HospitalInspections.org

Based on a review of facility documents, medical records (MR), and interview with staff (EMP) it was determined the facility failed to follow their policies related to the care of psychiatric patients for one of eight medical records reviewed (MR1) and failed to follow their policy related to patients leaving against medical advice (AMA) for one of three medical records reviewed (MR1).

Findings include:

Review September 6, 2018, of facility policy "Care of the Psychiatric or Violent Patient," last reviewed June 2018, revealed "Purpose: A. To define procedures for providing care to patients who present a potential danger to staff or other patients related to psychiatric or violent behaviors. ... II. Procedure: A. Upon entry to the ED, all patients who are emotionally unstable and demonstrate or verbalize a threat to themselves or others will: 1. Immediately be placed in a private room, if possible, and observed constantly by ED staff and/or hospital security. Documentation will reflect observation at 15-minute increments when unstable, progressing to every half hour then hourly when calm and cooperative. Patient room will be made "safe" -- all extra furniture removed/all potentially dangerous items removed/headwall secured with door. 2. Be undressed and given a paper scrubs and slipper socks to wear. All clothes and accessories will be removed from patient area. 3. Have belongings assessed for medications and weapons. These will be removed from patient area. Security will secure all guns, knives, mace, and other weapons. All patient belongings will be gone through and logged on the BH personal belonging sheet. Clothing and other belongings will be placed in clothing bag and locked in the med room or ED safe. If feasible, you can secure all belongings in a pt. belongings bag. Wrap with evidence tape, have patient sign the white area and secure in med room. Bag should not be open except in presence of patient. ... D. Patient will be give reassurance and support by staff. E. If mental health placement is in progress, address the patient's medical and physical needs: vital signs every shift, diet as per physician order, patient maintenance/home medications as per physician order, diversion as appropriate, toileting and comfort measures as needed. ... ."

Review on September 6, 2018, of facility policy "Patient Leaves Against Medical Advice," last reviewed June 2018, revealed "... I. Policy: A. When a patient leaves the Emergency Department against medical advice (AMA), the medical record should reflect exactly what treatment and instructions were advised, with thorough documentation. All patients indicating the desire to leave against medical advice shall be provided an AMA form to sign. II. Procedure: A. Emergency Department and Registration Staff may inform the patient that you are notifying the physician that the patient wishes to leave prior to the completion of tests or treatment. Request that the patient remain to discuss the situation with the physician. B. The Registered Nurse and/or physician shall discuss and document, with the patient and/or family, the potential risks and consequences that may occur if the patient leaves prior to the physician discharging the patient. C. After explanation of potential risks and consequences, if the patient refuses to wait for the physician, or if the patient talks to the physician and still desires to leave "against medical advice", request that the patient sign the AMA form and give a copy to the patient. D. The Registered Nurse shall provide written instructions to the patient to follow up with the his/her family physician or return to the Emergency Department if his/her condition worsens. E. If the patient refuses to sign the form, complete the form except for the patient's signature, write across the signature area that the patient refuses to sign and have a second witness sign the form. F. Document on the chart: 1. The patient's desire to leave AMA and specific reasons stated by the patient for leaving; 2. Instructions on potential risks and complications; 3. Patient's condition prior to leaving the Emergency Department; 4. Patient's mental status and objective behavior; 5. What efforts were made to prevent the patient from leaving without being seen and what attempts were made to secure consent; and 6. Written instructions and recommendations for follow-up given to patient. F. The hospital has no right to impose false imprisonment of any patient in full possession of reasoning power. ... ."

Review of MR1 revealed MR1 was brought to the hospital via ambulance at 3:17 pm on August 30, 2018. Chief complaint was suicidal thoughts, thoughts of harming self and homicidal thoughts. MR1 stated they did not want to live anymore. A self harm assessment revealed MR1 was at a heightened risk of harming self and was placed on suicide precautions with 15-minute checks. A safety sweep of the room was done, MR1 changed into paper scrubs and belongings were taken and placed into the medication room. The "Patient Item Inventory" revealed MR1 had keys, cigarettes, phone, phone cable, folders, checks, mail, jewelry and $1,875.00. MR1 was agitated with pressured speech at 4:10 pm. MR1 asked for medication for back-pain, became frustrated waiting for the pain medication and requested their belongings. EMP8 returned MR1's belongings to them. MR1 changed into clothing and walked out of the ED at 6:15 pm. MR1 refused to sign the AMA form. The physician was notified of MR1's departure after they left.

Further review of MR1 revealed no documentation EMP8 told MR1 they notified the physician that MR1 wanted to leave prior to MR1's departure. No documentation EMP8 or CF1 discussed and documented the potential risks and consequences that may occur if MR1 left the hospital AMA. No documentation EMP8 provided written instructions to MR1 to follow up with their family physician or return to the Emergency Department if their condition worsens. No documentation of the following: specific reasons stated by MR1 for leaving, MR1's condition prior to leaving the Emergency Department, MR1's mental status and objective behavior, what efforts were made to prevent MR1 from leaving and what attempts were made to secure consent.

The Physician Progress Note noted MR1 was depressed and did not sleep the night before. MR1 had a history of two previous suicide attempts. MR1 left AMA. The physician noted it would not be safe for MR1 to be alone and requested for the police to return him to the ED.

Interview with EMP2 at 1:45 pm on September 6, 2018, revealed EMP2 called the Pennsylvania State Police (PSP) on September 4, 2018, to verify MR1's death. EMP2 stated the facility cannot hold the patient against their will. MR1 was in the ED when they decided to leave.

Interview with EMP8 at 9:45 am on September 7, 2018, revealed they were assigned the care of MR1 on August 30, 2018. MR1 arrived by ambulance, they stated they did not want to live. MR1 was angry. MR1 changed into paper scrubs. EMP8 took and secured MR1's belongings EMP8 told MR1 the admission process could be take a long time. MR1 asked for pain medication. EMP8 told MR1 they would have to get an order from the physician for the medication. MR1 asked if they could smoke and when told no, MR1 said this place is like a prison. MR1 stated they just wanted to go upstairs to the Behavioral Health Unit. MR1 was frustrated with the process and requested to have their belongings returned. MR1 stated they were leaving the hospital. EMP8 told MR1 they could not keep them against their will and returned MR1's belongings to them. EMP8 told MR1 they were welcome to stay or to come back if they desire treatment. EMP8 informed the physician MR1 left.

Interview with CF1 at 9:30 am on September 24, 2018, revealed they took care of MR1 on August 30, 2018. CF1 confirmed MR1 did have a psychiatric emergency medical condition. CF1 was told that MR1 left AMA, after they left.

Interview with EMP1 at 10:00 am on September 24, 2018, confirmed the facility did not follow their policy "Patient Leaves Against Medical Advice" as written. EMP1 also confirmed EMP8 did not follow the facility policy "Care of the Psychiatric or Violent Patient" when they returned MR1's clothing to them.