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.

WELLSPAN EPHRATA COMMUNITY HOSPITAL 169 MARTIN AVENUE EPHRATA, PA 17522 Dec. 28, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility documents, medical records (MR) and interviews with staff (EMP), it was determined that Ephrata Community Hospital failed to provide and maintain care in a safe setting (A144) for one of 19 medical records reviewed (MR1).

Findings:

A review on December 27, 2012, of the Ephrata Community Hospital policy entitled "Patient Rights and Responsibilities" last revised June 2011, revealed, Your rights ... As our patient, you have the right to safe, respectful and dignified care at all times. ... ."

A review on December 21, 2012, of MR1 Triage assessment revealed, "Patient is feeling suicidal today. Patient's Visiting Nurse was there to visit today and felt patient was not safe at home. Patient is hearing voices and seeing demons according to the patient ...." Further review of MR1 revealed, Nursing documentation, " ... eloped from waiting room... . "

A review of video tape on December 21, 2012, revealed that on December 18, 2012, at 1:28 PM, MR1 was accompanied by a female in the Registration corridor and sitting in the ED Waiting area. The female who accompanied MR1 got up from her seat in the Waiting area at 1:39 PM and walked out of view. MR1 followed the female. The female came into view at 1:40 PM and exited through the Registration corridor. MR1 was seen in the Waiting room again at 1:57 PM and exited the building at 2:00 PM. (db)

An interview was conducted on December 21, 2012, at 1:25 PM with EMP6. EMP6 confirmed that MR1 was brought to the ED by a Psychiatric Nurse, who told the Registrar that the patient was suicidal. There was no report to the Triage Nurse from the Psychiatric Visiting Nurse regarding MR1's complaints. Further interview at 1:50 PM confirmed that local police, Hospital Security and Crisis had been notified of MR1's elopement. EMP6 was notified by the RN House Supervisor on December 18, 2012, at approximately 5:00 PM that MR1 was deceased . MR1 was wearing the Ephrata Community Hospital registration bracelet.

Cross Reference with:
482.21 QAPI
482.23(b) Staffing and Delivery of Care
VIOLATION: QAPI Tag No: A0263
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility documents, medical records (MR) and interview with staff (EMP) it was determined that Ephrata Community Hospital failed to initiate Quality Improvement activities for problem prone areas which could affect health outcomes and patient safety (A285), and failed to monitor the number of mental health patients that presented to the Emergency Department (ED) and eloped before receiving an evaluation by Crisis (A275) for four of 17 MR reviewed (MR1,MR11, MR17 and MR19).

Findings include:

A review on December 27, 2012, of the Ephrata Community Hospital, "Quality Improvement Plan," last revised July 2011 revealed, " ... Goals and Objectives ... To exceed the quality expectation of our internal and external customers ... To provide effective, appropriate, timely safe, respectful, caring and cost effective care and services. ... To ensure compliance with accrediting, federal, and state requirements associated with quality improvement. ... ."

A review on December 28, 2012, of the Emergency Department Dashboard for Fiscal Year 2012 revealed there were no indicators for Mental Health patients.

A review of MR1 on December 21, 2012, revealed the patient was a [AGE] year old male who presented on December 18, 2012, at 1:33 PM, and was triaged at 1:40 PM. "Patient is feeling suicidal today. The Visiting Nurse was there to see patient today and felt patient was not safe at home. Patient is hearing voices and seeing demons according to the patient. The Visiting Nurse left after the patient came into the Triage room. ... Patient is in Waiting room awaiting room in the ED ... ." Further review of MR1 revealed, "Chief Complaint and Priority was, "... Psychiatric, 3 ... Discharge ... eloped from waiting room ... ."

A review on December 28, 2012, of MR11, MR17 and MR19 revealed that these patients had presented to the ED for mental health related complaints and had not received a Behavioral Health consultation.

