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ST ALEXIUS HOSPITAL 3933 S BROADWAY SAINT LOUIS, MO 63118 March 11, 2011
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on medical record reviews, staff interviews, review of the facility internal investigation and review of facility policies and procedures, the facility failed to provide the necessary services to ensure a safe setting for one of one patient ( #1). This patient, admitted to the medical/surgical unit, had a physician order for 1:1 sitter and involuntary (96 hour hold) admission to the psychiatric unit but instead, was escorted to the door of the facility, leaving against medical advice (AMA). This finding presented an immediate threat to the health and safety of this patient and potentially any patients admitted to the medical/surgical unit (capacity of 87 patients) with potential involuntary orders.

The hospital administration was notified of the Immediate Jeopardy (IJ) on 03/11/11 at 2:30 PM. An immediate plan of correction was received and accepted prior to exit, therefore, the IJ was considered abated. The facility census at St. Alexius Hospital - Broadway Campus was 112.

Findings included:

1. Review of the facility policy titled "Involuntary Patients" revised 11/09 showed it was the policy of the Psychiatric Program to accept involuntary patients when resources were sufficient to provide necessary treatment. The general guidelines for involuntary procedures included the following:
Substantial risk that serious physical harm to a person will result or is occurring because of impairment in his capacity to make decisions with respect to his hospitalization and need for treatment as evidenced by his inability to provide for basic necessities of:
a. Food
b. Clothing
c. Shelter
d. Safety
e. Medical care or
f. Mental health care
g. Information about patterns of behavior that historically have resulted in serious harm.
Patient may be detained for 96 hours for evaluation, detention and treatment.

2. Review of the facility policy titled "AMA" (Against Medical Advice) revised 10/07 showed the documented purpose of the policy included to recognize the patient ' s right to refuse continuation of treatment against the advice of the physicians and staff - - - -, An incompetent patient was defined as a patient who was unable to make rational and objective decisions for him or herself. The procedure included the following:

When a patient makes known their desire to leave treatment, staff will assess the patient for the presence of substantial danger to self and/or others and determine if the patient is competent to make decisions.
If, after assessment and completion of front of AMA form, a Med/Surg patient is deemed unable to make appropriate medical decisions (i.e., leaving AMA may result in life threatening situations, and/or death), the following should be initiated and documented in the patient ' s medical record:
a. Provide 1:1 intervention to assess the patient's risk and gain rapport;
b. Notify the attending physician to ascertain need for psychiatric evaluation, and/or obtain an order to detain involuntarily. A mental health professional may initiate involuntary proceedings if imminent risks are assessed.

3. Review of the policy titled, "Psychiatric Intake Admission Criteria, Inpatient" revised 10/09 showed that patients who evidenced current symptoms of acute psychiatric disorders would be accepted for admission if they were medically cleared.

4. Review of the policy titled, "Psychiatric Intake, Admission Process" revised 11/10 showed that referrals from the medical units to psychiatric units included the following:
a. The Intake Staff will complete a face-to-face assessment on the patient and notify the psychiatrist of record, the psychiatrist consulted by the attending or the psychiatrist on call, to determine the disposition of the patient.

5. Review of Patient #1's medical record showed the patient was brought to the facility emergency room (ER) on 02/26/11 at 12:52 PM, by Emergency Medical Services (EMS) due to disruptive behavioral changes and complaints of agitation. The patient's apartment manager notified EMS and reported "the patient was sitting outside last night in his/her underwear, pulled the emergency alarm in his/her apartment and became violent towards the apartment manager". EMS documented the patient was living alone in filthy, deplorable conditions with cockroach infestation. They reported that you could not walk through the apartment due to garbage, furniture and bugs. No food or medications were found in the apartment. Concerns for self-neglect and abuse were evidenced by multiple bruises and multiple areas of skin breakdown in various stages of development. The patient looked extremely emaciated and malnourished (139 pounds and 6 foot plus tall). Results of laboratory tests of his/her cardiac isoenzymes revealed mildly elevated CK MB and total CK with normal Troponins.
Note: CK (Creatine Kinase) a rise in total CK is not specific for myocardial injury, because most CK is located in skeletal muscle and elevations are possible from a variety of non-cardiac conditions. CK MB factor is present in both cardiac and skeletal muscle but is less sensitive than Troponins. Troponins are structural components of cardiac muscle. They are released into the blood stream with a myocardial injury (MI). This makes Troponins a superior marker for diagnosing MI.

