HospitalInspections.org

Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by failure to provide an appropriate medical screening exam as evidenced by the physician failing to perform a neurological and psychiatric examination for 1 (#1) of 11 patients (#1, 3, 4, 7, 9, 10, 11, 13, 14, 15, 20) who presented to the emergency department with a psychiatric emergency medical condition (See findings at A-2406).

Based on record review and interview, the hospital failed to provide an appropriate medical screening exam as evidenced by the physician failing to perform a neurological and psychiatric examination.for 1 (#1) of 11 patients (#1, 3, 4, 7, 9, 10, 11, 13, 14, 15, 20) who presented to the emergency department with a psychiatric emergency medical condition.
Findings:

Review of the medical record for Patient #1 dated 06/06/2024 at 6:07 p.m. revealed a 24 year old male who presented to the emergency department via EMS with complaints of having done meth yesterday and has not slept in the last couple of days. Per EMS, the patient was found wandering the streets naked and local police called them. The patient denied any chest pain or shortness of breath. The patient reported having a history of meth use for which he has been in and out of rehab. The patient was unsure when his last rehab stay was.

Patient #1 was triaged as level ESI 2/Emergent. At 6:10p.m., a Rapid Initial Assessment was conducted by an RN. The assessment revealed the patient was restless, tachycardic, unable to sit still, anxious, afebrile, pupils 5+, no acute respiratory distress. His Broset (violence/aggression) score was 0. He was noted to remove his IV access more than once.

At 6:15 p.m., an HPI was conducted by the NP - Chief complaint: meth use, wants help. The
physical exam revealed he was awake, alert, in no acute distress, well appearing, well developed, well hydrated, well nourished, cooperative, not toxic appearing. Psychiatric exam revealed the following: affect NL, mood NL, not suicidal, not homicidal, no hallucinations, cognitive function NL, judgment/insight NL, thought content NL.

Labwork included: Chemistry, Hematology, Toxicology - positive for marijuana; an EKG was performed. He was treated with Ativan x2 doses; Benadryl x1 dose; Nicotine patch; Geodon x1 dose.

Re-evaluation notes revealed: called and spoke with Inpatient Rehabilitation Center A - accepted patient and will send someone to get him as soon as he was ready for discharge. The patient was in agreement with the plan of care, and was discharged on 06/06/2024 at 11:47 p.m. in stable condition when rehab van picked up up for transport to the rehab. He was counseled regarding diagnosis, lab results, need for followup, when to return to ED.

On 06/07/2024 at 1:21 a.m., Patient #1 returned to the emergency department with complaint of drug overdose. He was triaged as level ESI 1 - Resuscitation.
On 06/07/2024 at 1:21 a.m., a Rapid Initial Assessment was conducted by an RN. The assessment notes revealed that he was released from the hospital at 12:11 a.m. to the rehabilitation facility. Upon arrival to the rehab, the patient was noted to have pinpoint pupils and was unresponsive. Narcan was administered per EMS; he arrived to the emergency department via EMS with restraints intact due to combativeness. He arouses to tactile and painful stimuli. No respiratory compromise noted. Pupils pinpoint.

A PEC was completed by S1MD on 06/07/2024 at 1:25 a.m. for Patient #1 due to overdose on the way to Inpatient Rehabilitation Center A, polysubstance abuse, and bizarre behavior. Mental condition was assessed as bizarre, avoidant, positive for hallucinations. Documented revealed he was not currently suicidal, homicidal or violent; Opinion documented: dangerous to self; gravely disabled; unwilling/unable to seek voluntary admission.

On 06/07/2024 at 1:29 a.m., the HPI notes documented by S1MD for Patient #1 revealed: he had been in the ED here earlier today for strange behavior, methamphetamine positive and voluntarily went to check himself in at the drug rehabilitation facility. He had a ride there on their bus and while checking in he lost consciousness and had pinpoint pupils. He responded to Narcan. Arrives with ongoing bizarre behavior.
The physical exam conducted by S1MD revealed: VS normal; avoiding interaction. Psychiatric exam revealed: bizarre affect, hallucinations.

