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VILLAGES REGIONAL HOSPITAL, THE 1451 EL CAMINO REAL THE VILLAGES, FL 32159 March 20, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on ambulance report (EMS), emergency department log, medical record review, security video footage, facility's chronological of event review, staff interview, and policy and procedure review the hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department to determine whether or not an emergency medical condition existed for an individual who presented with signs and symptoms of suicide attempt and intoxication for 1 of 25 sampled patients, Patient #1. Refer to findings in Tag A- 2406.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on ambulance report (EMS), emergency department log, medical record review, security video footage, facility's chronological of event review, staff interview, and policy and procedure review the hospital failed to ensure an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department to determine whether or not an emergency medical condition existed for an individual who presented with signs and symptoms of suicide attempt and intoxication for 1 of 25 sampled patients, Patient #1.

Findings:

Review of the EMS (Emergency Medical Services) report for Patient #1, dated 03/06/2018 revealed Response Priority: Emergency. Nature of Call: Psychiatric/Suicide Attempt. Narrative: Arrived on scene to find a male patient in his chair. The patient stated that he has been drinking all day. The patient's neighbor stated that he has been in his car with the vehicle running with the garage door down. He stated that he got intoxicated and wanted to listen to music got in his vehicle. He stated that he left the door open. The patient stated that he fell asleep in the car woke up and then went to his chair to go to sleep. He then stated that he was woken up by police entering his house. The patient became belligerent towards police and crews on scene due to being intoxicated. The patient had no other person there to care for him and with unknowing if the patient was attempting suicide as the neighbor had suggested. The patient was transported to The Villages Regional Hospital without incident.

Review of the security video footage of the arrival of patient #1 by EMS through the EMS doors on a stretcher on 03/06/2018 at 10:19 PM., where he remained on a stretcher against the glass wall with EMS staff present. At 10:37 PM the EMS wheeled the stretcher with patient #1 into a holding room called the vertical room. At 10:30 PM and 9 seconds, RN staff #A disappeared off the video footage and entered into the Vertical Room , and returned back out at 10:38 and 49 seconds later to the nurses's station. The security video footage revealed that Patient #1 exited the facility by way of the EMS doors on his own accord at 10:55 PM, left Without Being seen (LWBS). RN Staff #A, was notified by the registration clerk that went in the vertical room to see patient #1 to obtain additional information that was needed and found he had left.

Review of the emergency department log revealed dated 03/06/2018 Patient #1 arrived by ground ambulance on 03/06/2018 at 10:19 PM and documented at an acuity level of 3 - Urgent. Depart Date & Time: 03/07/2018 at 2:17 AM. Home or Self Care.

Review of the Emergency Documentation ED (Emergency Department) Triage Part 1 - Adult Entered On: 03/06/2018 at 22:30 EST (10:31 PM). Performed On: 03/06/2018 at 22:25 EST (10:25 PM). Chief Complaint: EMS from home. Was called due to patient causing disturbance to neighbors. Sheriff office told patient he could go to hospital voluntarily or be Baker acted. Patient reports drinking Jim Bean today. Problems (Active) ETOH (Ethanol Alcohol Oxygen Hydrogen) - Alcohol. Diagnoses (Active) Acute alcohol Intoxication. The Triage Part 1 did not provide documentation of an assessment for possible suicide attempt or continued suicidal ideations.

Review of the Emergency Documentation ED (Emergency Department) Triage Part 2 - Adult Entered On: 03/06/2018 at 22:31 EST (10:31 PM). Performed On: 03/06/2018 at 22:25 EST (10:25 PM). General Assessment: Document Falls Risk: Altered mental status. Domestic Concerns: None. Document Social History: Open social history. The Triage Part 2 did not provide documentation of an assessment for possible suicide attempt or continued suicidal ideations.

