HospitalInspections.org

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*Mental health patients removed their street clothes and put on hospital attire for safety purposes for one of one patient (5) who had eloped in their street clothes from the emergency department (ED).
*The ED was adequately staffed to ensure patient safety for one of one mental health patient (5) who was on a mental health hold and who had eloped from the ED.
*Health unit coordinators responsible for 1:1 (one-to-one) monitoring of mental health patients were trained regarding their job responsibilities.
*Staff documented 1:1 observations for one of one mental health patient (5) who had eloped from the ED.
*The hospital supervisor implemented Crisis Intervention policy to ensure a trained staff watcher had been contacted to conduct 1:1 monitoring for one of one mental health patient (5) who eloped from the ED.

1. Observation and interview on 12/15/15 at 10:40 a.m. of the ED with ED director C and house supervisor registered nurse (RN) D revealed:
*ED rooms 1 and 2 were used for those patients that had been brought there with mental health issues. Both rooms were located next to the exit doors of the ED.
*Watchers were used when mental health patients were admitted to the ED; those individuals were contracted by the county and were not employed by the hospital.
*There was a panic button behind the nurses station the staff could use if there was a patient that was having escalating behaviors or that had been attempting to leave the premises. The panic button went directly to the police department and would notify law enforcement of the exact location of the incident. The staff then would follow-up with a call to 911.
*If there were more than one mental health patient in the ED then two watchers would be used. The list for the watchers was located at the nurses station.
*There were two RN's in the ED on the day shift from 11:00 a.m. to 11:00 p.m., and then from 11:00 p.m. to 7:00 a.m. there was only one RN in the ED.
*The house supervisor would be the back-up for the RN at night if she became busy in the ED.
*When a mental health patient presented to the ED the crisis intervention procedure would be initiated.
*The patient would have been placed in a hospital gown, and their clothes and belongings would have been taken out of the room.
*A nursing assessment would have been completed.
*The social services department would have been notified.
*A 1:1 (one-to-one) Mental Health Observation Flow Sheet was initiated by the watcher.
*The watcher would always have "eyes on" the patient.

Review of patient 5's electronic medical record revealed:
*The patient had been admitted on 10/30/15 at 1:41 a.m.
*She had been admitted with a drug overdose per ambulance.
*The medical record indicated she had ingested (swallowed) forty Tylenol tablets and twenty Xanax (for anxiety) tablets.
*She had a history of suicidal ideations and seizures.
*She had been placed on a mental health hold on 10/30/15 at 2:00 a.m. by law enforcement.
*The physician had ordered suicide precautions.
*The patient had been cooperative and had slept much of the night.
*She had been awoken at approximately 5:05 a.m. for a consultation with a behavioral health facility staff person. She then had become aware she was on a mental health hold and was going to be transferred to a behavioral health facility. The patient became upset, pulled out her IV (intravenous), and walked out the ED at approximately 5:55 a.m.
*Law enforcement was called per phone and notified of the patient exiting the ED.
*She was returned to the hospital approximately three hours later at 8:59 a.m. by law enforcement.
*She was then transferred at 11:22 a.m. by law enforcement to the accepting behavioral health facility.

Interview on 12/15/15 at 1:30 p.m. with the vice president (VP) of patient care regarding patient 5's above incident revealed:
*The staff on the night of 10/30/15 had not followed the hospital policy and procedure in regards to the May 2015 dated Crisis Intervention policy.
*The patient should have been undressed, placed in a patient gown, and her belongings removed from the ED room.
*After the patient had been placed on a mental health hold the police officer had not stayed with the patient.
*The patient had escalating behavior after she found out she was on a mental health hold and was going to be transferred to a behavior health facility.

Interview on 12/15/15 at 2:30 p.m. with ED director C in regards to patient 5's incident on 10/30/15 revealed:
*Suicide precautions were ordered for patient 5 upon admission to the ED.
*The 1:1 Mental Health Observation Flow Sheet was initiated after the incident on 10/30/15 with patient 5.
*If and when the ED would become busy a watcher would be called to assist if there was a mental health patient.
*There was no formal training for the HUC (health unit coordinator) who conducted the 1:1 observations. The situation/requirements would have been discussed with the HUC by the ED supervising RN.
*There had been a staff meeting on 11/4/15 with the ED staff and the house supervisors.
*There was no policy or procedure on suicide precautions.
*Suicide precautions meant there should be 1:1 eyes on patient.
*There was no formal training on suicide precautions.
*There was no documentation of 1:1 observation of patient 5 the night of 10/30/15.