Labwork included: Chemistry, Hematology. Toxicology - positive for THC, amphetamines; CXR and EKG was performed.
Treatment included Naloxone x1 dose; IV fluids; Ondanestron x1 dose.

Re-evaluation notes documented by S1MD revealed: 24 year old presents complaint of bizarre behavior, overdose and ongoing substance abuse. He is obviously a danger to himself at this point having overdosed on his way to rehabilitation center. Will continue to observe. Will medically clear. Will PEC for his protection.

Re-evaluation progress notes documented by S1MD revealed: Patient's labs benign other than elevated CK. Will give additional 20cc/kg normal saline bolus. Patient is medically cleared for transfer for psychiatric care.

Clinical Impression: polysubstance abuse, overdose by ingestion, psychosis.
Disposition Decision on 06/07/2024 at 2:00 a.m: transfer for psychiatric services.
Certification was completed for transfer and signed by S1MD with: medical condition; reason for transfer; risks and benefits for transfer; mode/support during transfer; receiving facility and individual; accompanying documentation.

Nursing assessments were completed hourly for ingestion. Nursing Notes: 06/07/2024 at 6:00 a.m. - Patient PEC; moved to pod room; patient stable and medically clear at this time; suicide safe environment. Review of patient monitoring forms completed every 15 minutes from 06/07/2024 at 6:00 a.m. until discharge at 11:15 a.m. revealed behavior was documented as agitated/sleeping/sitting - no combativeness or restraint use documented.

Review of the nurse notes revealed: On 06/07/2024 at 10:45 a.m., Patient #1 was accepted for admission to Psychiatric/Behavioral Hospital B with accepting MD noted. At 10:53 a.m., EMS was contacted to set up transportation, which was to be available within an hour. At 11:12 a.m., the nurse documented report was given to the receiving hospital. 06/07/2024 at 11:16 a.m., Patient #1 departed via EMS to the receiving psychiatric hospital in stable condition.

Review of Patient #1's medical record retrieved from Psychiatric/Behavioral Hospital B revealed an admission date of 06/07/2024. Review of the multidisciplinary note dated 06/07/2024 at 12:15 p.m. revealed in part, S4RN called all staff for help due to the patient being in 4 point restraints and still launching his upper body off the stretcher. After attempting to calm the patient down, S2Psych was notified of patient arrival and current situation. PRN order was given at this time. Haldol 15mg IM, Ativan 4mg IM, and Benadryl 50mg IM. Patient #1 remained on stretcher in 4 point restraints due to patient being extremely combative with EMT and staff. IM injection was given at 12:25 p.m. by LPN. We again attempted to calm patient down and waited on injection to take effect approximately 40 minutes (injection was ineffective). EMTs could not release patient out of restraints due to patient trying to flip stretcher.
Review of Patient #1's medical record that the provider failed to evaluate, assess or treat Patient #1's psychiatric condition prior to transferring the patient back to Rapides Regional Hospital.

In an interview on 07/15/2024 at 1:39 p.m., S2DON verified Psychiatric/Behavioral Hospital B had 14 patients on 06/07/2024. He stated that did not include Patient #1. He verified the hospital had available beds for Patient #1. S2DON stated Patient #1 should have been wheeled on the stretcher to the seclusion room with enough staff to secure Patient #1 in restraints to get Patient #1 off the EMS stretcher. S2DON verified Patient #1 would have been safer here than being transferred back to the emergency department. After reviewing the admission criteria policy, S2DON verified that Patient #1 did meet admission criteria and did not meet any exclusionary criteria.

On 06/07/2024 at 1:26 p.m., Patient #1 returned (for the third time in 19 hours) to the emergency department via EMS, triaged as level ESI 2/Emergent. Chief complaint: Drug use.

On 06/07/2024 at 1:31 p.m., a Rapid Initial Assessment was conducted by S2RN. Assessment revealed the patient was recently sent to Psychiatric/Behavioral Hospital B, but was "too combative", so they gave a B52 and then sent back here; patient denies complaints; awake, alert and oriented x3, respirations even and unlabored, bilateral breath sounds clear to auscultation, Skin warm, dry and pink. Appears well.

