HospitalInspections.org

Based on medical record review, document review, policy review and interview, the hospital does not have written on-call policies and procedures that clearly define the responsibilities of the on-call Psychiatrist to respond, examine, and treat patients with an emergency condition. Additionally, there are no policy provisions requiring the on-call Psychiatrist to document their assessment, recommendations and/or collaboration with other healthcare providers in determining the disposition and needs of a psychiatric patient.

Findings Include:

Review on 02/16/23 of the emergency department (ED) medical records for Patient #1 dated 03/18/22, Patient #2 dated 10/01/22, Patient #3 dated 06/01/22, Patient #4 dated 03/24/22, Patient #5 dated 03/24/22 and Patient #6 dated 06/16/22 revealed all of the patients presented to the ED with behavioral health complaints. No documentation was found in any of the ED records related to the content of the telephone call between the Psychiatric Assessment Officer (PAO) and the Psychiatrist on-call, no documented recommendations or consult note from the Psychiatrist on-call, and no documented communication between the ED Provider and the Psychiatrist on-call regarding the coordination of care and psychiatric evaluations. There is no documentation of reassessments by the ED Providers prior to the discharge.

Telephone interview on 02/14/23 at 02:30 PM with Staff (N), Psychiatrist revealed he works in outpatient child and adolescent psychiatry program attached to the facility. Staff (N) does on-call for the in-patient Behavioral Health unit and the ED approximately 3 to 5 nights per month. Staff (N) has the ability to access medical records off site, can review assessments, as well as past visits to the facility and other facilities. Staff (N) was on on-call duty the night Patient #1 presented to the ED, however, does not remember details of the case. When Staff (N) receives a call regarding a patient in the ED, it is from a licensed clinician that is a PAO. They go over in depth, the patient's psychiatric history, family history, medical history, drug or alcohol use, past admission history if needed, information of why/how the patient came to the ED, and how they are currently presenting. Prior to the new process, Staff (N) did not sign off on the PAO evaluations or put a note in the medical record. Staff (N) only spoke to the ED provider if the patient was going to be admitted to the in-patient Behavioral Health unit, or if the ED provider wanted to further discuss the patient and any recommendations Staff (N) made for discharge.

Interview on 02/14/23 at 11:30 AM with Staff (S), Director of Behavioral Health, stated that prior to the new process, the PAO would complete their evaluation and then call the Psychiatrist to discuss the case and disposition of the patient. The PAO would then call the ED Provider to go over the evaluation and recommendations. Staff (S) stated that the ED Provider would put in the disposition orders for admission, transfer, or discharge based on that collaboration. Additionally, the ED Provider would speak directly with the Psychiatrist if a patient was being admitted.

Interviews on 02/14/23 at 12:00 PM with Staff (U), PAO; on 02/15/23 at 10:40 AM with Staff (FF) PhD-Clinical Evaluator; and telephone interview on 02/15/23 at 01:00 PM with Staff (L), PAO/LMSW all stated that once they complete their assessment, they contact the Psychiatrist on-call and present the evaluation of the patient which includes current patient presentation, current symptoms, current outpatient treatment, past history of symptoms, past hospitalizations, collateral information form family/friends/outpatient providers, as well as risk/lethality assessments. The PAO and Psychiatrist on-call would discuss the patient to determine disposition (Admission or Discharge) and the plan of care. Prior to the new process being implemented on 01/31/23, the PAO would then call the ED Provider to go over the evaluation and recommendations. The ED Provider would put in disposition orders for admission, transfer, or discharge based on that collaboration. Additionally, the ED Provider would speak directly with the Psychiatrist if a patient was being admitted.

Review on 02/14/23 of the On-Call schedule for March 2022 revealed a there was one Psychiatrist assigned Monday through Friday from 08:00 AM to 05:00 PM, one Psychiatrist assigned Monday through Friday from 05:00 PM to 08:00 AM, one Psychiatrist assigned Saturday 08:00 AM to 08:00 AM, and one Psychiatrist Sunday from 08:00 AM to 08:00 AM. Staff (N), Psychiatrist, was assigned to on-call duties on 03/18/23 from 05:00 PM to 08:00 AM.

Review on 02/14/23 of policy "Admission to Behavioral Health Services" last revised 08/2021 indicates that all individuals seeking behavioral health treatment shall undergo an admission assessment to determine treatment needs, assessment of risk, diagnosis and needed level of care for behavioral health services. The admission assessment is conducted or supervised by licensed staff member or a designate Qualified Health Professional (QHP). The rationale and decision to admit a patient is made by the QHP/licensed clinician.

Review on 02/14/22 of policy "Admission Clinical Standards of Care for Inpatient Mental Health" last revised 08/2021 revealed authorization and coordination of admission to the inpatient unit are functions of the Medical Director of Mental Health Unit or his/her designee. It is ultimately the responsibility of the admitting Psychiatrist to determine if a patient meets criteria for admission as well as whether the patient requires voluntary (9.13) or involuntary (9.39) Emergency Admission.

Review on 02/16/23 of Rochester General Department of Psychiatry Rules and Regulations (no date) indicates on-call coverage physicians will be expected to receive phone calls and respond to pages from Psychiatric Assignment Officers (PAO) or other staff. Will provide telephone consultation regarding admissions, discharges, or treatment of any patients that were consulted while on call. As necessary, return to hospital for direct supervision and document any contact with patients that occur during on-call period.

