HospitalInspections.org

Based on observation, interview and record review, the hospital failed to comply with CFR 489.24, the Emergency Medical Treatment and Labor Act (EMTALA) requirements when there was no evidence of:

Ongoing re-assessments, interventions and monitoring to ensure the Emergent Medical Condition (EMC) was stabilized prior to transfer.

Findings:

1. Patient 1, who presented to the Emergency Department (ED) with a psychiatric condition did not receive ongoing re-assessments, behavioral monitoring by a licensed nurse or interventions defined as facility standards which thereby resulted in his elopement.

Patient 1 was found by the police at his home several hours after the elopement and was transported to an acute care psychiatric facility. (Refer to A2407)

2. One of 20 sampled patients (Patient 1) who presented to the ED with a psychiatric condition did not receive ongoing re-assessments, behavioral monitoring by a licensed nurse or interventions defined as facility standards which thereby resulted in his elopement. In addition, four of 20 sampled patients (Patient 2, 6, 7, and 11) who presented to the ED with psychiatric conditions including suicidal attempt, suicidal ideations or an altered level of consciousness were not provided ongoing reassessments and monitoring to ensure the condition did not deteriorate and the patient remained safe as per facility Policy. (Refer to A2407)

Based on interviews and record review, the hospital failed to ensure five of 20 sampled patients (Patients 1, 2, 6, 7, 11) who presented to the Emergency Department (ED) between 4/24/12 and 7/6/12 including suicidal attempt, suicidal ideations or an altered level of consciousness received ongoing assessments and monitoring to ensure appropriate interventions were being taken to stabilize the patient, provide for their safety and prevent deterioration of a patient on suicide precautions. In addition, facility policies for the management of suicidal patients were not followed.

These failures resulted in the potential for the undetected deterioration of the Emergent Medical Condition (EMC) which would place patients at harm, including elopement.

Of the 14 sampled patients who presented with a psychiatric condition, there was one elopement (Patient 1).

Findings:

1. Patient 1, a 26 year old, was brought to the ED by ambulance on 7/6/12 at 11:37 a.m. and triaged as a Level 2 (High Risk Situation). Patient 1 had a history of schizophrenia (a mental disorder characterized by a breakdown of thought processes and emotional instability) and prior suicidal attempts within the past six to twelve months. For approximately two and a half months, Patient 1 had refused to take the medications prescribed for his schizophrenia (Adderall and Haldol) and the chief complaint on admission was fatigue and insomnia.

In review of a form in the medical record titled Suicide/Self-Harm Assessment Tool, dated 7/6/12 at 11:50 a.m., Patient 1 was assessed with a score of 11 defining the need for High Risk Suicide Prevention Interventions, including 1:1 supervision (a personal care assistant-PCA), an environmental safety check of the room and the removal of personal belongings. In a Medical Screening Examination (MSE) conducted at approximately 12:55 p.m., the physician noted Patient 1 was acutely psychotic with delusions that made it unsafe for him to make decisions for himself. The physician documented the need for a psychiatric evaluation and Patient 1 was placed on a 5150 (involuntary 72 hour hold) by behavioral health staff pending transfer to an acute care psychiatric facility. Patient 1 eloped from the ED at approximately 6:04 p.m.

In review of a form titled Behavioral Evaluation, dated 7/6/12 at 3:30 p.m., the behavioral staff documented Patient 1 had delusions that his mother was poisoning him. Patient 1 was described as angry, depressed and agitated during the evaluation.

In review of a form titled Physician Certification Statement, dated 7/6/12 prior to transport, the physician documented Patient 1 was on a 5150 hold and was a flight risk.

In review of the medical record, there was no evidence of:
a. A general medical assessment performed at the shift change of the nursing staff on 7/6/12 at 3 p.m.
b. Vital signs at a minimum of every four hours (the only vital sign taken was at 1:30 p.m.).
c. Any ongoing assessments by the nurse of Patient 1's mood or affect, behaviors, delusions, irritability or depression. There was no documentation of Patient 1's reaction to being placed on an involuntary hold or response to being informed he was to be transferred to an acute care psychiatric facility.