Interview on 12/15/15 at 3:40 p.m. with qualified mental health professional (QMHP) regarding patient 5's ED admission on 10/30/15 revealed:
*She was the only QMHP in the hospital.
*When the the patient's were brought into the ED she completed the evaluation. She then makes the recommendations for the patient. She would collect the information from the patient and/or family/friends.
*The evaluation for patient 5 was not documented until 8:52 p.m. on 10/30/15. She explained she had documented on the wrong patient, and that was why the documentation was not done until ten hours after the patient had been transferred to another facility.
*Law enforcement transferred all patients who had been cleared medically by the physician. "So the hospital was at the mercy of the county sheriff's police force when they were able to transfer the patient to a behavioral health facility."
*She or another social worker would have been on call until 10:00 p.m. Monday through Friday. If there was an evaluation that would have been required the patient would have been evaluated after she had returned to work the next day or if the patient was taken into custody there was another counseling agency that could perform the evaluation in jail.

Interview and observation on 12/15/15 at 4:00 p.m. in the ED with patient care technician/certified nursing assistant J in regards to the Mental Health Observation Flow Sheets and 1:1 observations of mental health patients revealed:
*She had no formal training to be a watcher.
*She was observed during the ED visit to have a patient who was on a 1:1 observation and had placed herself right in front of patient room 1 to observe a current ED patient.
*She stated that 1:1 meant "eyes on" the patient at all times.

Interview on 12/16/15 at 8:15 a.m. with quality analyst supervisor H in regards to transporting mental health patients revealed:
*The transferring of the mental health patient was dependent on the availability of the sheriff's department. The sheriffs department provided all the transportation for mental health patients to behavioral health facilities.
*The sheriff's department usually did not transfer any patients after 4:00 p.m.

Telephone interview on 12/16/15 at 8:44 a.m. with ED RN E, quality analyst F, and ED director C in regards to patient 5's incident on 10/30/15 revealed:
*The ED was very steady for a Thursday night.
*There were two people staffed in the ED, herself and a HUC.
*The provider's protocol was to call the house supervisor for assistance if the ED became busy. The house supervisor came down to the ED a few times during the night to assist her.
*When suicidal precautions were implemented a watcher would have been called in to assist. They had not called in a watcher that night. The HUC had been used to watch patient 5.
*She did not have patient 5 remove her clothes and put a hospital gown on as per policy protocol. The patient was wearing a sweat shirt (no hood), sweat pant with no under garments, and slippers when she exited the ED.
*The patient had become upset after finding out she was going to be transferred to a behavioral health facility. She was in another ED room when the HUC informed her the patient had walked out of the ED. The police were notified immediately. There was a panic button that was used and would inform law enforcement where the emergency was in the hospital.
*She felt as though the ED was not sufficiently staffed the night of
10/30/15.

Review of the ED log on 10/30/15 from midnight through 6:00 a.m. there was nine patients admitted to the ED as follows:
*At 12:16 a.m. a four year old with an allergic reaction.
*At 1:25 a.m. a three year old admitted with a croup.
*At 1:36 a.m. a twenty-two year old admitted with a toothache.
*At 1:41 a.m. patient 5 was admitted with a drug overdose.
*At 1:55 a.m. a two month old admitted with vomiting.
*At 3:31 a.m. a seventy-six year old admitted with back pain.
*At 4:16 a.m. a five month old admitted with a pediatric illness.
*At 5:28 a.m. a forty-three year old admitted with abdominal pain.
*At 6:00 a.m. an eighty-one year old admitted with hip pain or injury.

Interview on 12/16/15 at 8:59 a.m. with ED director C in regards to the above phone interview revealed the provider had been working on increasing the staffing in the ED during the night shift.