Review on 02/16/23 of Emergency Medicine Unit Structure Standards dated 1/17/22 revealed multiple specialty consultants are available to support ED patient care. Responsibilities of the consultant include communication with the ED provider and the nursing staff regarding patient management, providing appropriate documentation to help guide the patient care, discussing the plan of care with the ED provider, and updating patient and family as necessary, and providing appropriate direction to nursing staff. For Psychiatric Emergencies, the ED provider evaluates all psychiatric or behavioral health patients in order to medically screen/clear the patient prior to the patient being seen by a psychiatrist or their designee. The decision to admit a psychiatric patient occurs after the Clinical Evaluator (CE) consults with the psychiatrist on call. If a patient is felt to be safe to discharge, the CE will notify the ED attending and/or psychiatrist. The ED provider will discharge the patient in conjunction with the behavioral health team providers. The psychiatric staff will evaluate the patient. The recommendation to discharge or to admit the patient will take place after the psychiatric staff has consulted with the Psychiatrist on call.

Corrective Actions:

Review on 02/15/23 of email from Staff (J), MD-Emergency Chief to all ED providers dated 01/25/23 indicates that providers are now required to clearly document a patient "reassessment" prior to discharge. Additions were made to the medical decision making (MDM) form (in the electronic medical record). A screen shot shows the "Disposition section" and includes a new question "patient reassessment-yes/no" and a new area "Reassessment comment" which is a section for the ED provider to write a note.

Review on 02/15/23 of email from Staff (S), Director of Behavioral Health to all facility Psychiatrists who perform on-call services dated 01/30/23 and an email to all PAO's and clinical evaluators dated 01/30/23 that indicates "last week discussed few minor tweaks to the psychiatric evaluation and re-evaluation. Added verbiage regarding psychiatrist on-call being collaborated with and being in agreement with the plan; we are asking that everyone document the time that the psychiatrist on-call was contacted, and we added a line stating that the clinical evaluator attested discussing disposition with the attending ED provider. There are a few more modifications: starting today, need to ensure that the psychiatrist on-call discusses every case that a psychiatric evaluation occurs in the ED with the attending ED provider. The other new add is that the psychiatrist on-call will need to attest to reviewing the case with the clinical evaluator as well as having a discussion with the attending ED provider."

Review on 02/15/23 of Department of Psychiatry and Behavioral Health Joint Medical Provider Meeting dated 02/07/23 revealed new on-call process was discussed. All new patients (not just new admissions) now require MD to MD hand-off. Patients seen by the PAO will need their notes signed off with an attestation added by the Psychiatrist on-call.

Review on 02/16/23 of Crisis Intervention Unit (Behavioral Health treatment area of the ED) daily audits dated 01/30/23 to present revealed auditing starting on 01/31/23 for all ED records of all patients who presented to the ED for a psychiatric evaluation, regardless of their disposition (Admitted or Discharged). The audits include : date of presentation, medical record number, name of the PAO evaluator, the time/documentation of the PAO consult with Psychiatrist on-call, documentation of PAO discussion with attending provider (ED provider), PAO documentation of case discussion with Psychiatrist on-call in the disposition plan, name of Psychiatrist on-call, that the PAO coordinates the Psychiatrist on-call with attending ED provider for evaluations/re-evaluations, Psychiatrist on-call co-signature of the PAO note with an attestation of the PAO note review, documentation of PAO discussing assessment/disposition with attending ED provider, and ED provider documentation of patient re-assessment.

Interview on 02/16/23 at 10:00 AM with Staff (S), Director of Behavioral Health, Staff (T), Interim Chair of Psychiatry, and Staff (J), MD-Chief of Emergency Department revealed all PAO's, and Psychiatrists on-call were informed of the new process. Starting on 01/30/23, Staff (S) began auditing ED medical record for every patient presenting with mental health complaints, regardless of the disposition. Staff (S) stated that between 5 to 10 patients present daily. Staff (T), Interim Chair of Psychiatry stated that if the ED record is missing any item that is being audited, that staff member is re-educated regarding the new process.

Interview on 02/14/23 at 11:30 AM with Staff (S), Director of Behavioral Health; on 02/14/23 at 02:40 PM with Staff (T), Interim Chair of Psychiatry; Telephone Interview on 02/14/23 at 02:30 PM with Staff (N), Psychiatrist; on 02/15/23 at 10:40 AM with Staff (FF) PhD-Clinical Evaluator; on 02/15/23 at 10:40 AM with Staff (FF) PhD-Clinical Evaluator all confirmed that a new process was implemented on 01/31/23 and stated that the new process includes: the PAO and on-call Psychiatrist speak; collateral information is given to the ED Provider by the PAO; the Psychiatrist is now required to speak with the ED Provider; the PAO is required to document the time of discussion and what was talked about with Providers; and the ED Provider now reassesses the patient prior to discharge. In addition, the on-call Psychiatrist now signs an attestation indicating that they were notified, have reviewed the case, and are in agreement with the PAO's findings.

Interview on 02/14/23 at 01:15 PM with Staff (W), ED MD, at 01:30 PM with Staff (X), ED MD, and at 02:00 PM with Staff (Y), ED MD revealed when a patient presents to the ED for a psychiatric complaint, they are given a medical and psychiatric screen including discussing what brought the patient in to the ED, if they have history of anxiety or depression, if they have suicidal or homicidal ideation, and at any recent admissions. Psychiatric patients that have been cleared medically are taken over to the CIU for evaluation by the PAO. On occasion a Psychiatrist may be in house for evaluation/collaboration. Once the PAO evaluates the patient, Staff (W), (X), and (Y) indicated that they would speak and consult with the on-call Psychiatrist and would re-evaluate the patient if they were being discharged.

Review on 02/15/23 of ED medical record for Patient #7 dated 01/31/23 and Patient #8 dated 01/31/23 revealed both patients presented to the ED with behavioral health complaints. Documentation was found in the record indicating that the ED provider discussed the patient case/disposition with the Psychiatrist on-call, the Psychiatrist on-call co-signed the PAO evaluation, and the ED Provider performed a re-assessment of the patient prior to discharge.