In narrative notes prior to the elopement, the licensed nurse (RN1) documented the following:
"5:48 p.m. Dressed, ready to go. Department Secretary calling for ambulance."
"6:04 p.m. Patient not in room. Sitter [PCA] did not see him leave."
"6:26 p.m. Entire hospital searched. Pt. [patient] not located. PD [police department] aware."

In an interview with RN1 on 7/16/12 at 9:34 a.m., she stated she was a nurse in the Float Pool (a group on nurses who work between multiple units in the hospital) and worked in the ED three to four shifts a month, sometimes less. RN1 did not recall any formalized ED training for the management of psychiatric patients in the past year, however stated "a policy was put in my mailbox". RN1 further revealed "I do competencies every year and get e mails and memos for updates".

RN1 stated she was the nurse who was assigned to Patient 1 when she came on shift 7/6/12 at 3 p.m. RN1 stated she was not aware Patient 1 was on a 5150 or had been determined to be a flight risk. RN1 acknowledged she did not do a general medical assessment at the beginning of the shift. RN1 stated Patient 1 had asked her for medication for pain shortly after the beginning of the shift but she could not recall the pain score. She stated she told Patient 1 the doctor would not order any medication for his chronic pain prior to transfer. RN1 acknowledged she did not document the pain assessment or inform the physician of Patient 1's complaint of pain because "I was probably distracted". RN1 acknowledged she informed Patient 1 of the transfer to the acute care facility and completed the Consent for Patient Transfer form at 5:37 p.m. RN1 revealed she called security to bring Patient 1's belongings and gave them to him to get dressed at approximately 5:40 p.m.. RN1 stated the PCA informed her the patient was not in his room at approximately 6 p.m. RN1 acknowledged she had not communicated her expectations with the PCA at the beginning of the shift or at any time prior to the elopement and was not aware of any behavioral changes noted by the PCA.

In an interview on 7/16/12 at 8:59 a.m., the Charge Nurse (CN1) on at the time of Patient 1's elopement stated she would expect documentation of general rounding on patients with a PCA at least every two hours and this should include a review of the PCA's 15 minute behavioral checks. CN1 further revealed that prior to the transfer of a patient on a 5150 hold to an acute care psychiatric facility, the personal belongings are obtained from security and given to the transport team. "The patient isn't dressed; this is standard practice"

In an interview with the Chief Nurse Executive (CNE) on 7/16/12 at 10:43 a.m., she stated she "expects report at bedside" whereby the nurse would define the expectations of the PCA for that shift.

In an interview on 7/16/12 at 11 a.m., the Certified Nursing Assistant, who was assigned as a PCA (PCA1) to provide constant attendance to Patient 1 on 7/6/12, revealed she had not been given a report by the nurse at 3 p.m. as "she was busy with the other report". She stated she had been told by the prior PCA Patient 1 was a "behavior problem". She stated she observed RN1 give Patient 1 his clothes but "usually patients go to the hospital in a gown". CNA1 stated she observed Patient 1 dressed and standing in his room at approximately 5:45 p.m. She described Patient 1 as being irritable, "his face was upset" as he had been waiting for the ambulance "too long". CNA1 stated she glanced down and when she looked up Patient 1 was not in the room.

In a concurrent review of a form titled Suicidal Patient Observation, PCA1 acknowledged the behavioral assessments from 3:45 p.m. until 6 p.m. were documented by her. PCA1 was asked if she had reported Patient 1's irritability, documented at 5:45 p.m. and 6 p.m. to the nurse, she responded "no". PCA1 also acknowledged she had not signed the form where indicated for a signature of the PCA.

