HospitalInspections.org

Based on medical record review, hospital policy review and staff interviews, the Hospital's administrative staff failed to ensure emergency department (ED) staff provided the following, within their capabilities, per hospital policy, for patients that presented to the ED seeking medical care from 9/1/23 to 3/1/24:

1) an appropriate Medical Screening Exam (MSE) for 1 of 20 sample patients (Patient #17); and,

2) the appropriate stabilizing treatment for 1 of 20 sample patients (Patient #17).

Failure to provide the appropriate MSE and stabilizing treatment per hospital policy, placed patients at risk for undiagnosed emergency medical condition (EMC), deterioration of health and potential risk of death.

Findings include:

I. Review of policy "MercyOne Dubuque Medical Center- Emergency Department Admissions", dated 8/8/19, revealed in part, " ... All Patients who present to the Emergency Department (ED) requesting care will be assessed by an ED nurse and provided with stabilizing treatment and admitted or transferred to an appropriate facility ..."

II. Review of policy "MercyOne Dubuque Medical Center- Elopement", dated 10/3/22, revealed the policy addressed what staff should do after a patient elopement, and lacked any direction to staff on what staff should do to prevent an elopement.

III. Review of the undated policy " Care of Brain Health Substance Use Disorder" revealed in part,"...Patients in the ED (with an) "Elopement risk (per history or police/family report)"...Security presence may be requested when the nurse or physician have a high suspicion for any of the above or are concerned about the patient's immediate safety ...ED staff will inform security staff of the safety concern. As soon as the patient has been assessed as not to be a safety risk, or other resources (e.g., CNA, behavioral health tech, Avasys camera monitoring system) have been secured to watch the patient, security staff will be released ...Security personnel will be utilized for the following patients/situations (safety concerns)...Elopement risk (per history or police/family report)." The policy identified the use of a 1:1 sitter for high risk suicidal patients only.

IV. Review of policy "MercyOne Dubuque Medical Center- Security Officer-5117", dated 3/2023, revealed in part,"... (Security) Manages non-physical and physical situations involving patients, visitors, staff, etc. using Mandt System (holistic training to reduce workplace violence), while ensuring the safety of all concerned. This will potentially involve holding/restraining individuals who may be violent in nature."

V. On 4/9/24 at 2:00 PM, during an interview, Staff A ED DO explained ED staff used the Columbia suicide screening versus other screening to determine a patient's elopement risk. Staff A ED DO reported they did not really have a scale for elopement; they went by more of a "feeling". Staff A ED DO explained that they were more worried about patients voicing suicidal ideations. When asked if ED staff use a tool to assess a patient's level of agitation, Staff A ED DO reported they do not use any type of screening tool, the ED staff determine a patient's level of agitation based on talking with the patients and with her "gut feeling".

VI. During an interview, on 4/8/24 at 7:02 PM, Staff T Security Officer explained when nursing staff was not available, they asked Security staff to sit 1:1 with patients. If security had to leave for an emergency, they would notify the nurse. The nurse would watch the patient until Security staff returned. Staff T Security Officer explained ED staff instructed security to watch the Court Committal patients during admission. If a patient was not violent, or a threat to others, then ED staff would dismiss security, and nursing staff would sit with them. Staff T Security Officer reported if a patient was violent, they would be there during the violent episode..

VII. Review of Patient #17's medical record revealed:

1. On 2/11/2024 at 10:13 AM Staff B ED RN documented triage notes: Focused Assessment: Patient #17 neighbors reported to local law enforcement that the patient was throwing items in the apartment, screaming and yelling on February 7th. Local Law Enforcement obtained a Court Order on February 8, 2024. Local law enforcement picked the patient up by the train tracks on 2/11/2024 and brought the patient to the ED under a court committal order. Staff B ED RN documented vitals signs as follows: temperature measured Fahrenheit (F) 98.6 Degrees F; pulse rate measured 119 beats per minutes (BPM), (High- normal range measured between 60 to 100 beats per minute); systolic blood pressure (BP) measured 158 millimeters of mercury (mmHg), (High- normal range measured between 70 to 145 mmHg); diastolic BP measured 83 mmHg; respiratory rate: 18 breaths per minutes (Br PM); pulse oximetry measured 94 percent (out of 100 percent) on room air; and no pain.

2. Review of the court order, dated 2/8/24, revealed an order immediate custody and for the hospital to detain Patient #17 until a court hearing, dated 4/12/24. The judge issued the court order based on the probable cause that Patient #17 was seriously mentally impaired and was likely to injure him/herself. If the hospital was unable to house Patient #17, local law enforcement would transport (the patient) to a suitable facility.

3. On 2/11/2024 at 10:19 AM Staff B ED RN completed a self harm risk assessment screen on Patient #17. The patient denied suicidal ideation and did not have a history of self harm. Staff B ED RN documented the patient did not have a risk of self harm.