Record review showed Patient #1 had a history of schizophrenia and hypertension. The differential diagnosis included Bipolar, Borderline Personality Disorder, depression and psychosis secondary to non-compliance. Documentation showed the patient's behavior in the ER was uncooperative, belligerent, defensive, hostile, restless and speech was loud and rambling. The patient was admitted to the medical floor on telemetry, due to the elevated CK MB and total CK laboratory values. The plan included cardiac, psychiatric and dietary consults, physical and occupational therapy evaluations and treatment, and wound treatment to include antibiotic therapy, debridement, dressing changes and possible wound flap closure.

6. The nursing admission assessment on 02/26/11 at 6:55 PM, documented numerous skin ulcers to include a necrotic area of the coccyx/sacral that measured 5 centimeters (cm) by 6 cm (approximately the size of a tennis ball).

7. The patient's metabolic laboratory results showed the following results:
On 02/26/11 at 3:47 PM, the CK results were high at 216 (normal range 25 - 174), the CK-MB results were high at 13.7 (normal range 0.0 - 2.37) and the Troponin results were within normal range of 0.03 (normal range 0.0 - 0.12);
On 02/26/11 at 9:42 PM, the CK results were high at 199, the CK-MB results were high at 11.4 and Troponin results were within normal limits at 0.04; and
On 02/27/11 at 4:16 AM, the CK results were within normal limits at 171, the CK-MB results were high at 6.31 and Troponin results remained within normal limits at 0.04.

8. Documentation review of the cardiac consultation conducted on 02/27/11 (no time noted) showed the following:
Conclusion
1. Elevated CK MB, suspect secondary to mild rhabdomyolysis, not cardiac.
(Note: Rhabdomyolysis is the breakdown of muscle fibers resulting in the release of muscle fiber contents into the bloodstream. The disorder may be caused by any condition that results in damage to skeletal muscle, especially trauma. Signs and tests upon examination may include a CPK that is very high and the disease may also alter the results of CPK isoenzymes tests. Treatment includes early and aggressive fluid hydration.)
Recommendations
1. Follow up CPK and MB, labs for which should come down to within normal limits.
2. Echocardiogram for evaluation.
3. Stress test in the form of an exercise scan to rule out ischemia.
In conclusion, from a cardiac standpoint, the patient's MB fraction is elevated; however, this is not specific since the Troponin is within normal limits. The patient is totally uncooperative and wanting to go home.

9. Documentation of the nurses notes dated 02/27/11 at 8:00 AM, showed the nurse was not able to conduct an assessment, the patient refused medications, pulled IV (intravenous , allows for injection of fluids and/or medications into a vein) out and refused wound culture and dressing change . The patient's primary care physician and psychiatrist were telephoned and messages were left.
On 02/27/10 at approximately 12:00 Noon, a telephone physician's order was received for a 1:1 sitter and psychiatric involuntary admit. At approximately 12:30 PM, the house supervisor was notified of the order and determined that due to the wounds, elevated cardiac enzymes and lack of psychiatric beds, they would not be able to re-admit the patient to the psychiatric unit and a 1:1 sitter was not available.
Documentation showed on 02/27/10 at approximately 1:00 PM, the patient continued to refuse all care and treatment, sat in his/her room with the curtains drawn and when the staff nurse entered the room, patient #1 rushed at the nurse through the curtains.

On 02/27/11 at approximately 3:30 PM, the patient was dressed and sitting in his/her chair stating, "I need my keys", and requested to leave. The staff nurse encouraged the patient to stay (told him/her that the doctors wanted him/her to stay), but the patient insisted on leaving. The house supervisor was called, but informed the staff nurse that they could not hold the patient against his/her will. The "Patient Leaving Against Medical Advice" (AMA) form was signed by the patient and the staff nurse was a witness. The staff nurse documented on the form the risks of leaving the hospital without being seen and/or receiving further care was "death". Patient #1 was escorted to the cashier to get his/her keys and was escorted to the door.