Further review of this form revealed Suicidal Patient Observation was "DEFINED AS STAFF ALWAYS BEING IN DIRECT CONSTANT VISUAL OBSERVATION OF A PATIENT".
In review of an ED policy titled Assessment/Reassessment of Patients in the Emergency Department, revised 6/12, the following was stipulated for Level 2 patients who may present with a high risk situation; may be confused, lethargic, disoriented, in severe pain/distress or suicidal:
a. Reassessments and vital signs will be performed as frequently as necessary based on patient's medical condition and medical treatments. The standard minimum of documentation for ESI [Emergency Severity Index] Level 2 patients will be every four hours.
b. General medical assessment performed with change of each nursing shift.
In addition, Page 8, #10 Psychosocial Assessment defined the need for "ongoing assessment of the patient's cognitive and communicative skills, response to teaching and hospitalization, coping skills, ...." and stipulated documentation should be done in the computerized section for ED Patient Rounding, noting suicide precautions and actions taken to ensure patient safety". The policy further stipulated complete patient information was to be documented in the Suicidal/Violent Behavior Sitter Log (if patient requires direct observation) located at the charge nurse workstation.

In review of a form titled Suicidal and Violent Behavior Sitter Log, Patient 1 was not entered as a sitter [PCA] patient on the date of 7/6/12.

In review of a patient care hospital policy titled Direct Observation Patient Watch/Personal Care Assistants, revised June 2012, page 2, there was stipulation "E. Float pool personal care assistants will be evaluated each shift by the responsible nurse. The evaluation forms are available in the Staffing Office and should be returned there after completion".

In review of a patient care hospital policy titled Suicidal Patient Monitoring, revised June 2012, page 4, there were instructions "D. Transfer: Patients transferred at discharge to a mental health facility under involuntary hold (5150) will be transported by ambulance. They will remain in hospital gown/pajamas. Personal belongings and clothing will remain bagged and will be given to the ambulance crew for safekeeping."

In review of RN1's education files there was no evidence of formal training in the ED for the management of a suicidal patient.

In an interview on 7/12/12 at 11:51 a.m., the ED CNS stated the float nurses have not been required to complete the ED Suicide Risk Assessment module and that it would be rare for a float nurse to be assigned to a Level 2 patient in the ED.

In an interview with the hospital risk manager (RM) on 7/14/12 at 12:20 p.m., she stated the hospital had not yet done an investigation of Patient 1's elopement as clarification was still being sought to determine whether Patient 1 eloped or left AMA "against medical advice". In a concurrent review of the medical record, Patient 1's discharge dispostion was noted as AMA. The RM further revealed staff "usually wait until the ambulance is here to get the patient dressed".

In a subsequent interview with the CNE on 7/12/12 at 1:30 p.m., she stated the computer program does not have a designation for elopement. On discharge, patients in the ED must be coded as discharged home, transferred to another facility, left without being treated or left against medical advice.

2. Patient 11, a 29 year old homeless male, presented to the ED on 6/27/12 at 10:42 p.m. with a self inflicted laceration to his right hand. Patient 11 had a history of schizophrenia and bipolar disorder (mood swings between mania and depression).

In review of a form in the medical record titled Suicide/Self-Harm Assessment Tool, dated 7/6/12 at 11:50 a.m., Patient 11 was assessed with a score of 11 defining the need for High Risk Suicide Prevention Interventions, including 1:1 supervision (a sitter), an environmental safety check of the room and the removal of personal belongings. In a Medical Screening Examination (MSE) completed at approximately 4:04 a.m., the physician documented the need for a psychiatric evaluation. Patient 11 was seen by behavioral health staff on 6/28/12 at 7:30 a.m. and placed on a 5150 (involuntary 72 hour hold) as a gravely disabled adult. Patient 11 was transferred to an acute care psychiatric facility on 6/28/12 at 9:02 a.m.

