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 documents review and interviews, the facility failed to provide further medical examination and/or stabilizing treatment for a patient who had a medical emergency as well as a psychiatric emergency. The facility treated the medical emergency, but failed to provide further examination and/or treatment for the psychiatric emergency that ultimately led to an adverse outcome for the patient. The facility provided no examination or interventions aimed at stabilizing the patient's psychiatric condition during the hospital stay.

It was determined this deficient practice created an Immediate Jeopardy situation and placed patients at risk of potential harm, serious injury, and subsequent death. These failed practices had the potential to affect all patients admitted to the facility

On 7/19/2013, at 9:00 AM, in the hospital's conference room, the medical record (MR) for patient (Pt) #6 was reviewed. The MR document titled "Short Stay Summary" revealed Pt #6 arrived by ambulance to the Emergency Department (ED) on 6/23/2013, at 22:02 (10:02 PM), following a deliberate overdose of Xanax (a drug commonly used to treat anxiety and panic attacks). Pt #6 indicated to the ED physician that she had swallowed 48 of the 1 mg (milligram) Xanax tablets she had in a suicide attempt because she was arguing with her boyfriend.

Further review of the "Short Stay Summary" revealed that the community psychiatric service (ACCESS) attempted to evaluate Pt #6 in the ED, but felt she was too lethargic at that time. They planned to assess her on 6/24/2013. Pt #6 was admitted to the ICU (Intensive Care Unit) of the hospital. She was somewhat lethargic, according to staff. Her pulse was 106, blood pressure 112/89, respirations 18, pulse oximitry 99%. Her clinical examination otherwise was essentially normal, according to nursing staff and ED Physician.

Review of Pt #6 ED MR titled "ED Medication Orders" revealed Pt #6 was treated medically with Activated Charcoal with Sorbitol at 22:31 (10:31 PM) (Activated Charcoal works by binding with the poison in the stomach to decrease absorption of the poison into the body. Sorbitol works to help move the charcoal and poison out of the stomach and intestines more quickly). Patient #6 was transferred to the ICU at 2:00 AM on 6/24/2013.

An interview with staff #9 on the morning of 7/19/2013, revealed the following: when it was needed, a psychiatric patient would be admitted to the ICU because the unit was secure and the rooms were private. Each room had a window in the door, allowing visual observation of the patient. The rooms were also designed to be able to remove any objects from the room that a psychiatric patient might use to harm themselves or another person. The patient might or might not have a medical acuity that required ICU level nursing care and observations.

Further MR review of a document titled "Law Enforcement Application for Detention of person as Mentally Ill" revealed Pt #6 was transported by EMS, escorted by Police under an EDW (Emergency Detention Warrant) because of the failed suicide attempt.

Review of the hospital's policy and procedure titled, "Assessment Plan: Patients with Mental Health Disorders," revealed the following:

1.6 Consult Physician regarding need for specialized patient psychiatric evaluation assistance. Options available:
ACCESS-Mental health services available for patients. 24 hour hotline #1-800-621-1693
The Behavioral Center-Inpatient and Outpatient Mental Health Treatment.
The local Regional Hospital Inpatient Psychiatric Facility.

1.8 Patient disposition options available:
In-house admission for patients needing further observation or treatment of a medical condition prior to transport to a psychiatric facility.
* "Transfer to a psychiatric facility for further evaluation and care by voluntary admission or by court ordered committal. Patients under order of court committal should be transported via law enforcement. All transfers to psychiatric facilities should follow the requirements of HOM (House Operations Manual) policy on Patient Transfers.
* Discharge to home with adequate arrangements for the patient's follow-up. The 24 hour hotline number should be be provided to the patient and family as appropriate.
* The law enforcement should be notified of any patient attempting to leave AMA, who is considered to be a suicide risk."

Review of the hospital's policy and procedure titled, "Release Against Medical Advice," revealed the following:

1.0 A competent adult patient or legally appointed representative of the patient has the right to refuse treatment at any time.

2.0 The patient's physician should be notified as soon as possible in order that an attempt may be made by the physician to persuade the patient to remain in the hospital.

3.0 If the physician is unable to persuade the patient to remain hospitalized or if the patient is unwilling to wait for the physician, the hospital staff should request that the patient and/or guardian of the patient sign the Release Against Medical Advice form.

4.0 The physician or nurse in the physician's absence should inform the patient of the risk associated with leaving the hospital.

On the morning of 7/19/2013, in the hospital's conference room, a discussion concerning the evaluation process that occurred for Pt #6 revealed the following:

Staff #2 indicated both ICU nurses, staff #5 and #7, had been terminated for the following reasons: Pt #6 did not receive a psychiatric evaluation. She further indicated that ICU nurses #5 and #7 failed to notify ACCESS that the patient was awake and coherent, but rather allowed Pt #6 to place a phone call to her boyfriend. Afterward, Pt#6 became very angry and agitated, pulling at the IV (Intravenous) lines and EKG (Electrocardiogram) leads and demanding to leave.

Staff #2 indicated ICU nurses #5 and #7 failed to notify the attending physician, who had not made rounds or seen Pt #6 yet. The attending physician was made aware of Pt #6 AMA (Against Medical Advice) status when he made afternoon rounds.

Staff #2 further indicated ICU nurses #5 and #7 failed to notify the police of Pt #6's desire to leave AMA, failed to recognize that Pt #6 was not mentally stable to authorize her AMA status, and were unaware of the existing EDW that legally held Pt #6 for 48 hours. Staff #2 further indicated no member of Pt #6's family was notified of her demand to leave AMA. In fact, no arrangement was made to insure Pt #6's safety or transportation to an appropriate location by the ICU nurses. Pt #6 was unsteady on her feet and was escorted by staff #7 to the property's boundary and allowed to ambulate away from the hospital. Later in the day, Pt #6 was found with a self-inflicted gun shot wound that was fatal.

An interview with local law enforcement confirmed no notification was made of patient #6 attempts to leaving the hospital on [DATE]. Law enforcement confirmed that Pt. #6 was found later that same day of hospital discharge, deceased from a self-inflicted gunshot wound.