HospitalInspections.org

Based on Record Review and Interview the hospital failed 1 of 1 Patient (Pateint #1) by failing the patient to receive care in a safe setting. Patient #1 was admitted to the hospital after being with another provider for 2 days and medical clearance was required. Patient #1 was diagnosed with Type 1 diabetes mellitus with hyperglycemia. Patient #1 admits to consuming multiple sodas and attempting to increase blood sugar. Upon arrival to the emergency department blood sugar level was 1600.

Findings Include:

During Record Review of the hospital Clinical Progress Note on 02/11/2024 at 1128 Patient #1 was assessed and determined to be a High Risk for Suicide Ideation, although Patient #1 denied all suicidial ideation in completion of the Crisis Evaluation Assessment. The Behavioral Health Crisis Clinician has completed there assessment and reviewed the findings with the attending physician. The Patient has been recommended for transfer to inpatient behavior healthier care at the conclusion of the assessment the patient was not medically cleared per the attending physician.

During Interview with Hospital Staff #1 at 1:45 PM on 02/22/2024, it was reported by Staff #1, "This Patient was deemed to be a High-Risk Suicide, we should have gotten her a Involuntary EDO. Patient #1 vesiculated back and forth."

During Interview Staff #1 on 02/22/2024 at 2:00 PM Patient #1 signed out of the hospital Against Medical Advice, and walked approximately a quarter of a mile onto the freeway and was struck and killed on the Southbound Side of I-35 by U-Haul truck.

During Interview with Hospital Staff #4 at 4:30PM on 02/22/2024 it was reported, "The Patient requested to leave the hospital Against Medical Advice (AMA). Patient #1 signed to leave and stated wished to return to...[original provider}. The hospital felt Patient #1 was oriented x4 and reported that they do not transport Patients who request and are discharged AMA. The Patient requested directions to get back to {original provider}, which is "less than a mile away." We felt if we transported Patient #1, Patient would continue not to be accepted. If she entered on own accord Patient #1 would be accepted as a walk-in."

"In review of bingmaps.com mental health facility is 1.6 miles away opposite of the direction Patient #1 walked and takes 30minutes to walk."

During Interview on 02/22/2024 at 4:45 PM Staff #4 and Staff #11 reported "Patient #1 signed the AMA, attempts to encourage not to discharge were unsuccessful, but Patient #1 requested direction to get to mental health facility, and directions were provided verbally and hand written. "


Policy

The Texas Health Presbyterian Policy Assessment, Reassessment, and Documentation Policy 10/2022, "The Registered Nurse (RN) is responsible for patient assessment, reassessment and the coordination of patient care.

The Texas Presbyterian Hospital - Denton Policy on "Abuse, Neglect, and Sexual Exploitation of Patients while in the hospital, 08/2022, 'An employee, medical staff member, advanced practice professional ('APP'), allied health professional ('AHP'), or volunteer who reasonably believes a patient has been Abused, Neglected, or Sexually Exploited while the patient is in the hospital shall promptly report it in accordance with this policy .

The Texas Presbyterian Hospital-Denton Policy on "Patient Rights and Responsibilities, 11/2020, "It is the Policy of each Texas Health member facility that every patient has the right to care, treatment, and services within the Facility capacity and capabilities as they may change from time to time, within the Facility mission, and in compliance with federal and state laws, and regulations. "