HospitalInspections.org

Based on record review and interview, the facility failed to establish policies and procedures for treatment of 3 of 3 patients (Patient #1, Patient #2, and Patient #7) who failed to receive timely treatment during an emergency medical crisis and failed to protect the safety of vulnerable patients by failing to arrange safe discharge for patients with an emergency medical crisis in 1 of 1 patients (Patient #1) unable to request care themself in a total of 10 records reviewed.

Findings include:

The facility failed to establish policies and procedures for staff to indicate the rights of how a patient requests treatment in an emergency medical crisis. See Tag A-0131

The facility failed to protect the safety of vulnerable patients by failing to arrange safe discharge. See Tag A-0144

The cumulative effect of these deficiencies results in the hospitals inability to provide care in the Emergency Department.

Based on record review and interview, the facility failed to establish policies and procedures to indicate how a patient is to request treatment as evidenced in 3 of 3 patients (Patient #1, Patient #2, and Patient #7) failing to receive care in the Emergency Department 10 medical records reviewed.

Findings include:

Review of Patient Rights and Responsibilities brochure, revised date 5/2017, revealed "As a patient, you have the right...1. Not be denied the right to appropriate care... because of your physical or mental impairment, socioeconomic status, or source of payment...4. Participate in the development, implementation, and revision of your plan of care...8. Participate in resolving dilemmas about care... or discharge."

Review of Medical Staff rules and Regulations dated 2/25/16 page 2 Patient Care Policies A. (the "Hospital") shall admit patients suffering from all types of diseases or injuries that can be properly served with safety to the patient... E... medical screening examinations for provisional diagnosis or medical indications for admission may include the following... 3. a comprehensive mental health or AODA (alcohol and other drug addictions) assessment performed by a qualified Registered Nurse or Masters-prepared Social Worker to determine the appropriate level of care or treatment."

Review of policy "Patient Rights and Responsibilities" #4864999, last revised 4/2018 under Procedure 1. "Responsible staff will provide a copy of the patient rights and responsibilities to all inpatients, and make copies available to all outpatients."

On 2/05/19 at 10:40 AM during interview with Quality Manager D, Quality Manager D stated a patient "Rights and Responsibilities brochure is offered to patients when they present to the ED, when the patient signs consent for treatment."

Patient #1's medical record was reviewed 2/01/19 at 11:52 AM with Risk Management Manager A and revealed Patient #1 is a 33-year-old who presented to the Emergency Department (ED) with alcohol intoxication 6 times between 12/25/18 and 12/29/18 for alcohol intoxication within a 91-1/2 hour time period.

On 12/25/18 at 2:36 PM Patient #1 arrived by emergency medical service for alcohol intoxication. ED Provider note 12/25/18 at 3:26 PM revealed "The plan is to have this patient go to alcohol detox once his alcohol level is below 0.200." Patient #1' s blood alcohol reached 0.182. Patient #1 was discharged 12/26/18 at 3:58 AM with mobile response who transported Patient #1 to SAIL (Stabilization Assessment Information and Linkage) outpatient facility. Discharge instructions printed 12/26/18 at 3:13 AM provided by Nurse Practitioner II revealed "return as needed for worsening symptoms... Stop drinking alcohol. Partake in your detox plan."

On 12/26/18 at 11:53 PM Patient #1 was found in a park where s/he was laying down face ground in grass, for alcohol intoxication and homeless and brought into the ED. ED physician note 12/26/18 at 11:38 PM by Physician JJ, revealed "[S/he] has been drinking all day. [S/he] does not remember what happened.[S/he] does have a contusion on the top of [his/her] forehead... Review of Systems... Neurological: Positive for loss of consciousness." 12/26/18 at 11:43 PM blood alcohol 0.356. ED Provider notes dated 12/26/18, not timed, by Physician JJ under medical decision making, patient update revealed "alcohol intoxication... Patient understands to return immediately to the ED for worsening or other concerning symptoms and is agreeable with this plan." Patient #1 was discharged 12/27/18 at 5:47 AM. Discharge instructions revealed "You should cut back on your alcohol intake" signed by Patient #1. There was no documentation of where patient went after discharge or how patient left. No social service consult was ordered.

