Eyler, Deborah S., Watts, Rodowsky, Lawrence F. (Retired, Specially Assigned), JJ.
Eyler, Deborah S., J.
Richard Crise, the appellant, was a patient in the Emergency Room ("ER") at Maryland General Hospital ("MGH"), the appellee, on December 31, 2008. He suffered from numerous mental illnesses and before that day had been admitted to MGH for psychiatric treatment at least four times. He was examined by a nurse and an ER doctor, given a sedative, and was awaiting a psychiatric evaluation. Before the evaluation took place, he walked through the ER to a back door, and left the hospital. Clad only in a hospital gown, he walked in the cold weather in the direction of his house. When he got to the Howard Street Bridge, he saw police cars and two police officers slowly approaching him. He jumped off the bridge, fracturing his pelvis, left wrist, right arm, and right leg.
In the Circuit Court for Baltimore City, Crise sued MGH for medical negligence, alleging that steps should have been taken to monitor him so he would not have left the ER.
The case went to trial, with the first day devoted to jury selection. The next morning, the court entered judgment in favor of MGH on its own initiative, under Rule 2-502, on the ground that MGH did not owe Crise a legal duty of care. Specifically, the court ruled that MGH had no legal authority to keep Crise in the hospital, and his malpractice claim depended upon MGH's having such authority. Crise filed a motion for reconsideration or a new trial, which was denied.
On appeal, Crise presents one question for review:
Did the lower court err in ruling that [MGH] owed [him], its patient, no duty of care unless it had the legal authority to detain him?
For the reasons that follow, we conclude that the ruling was in error. Accordingly, we shall reverse the judgment and remand the case to the circuit court for further proceedings.
FACTS AND PROCEEDINGS
Crise, now age 30, was diagnosed with bipolar disorder at age 17. In the intervening years, he also was diagnosed at various times with schizoaffective disorder, schizophrenia, and depression. He has been admitted voluntarily to numerous Maryland hospitals for psychiatric treatment. At the time pertinent to this case, he was living with his mother, Mary Joanell Crise ("Ms. Crise"), and his teenage sister, Mary Crise ("Mary"), at a house in the Remington neighborhood of Baltimore City.
Before the events giving rise to this litigation, Crise had been admitted to the psychiatric unit at MGH at least four times, most recently in June of 2008. On that occasion, Ms. Crise took Crise to the MGH ER because he had been "non-compliant with treatment" and was "becoming increasingly psychotic." He had not been taking his medications or sleeping and was exhibiting "pressured speech." He was admitted to MGH's psychiatric unit for eight days with diagnoses of "[s]chizoaffective disorder chronic in acute exacerbation" and severe hypertension. During that admission, MGH maintained a "physically safe and emotionally supportive milieu" for Crise; monitored him "close[ly] . . . to prevent any harm to himself or others"; counseled him about environmental stressors; encouraged him to attend counseling and group therapy; and adjusted his medications. Crise was discharged when his psychosis was under control and his treating doctors at MGH determined that he could "adequately and safely be managed in the community . . . and that he would be no danger to himself or to others." He was prescribed Seroquel and Depakote, both to be taken twice daily,  and two medications for hypertension.
The events giving rise to the instant litigation began around 2:30 p.m. on December 31, 2008, when Crise, then age 25, arrived at MGH's ER accompanied by Ms. Crise and Mary. He was complaining of chest pain and heart palpitations. Upon arrival in the E.R., Ms. Crise told the nurses that Crise had bipolar disorder and was experiencing a psychiatric crisis. She further informed the nurses that for the past five days Crise had not taken his prescribed psychiatric medications, eaten, had anything to drink, or slept.
Vicki Chitwood, R.N., the ER Head Nurse, immediately took Crise to Room 3 to have his cardiac condition evaluated. Room 3 is ten to twelve feet from the nurses' station. It contains a stretcher that the patient assigned to the room uses as a bed.
At 2:45 p.m., Nurse Chitwood performed an initial triage assessment of Crise, recording her notes on a "Physical Assessment Flow Sheet" ("Nursing Assessment"). Ms. Crise and Mary were present at that time. Also present was Trina Dixon Holmes, a patient care technician ("PCT").
With respect to Crise's health history, Nurse Chitwood checked a box on the Nursing Assessment for "Mental Illness, " making handwritten notations of "Bipolar" and "Acute Mania." She wrote that Crise was living with his family members and that in the last three months he had been prescribed Depakote 250 mg, Depakote 500 mg, and Trazadone 500 mg.
Crise's chief complaint was "chest pain" that had started earlier that day. He reported a history of panic attacks and said he had not slept or taken his psychiatric medications for five days. In the neurological assessment part of the Nursing Assessment, Nurse Chitwood wrote that Crise was appropriately dressed; alert; oriented to person, place, time, and event; anxious and restless; and had clear but "pressured" speech.
In the psychiatric assessment, Nurse Chitwood noted that, according to Ms. Crise, Crise was suicidal and had a history of prior suicide attempts. Specifically, Ms. Crise advised that, just a few months earlier, Crise had become manic and had run naked along a highway in Delaware. Crise "denie[d] active suicidal ideation, " however, and was not homicidal. Nurse Chitwood checked the "auditory hallucinations" box on the Nursing Assessment form.