4. On 2/11/24 at 10:20 AM Staff B ED RN documented, Patient #17 admitted they threw items around in the apartment to relieve stress about their child's death. Staff B ED RN documented the patient reported being down by the train tracks today (2/11/24) watching the eagles fly. The patient denied feeling like hurting themselves or others. Staff B ED RN documented Patient #17 demeanor's changed when the nurse described the court commitment order to the patient and explained the need to stay until the court date on 2/12/24. Patient #17 agreed to stay and be assessed, but insisted on going home after the doctor exam.

5. On 2/11/24 at 10:31 AM Staff B ED RN documented, security was called for assistance. Patient #17 appeared agitated, but was able to calm themselves.

6. On 2/11/24 at 10:42 AM, Staff A ED DO documented Patient #17 was brought in by local law enforcement with committal papers. Local Law enforcement had responded to Patient #17's home numerous times over the past 3 to 4 days. They reported that Patient #17 had been naked, destroying property inside the apartment and creating a nuisance.

Staff A ED DO documented, local law enforcement officers believed Patient # 17 was in a psychotic state, not able to communicate, not able to make good decisions and they were worried about patient safety. Patient #17 reported they felt better just had a bad couple of days. Patient #17 reported they had received services from a Mental Health provider previously, but stopped 6 years ago due to medication side effects. Patient #17 reported they did not intend to harm themselves or others. Patient #17 just wanted to go enjoy the fresh air. Patient #17 had a mild cough but denied fever, or shortness of breath (SOB).

Staff A ED DO documented Patient #17 had a diagnosis of acute psychosis. Patient #17 initially wanted to leave but was redirectable and remained cooperative and calm with staff. Staff A ED DO documented they obtained labs and the patient's electrolytes and creatinine were normal. Staff A ED DO documented the patient's white blood cell (WBC) count (indicative a possible infection) was slightly elevated but a respiratory swab was negative and the patient was not hypoxic (low oxygen levels in the blood). Patient #17 reported a cough for a couple of days but no other symptoms with it, and did not have a fever. The patient's urine analysis (UA) positive for marijuana (THC).

In the same entry note (dated 2/11/24), Staff A ED DO documented that they spoke with Staff E MD at 2:50 PM, regarding admission to the Behavioral Health unit pending a completed Chest X-ray. Patient #17 declined medications in the ED and remained cooperative at shift change (3:00 PM).

7. On 2/11/24 at 12:15 pm, Staff B ED RN documented when Patient #17 was offered PRN anxiety medications, Patient #17 stated they did not like how the medication made them feel. Staff B ED RN gave Patient #17 the option to agree to behave or take the medications; the patient agreed to behave.

8. On 2/11/2024 at 3:00 PM, Staff F ED MD assumed medical care of the patient.

9. Patient #17's medical record lacked documentation of an entry into the patient's record by Staff F ED MD until 2/11/2204 at 5:31 PM. At 5:31 PM, Staff F ED MD documented the following: "Patient signed out from (Staff A ED DO) to (Staff F ED MD) pending chest x-ray and then admission to the psychiatric floor at 10:00. (Staff A ED DO) already spoke with (Staff E Psychiatrist MD) and he accepted the admission of the patient. The patient assaulted one of our nurses at 530 out of nowhere. (Patient) came out of (the) room and punched our nurse and then (the patient) eloped and ran out from the ER. The police were called. Our staff tried to go after the patient on hospital property to bring (the patient) back to the ER but he ran off hospital grounds."

10. On 02/11/2024 at 5:28 PM, Staff C ED RN documented Patient #17 had been witnessed coming out of the Brain Health (BH) room and yelled at their nurse. Staff C ED RN witnessed Patient #17 turn and walk through the double doors and out the ambulance garage side door barefoot while holding up the patient's pants. Staff C, B and Staff O followed Patient #17 at a safe distance, asked to stop and come back. Patient #17 did not acknowledge the staff, Patient #17 continued to walk down the parking lot until passed the daycare area then turned and entered the woods. Patient #17 observed walking down the steep hill into the ravine. Patient #17 walked across a flat area, fell to their knees and forward onto their chest. Patient #17 was observed to be laying with his/her head turned to the left, right arm flexed toward the patient's face and right knee slightly flexed. Police arrived and EMS was notified by the police. Security was at the road side with staff and the police. Security said they would continue to observe Patient #17 until EMS arrived, 2 police officers were present. Staff B and C returned to the ED.

11. On 02/11/2024 at 5:33 PM, Staff B ED RN documented, Patient #17 ripped and chewed on hospital scrubs in the room via camera. Staff B ED RN entered Patient #17's room to discuss that Patient #17 needed to stop destroying hospital property. Patient #17 stated, wants to talk to the police. Patient #17 then exited the room and yelled for help and the police. Staff B ED RN made sure to stay between Patient #17 and other patients in the hallway. Patient #17 stated Staff B ED RN hurt them and Patient #17 swung at Staff B ED RN twice and connected once with Staff B ED RN right shoulder. Staff B ED RN explained to Patient #17 staff had taken care of them and notified the doctor about concerns. Patient #17 turned and looked for an exit and bolted out the door to the ambulance garage and exterior exit door.

