HospitalInspections.org

Based on staff interview and record review, the facility failed to provide appropriate security and monitoring in order to maintain the physical safety of 1of 10 patients [Patient #1] of the sample group.
Findings include:

Per record review Patient #1 was apprehended by law enforcement for traffic violations, following an elopement from a health care facility, and escorted to the ED (Emergency Department) on 5/24/13, for evaluation of a psychiatric condition. A crisis evaluation was conducted and the patient was determined to meet involuntary status. Despite the involuntary legal status and the fact that Patient #1 was on constant observations by security personnel, and despite his/her history of past recent elopement from another facility, the patient was allowed to use a bathroom, located in the ED waiting room, which included a locking mechanism that provided him/her the opportunity to elope through a small window contained within the bathroom. The patient was returned to the ED by law enforcement within a 2 hour period, and again placed on constant 1:1 observation, now conducted by the sheriff ' s department. While Patient #1 was under constant observation by the sheriff ' s department, h/she was able to obtain items that were used and items that could be used for self-harm.
1). Per record review of the Emergency Nursing Record for 5/24/13 at 10:00 A.M. Patient #1 " ambulated to waiting room bathroom with security. After approx. 6 minutes security knocked on door and patient didn ' t respond to security. Nurse notified. Patient continues to not respond. Maintenance Dept. notified. Patient continued not to respond so bathroom door was opened with a screwdriver and patient was not in bathroom. Bathroom window open. Police called and parking lot checked. No sign of patient " .
Per interview with the ED Nurse on 5/29/13 at 2:27 P.M. the patient had been in the same bathroom " 1 or 2 times already " before the elopement.
Per interview with the ED Nurse Manager on 5/29/13 at 11:40 A.M. h/her expectation is " to keep them [the patients] safe at all times " . The ED manager stated 1:1 observation is " sitting in a chair outside of the room with an eye on you at all times. If I take you to the bathroom, I make sure the bathroom is safe. If I can ' t see through the door- then it ' s not 1:1. You gotta keep an eye on them " .
Per record review of the Emergency Physician Record of 5/24/13 Patient #1 ' s past history includes ' prior suicide attempt ' & ' psychiatric problems ' , and on the facility ' s Suicide/Self Harm Assessment tool, dated 5/24/13, Patient #1 is scored as a " High Risk/Precautions= 1:1 supervision " .
2). Per interview with a Sheriff Deputy on 5/28/13 at 10:20 A.M., and confirmed during an interview with the ED Nurse on 5/29/13 at 2:27 P.M., while on 1:1 constant observation by the sheriff department, Patient #1 " pulled a piece of wood off the door and scratched [h/her] self. [H/she] was picking at scabs " .
3). Per record review of patient#1 ' s Emergency Nursing Record for 5/27/13, while the patient was escorted to the bathroom by the sheriff, the ED nurse found in the ' safety room ' " broken plastic spoons wrapped up in sheets- long gold necklace and silver ring with blue stone, large amount of paper, food, liquid, dirty bandages ...sheriff dept. will start to count everything going in and out of room. "

Based on staff interviews and record review the facility failed to conduct a timely investigation to analyze the cause of an adverse patient event and identify opportunities for improvement; failed to ensure through their Quality Assurance and Performance Improvement (QA/PI) that identified preventable actions and mechanisms were fully implemented to include feedback and learning throughout the hospital. Findings include:

Based on record review Patient #1 was apprehended by law enforcement for traffic violations, following an elopement from a facility, and escorted to the ED (Emergency Department) on 5/24/13, for evaluation of a psychiatric condition. A crisis evaluation was conducted and the patient was determined to meet involuntary hospitalization status. Despite the involuntary legal status and the fact that Patient #1 was on constant observations by security personnel, and despite his/her history of past recent elopement from another facility, the patient was allowed to used a bathroom, located in the ED waiting room, which included a locking mechanism that provided him/her the opportunity to elope through a small window contained within the bathroom. The patient was returned to the ED by law enforcement within a 2 hour period and a plan was implemented which included that the patient would only be allowed use of a bathroom without ability to lock and without windows. The patient remained in the ED, on constant observation by two sheriffs who accompanied him/her whenever out of the room, until bed placement was obtained, 5 days later, in an inpatient psychiatric facility. Despite the elopement and the plan of action implemented to prevent future elopement/unsafe behavior, the facility failed to fully assess and monitor the patient who, following his/her elopement, was able to obtain and retain within his/her room items that could be used for self harm. Per review of the Emergency Nursing Record for 5/27/13, 3 days following the elopement, while Patient #1 was escorted to the bathroom by the sheriff, staff cleaning the patient's room "found broken plastic spoons wrapped up in sheets- long gold necklace and silver ring with blue stone, large amount of paper, food, liquid, dirty bandages ...sheriff dept. will start to count everything going in and out of room." In addition,
Per interview with a Sheriff Deputy on 5/28/13 at 10:20 A.M., and confirmed during an interview with the ED Nurse on 5/29/13 at 2:27 P.M., while on 1:1 constant observation by the sheriff department, Patient #1 "pulled a piece of wood off the door and scratched [h/her] self. H/she was picking at scabs " .

Per observation on the morning of 5/29/13, the bathroom located in the ED waiting room contained a small window that was sealed and unable to be opened. The bathroom also contained a mechanism for locking the door from inside, and, for which there was no key available. In addition, the room also contained hand railings that were loopable and could be used as potential ligature sources. Both findings posed a potential safety risk for ED patients using the bathroom.

During interview, at 12:48 PM on 5/29/13, the ED Nurse Manager stated that, following the patient's elopement on 5/24/13, the immediate action taken included: the patient was no longer allowed use of any bathroom that had the ability to lock, the window in the ED waiting room bathroom was sealed closed, and the decision was made that the ED waiting room bathroom would no longer be used for any patient on 'involuntary' status. The Nurse Manager further stated that although these actions to decrease the risk of future patient elopement had been identified, communication of the changes to staff was conducted only through "putting the word out" to staff who were present at the time of the incident and asking those staff members to inform oncoming shifts. S/he confirmed that there had been no formal education provided to staff, to date and no process to assure all staff were aware of the changes. S/he further confirmed that the action plan included prohibiting use of the ED waiting room bathroom by patients on involuntary status only, and agreed the bathroom could pose potential risk of harm to some patients.