HospitalInspections.org

Based on document review and interview, it was determined for 1 of 10 ( Pt #9) patients, the Hospital failed to ensure a patient's personal privacy was maintained. This has the potential to affect all patients serviced by the Hospital with a average monthly census of 228 patients.

Findings include:

1. Internal documentation was presented by the hospital on 7/29/21. The documentation indicated a call was received from a family member of Pt #9 regarding having received discharge papers of another patient (Pt #8 - name was provided to the hospital).

2. During an interview conducted on 7/29/21 at approximately 9:15 AM with the Director of Emergency Services (E#3), E#3 stated Pt #9's family called back on 7/27/21 and stated, "(Pt #9) got the wrong discharge papers." E#3 informed family member to bring back the wrong pt's. discharge papers and to pick up the correct discharge papers. E#3 stated Pt #9 hadn't returned the incorrect discharge papers and/or picked up the correct discharge papers, as of this date. E#3 stated the hospital is just beginning the process for follow up to the privacy complaint, as it was just received.

A. Based on document review and interview, it was determined for 2 of 8 (Pt #5, Pt #7) visit records reviewed, the hospital failed to ensure the after visit summary (AVS/discharge instructions) was reviewed and a written copy of the AVS was provided to the patients. This has the potential to affect all patients who receive care by the Emergency Department (ED) with an average of 2280 patient visits per month.

Findings include:

1. The policy titled "Discharge of Patients from the ED" (approved 6/3/21) was reviewed on 7/29/21. The policy noted, "G. The After Visit Summary (AVS) is reviewed with the patient and/or designated caregiver prior to leaving the Emergency Department."

2. Pt #5 Date of Service (DOS): 7/24/21
Diagnosis: Psychiatric Evaluation. The record was reviewed on 7/28/21 at approximately 1:30 PM. The record noted Pt #5 was discharged at 12:05 PM and lacked documentation the AVS was reviewed with the patient and/or designated caregiver and that a copy was provided to the patient.

3. Pt #7 DOS: 7/21/21
Diagnosis: Psychiatric Evaluation. The record was reviewed on 7/21/21 at approximately 3:50 PM. The record noted Pt #7 was discharged at 3:05 AM and lacked documentation the AVS was reviewed with the patient and/or designated caregiver and that a copy was provided to the patient.

4. During an interview on 7/28/21 at approximately 4:00 PM, the Trauma/Quality Coordinator (E#6) reviewed Pt #5 and Pt #7's records and verbally agreed the records lacked documentation the AVS was reviewed with the patient and/or designated caregiver and that a copy was provided to the patients.

B. Based on document review and interview, it was determined for 3 of 8 (Pt #5, Pt #6, Pt #7) visit records reviewed, the hospital failed to ensure patients were evaluated as ordered prior to discharge. This has the potential to affect all patients who receive care by the Emergency Department (ED) with an average of 2280 patient visits per month.

Findings include:

1. Pt #5 Date of Service: (DOS): 7/24/21
Diagnosis: Psychiatric Evaluation. The record was reviewed on 7/28/21 at approximately 1:30 PM. The ED Provider Note authored by the Physician Assistant and dated 7/24/2021 at 5:51 AM noted, "Disposition:... Sign out follow up labs/ekg (laboratory/electrocardiogram) and consult crisis once medically cleared. The same ED Provider Note authored by MD#4 (ED Physician) noted, "The patient is endorsed over to me at shift change. Mental health evaluation (mental health evaluation) is made and (he/she) is stable for discharge..." The record lacked documentation a crisis consult (mental health evaluation) was completed prior to discharge on 7/24/21 at 12:05 PM.

2. Pt #6 DOS: 7/22/21
Diagnosis: Psychiatric Evaluation. The record was reviewed on 7/28/21 at approximately 3:50 PM. Pt #6's record indicated the following:
a. The Provider's Note dated 7/19/21 at 10:33 PM noted "Patient presents with history of manic episode this evening." The record lacked a crisis consult.
b. The Provider note authored by MD#2 (ED Physician) dated 7/22/21 at 3:05 PM noted "... drove (her/himself) to the police station and was having unusual behavior... having bizarre in tangential speech... goes from topic to topic and difficult to follow... brought here... via EMS (Emergency Medical Service) for psychiatric evaluation... patient is under arrest and therefore can have psychiatric evaluation in jail. After my evaluation patient is medically cleared and discharged into police custody." The consult note authored by MD#3 (Psychiatrist) dated 7/22/21 at 3:30 AM noted "Will continue involuntary status until social worker/case management can reach out... discharge disposition should be based on collateral information obtained by social worker/case management..." The record noted Pt #6 was discharged to the police at 3:30 PM by MD#2 without conferring with MD#3's recommendations.
c. The record noted Pt #6 was readmitted on 7/22/21 at 4:05 PM. The Crisis Assessment dated 7/23/21 noted "... put noose around (her/his) neck several times while in jail... client is assessed to be high risk of harm to self or others as evidenced by disorientation, delusions, threatening behaviors and lack of insight... is in need of immediate inpatient hospitalization for safety." The record noted Pt #6 was discharged on 7/25/21 when a treatment center accepted Pt #6 due to behavior.