12. Review of Patient #17's medical record revealed a lack of evidence of a 1:1 sitter, Security staff or any other hospital staff providing continuous observation of the patient while the patient received ED services.

13. Patient #17's medical record lacked evidence of a completed Chest X-ray.

14. On 2/11/2024 at 6:55 PM, Staff F ED MD documented the patient presented to the ED at 6:09 PM in asystole (absence of a heart rhythm). Staff F ED MD documented the patient was found face down in a field by Emergency Medical Services (EMS) and law enforcement. Patient #17 did not have a pulse and EMS started Cardiopulmonary Resuscitation (CPR). Staff F ED MD pronounced the patient dead at 6:19 PM.


VIII. During an interview on 4/3/24 at 2:00 PM, ED RN Nurse Manager revealed, Patient # 17 was cooperative, did not want medication, was not suicidal and did not cause any issues when brought to the ED. Staff did not feel patient was a risk for elopement. If staff felt a patient was an elopement risk, ED staff would complete 15 minute checks and document the patient's behavior. ED Nurse manager reported the hospital had Security staff available on site 24/7.

The medical record lacked evidence that the patient received a completed MSE. ED staff failed to ensure the patient received a physician ordered chest x-ray. The patient potentially had an undiagnosed EMC. The medical record lacked evidence ED staff maintained the patient's safety by preventing the patient from eloping through use of the hospital's Security and provided the appropriate stabilizing treatment for the patient's diagnosed EMC of acute psychosis.



See A-2406, A 2407, for further details.

Based on medical record review, review of the hospital's Security staff schedule and staff interviews, the Acute Care Hospital's administrative staff failed to ensure the Emergency Department (ED) staff provided, within the hospital's capabilities, an appropriate medical screening examination (MSE) to 1 of 20 emergency patients reviewed (Patient #17).

Failure to provide an appropriate MSE to all patients presenting to the ED seeking medical care places them at risk for an undetected emergency medical condition (EMC).

Findings include:

1. Review of Security Schedule showed 1 Security officer on duty from 6:30AM to 3:00 PM, 2 Security officers on duty from 2:30 PM until 11:00Pm and 10:30PM to 7:00 AM on 2/11/24.

2. On 4/9/24 at 2:00 PM, during an interview, Staff A ED DO explained ED staff used the Columbia suicide screening versus other screening to determine a patient's elopement risk. Staff A ED DO reported they did not really have a scale for elopement; they went by more of a "feeling". Staff A ED DO explained that they were more worried about patients voicing suicidal ideations. When asked if ED staff use a tool to assess a patient's level of agitation, Staff A ED DO reported they do not use any type of screening tool, the ED staff determine a patient's level of agitation based on talking with the patients and with their "gut feeling".

3. During an interview, on 4/8/24 at 7:02 PM, Staff T Security Officer explained when nursing staff was not available, they asked Security staff to sit 1:1 with patients. If security had to leave for an emergency, they would notify the nurse. The nurse would watch the patient until Security staff returned. Staff T Security Officer explained ED staff instructed security to watch the Court Committal patients during admission. If a patient was not violent, or a threat to others, then ED staff would dismiss security, and nursing staff would sit with them. Staff T Security Officer reported if a patient was violent, they would be there during the violent episode..

4. Review of Patient #17's medical record revealed:

a. On 2/11/2024 at 10:13 AM Staff B ED RN documented triage notes: Focused Assessment: Patient #17 neighbors reported to local law enforcement that the patient was throwing items in the apartment, screaming and yelling on February 7th. Local Law Enforcement obtained a Court Order on February 8, 2024. Local law enforcement picked the patient up by the train tracks on 2/11/2024 and brought the patient to the ED under a court committal order. Staff B ED RN documented vitals signs as follows: temperature measured Fahrenheit (F) 98.6 Degrees F; pulse rate measured 119 beats per minutes (BPM), (High- normal range measured between 60 to 100 beats per minute); systolic blood pressure (BP) measured 158 millimeters of mercury (mmHg), (High- normal range measured between 70 to 145 mmHg); diastolic BP measured 83 mmHg; respiratory rate: 18 breaths per minutes (Br PM); pulse oximetry measured 94 percent (out of 100 percent) on room air; and no pain.

b. Review of the court order, dated 2/8/24, revealed an order immediate custody and for the hospital to detain Patient #17 until a court hearing, dated 4/12/24. The judge issued the court order based on the probable cause that Patient #17 was seriously mentally impaired and was likely to injure him/herself. If the hospital was unable to house Patient #17, local law enforcement would transport (the patient) to a suitable facility.

c.On 2/11/2024 at 10:19 AM Staff B ED RN completed a self harm risk assessment screen on Patient #17. The patient denied suicidal ideation and did not have a history of self harm. Staff B ED RN documented the patient did not have a risk of self harm.