On 12/27/18 at 1:03 PM Patient #1 arrived by emergency medical services, with altered mental status, altered level of consciousness, and alcohol intoxication. Triage note 12/27/18 at 1:12 PM revealed "soaked with water from head to toe." ED Provider note dated 12/27/18 at 1:14 PM revealed "history of alcohol abuse, alcoholic cardiomyopathy presents to the emergency department with altered level of consciousness found down outside clinic next door wet. It has been raining outside... nonverbal when I went to assess him. On 12/27/18 at 1:22 PM blood alcohol was 0.413. On 12/27/18 at 1:35 PM a Cat scan (CT) of brain was done for potential of new head trauma. Emergency Department Provider notes dated 12/27/18 at 7 PM by Physician JJ revealed "Reassessment patient is sitting upright in bed artery (all ready) changing to [his/her] clothes without any symptoms... Stable for discharge home... Important signs and symptoms that would warrant return to the emergency department were reviewed" Discharge instructions printed 12/27/18 at 7:20 PM by Provider JJ revealed "It is important that you follow up as an outpatient as directed." ED note 12/27/18 at 7:21 PM by RN BB revealed "Went into the patients room to round. Patient not there" which was 6 hour and 18 minutes after patient presentation. No social service consult was ordered.

On 12/28/18 at 4:34 PM Patient #1 arrived by emergency medical services. Neurologic exam 12/28/18 at 4:30 PM by RN L revealed "Confusion, disoriented to place; Disoriented to time." Triage note 12/28/18 at 4:36 PM by RN L revealed "arrives apparently intoxicated after being found in the all saints daycare parking lot laying with a wet blanket around him." ED provider note dated 12/28/18 at 4:43 PM by Physician K revealed "Patient was witnessed walking unsteadily... fell to the ground, police were called... placed on a hold for potential for self-harm... and brought to the ER for further evaluation." Blood alcohol level 12/28/18 at 5:08 PM was 0.378. No other alcohol levels checked. ED Provider note dated 12/28/18 at 10:57 PM by Physician K revealed "Patient is up and ambulating without assistance, [s/he] desires discharge home. No other complaints, will discharge." ED note by Registered Nurse L dated 12/28/18 at 11:01 PM revealed "Pt (patient) aloped" which was 6 hours and 35 minutes after presentation. No social service consult was ordered.

On 12/29/18 at 2:22 AM Patient #1 presented to the ED for alcohol intoxication. Neurological assessment 12/29/18 at 3:12 AM by RN QQ revealed "Disoriented to time; slurred speech." ED Provider note by Physician Assistant PP on 12/29/18 at 4:39 AM revealed "Patient appears intoxicated... not cooperative with neurological exam...will re-evaluated with patient is clinically sober...Case endorsed to [M] Physician Assistant due to shift change... ED Provider note dated 12/29/18 at 6:20 AM by Physician Assistant M revealed "thought to be intoxicated on arrival... Plan for observation for metabolism and re-evaluation for clinical sobriety... 7:10 AM ... States that [he/she] has currently homeless and staying at [a homeless shelter]... 7:40 AM... walked out of the department without my re-evaluation." ED note 12/29/18 at 8:22 AM by RN N revealed "left with security escort." There was no documentation of where patient went after discharge. Patient discharged 12/29/18 at 8:10 AM, 5 hours and 50 minutes after presentation. No social service consult was ordered.

On 12/29/18 at 9:42 AM Patient #1 presented to the ED in police custody for medical clearance. ED Provider note dated 12/29/18 at 4:55 PM by Physician O revealed "appears to have alcohol related pathophysiologic changes including alcoholic cardiomyopathy and alcoholic hepatitis who returns to the emergency department approximately 94 min after [his/her] most recent discharge... Medical Decision Making... I do not believe repeat testing... indicated...medically cleared for incarceration." Patient #1 was discharged in police custody 12/29/18 at 10:07 AM. No social service consult was ordered.

On 2/04/2019 at 1:30 PM during an interview, while reviewing the medical record of Patient #1 with Emergency Department Medical Director (EDMD) J, J stated "we did what we could, [s/he] did not want help" referring to Patient #1.

On 2/06/2019 at 10:32 AM during telephone interview with County Crisis Services Operations Manager U, U confirmed there were no requests made for crisis intervention for Patient #1 on 12/26/18, 12/27/18, 12/28/18 or 12/29/18.

