HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the patient received a proper medical screening evaluation in one (1) of one (1) records reviewed.

Findings include:

Interview with registered nurse (RN) (ID# 56) on 1/12/2018 at 1120 stated she told the patients' (ID# 1) mother that she could not keep the patient without cause because she was 18 years old, and considered an adult.

Record review of the intake form from Cypress Creek on 12/11/2017 at 16:07 written by, RN (ID# 56) revealed the patient (ID# 1) an 18-year-old female visitor was brought to the facility by her mother because she was hearing voices.

Record review of the incident note written on 12/11/2017 by RN (ID# 56) revealed a psychotic 18-year-old female (ID# 1) did not consent to triage, assessment or possible treatment. Patient (ID# 1) punched the nurse (ID# 56) in the chest and continued to harm staff. A code was called because the patient (ID# 1) was terrorizing other visitors in the admissions lobby.

Record review of unsigned nursing notes by RN (ID# 56) noted the facts were the following: Patient was brought in by mom and friend for behavioral issues; Patient began pushing her body against the nurse; When asked to take her vital signs, the patient became belligerent, and continued to verbalize intent to harm staff and the nurse; Nurse called a code, other staff arrived; Patient was verbally and physically terrorizing other visitors in the admissions area; Nurse talked to mother and explained the patient does not consent to triage, assessment or possible treatment and cannot be forced to stay at the facility at this time; Mother wanted to drop patient off due to unmanageable behavior; Nurse counseled mother and reviewed the process of filing a mental health warrant and was given a phone number for Harris County; Mother verbalized understanding and left with patient; Patient was calm when permitted to leave.

Record review of the EMTALA log dated 12/11/2017 reviewed the patient (ID# 1), an 18 year old female arrived at 1617 via car, emergency medical Psych Condition Note revealed that patient (ID# 1) was not a psychiatry emergency and departed at 1625, because she refused triage and assessment.

In an interview on 1/11/2018 at 1015 with the Director of Nurses, he stated the patient would be evaluated by the intake staff and the physician would be notified if a patient did not want to stay. If the patient is not impaired or not at risk the patient would be released. Any patient who walks in the facility would be logged in. The intake nurse always notifies the physician if the patients are admitted. If the patient refuses, and is at risk, the physician decides if a warrant is needed. An order is obtained to get a warrant and the patient would be admitted to the facility.

In an interview on 1/ 11/2018 at 1050 with the Director of Intake, she stated "we determine the status of the patient, by law we have to let them go if they are not a danger to self or others". If a patient does not want to stay and is a threat to others or they change their minds the patients must sign the appropriate paper work. The physician utilizes the TeleMed System as a method to assess patients for admission. We have patients triaged and assessed within 15 minutes and seen through TeleMed prior to admission.

Record review of facility policy Emergency Assessments and Admissions, stated Initial Medical Screening: b. All patients shall be screened for medical stability by a qualified medial professional (register nurse, physician's assistant or MD) when possible within 15 minutes of presenting for care.

The medical record revealed Patient (ID#1) was not provided an evaluation by a qualified medical provider, or had a psychiatric assessment completed. Patient (ID# 1) was not stabilized prior to leaving the facility. She was improperly permitted to leave because she refused treatment, but never had an assessment of her capacity to make decisions for herself.