In review of the medical record, there was no evidence of:
a. A general medical assessment performed at the shift change of the nursing staff from evening to night shift.
b. Any ED Rounding or General Medical Assessments between triage 6/27/12 at 10:45 p.m. and 6/28/12 at 4:59 a.m.
c. Any ongoing assessments or observations by the nurse of Patient 11's mood or affect, behaviors, delusions, irritability or depression. There was no documentation of Patient 11's reaction to being placed on an involuntary hold or response to being informed he was to be transferred to an acute care psychiatric facility.

3. The following patients were seen in the ED prior to mid June and received ongoing assessments and monitoring according to the policy for Assessment/Reassessment of Patients in the Emergency Department, revised 2/12. This policy stipulated the following for suicidal patients:
"f. Physiologic assessment every 4 hours.
g. General medical assessment performed with change of each nursing shift.
h. Vital signs every four hours, unless unstable....
In addition, Page 8, #10 Psychosocial Assessment defined the need for "ongoing assessment of the patient's cognitive and communicative skills, response to teaching and hospitalization, coping skills, ...." and stipulated documentation should be done in the computerized section for ED Patient Rounding, noting suicide precautions and actions taken to ensure patient safety".

a) Patient 2, a 40 year old, was brought to the ED by the police department on 4/24/12 at 10:06 p.m. with an active plan to commit suicide. Patient 1 had a history of schizophrenia with multiple suicide attempts within the past six to twelve months and was triaged as a Level 2. Patient 2 had been placed on a 5150 and was assessed with a need for High Risk Suicide Prevention Interventions. Security was assigned to provide 1:1 observation and conducted the necessary suicide precaution interventions (room safety check, removal of personal belongings). Patient 2 was transferred to an acute care psychiatric facility on 4/25/12 at 10:30 a.m.

During the twelve hour stay in the ED, vitals were taken at 10:12 p.m. (during triage), 4/25/12 at 2:59 a.m. and prior to transfer at 9:06 a.m. The only other observations noted in the record were at 2:30 a.m. when the nurse noted the patient was sleeping without distress awaiting transfer and at 6:23 a.m. when the nurse noted the patient was on a 5150 waiting placement. There was no evidence of ongoing behavioral assessments or interventions taken to ensure the comfort or safety of Patient 2.

In an interview with the ED CNS on 7/11/12 at 2 p.m., she acknowledged Patient 2 was not having ongoing assessments according to ED protocols.

b) Patient 6, a 28 year old, was brought to the ED by ambulance on 5/2/12 at 1:06 a.m. with multiple plans to attempt suicide. Patient 6 was assessed with a need for High Risk Suicide Prevention Interventions. Security was assigned to provide 1:1 observation and conducted the necessary suicide precaution interventions (room safety check, removal of personal belongings). Patient 6 was seen by behavioral health staff at 8 p.m. and placed on a 5150 hold. Patient 6 was transferred to an acute care psychiatric facility at 11:15 p.m.

In review of the medical record, there was no evidence of any nursing documentation of vital signs, observations, ongoing assessments or nursing narrative from the time of triage at 1:06 a.m. until 6:19 a.m. (six hours) when the care of Patient 6 was assumed by another nurse.

c) Patient 7, a 55 year old, was brought to the ED by police officers on 5/8/12 at 11:02 a.m. with suicidal ideations, wanting to stab herself and others. Patient 7 was assessed with a need for High Risk Suicide Prevention Interventions. Security was assigned to provide 1:1 observation and conducted the necessary suicide precaution interventions (room safety check, removal of personal belongings). Patient 7 was seen by behavioral health staff on 5/8/12 at 4:15 p.m. and placed on a 5150 hold. Patient 7 was transferred to an acute care psychiatric facility on 5/9/12 at 2:03 a.m.

In review of the medical record, there was no evidence of any nursing documentation of vital signs, observations, ongoing assessments or nursing narrative from the 5/8/12 at 8:42 p.m. until 5/9/12 at 2 a.m. (five plus hours) when Patient 7 was transferred.

During the review of the medical records with the ED Clinical Nurse Specialist on 7/9/12 at 2 p.m. she acknowledged there was inconsistency in the documentation of re-assessments.