follow the Vulnerable Persons Act Section 43-47-7, Mississippi Code of 1972 which requires a complaint of abuse be reported to the Department of Health. The facility failed to report Patient #1's complaints of abuse, one (1) of one (1) patient reviewed.


Findings include:


Review of the State Hotline Intake Information Form revealed that the complainant (Patient #1) called a complaint into the State Hotline regarding the treatment she allegedly received while in the facility's Emergency Department (ED) on Friday, 9/25/15. She stated that she went to the ER for a bad anxiety attack around 6:10 p.m. At approximately 9:00 p.m. she left her ED room, after being told by the Mental Health Technician (MHT) not to, and walked to the nurse's station. Before she could say anything four (4) campus police walked up to her, two (2) of them grabbed her by the arms and dragged her back to her room. It was documented that the MHT had pushed the 'panic button' when the patient left her room.


There was no documented evidence that the facility self-reported the incident or the patient's complaints regarding abuse by campus police.


On 10/14/15 at 9:10 a.m. the facility was entered for a Complaint Survey. At that time an interview was held with the facility's Director of Adult Emergency Department and Chief Nursing Officer (CNO). The Director of the Adult Emergency Department stated that the patient initially did not complain that she had been abused and that he had talked with the patient about her original complaint for over an hour. He did not report the complaint because at that time he thought the patient was no longer concerned about her complaints.


Review of the facility's "Hotline Call Detail Report" printed 9/29/15 revealed, "The complaintant...called in a complaint in regards to the treatment she received while at the emergency room on Friday, September 25, 2015. (Patient) stated that she went to ER for a bad anxiety attack around 6:10 p.m. The staff ... placed her in a room...she was left in the room for several hours. After some time had passed she thought about her dog who was left at home unattended and told the tech that she was worried about her dog and needed to call someone....the tech kept telling her to sit down. She said she finally told the tech that 'she was going to get someone to help her.' She then walked down the hallway to the nurses station. Before she could say anything (4) campus police walked up to her and two of them grabbed her by the arms and drug her back to her room... The ER doctor came back to the room and release(d) her while under the influence of Ativan and Compazine and left her to drive home. She stated that (no)one was called or notified that she had been released. She could barely see and was literally falling asleep while trying to drive herself home...she contacted the campus police and patient affairs..."


Review of page two (2) of the facility's "Alleged Abuse and Exploitation of Patients, Occurrences on (facility name)" - Campus Manual Code HADM/A-13 (revision date 10/2013) revealed, "Reporting of Abuse: If the multidisciplinary committee (Nursing, Social Work, Human Resource, Hospital Administration and Risk Management) deems allegation is a reportable event according to the law, the Social Worker or designee shall verbally report possible abuse and/or exploitation of patients within twenty- four (24) hours and in writing within seventy-two (72) hours of discovery to the Mississippi State Department of Health and the Medicaid Fraud Control Unit of the Attorney's Office. Mandatory reporting times will be adhered to exclude weekends and legal holidays."


The facility failed to report to the Mississippi State Department of Health the incident concerning Patient #1 or Patient #1's complaints of abuse by the campus police.

Based on Emergency Department (ED) record review and staff interview, the facility failed to inform nine (9) of nine (9) patients treated in the ED of their rights. Patient #1, #2, #3, #4, #5, #6, #7, #8, and #9.


Findings include:


ED record review for Patient #1, #2, #3, #4, #5, #6, #7, #8, and #9 revealed no documented evidence that these patients were informed of their rights.


During an interview on 10/14/15 at 11:55 a.m. the Chief Nursing Officer stated that patients in the ED are given copies of patient rights, but that this information was given to inpatients only.

Based on Emergency Department (ED) record review, State Hotline Intake Information Form review, the facility's Hotline Call Detail Report, staff interview, and policy review, the facility failed to have policies and procedures in place regarding discharging Patient #1, one (1) of one (1) ED patient reviewed, from the ED after being given medications that may affect the patient's ability to drive.


Findings include:



Review of the 10/13/15 State Hotline Intake Information Form revealed that Patient #1 had complaints that on 9/25/15 the ED physician discharged her from the ED while she was under the influence of Ativan and Compazine and she was allowed to drive herself home. The patient stated that the facility did not call or notify any family members or friends that she had been released and that she "...could barely see and was literally falling asleep while trying to drive herself home."


Review of Patient #1's 9/25/15 ED record revealed that on 9/25/15 Patient #1 presented alone to the ED at 18:25 (6:25 p.m.) with complaints of an anxiety attack due to being harassed and threatened by a coworker. She was anxious and tearful during triage.
19:29 (7:29 p.m.) the patient was given lorazepam (Ativan) injection 1 mg (milligram) for anxiety.
19:49 (7:48 p.m.) a peripheral IV (intravenous) line was placed.
19:56 (7:56 p.m.) the patient was given prochlorperazine (Compazine) 10mg IV for complaints of a headache.
20:03 (8:03 p.m.) the patient was "up in bed asking for food, awake, alert, and oriented X3..."
She was observed by Mental Health Technician (MHT) #1 every 15 minutes during her ED stay.
21:15 (9:15 p.m.) MHT #1 documented "got up. got upset. started talking about walking out." She was informed that she had come to see the doctor. "then stated she was leaving and walked out".
The ED physician recorded the following information: "Patient had episode where she got acutely agitated, and campus security was called. I arrived to the room and de-escalated the situation. The patient calmed down. She felt some relief of her anxiety with Ativan and does not have a headache. The patient is not currently homicidal/suicidal. Feel that patient is safe for discharge home. She will follow up with her primary psychiatrist." The patient was discharged and left the facility on 9/25/15 at 9:43 p.m. There was no documented evidence in her ED chart of any family or friends to call regarding her ED admission or discharge.


An interview with the Clinical Director of Adult Emergency Department on 10/14/15 at 12:40 p.m. revealed that the facility did not have a policy regarding a patient being discharged after being given medications which may affect the patient's ability to drive.


A telephone interview with Registered Nurse (RN) #1 on 10/15/15 at 6:55 a.m. revealed that Patient #1 did not at any time ask for her family to be called. "Sometimes family members are contacted, but this patient did not request for her family to be notified."


A telephone interview with MHT #1 on 10/15/15 at 7:05 a.m. revealed that at no time did the patient ask for her family to be called.

The facility failed to ensure they had a policy/procedure in place regarding the discharge of patient's home alone after being given medications that might impair their ability to drive themselves and allowed Patient #1 to leave the ED and drive herself home after receiving medications which might affect her ability to drive.