d. On 2/11/24 at 10:20 AM Staff B ED RN documented, Patient #17 admitted they threw items around in the apartment to relieve stress about their child's death. Staff B ED RN documented the patient reported being down by the train tracks today (2/11/24) watching the eagles fly. The patient denied feeling like hurting themselves or others. Staff B ED RN documented Patient #17 demeanor's changed when the nurse described the court commitment order to the patient and explained the need to stay until the court date on 2/12/24. Patient #17 agreed to stay and be assessed, but insisted on going home after the doctor exam.

e. On 2/11/24 at 10:31 AM Staff B ED RN documented, security was called for assistance. Patient #17 appeared agitated, but was able to calm themselves.

f. On 2/11/24 at 10:42 AM, Staff A ED DO documented Patient #17 was brought in by local law enforcement with committal papers. Local Law enforcement had responded to Patient #17's home numerous times over the past 3 to 4 days. They reported that Patient #17 had been naked, destroying property inside the apartment and creating a nuisance.

Staff A ED DO documented, local law enforcement officers believed Patient # 17 was in a psychotic state, not able to communicate, not able to make good decisions and they were worried about patient safety. Patient #17 reported they felt better just had a bad couple of days. Patient #17 reported they had received services from a Mental Health provider previously, but stopped 6 years ago due to medication side effects. Patient #17 reported they did not intend to harm themselves or others. Patient #17 just wanted to go enjoy the fresh air. Patient #17 had a mild cough but denied fever, or shortness of breath (SOB).

Staff A ED DO documented Patient #17 had a diagnosis of acute psychosis. Patient #17 initially wanted to leave but was redirectable and remained cooperative and calm with staff. Staff A ED DO documented they obtained labs and the patient's electrolytes and creatinine were normal. Staff A ED DO documented the patient's white blood cell (WBC) count (indicative a possible infection) was slightly elevated but a respiratory swab was negative and the patient was not hypoxic (low oxygen levels in the blood). Patient #17 reported a cough for a couple of days but no other symptoms with it, and did not have a fever. The patient's urine analysis (UA) positive for marijuana (THC).

In the same entry note (dated 2/11/24), Staff A ED DO documented that they spoke with Staff E MD at 2:50 PM, regarding admission to the Behavioral Health unit pending a completed Chest X-ray. Patient #17 declined medications in the ED and remained cooperative at shift change (3:00 PM).

g. On 2/11/24 at 12:15 pm, Staff B ED RN documented when Patient #17 was offered PRN anxiety medications, Patient #17 stated they did not like how the medication made them feel. Staff B ED RN gave Patient #17 the option to agree to behave or take the medications; the patient agreed to behave.

h. On 2/11/2024 at 3:00 PM, Staff F ED MD assumed medical care of the patient.

i. Patient #17's medical record lacked documentation of an entry into the patient's record by Staff F ED MD until 2/11/2204 at 5:31 PM. At 5:31 PM, Staff F ED MD documented the following: "Patient signed out from (Staff A ED DO) to (Staff F ED MD) pending chest x-ray and then admission to the psychiatric floor at 10:00. (Staff A ED DO) already spoke with (Staff E Psychiatrist MD) and he accepted the admission of the patient. The patient assaulted one of our nurses at 530 out of nowhere. (Patient) came out of (the) room and punched our nurse and then (the patient) eloped and ran out from the ER. The police were called. Our staff tried to go after the patient on hospital property to bring (the patient) back to the ER but he ran off hospital grounds."

j. On 02/11/2024 at 5:28 PM, Staff C ED RN documented Patient #17 had been witnessed coming out of the Brain Health (BH) room and yelled at their nurse. Staff C ED RN witnessed Patient #17 turn and walk through the double doors and out the ambulance garage side door barefoot while holding up the patient's pants. Staff C, B and Staff O followed Patient #17 at a safe distance, asked to stop and come back. Patient #17 did not acknowledge the staff, Patient #17 continued to walk down the parking lot until passed the daycare area then turned and entered the woods. Patient #17 observed walking down the steep hill into the ravine. Patient #17 walked across a flat area, fell to their knees and forward onto their chest. Patient #17 was observed to be laying with his/her head turned to the left, right arm flexed toward the patient's face and right knee slightly flexed. Police arrived and EMS was notified by the police. Security was at the road side with staff and the police. Security said they would continue to observe Patient #17 until EMS arrived, 2 police officers were present. Staff B ED RN and Staff C ED RN returned to the ED.

k. On 02/11/2024 at 5:33 PM, Staff B ED RN documented, Patient #17 ripped and chewed on the patient's hospital scrubs in the room via camera. Staff B ED RN entered Patient #17's room to discuss that Patient #17 needed to stop destroying hospital property. The patient stated that the patient wanted to talk to the police. Patient #17 then exited the room and yelled for help and the police. Staff B ED RN made sure to stay between Patient #17 and other patients in the hallway. Patient #17 stated Staff B ED RN hurt them and Patient #17 swung at Staff B ED RN twice and connected once with Staff B ED RN right shoulder. Staff B ED RN explained to Patient #17 staff had taken care of them and notified the doctor about concerns. Patient #17 turned and looked for an exit and bolted out the door to the ambulance garage and exterior exit door.

