The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on staff interview, and review of medical records, ED logs, and CAH policies and procedures, it was determined the CAH failed to ensure emergency care was provided sufficient to meet the needs of 3 of 12 patients (Patient #13, #22, and #23) who presented to the ED seeking care for mental health conditions. This resulted in patients eloping from the CAH while under physician orders for suicide precautions. This resulted in immediate jeopardy to the health and safety of 3 patients and the CAH's inability to provide safety for patients receiving care for mental health conditions in the ED. Findings include:

The CAH's ED had 2 triage rooms and 8 treatment rooms. Triage room #1 and treatment room #8 were equipped with observation cameras that had monitoring screens at the nurse's station.

1. Patient #13 was a [AGE] year old male who was brought to the ED on 10/13/17 at 12:39 P.M. by local police. He was placed in treatment room #8 with camera monitoring.

The physician's assessment, at 12:55 P.M., stated Patient #13 was delusional and was experiencing auditory hallucinations.

A physician's order was entered at 1:15 P.M. for suicide precautions.

Patient #13 was given Zyprexa Zydis (an antipsychotic medication) at 1:19 P.M.

A nursing update at 2:15 P.M. stated Patient #13 was "Resting in bed. Officer at bedside."
No further nursing documentation was evident until 5:20 P.M.

A nursing update at 5:20 P.M. stated "Pt. eloped-police and hospital personnel notified."

A nursing update at 6:06 P.M. stated "Pt. returned to room by officer. Pt's parents in [city name] and will be here directly. Cousins at bedside."

In an interview on 11/02/17 at 4:00 P.M., RN #1 reviewed and confirmed the documentation and gave the following additional information related to Patient #13's ED visit on 10/13/17:

Patient #13 was being monitored "the whole time." RN #1 left the nurse's station and went to the supply room. Someone took the patient to the bathroom. Then he disappeared. An Amber alert was called and the hospital was locked down. The doctor and law enforcement were notified.
Patient #13 was picked up by some "random stranger" and driven to a local gas station. The stranger then called the hospital and asked if he [the patient] belonged to the hospital. The police went to the gas station and picked up Patient #13 and returned him to the ED.
RN A stated Patient #13 was not on a mental hold, "so technically he had the right to leave. It's a gray area. I didn't think about filling out an incident report because he was not on a mental hold."
She also stated "I didn't have time to document because the ED was a mess that day."

The CAH failed to protect Patient #13 while he was under suicide precautions.

2. Pt. #22 was a [AGE] year old male brought to the ED on 9/17/17 at 5:31 PM by law enforcement. He was placed in Triage room #1 with camera monitoring. The room was adjacent to, and visually accessible to the reception desk.

A patient narrative, entered by RN #2 at 5:57 P.M., documented "Pt homeless, reports little sleep and food for several days. Pt reports hx depression, anxiety. Admits to police officer hearing voices. Denies suicidal ideation at this time."

A physician assessment at 5:42 PM stated Patient #22 "came to the ED seeking help for his hallucinations. He reports hearing voices for a long time now ... He reports that the voices say his name causing him to not able [sic] to differentiate between what is actually reality."

Patient #22 told the physician he had been diagnosed with Paranoid Schizophrenia when he was in prison, but had not seen a psychiatrist since his release.

A physician's order for suicide precautions was entered at 5:58 P.M.

A Medication Administration Report documented Patient #22 was given Zyprexa Zydis (an antipsychotic medication) at 6:00 P.M.

A nursing update at 6:00 P.M. documented that RN #2 rounded and gave the patient education and emotional support.

A nursing update at 6:00 P.M. documented "Pt remains in Triage room #1, on camera for visual room. Pt notified front desk of need to void. Front desk notifies RN, This RN goes to bring pt sample cup. Pt not found in WR bathroom and not down hallway. [local police officer] contacted at this time."

Patient #22's medical record showed he was discharged at 6:55 P.M., AMA.

In an interview on 11/06/17 at 10:30 A.M., RN #B reviewed and confirmed the documentation and gave the following additional information related to Patient #22's ED visit on 9/17/17:

No other room was available, so Patient #22 stayed in Triage room #1 as a safety measure because the room had a camera. The police officer was there but she had to leave for a moment. Patient #22 was on camera and in view of the reception desk. Nurses communicate with the receptionist all the time. When RN #2 went to give Patient #22 a urine specimen cup he was gone. RN #2 stated "he was only here for 30 minutes so I didn't have time to implement any orders." RN #2 stated she contacted the physician who said there was "not much we could do." RN #2 contacted the House Supervisor, but did not recall the supervisor's response." RN #2 contacted the police who said they would look for him. She said her shift ended and she did not know if Patient #22 was located or returned to the ED.

The CAH failed to protect Patient #22 while he was under suicide precautions.