Telephone interview on 12/16/15 at 9:20 a.m. with house supervisor RN B, quality analyst F, and ED director C in regards to patient 5's incident on 10/30/15 revealed:
*She was the house supervisor on the night shift when patient 5 was admitted to the ED on 10/30/15 at 1:41 a.m.
*She had been intermittently down in the ED several times, because the ED was busy. She assisted as needed and went by what the ED nurse told her.
*When she was the house supervisor she was responsible for the entire hospital.
*Her office was in the ED area. She had come down to the Ed to assist in starting an IV for an ED patient and to give a medication.
*When a patient was admitted to the ED on a mental health hold or on suicide precautions the patients would normally be held overnight until the patient could be transferred to a behavior health facility. So the staff tried to ensure the patients were not a harm to themselves.
*All patients admitted to the ED for mental health issues were placed in a hospital gown, and their clothes and belongs were placed in a plastic belongings bag and taken out of the room.
*A watcher was usually called in to assist when there was a mental health patient however there was a HUC on the night of 10/30/15, so that staff person was used as the watcher.

Interview on 12/16/15 at 10:20 a.m. with QMHP A in regards to mental health holds and emergency permits revealed:
*Emergency permits and mental heath holds were the same.
*The patient would be evaluated for imminent risk. The ICU (intensive care unit) would be used for mental health patients requiring a 1:1 observation, but if the ICU was at capacity that unit would not be able to accept a mental health patient.
*If the patient had a violent history that patient would not have been admitted to the ICU.
*If the mental health patients were not transferred by 3:00 p.m. the sheriff's office would not have transferred them until the next day.
*Determination if the mental health patient was transferred to a behavior health facility was dependent on the sheriff's department.

Interview on 12/16/15 at 10:58 a.m. with county sheriff G in regards to mental health patients and transfers revealed:
*When law enforcement were on the scene of a mental health patient those law enforcement officers made the evaluation to see if that person required some form of mental health treatment.
*The law enforcement officer would search the patient at the hospital to verify they had no weapons, and they were safe to be in the ED.
*If a patient admitted to the ED was on a mental health hold that did not mean the law enforcement officer would stay with the patient in the ED.
*The watchers that were utilized at the hospital for mental health patients were employees of the county. The use of the watchers was determined by the ED or hospital staff.
*The patients on a mental health hold were only held for twenty-four hours.
*The panic button was used by hospital staff and the report came through the dispatch, and then law enforcement would have been dispatched to the hospital.
*The sheriff's department rarely transported any patients during the night.

Interview on 12/16/15 at 1:30 p.m. with the VP of patient services, ED director C, and quality analyst F in regards to the staffing in the ED revealed:
*The goal was to have two RN's in the ED during the night shift and a HUC.
*The positions had been posted.
*No one had been hired at this time.
*The administrative team was looking at adding another RN from their current staffing roster to fill the extra positions in the ED.

Review of the provider's revised May 2015 Crisis Intervention policy revealed:
*"It is the policy of [provider's name] to work cooperatively with other institutions and public officials in the care of the mental health patient, recognizing the hospital's physical limitations and staff capabilities in treating patients with mental health disorders.
*The purpose of the crisis intervention is to provide temporary short term care in a supportive and safe environment for patients who are experiencing a mental health issue.
*Patient's brought to the Emergency Department (ED) by a Peace Officer, family member or other concerned party will be seen by the E.D. physician or family physician and mental health professional or social services prior to admission with 1:1 observation maintained.
*Social Services Staff will be notified of all mental health admissions. They will provide discharge planning and case management services. The social worker should be paged Monday-Friday 8 AM - 5 PM. If patients are admitted between 5 PM and 10 PM Monday-Friday or on weekends and holidays, staff should notify the on-call Social Worker. Anytime a patient is admitted after 10 PM, the Social Worker should be notified at 7 AM the following morning by the nurse caring for the patient.
*Patients under Protective Custody or placed in Protective Custody after admission will have a Peace Officer Hold Authorization issued.
*Patients under Protective Custody will have 1:1 observation. The RN is responsible for the patient's plan of care. 1:1 observation may be delegated.
*The House Supervisor will notify staff called in to care for a crisis intervention patient to report to the Emergency Department.
*Clothing and shoes should be secured outside the room. Belongs should be sent home with family members whenever possible.
*Assist the patient to put on a approved gown/pants.
*Assure 1:1 observation is maintained. Documentation of the continuous observation should be made on the Mental Health 1:1 Observation Flow Sheet.
*The individual monitoring patients in protective custody will document the patient's status every hour assuring the patient's physical needs are met.
*If the patient is in Protective Custody, follow the patient maintaining visualization of the patient at all times until law enforcement arrives."

