HospitalInspections.org

TMBased on interview and record review, the hospital failed to maintain an accurate central log for patients who presented to the Emergency Department (ED) for care. The hospital failed to accurately document the disposition of one patients (#9) of 14 ED records reviewed from 03/15/23 through 07/17/23. The hospital's average monthly ED census over the past 6 months was 7,354.

Findings included:

Although requested, the hospital failed to provide a policy that addressed documentation on the ED log.

Review of the hospital's ED log dated 07/03/23, showed that Patient #9 had presented to the ED twice that day. The documentation showed that his first visit was entered into the ED log at 8:23 PM, then discharged at 9:40 PM, with a disposition of left without being seen (LWBS). His second visit was entered into the ED log at 10:11 PM, then discharged on 07/04/23 at 8:26 AM, with a disposition of against medical advice (AMA).

Review of Patient #9's first ED medical record, dated 07/03/23, showed:
- At 8:23 PM, he had arrived to the hospital via EMS, as a transfer from Hospital B (a nearby acute care psychiatric hospital).
- At 8:24 PM, his chief complaint was listed as a shoulder injury. He was wearing blue scrubs and had stated that he was admitted at Hospital B for "drug rehab, but it was easier to get admitted if you said you were suicidal/suicidal ideation (SI, thoughts of causing one's own death)."
- At 8:30 PM, his chief complaint was updated. He stated that his left shoulder had been injured when he was placed in a choke hold by staff members. He stated he was admitted at Hospital B for SI and "having thoughts of harming myself right now."
- At 8:32 PM, his acuity was listed as two, emergent.
- At 8:33 PM, documentation showed that he had indicated that his visit was related to a suicidal behavior/attempt. He was placed in the main ED waiting room.
- At 9:40 PM, his discharge disposition was documented as LWBS.

Review of Patient #9's second ED medical record, dated 07/03/23, showed:
- At 10:11 PM, he was returned to the ED via local law enforcement.
- At 10:12 PM, documentation under chief complaint was that Patient #9 had "eloped (when a patient makes an intentional, unauthorized departure from a medical facility) from this ED." He was a transfer from Hospital B where he had been admitted for a "drug problem, but if you tell them you are suicidal you get in faster." He needed to have his should evaluated due to self-injury after running into a metal mirror.
- At 10:13 PM, an order for clinical hold (an order that signifies that the patient cannot leave the hospital on their own, they require clinical evaluation for mental health issues and are unable to make their own decisions at that time) was documented.
- At 10:14 PM, an order for suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) was documented.
- At 10:19 PM, a note was entered that Patient #9 had eloped from the ED and local law enforcement were notified. He was returned to the hospital and placed in the triage room for closer observation.
- At 1:51 AM, the chief complaint was updated to include that Patient #9 had eloped from the ED after being transferred from Hospital B for evaluation of a self-inflicted shoulder injury he suffered after running himself into a metal mirror. He was admitted to Hospital B for SI. He voiced to EMS that he had been admitted for "drug rehab but it was easier to get in if you were suicidal". He complained of his left shoulder and was concerned for a wound to his right lower leg.
- At 2:46 AM, documentation indicated that Patient #9 was placed on a clinical hold, suicide precautions, and was to have a behavioral health (BH) consult.
- At 2:47 AM, it was documented that Patient #9 had checked into the ED but had eloped from the waiting room. Law enforcement were notified and he was returned to the ED. He was wearing scrubs.
- At 2:50 AM, the BH consult was delayed, he needed to be assessed in person.
- At 3:52 AM, the BH consult was delayed, he was asleep and not responding to vocal stimuli.
- At 5:14 AM, multiple laboratory tests and a shoulder radiology exam were ordered.
- At 5:41 AM, Patient #9 refused all laboratory testing and radiology exams. He stated that he had been at the hospital long enough, nothing was wrong, and he refused to have anything done. Risks and benefits explained and the physician was notified.
- At 6:15 AM, Patient #9 continued to refuse care, the physician was notified. Patient #9 wanted to leave against medical advice (AMA). Hospital B was updated on his continued refusal of care.
- At 6:22 AM, his disposition was set to AMA.
- At 6:23 AM, physician documentation stated that Patient #9 had eloped from the ED on 07/03/23. He informed staff the he was admitted at Hospital B for SI. He had suffered a shoulder injury and needed to have it evaluated and had voiced concern for a leg wound. He now denied having a shoulder injury or any other pain/discomfort.
- At 8:24 AM, EMS arrived to transport Patient #9 back to Hospital B. Hospital B were aware of his return and refusal of care.
- At 8:26 AM, Patient #9 was discharged.

Both ED medical records for Patient #9 clearly indicate the he had eloped from the ED on 07/03/23.

During an interview on 07/18/23 at 11:40 AM, Staff F, ED Nurse Manager, stated that Patient #9's first ED visit on 07/03/23 should have had the disposition listed on the ED log as eloped, not LWBS. The information on the ED log should be accurate, including the disposition.

The hospital's failure to accurately document patient information, including disposition, made it difficult to identify whether or not patients received a MSE, stabilizing treatment, were appropriately discharged, eloped or left AMA. This failure has the potential to effect all patient that presented to the hospital ED.