l. Review of Patient #17's medical record revealed a lack of evidence of a 1:1 sitter, Security staff or any other hospital staff providing continuous observation of the patient while the patient received ED services.

m. Patient #17's medical record lacked evidence of a completed Chest X-ray.

n. On 2/11/2024 at 6:55 PM, Staff F ED MD documented the patient presented to the ED at 6:09 PM in asystole (absence of a heart rhythm). Staff F ED MD documented the patient was found face down in a field by Emergency Medical Services (EMS) and law enforcement. Patient #17 did not have a pulse and EMS started Cardiopulmonary Resuscitation (CPR). Staff F ED MD pronounced the patient dead at 6:19 PM.

5. During an interview on 3/27/24 at 1:00 PM, Staff B ED RN recalled, they read court paperwork while sitting next to Patient #17. Staff B ED RN reported to Staff A ED DO that Patient #17 verbalized they wanted to leave, Staff A ED DO explained to Patient #17 why they needed to stay and Patient #17 agreed.

Staff B ED RN recalled that Patient #17 scored a medium on the suicide risk screen and did not require a 1:1. Patient #17 was calm, rational, not agitated and had an organized manner. Staff B ED RN recalled the patient had an elevated heart rate. Law enforcement left and Staff B ED RN got the patient dressed into scrubs.

Staff B ED RN recalled, Patient #17 refused a lab draw. Staff B ED RN explained to Patient #17 the reasons for the lab to be drawn as a standard. Patient #17 agreed to a lab draw. Staff B ED RN advised the lab technician to not enter the room alone. Security stood in the doorway and the lab tech drew the patient's blood.

Staff B ED RN recalled at one point, they checked on Patient #17 who was naked. The patient said they were meditating. Staff B ED RN asked the patient to put their clothes back on. Staff B ED RN checked the camera and Patient #17 had scrubs back on, but was ripping the scrubs.

Staff B ED RN recalled Staff B entered Patient #17's room and asked the patient to stop ripping the scrubs. Staff B ED RN threatened to get the police involved if the patient did not stop ripping the scrubs. Patient #17 escalated. The patient wanted a doctor and the police, and was not doing well. Patient #17 busted through Staff B ED RN. Patient#17 was shouting to get the police and said Staff B ED RN was hurting the patient. Out in the hall, Patient#17 was still agitated. Staff B ED RN recalled Staff B raised his hand to get the patient to stop and Patient#17 raised hands and took a swing at Staff B ED RN. Staff B ED RN recalled people were coming down the hall behind them. The charge nurse and a patient aide approached. Staff B ED RN recalled, Patient #17 turned went out the doors into the ambulance garage, turned to the left and went out a walk-in door. Staff B ED RN recalled, they continued to follow Patient #17.

6. During an interview on 4/3/24 at 2:00 PM, ED RN Nurse Manager revealed, Patient #17 was cooperative, did not want medication, was not suicidal and did not cause any issues when brought to the ED. Staff did not feel patient was a risk for elopement. If staff felt a patient was an elopement risk, ED staff would complete 15 minute checks and document the patient's behavior. ED Nurse manager reported the hospital had Security staff available on site 24/7.

7. During an interview, on 4/3/24 at 2:33 PM, Staff H Security Officer(SO) explained when sat across the hall in cubby watching Patient #17 on the camera feed from 10AM to 1:15PM on 2/11/24. Staff H SO reported the patient came to the door a few times and the patient stated they did not want to be there. Staff H SO explained to the patient that the patient could not leave. The patient went back in the room and settled down.

Staff H SO reported the ED nurse told Staff H that the patient seemed calm enough for Staff H to leave and the nurses would watch the patient. Staff H SO explained they had the same camera views in the Security office and Staff H continued to watch the ED camera views while eating lunch, which typically lasts 30 minutes. Patient #17 remained calm during the 30 minutes. After lunch, Staff H SO reported going back to their normal duties. At 2:15 PM, Staff H SO reported ED staff called Staff H to return to the ED for another patient. Patient #17 was still calm and cooperative at that time. Staff H SO was relieved at 2:30 by Staff I SO.

8. On 4/9/24 at 2:00 PM, during an interview, Staff A ED DO explained the use of chemical and physical restraints usage. Staff A ED DO explained that they first used chemicals in an attempt to calm patients with anxiety, depression, or who were extremely escalated. Staff A ED DO explained they used physical restraints for more violent and assaultive type patient behavior.

The medical record lacked evidence that the patient received a completed MSE. ED staff failed to ensure the patient received a physician ordered chest x-ray. The patient potentially had an undiagnosed EMC. ED staff failed to utilize the hospital's capabilities to ensure the patient did not elope prior to the completion of the MSE.