3. Pt #7 DOS: 7/21/21
Diagnosis: Psychiatric Evaluation. The record was reviewed on 7/28/21 at approximately 3:50 PM. Pt #7's record indicated the following:
a. The record noted on 7/21/21 at 1:50 AM "pt presents to ed via EMS with c/o (complaints of) hallucinations and bizarre behavior... pt at... currently for meth detox (methamphetamine). The 15 minute check flowsheet noted on 7/21/21 at 3:00 AM "Agitated... Delusional; Hallucinating; Paranoid..." The Provider note authored by MD#2 on 7/21/21 at 3:09 AM noted "Patient signed out to me at approximately 2:50 PM... patient is now willing to leave..." The record lacked documentation MD#2 evaluated Pt #6 prior to discharge at 3:05 AM. The record lacked documentation how Pt #7 was discharged or where her/his disposition was.
b. The record noted Pt #7 was readmitted on 7/21/21 at 8:54 AM. The Provider note authored by MD#4 noted "... was not able to get (her/his) inpatient bed back... because (she/he) went to ER (7/21/21 at 1:50 AM)... bystander saw (her/him) lying down next to train tracks in... paper scrubs..." The record noted Pt #7 was admitted to the mental health unit on 7/21/21 at 4:56 PM.

4. During an interview on 7/28/21 at approximately 4:00 PM, the Trauma/Quality Coordinator, (E#6) reviewed Pt #5 and Pt #6's records and verbally agreed the records lacked documentation a crisis consult was completed prior to Pt #6's discharge and should have been. E#6 verbally agreed MD#2 and MD#3 had conflicting discharge plans which were not addressed prior to discharge by MD#2 and should have been. E#6 reviewed Pt #7's record and verbally agreed the record lacked documentation MD#2 evaluated Pt #6 prior to discharge and should have.

C. Based on interview and document review, it was determined for 3 of 3 (Pt #5, Pt #6, and Pt #7) behavioral health patients, the hospital failed to establish and maintain a process for ongoing and continuous assessment of the medical care provided to its ED patients. This has the potential to affect all patients who receive care by the ED with an average of 2280 patient visits per month.

Findings include:

1. During an interview on 7/29/21 at approximately 11:00 AM, the Trauma/Quality Coordinator (E#6) stated the Medical Director of Emergency Director reviewed the returns within 48 hours visits for appropriateness of care, although wasn't sure "How caught up (he/she) was".

2. During an interview on 7/29/21 at approximately 1:15 PM, the Manager of Quality/Regulatory (E#1), the Vice President of Quality (E#2), the Director of Emergency Services (E#3) and the Chief Nursing Officer (E#7) stated the Hospital did not have a policy on governing the medical care provided in the ED. E#3 stated E#6 audited the returned visits and the Medical Director of Emergency Services reviewed them for quality of care provided. Upon inquiry, E#3 stated "(E#6) said the reviews haven't been done since 2019." E#1, E#2, E#3 and E#7 verbally agreed the quality of care provided in the ED was not assessed and should have been.

3. The Returns to the ED within 48 hour log was reviewed on 7/28/21. The log noted the following:
a. In May, there were 162 returns to the ED within 48 hours. 21 out of the 162 were behavioral health visits.
b. In June, there were 130 returns to the ED within 48 hours. 21 out of the 130 were behavioral health visits.
c. In July, there were 136 returns to the ED within 48 hours. 21 out of the 136 were behavioral health visits.

4. The following patients records who presented for a psychiatric evaluation were reviewed for returned admissions:
a) Pt #5: Presented to the ED on 7/24/21 at 5:00 AM and was discharged at 12:05 PM. Returned to the ED on
7/25/21 at 11:38 AM and remains in the hospital.
b) Pt #6: Presented to the ED on 7/19/21 at 4:20 AM and left without being seen at 4:22 AM. Pt #6 returned to the
ED on 7/19/21 at 12:30 PM and was discharged at 2:00 PM. Pt #6 returned to the ED on 7/19/21 at 10:23 PM
and was discharged on 7/20/21 at 12:00 AM. Pt #6 returned to the ED on 7/22/21 at 2:51 AM and was
discharged at 3:30 AM. Pt #6 returned to the ED on 7/22/21 at 4:05 PM and was discharged on 7/25/21 at
10:08 AM.
c) Pt #7: Presented to the ED on 7/21/21 at 1:50 AM and was discharged at 3:05 AM. Pt #7 returned to the ED on
7/21/21 at 8:54 AM and was discharged at 9:24 PM.