An interview was conducted with EMP3 on December 28, 2012 at 2:00 PM. EMP3 confirmed that the facility does not track elopements of the patients who present with mental health related complaints. (A275)

Cross Reference with:
482.13(c)(2) Patient Rights
482.55 Emergency Services
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility policy, medical records (MR), and interviews with staff (EMP) it was determined that Ephrata Community Hospital failed to ensure the immediate availability of Nursing supervision to a suicidal patient.

Findings include:

A review on December 21, 2012, of Ephrata Community Hospital policy entitled, "Triaging in the Emergency Department" revealed, " ... D. 2. Level 2 ... suicidal or homicidal patients ... ." The policy provided guidelines for triaging patients using the ESI 5-tier triage algorithm and outlined responsibilities of the Greeter and Triage nurses.

A review on December 21, 2012, of Ephrata Community Hospital policy entitled, "Behavioral Health Patients in the Emergency Department" last revised March 2011 revealed, " ... Patients who voluntarily present to the Emergency Department for mental health evaluation will be triaged and escorted to a treatment room or unlocked security room. a. If the patient presents with depression of suicidal thoughts, the patient will change into hospital clothing and belongings will be placed at the nurses station. b. These patients will be observed directly by a hospital staff member in the unlocked security room or a patient treatment room if there is any concerns for the patient's safety and must be able to contract for safety."

A review of MR1 on December 21, 2012, revealed the patient was a [AGE] year old who presented on December 18, 2012, at 1:33 PM and was triaged at 1:40 PM. Review of Triage notes revealed, "Patient is feeling suicidal today. The Visiting Nurse was there to see patient today and felt ptient was not safe at home. Patient is hearing voices and seeing demons according to the patient. The Visiting Nurse left after the patient came into the Triage room. ... Patient is in Waiting room awaiting room in the ED ... ." Further review revealed, "Chief Complaint and priority was, "... Psychiatric, 3. ... ."

An interview was conducted with EMP10 on December 21, 2012, at 3:00 PM. EMP10 confirmed they were working as the Triage Nurse on December 18, 2012, when MR1 presented to the ED. "I called the patient to come in. Patient was on the phone with their mom, ignoring me. Home Health nurse was with patient and did not say to me that patient was suicidal. The Greeter came back to me and said the Home Health nurse whispered that the patient was suicidal later. The Visiting Nurse said to [patient name] 'I will not be staying with you, but everything will be fine." EMP 10 confirmed theVisiting Nurse left and then EMP10 triaged MR1. The Nurse did not give us any paperwork and did not speak with EMP10. MR1 was very preoccupied and EMP10 had requested several times that MR1 remove their jacket so that vital signs could be assessed. The patient was cooperative and nicely dressed but had a flat affect. MR1 took their phone out and called someone and told them them that they were at Ephrata Hospital and was getting help. MR1 did not have anyone to be with them. EMP10 heard MR1 talking with their mother and patient stated that, "mother couldn't make it." MR1 asked to use the bathroom and EMP10 obtained a urine specimen. MR1 had a ED Psychiatric Assessment conducted by EMP10. MR1 said they presented to the ED because they were hearing voices and seeing demons. EMP10 questioned patient, "Are they telling you to hurt yourself? Do you feel like you want to hurt yourself? Patient said, "No". Do you have a plan? Patient said, "No." EMP10 asked if the patient could contract for safety while in the hospital. MR1 responded, "I thought the hospital was a safe place! Oh no, I wouldn't hurt myself." The patient was instructed to return to the Waiting room as they were getting a bed ready for patient in the ED. EMP10 told patient,"it would be a couple minutes and please come and get me if you need anything at all, we are here to help you." EMP10 called the next patient in and looked out and couldn't see MR1. EMP10 went to the hallway and saw MR1 standing there in the hallway. EMP10 asked the patient to sit where they were sitting before so EMP10 could see patient. Patient said they would sit by the TV. EMP10 said they were getting a bed ready, it would be a couple minutes, "so don't go anywhere." The Lab Tech came to draw blood and asked where the patient was. EMP10 saw that the patient was gone. EMP10 told the Charge Nurse and the Charge Nurse called Police and hospital Security. "The only reason I made patient a 3 and not a 2 was that they denied they would hurt themself."