Based on medical record review, security video footage review, Security staff schedule review and staff interviews, the Hospital's administrative staff failed to ensure emergency department (ED) staff provided, within their capabilities, the appropriate stabilizing treatment for 1 of 20 sample patients (Patient #17) that had an emergency medical condition (EMC) for patients that presented to the ED seeking medical care from 9/1/23 to 3/1/24.

Failure to provide the appropriate stabilizing treatment, placed patients at risk for deterioration of health and potential risk of death.

Findings include:

1. Review of Security Schedule showed 1 Security officer on duty from 6:30AM to 3:00 PM, 2 Security officers on duty from 2:30 PM until 11:00 PM and 10:30 PM to 7:00 AM on 1/26/24, 1/27/24 and 2/11/24.

2. On 4/9/24 at 2:00 PM, during an interview, Staff A ED DO explained ED staff used the Columbia suicide screening versus other screening to determine a patient's elopement risk. Staff A ED DO reported they did not really have a scale for elopement; they went by more of a "feeling". Staff A ED DO explained that they were more worried about patients voicing suicidal ideations. When asked if ED staff use a tool to assess a patient's level of agitation, Staff A ED DO reported they do not use any type of screening tool, the ED staff determine a patient's level of agitation based on talking with the patients and with their "gut feeling".

3. During an interview, on 4/8/24 at 7:02 PM, Staff T Security Officer explained when nursing staff was not available, they asked Security staff to sit 1:1 with patients. If security had to leave for an emergency, they would notify the nurse. The nurse would watch the patient until Security staff returned. Staff T Security Officer explained ED staff instructed security to watch the Court Committal patients during admission. If a patient was not violent, or a threat to others, then ED staff would dismiss security, and nursing staff would sit with them. Staff T Security Officer reported if a patient was violent, they would be there during the violent episode.

4. On 4/9/24 at 2:00 PM, during an interview, Staff A ED DO explained the use of chemical and physical restraints usage. Staff A ED DO explained that they first used chemicals in an attempt to calm patients with anxiety, depression, or who were extremely escalated. Staff A ED DO explained they used physical restraints for more violent and assaultive type patient behavior.

5. Review of Patient #17's medical record revealed:

a. On 2/11/2024 at 10:13 AM Staff B ED RN documented triage notes: Focused Assessment: Patient #17 neighbors reported to local law enforcement that the patient was throwing items in the apartment, screaming and yelling on February 7th. Local Law Enforcement obtained a Court Order on February 8, 2024. Local law enforcement picked the patient up by the train tracks on 2/11/2024 and brought the patient to the ED under a court committal order. Staff B ED RN documented vitals signs as follows: temperature measured Fahrenheit (F) 98.6 Degrees F; pulse rate measured 119 beats per minutes (BPM), (High- normal range measured between 60 to 100 beats per minute); systolic blood pressure (BP) measured 158 millimeters of mercury (mmHg), (High- normal range measured between 70 to 145 mmHg); diastolic BP measured 83 mmHg; respiratory rate: 18 breaths per minutes (Br PM); pulse oximetry measured 94 percent (out of 100 percent) on room air; and no pain.

b. Review of the court order, dated 2/8/24, revealed an order immediate custody and for the hospital to detain Patient #17 until a court hearing, dated 4/12/24. The judge issued the court order based on the probable cause that Patient #17 was seriously mentally impaired and was likely to injure him/herself. If the hospital was unable to house Patient #17, local law enforcement would transport (the patient) to a suitable facility.

c.On 2/11/2024 at 10:19 AM Staff B ED RN completed a self harm risk assessment screen on Patient #17. The patient denied suicidal ideation and did not have a history of self harm. Staff B ED RN documented the patient did not have a risk of self harm.

d. On 2/11/24 at 10:20 AM Staff B ED RN documented, Patient #17 admitted they threw items around in the apartment to relieve stress about their child's death. Staff B ED RN documented the patient reported being down by the train tracks today (2/11/24) watching the eagles fly. The patient denied feeling like hurting themselves or others. Staff B ED RN documented Patient #17 demeanor's changed when the nurse described the court commitment order to the patient and explained the need to stay until the court date on 2/12/24. Patient #17 agreed to stay and be assessed, but insisted on going home after the doctor exam.

e. On 2/11/24 at 10:31 AM Staff B ED RN documented, security was called for assistance. Patient #17 appeared agitated, but was able to calm themselves.

f. On 2/11/24 at 10:42 AM, Staff A ED DO documented Patient #17 was brought in by local law enforcement with committal papers. Local Law enforcement had responded to Patient #17's home numerous times over the past 3 to 4 days. They reported that Patient #17 had been naked, destroying property inside the apartment and creating a nuisance.