3. 4. Patient #21 was a [AGE] year old female who (MDS) dated [DATE] at 11:25 AM. An "ED MAIN Triage Report," dated 8/29/17 at 11:50 AM, stated "Patient here voluntary for feeling sad and suicidal. States she would 'make the furnace and light a match.' Is accompanied by social worker from [local] Clinic." Patient #3 signed a consent to treat form.

"Precautions Suicide" were ordered on [DATE] at 12:27 PM. A social service consult was also ordered at that time.

A nursing progress note, dated 8/29/17 at 11:51 AM, stated Patient #21's chief complaint was "depression - suicidal" and stated she was tearful and anxious. A nursing progress note, dated 8/29/17 at 12:55 PM, stated a sitter was positioned outside of Patient #21's room in the ED and she was being observed. The next nursing note, dated 8/29/17 at 1:38 PM, stated Patient #21 was given education and emotional support. The final nursing note, dated 8/29/17 at 2:56 PM, stated Patient #21 left AMA. The note stated she left without saying anything to anyone. The note stated the police and the house supervisor were notified.

A social service note, dated 8/29/17 at 6:15 PM, stated Patient #21 had a suicide plan "...using her lighter and gas from her furnace to blow up her house with she and her dogs inside. Pt left without being seen. [Police] located her and came back to get her stuff. Per Officer [name] they feel she is safe and does not need a psychiatric hold."

A "Summary" by the physician, dated 8/29/17 at 12:03 PM, stated Patient #21 eloped prior to assessment by the physician. The timing of the Summary was not clear since the above nursing note stated Patient #21 was present at 1:38 PM.

The Director of Emergency Services was interviewed on 11/03/17 beginning at 9:55 AM. She reviewed Patient #22's record. She stated 8/29/17 was a very busy night. She stated Patient #21 was placed on suicide precautions but was not examined by a physician. She stated she did not know how Patient #21 left the hospital while on suicide precautions. She stated police were notified and later found the patient. She stated the police decided not to bring Patient #21 back to the hospital.

The CAH failed to protect Patient #21 while she was under suicide precautions and failed to monitor her long enough to assess her to determine if she was a danger to herself.

4. A policy specifying suicide precautions was not included in a policy table of contents.

In an interview on 11/02/17 at 4:30 P.M., the Director of Emergency Services stated the ED staff followed a protocol, also known as an order set, for mental health patients. She stated the protocol included instructions for staff to "place in watch room (with precautions)." The Director stated there was no CAH policy addressing the use of suicide precautions and no definition explaining what suicide precautions included.

In an interview on 11/02/17 at 4:00 P.M., RN #1 said suicide precautions included placing patients in paper scrubs, taking personal belongings out of the room, placing patients in a visual bed or room #8, and monitoring patients continuously by camera. She said no staff was specifically designated to monitor the cameras at the nurse's station, but it was usually done by the charge nurse, or the CNA, or a law enforcement officer.

In an interview on 11/06/17 at 10:30 A.M., RN #2 stated suicide precautions included a safe room with a camera, a safe menu, close monitoring, a search for weapons, and placing the patient in disposable scrubs.

5. Incident reports were not completed for any of the above events. An investigation of the above events was not documented.

The Director of Quality was interviewed on 11/03/17 at 11:00 AM. She stated there was no documentation that the above incidents were investigated. She stated there was no documentation corrective action had been taken to prevent further elopements.

The CAH failed to define and implement a system to monitor and protect patients to ensure their safety. The CAH failed to monitor and protect 3 ED patients (#13, #21, and #22) with psychiatric conditions. The failure to monitor and protect patients from harm placed the health and safety of all psychiatric patients in the ED in jeopardy.

The CAH's CEO, CNO, and CQO were notified of the immediate jeopardy situation on 11/03/17 at 10:45 A.M. A plan of correction was provided and implemented that day. The plan included the following:

a. A new policy was created titled "Suicide Assessment." This policy:

i. Identified 2 levels of precautions, minimal and strict, to be ordered by the LIP after completion of patient risk assessment.

ii. Assigned specific responsibilities to hospital staff, nursing staff, and LIPs.

iii. Defined specific procedures for ED staff to follow in order to protect patients from self-injury, suicide, causing harm to others, or grave disability.

b. New Mental Health Packets were made available to staff in the ED. These packets included an initial safety checklist, guidelines for 1:1 observations, identification of potentially hazardous items, and instructions for documentation, including frequency.

c. Staff training for all ED staff prior was begun at approximately 3:30 PM for on-duty staff and the CAH committed to train each ED staff member prior to the start of their next shift.

The CAH's Plan of Correction was reviewed and accepted by surveyors on-site. Training of ED staff was observed on 11/03/17 at 3:30 P.M. It was then determined the immediate threat had been removed.