10. Documentation of the hospital's internal investigation showed on 02/28/11 at 5:30 AM, a body was found deceased near the hospital on a city sidewalk and was later identified as former Patient #1. An unidentified witness indicated this person was seen on the bus stop bench around 4:00 PM on 02/27/11 until about 5:00 AM on 02/28/11 when he/she was noticed on the ground.

11. During an interview on 03/10/11 at approximately 1:30 PM, Staff A (Chief Nursing Officer) stated that normally the psychiatric intake nurse would go and assess the patients who have a physician's order to transfer to the psychiatric unit from the medical unit. In this case, instead of completing the face to face assessment, the intake nurse reviewed the information, such as laboratory values, on the computer and made the determination, along with the house supervisor, not to admit to the psychiatric unit due to the patient's skin breakdown, elevated cardiac enzymes and having only one remaining Geri psychiatric bed left. Staff A said, "they didn't reassess the patient face to face as required".

12. During an interview on 03/11/11 at approximately 9:55 AM, Staff B (Registered Nurse, Risk Manager) stated that based on the intake assessment and the clearance from the cardiologist, the intake nurse could and should have completed a face to face assessment instead of relying solely on the computer information. The psychiatric intake nurse was responsible to conduct a face to face assessment, obtain the physician's order to discharge from the medical unit and to re-admit to the psychiatric unit. Staff B stated that the patient's wound care could have been managed on the psychiatric unit without difficulty and the patient had already received medical clearance from the cardiac consult. There was also confusion about admitting the patient to the Geri psychiatric unit (the intake staff did not think the patient met the Medicare criteria). Staff B stated that the patient did meet criteria, but even if the patient did not, they should have held the patient as ordered and provided the care necessary. Staff B also stated that the house supervisor documented that they did not have a sitter readily available, but there was no documentation that showed any attempt was made for a sitter. Staff B stated that there was a sitter in house and the situation could have been handled. Staff B stated, "An involuntary patient leaving AMA should have triggered that the patient was not capable of being safe by leaving".

13. Review of the facility's Performance Management record of conference with nursing staff dated 03/08/11, documented the reason for the conference included, "allowing an unstable patient to leave AMA, not following the AMA policy, having an order for involuntary confinement and not following the chain of command in calling the physician prior to the patient leaving".

14. During a telephone interview on 03/11/11 at 10:50 AM, Staff D (medical examiner supervisor) stated that at this point, the death certificate was not signed and it could take another six to eight weeks. Staff D stated that they could not release any information until the death certificate was signed and they received a release report from the hospital.

15. During a telephone interview on 03/11/11 at 11:10 AM, Staff E (physician) stated that it was very cold the night of the event. The patient was not dressed for the conditions and it was thought possible cause of death might be hypothermia.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on medical record reviews, staff interviews, review of the facility internal investigation and review of facility policies and procedures, this facility failed to provide the necessary services to ensure a safe setting for one of one patient (#1). This patient, admitted to the medical/surgical unit, had a physician order for 1:1 sitter and involuntary (96 hour hold) admission to the psychiatric unit but instead, was escorted to the door of the facility, leaving against medical advice (AMA).

The severity and cumulative effect of the systemic practices resulted in the facility being out of compliance with 42 CFR 482.13 - Condition of Participation: Patients' Rights and resulted in the facility's failure to provide a safe environment for this patient and potentially any patients admitted to the medical/surgical unit (capacity of 87 patients) with potential involuntary orders. Subsequently the situation constituted a condition of immediate jeopardy. The hospital administration was notified of the Immediate Jeopardy (IJ) on 03/11/11 at 2:30 p.m. An immediate plan of correction was received, accepted and implemented prior to exit, therefore, the IJ was abated. The facility census at St. Alexius Hospital - Broadway Campus was 112.

Refer to evidence A144 for findings.