Staff A ED DO documented, local law enforcement officers believed Patient # 17 was in a psychotic state, not able to communicate, not able to make good decisions and they were worried about patient safety. Patient #17 reported they felt better just had a bad couple of days. Patient #17 reported they had received services from a Mental Health provider previously, but stopped 6 years ago due to medication side effects. Patient #17 reported they did not intend to harm themselves or others. Patient #17 just wanted to go enjoy the fresh air. Patient #17 had a mild cough but denied fever, or shortness of breath (SOB).

Staff A ED DO documented Patient #17 had a diagnosis of acute psychosis. Patient #17 initially wanted to leave but was redirectable and remained cooperative and calm with staff. Staff A ED DO documented they obtained labs and the patient's electrolytes and creatinine were normal. Staff A ED DO documented the patient's white blood cell (WBC) count (indicative a possible infection) was slightly elevated but a respiratory swab was negative and the patient was not hypoxic (low oxygen levels in the blood). Patient #17 reported a cough for a couple of days but no other symptoms with it, and did not have a fever. The patient's urine analysis (UA) positive for marijuana (THC).

In the same entry note (dated 2/11/24), Staff A ED DO documented that they spoke with Staff E MD at 2:50 PM, regarding admission to the Behavioral Health unit pending a completed Chest X-ray. Patient #17 declined medications in the ED and remained cooperative at shift change (3:00 PM).

g. On 2/11/24 at 12:15 pm, Staff B ED RN documented when Patient #17 was offered PRN anxiety medications, Patient #17 stated they did not like how the medication made them feel. Staff B ED RN gave Patient #17 the option to agree to behave or take the medications; the patient agreed to behave.

h. On 2/11/2024 at 3:00 PM, Staff F ED MD assumed medical care of the patient.

i. Patient #17's medical record lacked documentation of an entry into the patient's record by Staff F ED MD until 2/11/2204 at 5:31 PM. At 5:31 PM, Staff F ED MD documented the following: "Patient signed out from (Staff A ED DO) to (Staff F ED MD) pending chest x-ray and then admission to the psychiatric floor at 10:00. (Staff A ED DO) already spoke with (Staff E Psychiatrist MD) and he accepted the admission of the patient. The patient assaulted one of our nurses at 530 out of nowhere. (Patient) came out of (the) room and punched our nurse and then (the patient) eloped and ran out from the ER. The police were called. Our staff tried to go after the patient on hospital property to bring (the patient) back to the ER but he ran off hospital grounds."

j. On 02/11/2024 at 5:28 PM, Staff C ED RN documented Patient #17 had been witnessed coming out of the Brain Health (BH) room and yelled at their nurse. Staff C ED RN witnessed Patient #17 turn and walk through the double doors and out the ambulance garage side door barefoot while holding up the patient's pants. Staff C, B and Staff O followed Patient #17 at a safe distance, asked to stop and come back. Patient #17 did not acknowledge the staff, Patient #17 continued to walk down the parking lot until passed the daycare area then turned and entered the woods. Patient #17 observed walking down the steep hill into the ravine. Patient #17 walked across a flat area, fell to their knees and forward onto their chest. Patient #17 was observed to be laying with his/her head turned to the left, right arm flexed toward the patient's face and right knee slightly flexed. Police arrived and EMS was notified by the police. Security was at the road side with staff and the police. Security said they would continue to observe Patient #17 until EMS arrived, 2 police officers were present. Staff B ED RN and Staff C ED RN returned to the ED.

k. On 02/11/2024 at 5:33 PM, Staff B ED RN documented, Patient #17 ripped and chewed on the patient's hospital scrubs in the room via camera. Staff B ED RN entered Patient #17's room to discuss that Patient #17 needed to stop destroying hospital property. The patient stated that the patient wanted to talk to the police. Patient #17 then exited the room and yelled for help and the police. Staff B ED RN made sure to stay between Patient #17 and other patients in the hallway. Patient #17 stated Staff B ED RN hurt them and Patient #17 swung at Staff B ED RN twice and connected once with Staff B ED RN right shoulder. Staff B ED RN explained to Patient #17 staff had taken care of them and notified the doctor about concerns. Patient #17 turned and looked for an exit and bolted out the door to the ambulance garage and exterior exit door.

l. Review of Patient #17's medical record revealed a lack of evidence of a 1:1 sitter, Security staff or any other hospital staff providing continuous observation of the patient while the patient received ED services.

m. Patient #17's medical record lacked evidence of a completed Chest X-ray.

n. On 2/11/2024 at 6:55 PM, Staff F ED MD documented the patient presented to the ED at 6:09 PM in asystole (absence of a heart rhythm). Staff F ED MD documented the patient was found face down in a field by Emergency Medical Services (EMS) and law enforcement. Patient #17 did not have a pulse and EMS started Cardiopulmonary Resuscitation (CPR). Staff F ED MD pronounced the patient dead at 6:19 PM.

6. During an interview on 3/27/24 at 1:00 PM, Staff B ED RN recalled, they read court paperwork while sitting next to Patient #17. Staff B ED RN reported to Staff A ED DO that Patient #17 verbalized they wanted to leave, Staff A ED DO explained to Patient #17 why they needed to stay and Patient #17 agreed.

