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 record review and interview, the facility's nursing staff failed to perform appropriate assessments and plan of care documentation according to the facility's policy and procedures to identify and ensure a safe environment is provided to 1 of 9 patients with a behavioral health concern (Patient #1) in a sample of 11 medical records reviewed.

Findings include:

Review of policy titled "Emergency Department Standards of Practice and Care" # 70, last revised 4/2020 revealed "Standards are authoritative statements by which the nursing profession describes the responsibilities for which its practitioners are accountable... written in measurable terms." Under standard 1, assessment, revealed " All patients will be assessed for all types of abuse and or self harm.. Safety concerns will also be addressed by the Registered Nurse." Under standard 2 nursing diagnosis, revealed "each patient's plan of care will be based on identified nursing diagnosis from patient assessment," Under standard 4 planning, revealed "The plan of care will also include strategies that address each of the identified diagnosis or issues" Under standard 5 implementation revealed "The Registered Nurse implements the plan of care... documents implementation, modification, or omissions in plan."

Review of policy titled "Safety Companion" # 22, last revised 4/2018 under Purpose revealed "to identify the process, and guide decision making in the utilization of safety companions and care of the confused patient at risk for safety issues." Under scope revealed "All clinical areas that provide care to patients." Under definition revealed "A safety companion is defined as someone employed to provide constance surveillance to a patient who exhibits the potential to cause harm to self or others due to behavior problems." Under procedure revealed "Identify the need for safety companion services 1. RN will identify Patient at risk for injury... 3. Initiate problem on Plan of Care... 5. Communicate strategies and responses to interdisciplinary team... will reassess the need for a safety companion... every shift and/or as needed for changes in patient condition."

Review of policy titled "Care of the Patient with Suicidal Ideation Policy" # 86, last revised 9/2020 under definitions, Suicide Risk Screening Tool revealed "A tool used to assist in identifying patients at risk for suicide or harming themselves... 1. ED... 2. Patients [AGE] and older... will be screened to identify their risk for suicide using the designated depression... and suicide risk screening... tools." 3. The patient will first be asked the depression screening question. If the answer to the question is positive the suicide risk screening tool will be completed... i. Low Suicide Risk - requires... purposeful routine rounding with focus on suicide risk factors... 10. The patient's risk level and type of precautions initiated will be communicated any time there is a hand-off between care givers." Under II RN responsibilities... A. Patients that screen as low... will be reassessed daily."

Review of Patient #1's medical record revealed patient #1 presented to the Emergency Department in police custody under chapter 51 (involuntary) hold for medical clearance on 7/09/20 at 11:08 AM with a history of depression and previous suicidal ideation's. No required safety screening for depression/suicide was completed by the registered nurse on admission. On 7/09/20 at 5 PM the mobile crisis team arrived and at 5:40 PM the ED timeline revealed "Mobile crisis is not lifting the hold" indicating Patient #1 was in a behavioral health crisis requiring inpatient behavioral health placement. Patient #1 eloped from the facility on 7/10/20 at 6:56 AM and was brought back to the Emergency Department, the police responded and remained at the bedside with Patient #1 in the Emergency Department greater than 8 hours after the elopement. There was no depression or suicide screening documented for safety by the registered nurse prior to the police leaving the Emergency Department on 7/10/20. A sitter was placed in Patient #1's room 7/10/20 at 7 PM thru 7/11/20 at 2 AM. There was no depression/suicide screening completed, or nursing note documenting need for sitter. On 7/11/20 at 3:40 PM ED timeline revealed "Uncertain if patient is having auditory hallucinations ... patient reassured, door closed to reduce stimuli." Patient #1 was transferred to an inpatient behavioral health facility on 7/15/20. There was no depression/suicide screening completed by the registered nurse to assess patient #1's safety or to develop a plan of care.