On 06/07/2024 at 1:32 p,m., an HPI was documented by S3DO and revealed: 24 year old male with history of drug abuse presented to the emergency department from psychiatric facility as they would not admit him due to agitation. Patient seen yesterday in emergency department. He unintentionally overdosed going to a rehab center. He was put under physician emergency certificate by previous doctor for this reason. Patient denies any SI, HI, AVH. Does report he would like to receive help for substance abuse though he would like to go to his grandmother's house where he stays before he checks in. No medical complaint.

Further review of the assessment by S3DO revealed:
Detailed Suicide Risk: positive suicide risk screen - no; 3 month suicide and self-injurious behavior - no SI; most severe SI past month - No SI; Other risk factors - gender; recent clinical status - substance abuse/dependence; overall level suicide risk - low risk. Risk stratification: suicide - adult risk factors reviewed.
Past medical history - combative at facility; now sleeping.

Continued review of the medical record failed to reveal a thorough neurological or psychiatric assessement was conducted. The physical exam did not contain a psychiatric section. There was no documentation of the patient's narrative of events surrounding his overdose and agitated behavior. The physician failed to document any discussion with the patient about what substances he potentially consumed or that he reached out to family for collateral information.

Review of the Re-evaluation notes documented by S3DO revealed: 24 year old male presented with agitation as he was being checked into a psychiatric facility. I reviewed physician emergency certificate from yesterday by previous physician. Will rescind this as patient without SI, HI, AVH. He is alert and oriented. He does admit to drug use though denies any suicidal intent. He does report he would like rehab services though he does not want to go until he can talk to his family. He was discharged to his family's care.
06/07/2024 1:35 p.m. - discharged to home; counseled regarding diagnosis, need for follow-up, when to return to ED. Instructions - Drug abuse. Additional instructions - Please present to rehab services. Please return at any time for re-evaluation or feeling unsafe in any way. No referrals.

Review of the Nursing Notes dated 06/07/24 at 3:00 p.m. revealed discharge instructions were given to and verbalized understanding by Patient #1 and his mother; patient left to home in stable condition.

On 07/18/2024 at 1:15 p.m., an interview was conducted with S2RN, who confirmed she was working in the ED on the day shift when Patient #1 was transferred to the psychiatric hospital, and also when he returned from the psychiatric hospital to the ED. S2RN stated Patient #1 did not want to go to the psychiatric hospital. She explained the PEC to him. She stated he was not violent or belligerent, but was not happy with the PEC or going to the psychiatric hospital, and was resistant - he wanted to go to the rehab. S2RN stated she talked with his mother, and she was "not a fan" of the PEC and wanted him in rehab as well, not psych. S2RN confirmed that when a doctor completes a PEC and refers a patient to the psychiatric hospital after medical clearance, the nurses mass fax the paperwork through the online system to psychiatric facilities. The admissions staff from the accepting facilities contact the sending hospital for details and get approval from their provider (MD), and confirm acceptance of the patient; the nurse from the sending hospital places a call to the receiving facility to give report as the patient is going out of our facility to theirs. When Patient #1 left the ER to go to the psychiatric hospital , he was still resistant to psychiatic treatment, but was calm. He did not receive any sedatives while he was in the ER before he left, and was calm when he returned a few hours later - she never saw him become combative or belligerent.
After Patient #1 returned to the ER and S3DO saw him, she talked with S3DO - he said the patient denied SI/HI was okay for discharge home, and he rescinded the PEC. She stated she pushed Patient #1 in the wheelchair to the car, gave discharge instructions to his mom and he left with his mom. She stated he said he planned to go to rehab the next day. S2RN further added that the rehab wouldn't have accepted him until he was clean for 24 hours.