Staff B ED RN recalled that Patient #17 scored a medium on the suicide risk screen and did not require a 1:1. Patient #17 was calm, rational, not agitated and had an organized manner. Staff B ED RN recalled the patient had an elevated heart rate. Law enforcement left and Staff B ED RN got the patient dressed into scrubs.

Staff B ED RN recalled, Patient #17 refused a lab draw. Staff B ED RN explained to Patient #17 the reasons for the lab to be drawn as a standard. Patient #17 agreed to a lab draw. Staff B ED RN advised the lab technician to not enter the room alone. Security stood in the doorway and the lab tech drew the patient's blood.

Staff B ED RN recalled at one point, they checked on Patient #17 who was naked. The patient said they were meditating. Staff B ED RN asked the patient to put their clothes back on. Staff B ED RN checked the camera and Patient #17 had scrubs back on, but was ripping the scrubs.

Staff B ED RN recalled Staff B entered Patient #17's room and asked the patient to stop ripping the scrubs. Staff B ED RN threatened to get the police involved if the patient did not stop ripping the scrubs. Patient #17 escalated. The patient wanted a doctor and the police, and was not doing well. Patient #17 busted through Staff B ED RN. Patient#17 was shouting to get the police and said Staff B ED RN was hurting the patient. Out in the hall, Patient#17 was still agitated. Staff B ED RN recalled Staff B raised his hand to get the patient to stop and Patient#17 raised hands and took a swing at Staff B ED RN. Staff B ED RN recalled people were coming down the hall behind them. The charge nurse and a patient aide approached. Staff B ED RN recalled, Patient #17 turned went out the doors into the ambulance garage, turned to the left and went out a walk-in door. Staff B ED RN recalled, they continued to follow Patient #17.

7. During an interview on 4/3/24 at 2:00 PM, ED RN Nurse Manager revealed, Patient #17 was cooperative, did not want medication, was not suicidal and did not cause any issues when brought to the ED. Staff did not feel patient was a risk for elopement. If staff felt a patient was an elopement risk, ED staff would complete 15 minute checks and document the patient's behavior. ED Nurse manager reported the hospital had Security staff available on site 24/7.

8. During an interview, on 4/3/24 at 2:33 PM, Staff H Security Officer(SO) explained when sat across the hall in cubby watching Patient #17 on the camera feed from 10AM to 1:15PM on 2/11/24. Staff H SO reported the patient came to the door a few times and the patient stated they did not want to be there. Staff H SO explained to the patient that the patient could not leave. The patient went back in the room and settled down.

Staff H SO reported the ED nurse told Staff H that the patient seemed calm enough for Staff H to leave and the nurses would watch the patient. Staff H SO explained they had the same camera views in the Security office and Staff H continued to watch the ED camera views while eating lunch, which typically lasts 30 minutes. Patient #17 remained calm during the 30 minutes. After lunch, Staff H SO reported going back to their normal duties. At 2:15 PM, Staff H SO reported ED staff called Staff H to return to the ED for another patient. Patient #17 was still calm and cooperative at that time. Staff H SO was revealed at 2:30 by Staff I SO.

9. A summary review of Security Video footage of Patient #17 revealed the following:

Video footage on 2/11/24 starting at 9:39 AM to 5:11 PM, showed Patient#17 being admitted with law enforcement present. Staff completed the admission of Patient #17 and the patient changed into hospital scrubs. Patient #17 remained in the room sitting on a couch or chair throughout the stay. Patient #17 remained calm and cooperative, refused a lab draw and medication at one point in the video. Patient #17 agreed to lab draw later in the day and cooperated while the lab drew blood with security in the room. Patient #17 would stretch arms and legs and get up and walk around the room and then return to the couch. At 3:04 pm 2/11/24 Patient #17 started removing clothing and sitting naked in the room. Staff and Security appeared in room and Patient #17 put clothing back on. At 4:43 PM, Patient #17 removed their pants and started picking at waistband. Patient #17 removed the elastic and hid it under a chair. Patient #17 chewed at the seam of the cuffs on pants and also chewed on the socks. Patient #17 then split the seam of the legs on the pants up to knees. Patient #17 chewed on the seam of scrub shirt, opened the side seam and then put the shirt back on. At 5:11 PM, staff entered the room to talk with Patient #17. Patient #17 stood and approached the staff member. Patient #17 pushed past staff, exited the room and took a swing at the staff member. At 5:12 PM, the video footage showed Patient #17 exiting the ambulance garage area while being followed by hospital staff. At 5:12 PM to 5:14 PM, Patient #17 and staff walked across the parking lot bare foot.
At 5:14 PM to 5:17 PM, Patient #17 walked into a wooded area behind the hospital. Hospital staff remained at the edge of the hospital property.

Weather from AccuWeather on 2/11/24 revealed an outside temperature of 41-degree Fahrenheit during the day time and 24 degrees Fahrenheit at night.