Review of the provider's revised September 2015 Safety policy revealed the staff should have provided and maintained a safe environment for patients, visitors, and personnel in the emergency department.

Review of the provider's undated Registered Nurse Emergency Room-Staff RN job description revealed:
*"The Registered Nurse (RN) is a licensed professional responsible for the delivery of patient care. The nurse is guided by professional nursing standards. The RN may direct activities of other nursing department personnel."
*General RN Job Responsibilities would include following established policies and procedures.

Review of the provider's undated House Supervisor Job Description revealed:
*"Under direction and broad supervision of the Directors of Patient Services, is responsible for nursing service activities/functions. Is responsible for administering hospital, nursing service and personnel policies; for maintaining quality and safety in patient care for acting in any nursing capacity as needed."
*Monitor appropriate staffing levels.

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*Mental health patients removed their street clothes and put on hospital attire for safety purposes for one of one patient (5) who had eloped in their street clothes from the emergency department (ED).
*The ED was adequately staffed to ensure patient safety for one of one mental health patient (5) who was on a mental health hold and who had eloped from the ED.
*Health unit coordinators responsible for 1:1 (one-to-one) monitoring of mental health patients were trained regarding their job responsibilities.
*Staff documented 1:1 observations for one of one mental health patient (5) who had eloped from the ED.
*The hospital supervisor implemented Crisis Intervention policy to ensure a trained staff watcher had been contacted to conduct 1:1 monitoring for one of one mental health patient (5) who eloped from the ED.

1. Observation and interview on 12/15/15 at 10:40 a.m. of the ED with ED director C and house supervisor registered nurse (RN) D revealed:
*ED rooms 1 and 2 were used for those patients that had been brought there with mental health issues. Both rooms were located next to the exit doors of the ED.
*Watchers were used when mental health patients were admitted to the ED; those individuals were contracted by the county and were not employed by the hospital.
*There was a panic button behind the nurses station the staff could use if there was a patient that was having escalating behaviors or that had been attempting to leave the premises. The panic button went directly to the police department and would notify law enforcement of the exact location of the incident. The staff then would follow-up with a call to 911.
*If there were more than one mental health patient in the ED then two watchers would be used. The list for the watchers was located at the nurses station.
*There were two RN's in the ED on the day shift from 11:00 a.m. to 11:00 p.m., and then from 11:00 p.m. to 7:00 a.m. there was only one RN in the ED.
*The house supervisor would be the back-up for the RN at night if she became busy in the ED.
*When a mental health patient presented to the ED the crisis intervention procedure would be initiated.
*The patient would have been placed in a hospital gown, and their clothes and belongings would have been taken out of the room.
*A nursing assessment would have been completed.
*The social services department would have been notified.
*A 1:1 (one-to-one) Mental Health Observation Flow Sheet was initiated by the watcher.
*The watcher would always have "eyes on" the patient.

Review of patient 5's electronic medical record revealed:
*The patient had been admitted on 10/30/15 at 1:41 a.m.
*She had been admitted with a drug overdose per ambulance.
*The medical record indicated she had ingested (swallowed) forty Tylenol tablets and twenty Xanax (for anxiety) tablets.
*She had a history of suicidal ideations and seizures.
*She had been placed on a mental health hold on 10/30/15 at 2:00 a.m. by law enforcement.
*The physician had ordered suicide precautions.
*The patient had been cooperative and had slept much of the night.
*She had been awoken at approximately 5:05 a.m. for a consultation with a behavioral health facility staff person. She then had become aware she was on a mental health hold and was going to be transferred to a behavioral health facility. The patient became upset, pulled out her IV (intravenous), and walked out the ED at approximately 5:55 a.m.
*Law enforcement was called per phone and notified of the patient exiting the ED.
*She was returned to the hospital approximately three hours later at 8:59 a.m. by law enforcement.
*She was then transferred at 11:22 a.m. by law enforcement to the accepting behavioral health facility.

