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UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER 2315 STOCKTON BOULEVARD SACRAMENTO, CA 95817 July 10, 2012
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record review, the hospital failed to provide ongoing monitoring appropriate to the needs of 7 of 20 Sampled Patients (1,3,5,10,12,16 and 20) who had been triaged with emergent medical conditions, resulting in :
1) An elopement prior to the determination the emergent medication condition had been stabilized, and
2) The potential for undetected deterioration of the emergent conditions of other patients.

The failure to provide appropriate ongoing monitoring resulted in a threat to the safety of Patient 1 and the potential threat to other patients.

Findings:

The "Medical Screening Exam and Triage - Adult and Pediatric Policy," revised 6/8/12, defined the Emergency Department's (ED's) triage process, including five assigned patient Levels including the following:
"Level 1 patients (Resuscitation/Red) are unstable and require immediate life, limb or organ-saving interventions...
Level 2 patients (Emergent/Orange) These patients are at 1) high risk for deterioration, require time-sensitive treatments and/or have potential threats to life, limb or organs, and/or 2) have acute changes in level of consciousness, and/or 3) are in severe pain or distress based on patient complaint and clinical observations. These patients are high priority for care and room placement.
Level 3 patients (Urgent/Yellow) do not need immediate life-saving interventions...

Patients of higher level acuity (i.e. Level 2) should have reassessments and vital signs done, at a minimum, every two hours but more frequently when possible...

Patients assigned Level 3 acuity should have reassessments and vital signs done, at a minimum, every two hours...."

In addition, the "Emergency Department Structure Standards," revised 5/6/12, state, "Patients of the higher acuity levels, Level 2 (Orange) and Level 3 (Yellow), will be rechecked, at a minimum, every two hours...This recheck must include...a focused reassessment...."

The facility policy "Emergency Medical Treatment and Active Labor Act (EMTALA), revised 6/25/12, stated, "The medical screening examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and continue until the patient is either stabilized or appropriately transferred."

ED nurses and physicians were reminded in a 5/2/12 e-mail from the RN Performance Improvement Coordinator, "All psychiatric patients should have a focused nursing assessment completed at least every 2 hours...which includes relevant assessment criteria for this patient population."

Patient 1 was a [AGE] year-old brought to the ED on an involuntary hold by law enforcement at 12:05 a.m., 6/8/12 after having called the police department stating she "wanted to hang herself from the vent in [her] motel." discharged from an inpatient psychiatric facility "a few months" before, Patient 1 had not been taking her antipsychotic medications (medications used to treat severe mental conditions) and was experiencing delusions (serious mental illness in which a person cannot tell what is real from what is imagined), paranoia (feelings of persecution) and auditory hallucinations (hearing things which weren't there). She described "feeling depressed" and was having "relationship difficulties" which included domestic violence, incarceration and her three-month old daughter being placed in protective custody at birth.

Patient 1 had a history of schizophrenia (a mental illness causing disturbed or unusual thinking, loss of interest in life, and/or strong or inappropriate emotions), alcohol abuse, depression and hospitalization s for prior suicide attempts.

1) Patient 1 was triaged as a Level 2 (emergent), placed in a hallway bed at 12:22 a.m. and later moved into a core ED bed at 1:43 a.m. A Crisis Services Licensed Clinical Social Worker (LCSW) described Patient 1 as having "impaired insight, impulse control and judgment" and continued the involuntary hold. Patient 1 was reassessed by her nursing caregiver at 2:11 a.m., had vital signs (blood pressure, pulse, respiratory rate, blood oxygen saturation measurement and temperature) taken at 4:11 a.m., and was reassessed at 6:48 a.m. and 7:03 a.m., when she was described by her RN as "anxious" and verbalizing "hopelessness." She was reassessed again at 7:28 a.m. Awaiting placement in an inpatient psychiatric facility, Patient 1 was moved from one ED care area to another at 8:02 a.m. She got up to use a bathroom located just outside the care area in which she had recently been placed. A staff member did not remain with Patient 1 while she was in the bathroom and she was noted to be missing at 8:24 a.m. She was never located.

2) Patient 3 was a [AGE] year-old brought to the ED by ambulance at 11:24 a.m., 5/22/12 with auditory hallucinations and a plan for suicide by "clawing [her] eyes out" after a family argument. She had been discharged from a mental health facility several months previously after a "psychological breakdown" but was no longer taking the medications with which she was sent home. She was assigned a Level 3 instead of a Level 2 in error, according to her triage nurse, and noted to be at high risk for suicide. Her psychological status was not reassessed until 3:28 p.m.