On 07/18/2024 at 12:20 p.m., a telephone interview was conducted with S1MD. He confirmed he was working in the ER on 06/06/2024, the evening that Patient #1 was brought into the ER by EMS. He recalled the patient had a drug overdose and was exhibiting bizarre behavior (found out in his yard naked); he recalled that the patient was seen by him and then transferred to the drug rehab facility for substance abuse treatment, and that the patient was picked up by the treatment center's bus for transfer.
S1MD recalled that Patient #1 returned shortly after he left via EMS after overdosing on the way to the rehab facility and had received Narcan. He confirmed that he examined Patient #1 on the return visit and conducted a PEC on the patient. He stated the PEC was performed in order to allow time to complete the observation and do a workup for metabolic causes for the psychosis. After medical clearance, if a patient does not improve, he is referred for psychiatric treatment and the nurse will then initiate contact with facilities for placement. He stated it is not common practice for the sending and receiving doctors to talk before transferring the patient to a psychiatric facility.
S1MD recalled that in the case of Patient #1, he felt the patient was too impulsive and lacked control, so he wanted him sent to an inpatient psychiatric facility for evaluation and treatment. He further stated he normally does not PEC for intoxication and overdose patients, "when they become lucid, they will be combative and averse to treatment, so we try to get them to go voluntarily to seek treatment for substance abuse," but Patient #1 had been in the ED twice within the last 24 hours. He stated he doesn't feel like he would have rescinded the PEC, but stated that "sometimes a PEC can harden a patient against therapy; the question for this young man was whether the PEC would benefit or hinder overall treatment. I felt he was a danger to himself when I PEC'd him, and was concerned about his impulse control, since he didn't make it to the rehab the first time. We usually use our own judgment to PEC, rather than consult psychiatrist - we leave that to the behavioral facility." S1MD confirmed the patient was not combative or belligerent when he declared him medically stable and ready for transfer to the psychiatric hospital on 06/07/2024 at 2:00 a.m., but did not personally see him for the remainder of the night before he left his shift. He stated if the patient had any changes in behavior, the nurses would have reported that to him.

On 07/18/2024 at 12:45 p.m., a telephone interview was conducted with S3DO, who confirmed he was working in the ED on the afternoon of 06/07/2024, when Patient #1 was returned from the psychiatric hospital via EMS. He stated he was told that he was too agitated at the psychiatric hospital for the staff to handle and they sent him back to the ED. He stated the patient was calm and cooperative when he assessed him. He talked with him and the patient stated he was seeking rehab services, and didn't need a psychiatric hospital. He stated that Patient #1 "freaked out" when he realized he was sent to a psychiatric hospital rather than a rehab facility. When he returned to the hospital ED he was alert, oriented and sober. He admitted he was a drug addict and wanted rehab, but said he wanted to go to his grandma's house first, and then to rehab.
S3DO stated the standard of care for overdose treatment is to observe for a few hours for recovery (in case they need Narcan, etc), and then discharge them. It is generally not their practice to PEC a patient if the overdose was unintentional and without suicidal ideations. He stated Patient #1 did not have suicidal ideations/homicidal ideations or audiovisual hallucinations at the time he returned from the psychiatric hospital. He further stated that it is not his view to take away a patient's rights due to drug overdose alone; he was clinically sober and acting normally at the time of discharge, so there was no reason for the PEC and he had no known psychiatric history. He confirmed that he did review all the notes from the 2 previous ED visits earlier that day, and stated it seemed a reasonable plan to him for Patient #1 to go home with his mom and then to rehab - that is what they both agreed to. His mom picked him up and took him home with understanding and agreement of that plan. The nurse went over the discharge instructions. When asked if he was aware if Patient #1 was admitted to the reahbilitation facility, he stated he heard he had overdosed and died a few days after discharge from the hospital.

On 07/18/2024 at 10:00 a.m., in a phone interview with the mother of Patient #1, she stated Patient #1 was discharged on Friday 06/07/2024 from Rapides Hospital and was to go to Rehab on Saturday 06/08/2024, but he wanted to use. He got a room at the casino and went home with individuals he did not know and he overdosed at their house on 06/11/2024.