Interview on 12/15/15 at 1:30 p.m. with the vice president (VP) of patient care regarding patient 5's above incident revealed:
*The staff on the night of 10/30/15 had not followed the hospital policy and procedure in regards to the May 2015 dated Crisis Intervention policy.
*The patient should have been undressed, placed in a patient gown, and her belongings removed from the ED room.
*After the patient had been placed on a mental health hold the police officer had not stayed with the patient.
*The patient had escalating behavior after she found out she was on a mental health hold and was going to be transferred to a behavior health facility.

Interview on 12/15/15 at 2:30 p.m. with ED director C in regards to patient 5's incident on 10/30/15 revealed:
*Suicide precautions were ordered for patient 5 upon admission to the ED.
*The 1:1 Mental Health Observation Flow Sheet was initiated after the incident on 10/30/15 with patient 5.
*If and when the ED would become busy a watcher would be called to assist if there was a mental health patient.
*There was no formal training for the HUC (health unit coordinator) who conducted the 1:1 observations. The situation/requirements would have been discussed with the HUC by the ED supervising RN.
*There had been a staff meeting on 11/4/15 with the ED staff and the house supervisors.
*There was no policy or procedure on suicide precautions.
*Suicide precautions meant there should be 1:1 eyes on patient.
*There was no formal training on suicide precautions.
*There was no documentation of 1:1 observation of patient 5 the night of 10/30/15.

Interview on 12/15/15 at 3:40 p.m. with qualified mental health professional (QMHP) regarding patient 5's ED admission on 10/30/15 revealed:
*She was the only QMHP in the hospital.
*When the the patient's were brought into the ED she completed the evaluation. She then makes the recommendations for the patient. She would collect the information from the patient and/or family/friends.
*The evaluation for patient 5 was not documented until 8:52 p.m. on 10/30/15. She explained she had documented on the wrong patient, and that was why the documentation was not done until ten hours after the patient had been transferred to another facility.
*Law enforcement transferred all patients who had been cleared medically by the physician. "So the hospital was at the mercy of the county sheriff's police force when they were able to transfer the patient to a behavioral health facility."
*She or another social worker would have been on call until 10:00 p.m. Monday through Friday. If there was an evaluation that would have been required the patient would have been evaluated after she had returned to work the next day or if the patient was taken into custody there was another counseling agency that could perform the evaluation in jail.

Interview and observation on 12/15/15 at 4:00 p.m. in the ED with patient care technician/certified nursing assistant J in regards to the Mental Health Observation Flow Sheets and 1:1 observations of mental health patients revealed:
*She had no formal training to be a watcher.
*She was observed during the ED visit to have a patient who was on a 1:1 observation and had placed herself right in front of patient room 1 to observe a current ED patient.
*She stated that 1:1 meant "eyes on" the patient at all times.

Interview on 12/16/15 at 8:15 a.m. with quality analyst supervisor H in regards to transporting mental health patients revealed:
*The transferring of the mental health patient was dependent on the availability of the sheriff's department. The sheriffs department provided all the transportation for mental health patients to behavioral health facilities.
*The sheriff's department usually did not transfer any patients after 4:00 p.m.

Telephone interview on 12/16/15 at 8:44 a.m. with ED RN E, quality analyst F, and ED director C in regards to patient 5's incident on 10/30/15 revealed:
*The ED was very steady for a Thursday night.
*There were two people staffed in the ED, herself and a HUC.
*The provider's protocol was to call the house supervisor for assistance if the ED became busy. The house supervisor came down to the ED a few times during the night to assist her.
*When suicidal precautions were implemented a watcher would have been called in to assist. They had not called in a watcher that night. The HUC had bee