Following Nurse Chitwood's initial evaluation, another ER nurse, Digma Lagmay, R.N., briefly took over Crise's care. At her request, Crise disrobed and donned a hospital gown. MGH staff performed a "sharps check" to make sure Crise did not have any weapons or sharp objects in his possession. MGH policy mandates that all psychiatric patients undergo a "sharps check." All of these tests were performed around 3:00 p.m.
Brian Finnegan, M.D., the attending physician in the ER that day, ordered blood and urine tests to evaluate Crise's cardiac function and determine whether he was under the influence of narcotics or alcohol. The latter tests are standard "psych labs." Nurse Lagmay inserted an intravenous ("IV") line, started IV fluids, administered oxygen, and performed an EKG.
According to Mary, while C rise w as undergoing the EKG, Ms. Crisehandwrote a note and gave it to a nurse at the nurses' station. At the top of the note, Ms. Crise wrote the date, the time Crise had arrived in the E.R., and his full name, date of birth, and address. She also wrote:
Diagnosis - Acute mania
Bipolar Mental Illness
patient has not slept for 5 days
No sleep. Is Manic, delusional, hearing of voices. Not eating or drinking.
Allergic to Xyprexa.
(Emphasis in original). At the bottom of the note, Ms. Crise listed Crise's current medications and dosages.
At some point, Ms. Crise and Mary returned to the ER waiting room. They may have been directed to do so by staff because Crise did not want them with him or because the staff found Ms. Crise to be disruptive. PCT Holmes overheard Ms. Crise protesting that she could not leave Crise alone because, if she did, he would leave the ER. She was "begging [them]" to watch him to make sure he did not leave.
At 3:20 p.m., Dr. Finnegan examined Crise. He already had reviewed the EKG results, which were normal. He recorded his observations on an "Emergency Physician Record." He noted that Crise was complaining of chest pain and heart palpitations that "come [and] go" and "tightness" around his mid-sternum. Crise told Dr. Finnegan that he had not slept in three days and had not eaten "much" either. In addition to chest pain, Crise reported having a sore throat and a headache.
Dr. Finnegan reviewed Crise's records from prior admissions to MGH, noting the previous diagnoses of schizoaffective disorder, schizophrenia, bipolar disorder, and hypertension. He observed Crise to be oriented, with normal mood and affect; alert; and in "no acute distress." He observed that Crise appeared "anxious." Crise did not report being suicidal or homicidal and denied that he was experiencing hallucinations. Dr. Finnegan did not speak to Ms. Crise or Mary. Dr. Finnegan acknowledged during his deposition that ordinarily he speaks to family members when evaluating patients for psychiatric problems and, had he known that Ms. Crise and Mary were in the ER waiting area, he would have communicated with them.
Dr. Finnegan's clinical impression was that Crise was suffering from "anxiety, bipolar, mania, [and] chest pains." He concluded that the likely cause of the heart palpitations was anxiety. He wrote an order for Crise to be assessed by a crisis evaluator. Crisis evaluators are not physicians and do not work on-site at MGH. They are expected1 to arrive to perform an evaluation within 90 minutes of being contacted. It is MGH's policy that a crisis evaluator will not be contacted until a patient's blood and urine laboratory tests have been returned.
Around 4:30 p.m., Elizabeth Svehla, R.N., the ER charge nurse, took over Crise's nursing care.
At 4:41 p.m., Crise's lab work came back. Nurse Svehla reported to Dr. Finnegan that all the test results were normal. The results did not reveal the presence of alcohol or narcotics in Crise's system and confirmed that he had not been taking his psychiatric medications, as those drugs were present in his blood below any therapeutic level.
At 5:00 p.m., a crisis evaluator was called.
Throughout the more than two hours that Crise had been in the ER, he had remained in Room 3, which was "in [Nurse Svehla's] direct eyesight" from the nurses' station. Upon taking over his care, she began watching Crise to "make sure he [stayed] in the room." She observed him "climbing off of the stretcher [in his room] and being restless"; "pacing" around his room; and "occasionally venturing out and looking at the other patients." On several occasions, Nurse Svehla or other hospital staff redirected Crise back to his bed.
PCT Holmes advised Nurse Svehla that Ms. Crise told her that Crise needed to be watched and was likely to run. She volunteered to act as a "sitter." A sitter is a hospital employee, usually a PCT, assigned to monitor a patient one-on-one. If the patient exhibits any harmful or dangerous behavior or attempts to leave, the sitter is to alert medical or security staff. According to PCT Holmes, Nurse Svehla responded that the ER did not have enough staff to assign a sitter and that Crise had been placed in Room 3, across from the nurses' station, so she (Nurse Svehla) could "eyeball" him.
Because Crise was exhibiting "increasingly restless" behavior, Nurse Svehla contacted Dr. Finnegan and requested medication to calm him down. At 5:30 p.m., Dr. Finnegan ordered that Crise be given 1 milligram of Ativan, a sedative, by IV. Nurse Svehla administered the Ativan.
Immediately thereafter, Crise asked to use the bathroom. Nurse Svehla escorted him to a bathroom and waited outside the door for him. He was in the bathroom for some time, causing Nurse Svehla to ask him to hurry up. When Crise came out of the bathroom, Nurse Svehla saw that he had pulled his IV out of his arm and was bleeding. She asked him why he had done that; he replied that "he didn't ...