Review of the Emergency Documentation ED Clinical Summary Person Information dated 03/07/2018 revealed Person Information: Patient #1, Visit Reason: Acute alcohol. Acuity: 3 - Urgent. Arrival: 3/6/2018 at 22:19 (10:19 PM). Laboratory or Other Results This Visit: No Laboratory or Other Results This Visit. Medications Administered: was blank. Discharge Information: Discharge Disposition: Home or Self Care. Depart Reason Incomplete Information. Depart Action: Incomplete Reason. Discharge, Diagnosis, Patient Education, Follow-up Date, Disposition, Documentation, Patient Understanding were all documented as LWBS (Left Without Being Seen). Problems Active: ETOH - Alcohol.

The facility's Chronological event related to patient #1 was reviewed. The Chronological event revealed in part, "3/16/2018- 9:26 EMS - EMS called and dispatched to pt's home for Psychiatric/Suicide attempt.
9:35 PM- EMA at the scene
9:39 PM- EMS with Chief complaint: Poisoning/Overdose type: ETOH intoxication. WNL. Primary Ingestion: ETOH abuse with intoxication. . .
10:38 PM Triage- RN: EMS from home. Local PD (police Department) called to patient's home d/t causing disturbances to neighbors. PD told pt. he could go to the hospital voluntary or be Baker acted. VS: 138/78; 102-24-99% RA. No pain.
10:55 PM- Security Video Footage- AMR EMS is seen entering pt on a stretcher.
10:56 -Patient #1 exits the facility via EMS doors. Security notified by AMR that ambulance went missing and SCSO was called. A Deputy with SCSO located the ambulance across the street from the pt's home in his neighbor's driveway. Pt's home was searched and pt found in the trunk of his car in the garage."

During an interview on 03/19/2018 at 2:55 PM with Staff A, RN (Registered Nurse), she stated, "Patient #1 was loud at the nursing station when being admitted by EMS on 03/06/2018 at 10:19 PM, and he kept repeating, stating that he had only been drinking, and had no plans of hurting himself. I received report and vital signs from EMS with a chief complaint of alcohol intoxication, and no report of suicidal attempt or suicidal ideation. We took his vital signs again and did an assessment once EMS transferred him into the Vertical room. It is called the Vertical room because the patient is placed vertical, in a recliner chair. About ten minutes later the registration clerk informed me that Patient #1 had been gone LWBS."

Review of the policy and procedure titled, "Medical Screening Policy", Effective Date: 05/25/2016 revealed Purpose: To require that a hospital with an emergency department provide an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C., Section 1395dd and all Federal regulations and interpretive guidelines promulgated thereunder. Policy: The hospital with an emergency department must provide to an individual that is not a patient who "comes to the emergency department" an appropriate MSE (Medical Screening Examination) within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition exists.

Review of the policy and procedure titled, "Security in the Emergency Department TVRH ED (The Villages Department Emergency Department), Effective Date: 06/10/2013 Policy: Emergency Department Personnel will provide a safe, secured environment for patients, visitors, and staff members by utilizing appropriate precautions, available in-house security officer/measures, and community law enforcement. Procedure: 1. Emergency Department staff will be familiar with and enforce appropriate safety and precautionary security measures to include: c. Observation of the behavior of patients/visitors in the waiting room, patient care areas and surrounding the Emergency Department; interventions as necessary for anger, intoxication, crisis management. 2. Patients will be examined and maintained in a manner and environment appropriate to their circumstance so as to insure their safety and that of others: a. Patients will be disrobed for exam as appropriate to their complaint and their potential for hidden weapons. Clothing or personal belongings may be itemized and placed in the hands of TVHS Security or law enforcement officers to remove it from the immediate environment for security reasons. b. Items, which may be utilized as weapons toward themselves or others, will be removed from their environment as appropriate to their behavior, status, and perceived security threat.

The facility failed to ensure that on 3/6/2018 Patient #1 received an appropriate medical screening examination , as evidenced by failing to ensure their own policy and procedure was followed by not providing interventions of constant observation; Patient #1 was left unattended in the vertical room given the patient's presenting signs and symptoms of suicide attempt and alcohol intoxication.