Patient #2's medical record was reviewed on 2/01/2019 at 2:02 PM with Risk Management Manager A and Emergency Department Supervisor G, revealed Patient #2 presented to the Emergency Department requesting inpatient psychiatric admission for suicidal ideation. High risk suicide precaution ordered 1/04/19 at 12:32 PM and continued until discharge. ED provider note 1/04/19 at 1:17 PM revealed "has had increased depression... Review of Systems ... Psychiatric/Behavioral: Positive for dysphoric mood, self-injury, sleep disturbance and suicidal ideas. The patient is nervous/anxious ... Physical Exam ...Psychiatric ... Reports current suicidal ideation's with plan to run in front of traffic. ED note on 1/04/19 at 12:40 PM by Social Worker R revealed "Plan for inpatient treatment... facilities are all full." ED provider note 1/04/19 at 2:45 PM revealed "for monitoring in the emergency department until disposition is found for inpatient psych."ED note dated 1/04/18 at 7:24 PM by Social Worker Q revealed "Pt's insurance is out of network... Pt will not be accepted for this reason. Patient #2 was discharged 1/04/19 at 9:07 PM with parent. ED note dated 1/04/18 at 9:33 PM by Social Worker Q revealed "Pt is crying and yelling... pt denied at the one facility that has beds... Pt screaming [s/he] wants to go to SAIL." There was no new request for county crisis worker consult ordered.

On 2/06/19 at 3:07 PM, during telephone interview with County Crisis Worker (CCW) V, when CCW V was asked if s/he reassessed Patient #2 after she was discharged with her parent on 1/04/19, CCW V stated "I was never asked to reassess" Patient #2.

Patient #7's medical record was reviewed 2/05/19 at 9:50 AM with Risk Management Manager A and Emergency Department Supervisor G and revealed Patient #7 presented to the ED 1/04/19 at 6:22 PM requesting alcohol detox. On 1/04/19 blood alcohol was 0.24. ED provider note dated 1/04/19 at 7:35 PM by Physician P revealed "attempted to detox at home last weeks and had first time seizure 1.5 days into period of sobriety." ED note by Social Worker Q dated 1/04/19 at 8 PM revealed "Plan: inpatient detox... 2230 (11:30 PM) Pt (Patient #7) will be discharged. [inpatient facility] has not been responsive and all other facilities are full... encouraged to check facilities for possibility of admission tomorrow." ED Update dated 1/04/29 at 11:40 PM by Physician S revealed "We made extensive attempts to find inpatient detox for [him/her] but unfortunately we were not successful...follow up with outpatient detox resources." There was no order for a crisis worker consult.

On 1/06/19 at 1:20 PM, Patient #7 returned to the ED again requesting inpatient detox. 1/06/19 at 2:54 PM Blood alcohol was 0.072. Social Service note dated 1/06/19 at 7:08 PM revealed "Pt shared that the workers through IOP (Intensive Outpatient Program) recommended that pt DTX IP (detox inpatient) prior to starting IOP. Writer reviewed with [inpatient facility] who declined pt d/t (due to) them not having a medical staff and pt recently having seized 12/30/18. Pt was admitted medically." ED Provider consulted with on-call Physician T and hospitalist, and inpatient order was documented 1/06/29 at 5:21 PM, 47 hours after presenting to the Emergency Department requesting alcohol detox.

On 2/06/2019 at 10:32 AM during telephone interview with County Crisis Services Operations Manager U, U confirmed there were no requests made for crisis intervention for Patient #7 on 1/04/19.

On 2/05/2019 at 9:40 AM during interview with Quality Manager D, Quality Manger D confirmed there was no policy on when patients are offered their rights and responsibilities brochure in the Emergency Department.

On 2/05/2019 at 10:40 AM during interview with Risk Manager A, and Director of Care Management NN, it was confirmed there was no policy on when social service consults are ordered for patients treated in the Emergency Department.

Based on record review and interview, the facility failed to protect the safety of vulnerable patients by failing to arrange safe discharge for patients with an emergency medical crisis in 1 of 1 patients (Patient #1) unable to request care themselves in 22 medical records reviewed.