While she was subsequently awaiting placement in an inpatient psychiatric facility, there was an additional gap in reassessments between 5:45 a.m. - 10:07 a.m., 5.23/12. Patient 3 was transferred to an inpatient acute psychiatric hospital (APH) at 8:07 p.m., 5/23/12.

3) Patient 5 presented to the ED at 6:07 p.m., 5/3/12 after attempting to "cut his head off." Patient 5 had a history of schizophrenia, bipolar disorder and substance abuse "to help [him] with...suicidal tendencies." He had "no support system," was homeless and on parole after incarceration for molestation during a psychotic episode. Patient 5 was anxious and agitated, stating his "mom is talking to [him] from ashes" and "vampires are following [him] and [he] will hurt them." He was assessed to be at high risk for suicide and assigned a triage Level 2. Gaps in reassessment were noted between 7:47 p.m., 5/31/12 - 1:09 a.m., 6/1/12 and 1:09 a.m. - 11 a.m., 6/1/12. Patient 5 was transferred to an APH at 7:03 p.m., 6/1/12.

4) Patient 10 was an intoxicated [AGE] year-old brought in by ambulance at 5:55 p.m., 6/15/12 after attempting to cut his wrists. Patient 10 had a history of polysubstance abuse and depression with "3 - 4" previous suicide attempts; his last attempt was one week earlier for which he was hospitalized . He was triaged a Level 2 and evaluated by the Crisis Services LCSW. He felt "hopeless about his life getting better," support systems were inadequate and he could not afford medications for his depression. He was felt to be at moderate to high risk for suicide with impaired insight, judgment, decision-making capacity and impulse control, and placed on an involuntary psychiatric hold. Significant gaps in reassessments were noted between 8 a.m. - 12:50 p.m. and 12:52 p.m. - 4:41 p.m., 6/16/12 and 9:11 a.m. - 4:41 p.m., 6/18/12. Patient 10 was transferred to an APH at 6:58 p.m., 6/18/12.

5) Patient 12 was a [AGE] year-old brought in by ambulance at 5:56 p.m., 6/26/12 for a chief complaint of "sharp" chest wall pain, "active cardiac features." He had a history of human immunodeficiency virus (HIV). He was triaged a Level 3 but not reassessed until 9:25 p.m. He was moved from the hallway bed back into the waiting room at 10:14 p.m. He left without being seen by a physician before leaving without treatment at 11:36 p.m.

6) Patient 16 was a [AGE] year-old who presented to the ED at 8:21 p.m., 7/1/12 with anxiety, depression and plans "to overdose" or "jump in front of the light rail [train]" after being released from an inpatient psychiatric facility. The patient stated he had "no emotional support," felt "very alone" and "no longer [had] a home since his mother was evicted from his former home, where he was her primary caregiver." He had previously attempted suicide and an uncle and grandmother had taken their own lives. Patient 16 was assigned a suicide risk level of "moderately high" and triaged a Level 2. He was placed on an involuntary hold. While awaiting inpatient psychiatric facility admission, gaps in reassessments were noted between 2:57 a.m. - 6:31 a.m. and 6:04 p.m. - 10:26 p.m., 7/2/12. Patient 16 was transferred to an APH at 7:51 a.m., 7/3/12.

7) Patient 20, a [AGE] year-old with a history of bipolar disorder, depression and suicide attempts presented to the ED at 8:30 a.m., 7/2/12 with complaints of severe depression and suicidal ideation of one week. She had "several prior hospitalization s" for mental health care but had been "off medications" for 1-2 months. Patient 20 was triaged as a Level 2, evaluated by the Crisis Services LCSW and found to have "profound depression...worthlessness, hopelessness" and "significant anxiety." She was determined to be a "moderate to high suicide risk" and placed on an involuntary psychiatric hold at 1:45 p.m., 7/2/12. Gaps in reassessment were noted from 10:46 a.m. - 6:30 p.m., 7/2/12, from 8:27 p.m., 7/2/12 - 12:27 a.m., 7/3/12 and from 1:34 a.m. - 6:17 a.m., 7/3/12. Patient 20 was transferred to an APH at 12:10 a.m., 7/4/12.

A 4:44 p.m., 7/3/12 nursing note stated, "Patient up to use the restroom on her own." A 6:17 a.m., 7/3/12 entry read, "Patient self-showered." The medical record reflected no evidence that Patient 20 was accompanied by staff while on the involuntary hold.

The facility policy "Identification and Management of Patients at Risk for Suicide," revised 4/23/12, stipulates, "Patients will be placed in an appropriate, safe area where he/she can be directly observed by reliable caretaker or hospital personnel...Staff should make reasonable efforts to prevent elopement."

During an 11:21 a.m., 7/10/12 interview, AM1 confirmed, "Pts. are to be reassessed at least q [every] two hours if they are Level 2 or 3."