HospitalInspections.org

Based on policy reviews, medical record reviews and hospital interviews, the hospital failed to have organized emergency services by failing to have systems in place to prevent an IVC (Involuntary Committed) behavioral health inpatient transported to the emergency department from eloping for 1 of 32 ED records reviewed (Pt #7)

The findings include:

Review of the policy titled "Triage - Emergency Department...", dated 07/05/2023, revealed "...The dynamic process of sorting, prioritizing, and assessing the patient...performed by a qualified RN (registered nurse) at the time of presentation....Reassessment - A process of periodic re-evaluation of the patient's condition....Behavioral health patients: A comprehensive triage assessment should be completed after establishing safe environment for the patient. ..."
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Review of the DED (dedicated emergency department) record for Patient #7, on 08/07/2024, revealed Patient #7 was transported from Hospital A's inpatient behavioral health campus (Campus B) to the main campus (Campus A)'s DED. Review of the Transport Services Patient Care Record revealed they were dispatched for a patient with complaints of "breathing problem." Review of the Transport Services Narrative noted " ...When we arrived on scene ...nursing staff ...informed us that the pt was having difficulty breathing and needed to be placed on O2 (oxygen) to keep sats (oxygen saturation) up. Vitals were taken and were within normal range besides her SPO2 (oxygen saturation). Pt has behavioral health history and was taking medication for this ....Pt was transported w/o (without) incident. When we arrived at destination transfer of care was given to nursing staff at ED. ..."

Review of Involuntary Commitment paperwork, dated 12/11/2024 at 1230, revealed a second examination which indicated Patient #7 needed inpatient commitment for 14 days due to " ...suicidal ideation with a plan and means ....high risk of suicide w/out acute inpatient admission and has 3 previous attempts. ..."

Review of the ED Triage Note performed 05/22/2024 at 1230 revealed Patient #7 received an acuity of 2 (on a scale of 1-5 with 1 being most severe). Vital signs were: Temperature 98.3, Pulse 84, Respirations 25, Blood Pressure 132/61, with an oxygen saturation of 98% on 3 liters oxygen and a pain score of 4. Triage Note review further revealed " ...Mental Health Status - ED Triage ...Assess CSSRS (Columbia Scale Suicide Risk Screening - tool used for suicide screening)? : Patient with no chief BH complaint. ..." Review failed to reveal if the triage nurse was aware of Patient #7's IVC status.

Review of the provider's "ER Report" note, dated 05/22/2024 at 1435, revealed " ...This is a 58-year-old female who is brought into the emergency room via EMS secondary to nausea, vomiting and concern for possible aspiration pneumonia with report of O2 saturations being 84% on room air and increasing to 99% on 2 L (2 liters oxygen). The patient undergoes electronic shock therapy treatment and states she has tolerated well up until today. She states that she has felt nauseated and had intermittent episodes of vomiting today. She also reports a mild headache. She did not have symptoms like this after her other electronic shock therapy sessions. She has no complaints of photophobia, difficulty with speech or swallowing or difficulty with ambulating .... She does have behavioral health records which I have reviewed. On reviewing the patient's ECT (electroconvulsive Therapy) procedure note, the patient apparently became very nauseous and vomited approximately 700 mL. The anesthesiologist decided to cancel the procedure and infused 1 L (liter) of lactated Ringer's as well as 4 mg (milligrams) of IV (intravenous) Zofran (medication for nausea). Patient apparently did improve, but O2 sats were documented to be in the upper 70s .... upper 80s on room air. Patient was placed onto 2 L via nasal cannula and opt for sending the patient to the ER ....Here in the ED the patient stated that she just feels nauseated and not quite herself. She does confirm a mild headache as well .... Assessment/Plan ....concerned about possible aspiration pneumonia, given the report. I have requested for a portable chest x-ray, laboratory studies and I am going to get a CT scan of the head to evaluate her headache. Urinalysis and urine drug screen have both been ordered as well. Patient will receive antiemetics (medication for nausea) and fluids. Reexamination/ Reevaluation ....Patient's laboratory studies showed a slightly low sodium at 132 and slightly elevated liver function tests, calcium corrected was just minimally low. CBC (complete blood count) is normal. CT scan of head showed no significant abnormality and our portable chest ray (sic x-ray) showed no significant abnormality. (space) I was made aware by nursing staff that the patient actually got up and left the emergency department with an IV in. I went out to the parking lot with nursing staff to try and convince the patient to come back in, she ripped her IV out and left. My recommendations are for the patient to be brought back into the emergency department for continued workup and evaluation. ..."