On 10/20/20 at 12:02 PM during interview with Emergency Department Supervisor B, Supervisor B stated the nursing staff "should have had a suicide screen done" with that type of admission diagnosis. Supervisor B stated staff document according to the Emergency Department Standards of Practice and Care and stated the registered nurses do not use "care plans in the Emergency Department" stating "our patients don't usually stay that long."

Based on record review and interview, the facility failed to track patient safety events to analyze their causes and implement preventative actions in 1 of 3 patient grievances (Patient #11) and 3 of 7 patient events identified (Patient #1 ) in a total of 3 patient grievance reviews and 11 medical record reviews.

Findings include:

Review of policy titled "Event Reporting System (ERS): Safety Event Manager (SEM) and Feedback Manager (FM)" # 28, last revised 7/2018 under purpose revealed "supports all... reporting... safety events... to determine specific ways to improve patient safety." Under definitions A. revealed Safety Event Manager (SEM) is used to report patient near misses... patient actual events and unsafe conditions."

Review of training titled "Introduction to the Event Reporting System" not dated, under Just Culture revealed "Commitment and accountability from associates and leadership to safety and quality... Focused on identifying and addressing systems issues that lead individuals to engage unsafe behaviors... Recognizes many individual or "active" errors represent predictable interactions between human operators and system in which they work."

Review of policy titled "Patients Leaving Against Medical Advice/Elopement" # 79, last revised 2/2019 under procedure Competent Adult Patient(s) eloped/missing from the facility (unauthorized Departure) #10 revealed "An event should be entered into the Event Reporting System."

Review of patient #11's complaint CV 925 reported 6/30/20 under description revealed "The patient stated that their armband had someone else's name on it, so they brought it to the attention of the staff, but it never got changed." Investigation summary 7/01/20 revealed "There was a patient with similar name and date of birth when patient arrived the patient info was charted in the correct cart but the wrist band was not changed/updated." Under immediate Action Taken revealed "Followed up with staff... We have had education on making sure wrist band and patient info is correct multiple times within the past year." Under probability of this type of feedback recurring? revealed "Remotely."

On 10/21/20 at 2:14 PM during interview with Quality Improvement Coordinator H, Quality Manager D, and Emergency Department Supervisor B, Quality Manager D stated there was no safety event initiated on Patient #11 and stated it is the expectation that an incident report is completed when a name band with the incorrect name is placed on another patient.

Review of Patient #1's medical record revealed Patient #1 presented to the Emergency Department (ED) on 7/09/20 with a history of depression and previous suicidal ideation's. On 7/20/20 at 6:56 AM ED provider note revealed "Patient did elope the department and [police] were notified." On 7/22/20 at 4:43 PM the provider noted Patient #1 "kicked [him/her] in the left thigh" leading the provider to "chemically restrain the patient ... for the safety of the staff." ED physician note on 7/15/10 at 10:07 AM revealed "After significant involvement of administrative teams on both sides, patient was accepted." Patient #1 was discharged [DATE], 6 days after presentation to Emergency Department for medical clearance, 3 days 17 hours after being medically cleared.

On 10/20/20 at 12:17 PM during review of patient #1's medical record with Quality Coordinator C and Emergency Department (ED)Supervisor B, Supervisor B stated Patient #1 did not elope, s/he was redirected back to their room. Quality Coordinator C stated the elopement policy requires an incident report to be completed when a patient elopes.

On 10/21/20 at 2:14 PM during interview with Quality Improvement Coordinator (QIC) H and Quality Manager D, QIC H stated when a staff member gets injured at work, they are to report the incident through "ViaOne" used to report staff injuries. Quality Manager D stated there were no patient or staff events reported through either the Event Reporting System (ERS) or ViaOne.

On 10/21/20 at 2:45 PM during interview with Vice President of Patient Care (VPPC) I, VPPC I stated Patient #1's delay of care was not documented in the event reporting system and was not discussed with Leadership in the Serious Event Review Team (SERT) weekly meetings. VPPC I stated SERT will be looking at "what we could have done better."