Findings include:

Record review of security "Incident Report" #ASHI-2018-038339 revealed "Occurred From Date/Time: 12/28/2018 12:50 AM Occurred To Date/Time: 12/28/18 1:40 AM." Category: "Trespassing" Sub Category: "Citation" written by Security Shift Supervisor VV revealed "identified the [wo/man] as a patient that had been discharged and reported the patient had checked in for ETOH intoxication 3 days in row and left AMA (against medical advice) each time; [s/he] also insisted that [s/he] had no place to go... I agreed that [Patient #1] needed to leave All Saints property... [Patient #1} reiterated that [s/he] had no place to go and we could "call the cops if you want to... I wrote a Trespass Notice... and informed [him/her] that we had contacted law enforcement... Police Department arrived... [Patient #1's] parents informed the PD (police department) that their [child] was unwelcome in their home if [s/he] was intoxicated. At 1:40, the PD took [Patient#1] out of the ED Lobby with the intent to drop [him/her] off at [homeless shelter]."

Record review of security "Incident Report" #ASHI-2018-000294 revealed "Occurred From Date/Time: 12/28/2018 3:48 PM Occurred To Date/Time: 12/28/18 4:12 PM." Category: "Suspicious Person" Sub Category: "Contacted" 1=Uniformed Presence" written by [Police] revealed " received a call ... about a [wo/man] who had been wandering back and forth... and in the parking lot... was laying on the ground. S/O (Security Officer) XX identified the individual as [Patient #1] having great difficulty in responding both verbally and physically to our attempts to communicate with [him/her]. I asked if [s/he] wanted me to call Rescue for [him/her] so [s/he] could get checked out from the fall on the rocks. [S/he] nodded."

Record review of security "Incident Report" #ASHI-2018-429219 revealed "Occurred From Date/Time: 12/29/2018 12 AM Occurred To Date/Time: 12/28/18 9:30 AM." Category: "Patient Assistance" Sub Category: "Other" 3=Open hand De-escalation" written by Security Officer YY revealed " I arrived at midnight... I was told by registration that [Patient #1] was released from ER (Emergency Room & waiting until morning to leave...I returned to post 3 & noticed [Patient #1] laying on floor in the ER lobby...Charge Nurse ZZ was called & she decided to readmit [Patient #1] for intoxication. I was then informed by S/O VV that [s/he] trespassed [him/her] the day before... 8 am...I walked [Patient #1] out & informed him/her] that [s/he] was trespassed & [s/he] needed to leave the property... About an hour and a half later...[Patient #1] walked right up to us... call police...officers... took [him/her] to ER to be medically cleared & took [him/her] to jail"

Patient #1's medical record was reviewed 2/01/19 at 11:52 AM with Risk Management Manager A and Emergency Department Supervisor G and revealed Patient #1 had 6 Emergency Department (ED) visits between 12/25/18 and 12/29/18 for alcohol intoxication. Complete medical screening exams were not completed in 5 of the 6 ED visits as evidenced by:

On 12/25/18 at 2:36 PM Patient #1 arrived by emergency medical services, intoxicated. Police report patient was threatening to harm him/herself. Blood alcohol on admission was 0.355, on discharge blood alcohol was 0.182. 12/25/18 at 4:19 PM County Crisis Worker W assessed Patient #1 with plan to call for ride back to the Stabilization Assessment Information and Linkage (SAIL), an outpatient voluntary detox program SAIL when patient's blood alcohol count was below 0.2. ED note dated 12/25/18 at 7:43 PM revealed "awake, given sandwich and juice." Blood alcohol was checked five times during observation of patient 12/25/18 from 2:36 PM through discharge 12/26/18 at 3:58 AM (12 hours and 22 minutes later). ED note 12/26/18 at 3:25 AM by RN X revealed "Pt ambulated in hall, gait steady." Patient #1 was discharged 12/26/18 at 3:58 AM with mobile response from SAIL. Discharge instructions stated "Stop drinking alcohol. Partake in your detox plan."