An interview was conducted with EMP6 on December 21, 2012, at 1:25 PM. EMP6 confirmed MR1 was brought to the ED by a Psychiatric Visiting Nurse and told the Registrar that the patient was suicidal. There was no report to the Triage Nurse from the Psychiatric Visiting Nurse regarding MR1's complaints. Further interview at 1:50 PM confirmed that local police, Hospital Security and Crisis had been notified of MR1's elopement. EMP6 was notified by the RN House Supervisor on December 18, 2012, at approximately 5:00 PM that MR1 was deceased . MR1 was wearing the hospital registration bracelet.

An interview was conducted with EMP5 on December 21, 2012, at 1:45 PM. EMP5 confirmed that MR1 should have had a priority status of ESI 2 because MR1 presented with suicidal ideation. Suicidal ideation is considered high risk

An interview wasconducted with EMP3 on December 28, 2012, at 2:00 PM. EMP3 confirmed that MR1 had not received direct supervision while the patient was in the ED on December 18, 2012.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility policy, facility documents and interview with staff (EMP), it was determined that Ephrata Community Hospital failed to ensure that the Emergency Department (ED) services were provided to meet the emergency needs of patients presenting with mental health related complaints in accordance with acceptable standards of practice for five of 19 patients medical records reviewed (MR1, MR6, MR13, MR17 and MR19).

Findings include:

A review on December 21, 2012, of Ephrata Community Hospital policy entitled, "Triaging in the Emergency Department" revealed, " ... D. 2. Level 2 ... suicidal or homicidal patients ..." The policy provided guidelines for triaging patients using the ESI 5-tier triage algorithm and outlined responsibilities of the Greeter and Triage nurses. The policy met regulatory requirements.

A review on December 21, 2012, of Ephrata Community Hospital policy entitled, "Behavioral Health Patients in the Emergency Department" revealed, " For patient who voluntarily present ... If the patient presents with depression or suicidal thoughts, the patient will change into hospital clothing ... These patients will be observed directly by a hospital staff member in the unlocked Security room or a patient treatment room if there is any concern for the patient's safety and must be able to contract for safety. All behavioral health patients should be kept under close observation at all times with the Security present as needed until their final disposition is accomplished. ... ." The policy addressed procedures for patient who involuntarily present to the ED and referred to policy addressing restraint/seclusion in the ED. The policy did not define levels of observation.

A review of the Ephrata Community Hospital Behavioral Health Services Departmental Policy and Procedure Manual on December 28, 2012, last revised November 2011, revealed, " ... Behavioral Health Service Staff shall work collaboratively with the On-Call Psychiatrist in the completion of Emergency Department Behavioral Health Consultations. ... Consults shall be initiated as soon as possible with a projected response time of 30 minutes ... ."

A review of MR1 on December 21, 2012, revealed the patient was a [AGE] year old who presented on December 18, 2012, at 1:33 PM and was Triaged at 1:40 PM. "Patient is feeling suicidal today. The Visiting Nurse was there to see patient today and felt patient was not safe at home. Patient is hearing voices and seeing demons according to the patient. The Visiting Nurse left after the patient came into the Triage room. ... Patient is in Waiting room awaiting room in the ED ... ." Further review revealed, "Chief Complaint and priority was, "... Psychiatric, 3... Discharge ... eloped from waiting room ... ." (A1104)

A review on December 21, and 28, 2012, of MR1, MR17 and MR19 revealed that these patients had no Behavioral consults. A review of MR6 and MR13 revealed the Consults had not been responded to within the 30 minute facility guideline.

An interview was conducted with EMP6 on December 21, 2012, at 2:00 PM that confirmed that no Behavioral Consult was conducted for MR1.

An interview was conducted with EMP12 on December 28, 2012, at 1:30 PM. EMP12 confirmed there was no documentation that MR1, MR17 and MR19 had been evaluated by Behavioral Health. (A1104)

Cross Reference
482.13 Patient Rights
482.21 QAPI
482.23(b) Staffing and Delivery of Care