A Nurses Note, at 1627, revealed " ...The patient left ED room 54 with her husband by her side, (Nurse Name) RN and Doctor followed patient outside, IV was removed in the parking lot. The patient refused to come back into the ED, the patient and her spouse drove away in their private vehicle. ..." Another Nurse Note at 2013 indicated "This ED manager spoke with patient and her husband via phone call to follow up after they abruptly departed the ER this afternoon. Patient states she was well and had taken a shower and was relaxing on her couch. I expressed concern for patient not completing treatment and requested, if she was willing, we would like her to return to finish her workup. Patient stated that she would 'never come back to this hospital because we never let patients leave.' Patient continued to express that she was fine and if she needed treatment would seek it elsewhere."

A Mental Health Contact Note, on 05/22/2024 at 2158, revealed " ...Received call from (Officer Name) @1800 who reports that she was informed by (Campus B) staff that pt had gone to ED due to medical issue and then left the ED without returning to (Campus B). She reports that they have said that the pt needs to return to (Campus B), but they are unsure regarding her IVC status. They are unable to determine from pt's EMR (electronic medical record), and the paper chart was sent to ED with pt per protocol .... request assistance with locating pt's paper chart in ED....Eventually spoke with EDMD (Name) @1945 and she was able to locate pt's paper chart. Review of papers indicates that pt is on IVC.... Spoke with .... AOC (administrator on call at (Campus B) @2000 who reports that ....treating psychiatrist ....said that pt needs to be brought back under IVC. AOC requests that ....Magistrate be contacted for direction regarding how to proceed ... Contacted ....Sheriff Dept explaining the situation and requesting a return call from the magistrate .... Received call @2120 ....(Magistrate) directs me to fax all of the IVC to the ...County Detention Center and states....will contact the sheriff to have them pick up pt to return to (Hospital A Name) ....Spoke with Detention Center staff again @2230 and they report that deputy is on the way to pt's residence at this time. ..." Review of a Mental Health Contact Note from 05/23/2024 at 0029 revealed " ...Contacted .... Sheriff Dept for an update ....reports they went to pt's home earlier and no one came to the door. He reports that they have not been able to check again as they have had other calls to work. ..." DED record review did not reveal any additional notes in the ED record related to Patient #7's return.

Telephone interview with MD #14, on 08/08/2024 at 1240, revealed MD #14 recalled the situation involving Patient #7 very well. Interview revealed the patient came in the low oxygen levels and they were concerned for possible aspiration pneumonia. Interview revealed MD #14 evaluated Patient #7. MD #14 stated when Patient #7 was evaluated, the MD could tell she was not feeling well and the patient was complaining of a headache. Interview revealed MD #14 got labs and a CT and then went to check on the patient. MD #14 indicated she was getting ready to go back into Pt #7's room when the nursing staff stated the patient was not in the room. MD #14 stated "I said she can't leave." Interview revealed MD #14 literally ran to the parking lot to try and get the patient to come back in. Patient was there, tore out her IV, threw it on the ground and kept going. MD #14 said she tried to convince the patient to come back in and finish treatment, but Patient #7 said "no, you're trying to kill me", but then said "I know you're not but its taking too long." MD #14 said she explained to Patient #7, that they needed to observe her and check on some things. Interview revealed it was not working, the patient seemed determined to leave. MD #14 went back into the ED but explained to the Social Worker she couldn't get Patient #7 to come back in but Pt#7 needed to stay, couldn't leave. She had an abnormal workup and was sent from behavioral health. Interview revealed MD #14 knew Patient #14 arrived from Campus B, but did not recall knowing if there was an IVC. MD #14 said she was concerned for the patient medically, she had low sats and possible aspiration pneumonia and needed to complete the work-up. The Social Worker, per interview, said she would continue to investigate. MD #14 stated Patient #7 did not come back on her shift.

Request to interview the nurse (RN #20) involved with Patient #7 in the ED, revealed the nurse was no longer at the hospital and thus not available.

Interview on 08/08/2024 at 1645 with three leaders from Campus B, Administrative Staff (AS) #1, AS #2, and Supervisor#3, revealed that prior to transport of Patient #7 from Campus B to the ED at Campus A, Supervisor #3 called the Charge Nurse at the ED, explained there was concern for aspiration and the patient needed to be evaluated by a physician, then either be returned to Campus B or be admitted as an inpatient for medical care at Campus A. Interview revealed it was reported the patient was IVC. Interview revealed a call was later made from the ED to AS#1 that Patient #7 had eloped. AS#1, per interview, then called the Medical Director who indicated Patient #7 was not ok to be discharged. The patient's home county magistrate was notified and Patient #7 was picked up. Interview revealed because Pt #7 lived in a different county the patient was taken to Hospital E for medical screening and clearance. Patient #7 then returned to Campus B and was later discharged home. Interview revealed that since this event there were actions taken to try and prevent this from occuring again.

NC00220198, NC00220215, NC00220167, NC00220241