On 12/26/18 at 11:53 PM Patient #1 was brought in by police who found him/her in a park where s/he was laying down face ground in grass. Triage note 12/26/18 at 11:26 PM by RN Z revealed "Pt (patient) is homeless and chronically intoxicated." ED physician note 12/26/18 at 11:38 PM, revealed "patient states s/he has been drinking all day, does not remember what happened... Review of Systems... Neurological: Positive for loss of consciousness...Physical Exam... Slight forehead contusion on the right with associated abrasion." 12/27/18 at 1:13 AM a CT of the head was negative. 12/26/18 at 11:43 PM blood alcohol was 0.356. ED Provider note dated 12/26/18 by Physician AA revealed "Patient Update... Patient will be discharged... understands to return immediately to the ED for worsening or other concerning symptoms." ED note 12/27/18 at 5:42 AM by RN X revealed "Pt (patient) ambulated in halls, gait steady." Patient was discharged 12/27/18 at 5:47 AM 6 hours and 5 minutes after presentation. There was no documentation of where patient went after discharge or how patient left. There was no order for social service consult to assess patient's discharge needs.

On 12/27/18 at 1:03 PM Patient #1 arrived by emergency medical services found down outside clinic next door with altered mental status, altered level of consciousness, and alcohol intoxication. Triage note 12/27/18 at 1:12 PM revealed "soaked with water from head to toe." It was documented it had been raining outside. On 12/27/18 at 1:22 PM blood alcohol was 0.413. On 12/27/18 at 1:35 PM a CT of Brain was done for potential of new head trauma, which was negative. Emergency Department Provider notes dated 12/27/18 at 7 PM by Physician (Andrew Lau) revealed "Reassessment patient is sitting upright in bed artery (all ready) changing to [his/her] clothes without any symptoms... Stable for discharge home. When I went to speak give patient [his/her] discharge paperwork, [s/he] had eloped prior to receiving discharge paperwork and instructions." Discharge instructions printed 12/27/18 at 7:20 PM revealed "It is important that you follow up as an outpatient as directed." ED note 12/27/18 at 7:21 PM by RN BB revealed "Went into the patients room to round. Patient not there."

On 12/28/18 at 4:34 PM Patient #1 arrived by emergency medical services. Triage note 12/28/18 at 4:36 PM by RN L revealed "arrives apparently intoxicated after being found in the all saints daycare parking lot laying with a wet blanket around him." ED provider note dated 12/28/18 at 4:43 PM by Physician K revealed "Patient was witnessed walking unsteadily... fell to the ground, police were called... placed on a hold for potential for self-harm... and brought to the ER for further evaluation." Blood alcohol level 12/28/18 at 5:08 PM was 0.378. ED Provider note dated 12/28/18 at 10:57 PM by Physician K revealed "[s/he] desires discharge home. No other complaints, will discharge." ED note by Registered Nurse L dated 12/28/18 at 11:01 PM revealed "Pt (patient) aloped." No social service consult was ordered.

On 12/29/18 at 2:22 AM Patient #1 presented to the ED for alcohol intoxication. No alcohol level was drawn this visit. ED Provider note dated 12/29/18 at 6:20 AM by Physician Assistant M revealed "thought to be intoxicated on arrival... Plan for observation for metabolism and re-evaluation for clinical sobriety... 7:10 AM ... States that [he/she] has currently homeless and staying at [a homeless shelter]... 7:40 AM... attempted to ambulate... able to stand at the edge of the bed but states that [s/he] felt nauseous. Will order Zofran (medication for nausea) and then provide p.o. (by mouth) challenge and attempt ambulation trial again... walked out of the department without my re-evaluation." ED note 12/29/18 at 8:22 AM by RN N revealed "left with security escort." There was no documentation of where patient went after discharge. Patient discharged 12/29/18 at 8:10 AM. No social service consult was ordered.

On 12/29/18 at 9:42 AM Patient #1 presented to the ED for medical clearance. ED Provider note dated 12/29/18 9:50 AM by Physician O revealed "appears to have alcohol related pathophysiologic changes including alcoholic cardiomyopathy and alcoholic hepatitis who returns to the emergency department approximately 94 min after [his/her] most recent discharge... Medical Decision Making... I do not believe repeat testing... indicated...medically cleared for incarceration." Patient #1 was discharged in police custody 12/29/18 at 10:07 AM 25 minutes after presentation. No social service consult was ordered.

On 2/04/2019 at 1:30 PM during an interview, while reviewing the medical record of Patient #1 with Emergency Department Medical Director (EDMD) J, J confirmed the medical staff did not consult social service for help with discharge placement stating "we did what we could, [s/he] did not want help."