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Based on review of documents, policies, medical records, the hospital failed to provide within its capabilities and capacity, including the services of an on-call psychiatrist, appropriate stabilizing treatment to an individual with a psychiatric emergency (Patient #2) who presented to the ED requesting psychiatric care and services, out of 12 cases selected for review.

The ED nursing director identified an average daily census of behavioral/psych patients of approximately 2 patients.

The Behavioral Medicine Unit nursing director identified an average daily census of approximately 8 patients.

The hospital failed to provide within its capabilities and capacity, including the services of the on-call psychiatrist, appropriate stabilizing treatment to an individual (Patient #2) with a psychiatric emergency. The ED staff contacted the on-call psychiatrist multiple times and no action was taken when the on-call psychiatrist failed to respond.

Findings include:

1. Review of the hospital policy titled, "Examination of Emergency Patient and Hospital Transfers" effective date 10/26/16, revealed the following in part, "The hospital will provide a medical screening examination to anyone who presents to the hospital...and who requests an examination or treatment...the medical screening examination follows the clinical guidelines for appropriate care and may only be performed by a physician of Behavioral Medical Unit Associate Registered Nurse Practitioner (ARNP).. included the following conditions: depression with feelings of suicidal hopelessness, delusions, severe insomnia, and helplessness, history of recent suicide attempt or suicidal ideation...impaired reality testing accompanied by disordered behavior (psychotic)...stability - The degree to which one can be assured within reasonable medical probability that no deterioration is likely to occur from any remaining differential diagnosis...no patient shall be arbitrarily transferred to another hospital. Patient/family wishes are also considered when making the transfer."

2. Further review of the hospitals "Medical Staff Bylaws" revealed, "Emergency Department Policy"...the physician will comply with all hospital and medical staff bylaws, rules and regulations...On call Physician Coverage....the on call schedule covers only the patients in the Emergency Department...determination as to Specialist coverage is based on physician experience...and privileging status."

Refer to A 2407 for additional information concerning the medical/psychological screening examination of Patients #2.



22898

Based on review of hospital documents, policies, medical records, and staff interviews, the hospital failed to ensure Patient #2 received further examination and stabilizing treatment for his emergency medical/psychiatric condition within the capabilities and capacity prior to transfer to a psychiatric hospital with the same capabilities and capacity. The revisit involved review of the Emergency Department (ED) medical records for 12 sampled patients who presented to the ED for an emergency medical condition from September 21, 2016 to October 24, 2016.

Failure to ensure Patient #2 received further examination and stabilizing treatment within the scope of services available at St. Anthony Regional Hospital placed the patient diagnosed with delusional disorders and paranoia at risk harm and delayed treatment of Patient #2's emergency medical/psychiatric condition.

Findings include:

Review of the closed medical record showed Patient #2 presented to the ED (Emergency Department) accompanied by police on 10/3/16 at 9:02 PM complaining of psychological disorders, Nursing staff documented the patient was a level 4 and immediately implemented 15 minute safety checks, donned the patient in paper scrubs, and completed a mental health assessment.

ED Physician P examined the patient on 10/3/16 at 9:09 PM and documented the patient had paranoid ideation and visual hallucinations and was afraid someone was going to harm him. Further documentation showed that ED Physician P diagnosed patient # 2 with high blood pressure (hypertension), psychoactive substance abuse and unspecified withdrawal. At 9:01 pm patient # 2's blood pressure was recorded at 174/118 (normal 120/80).

On 10/3/16 at 9:09 PM, nursing staff documented the patient was anxious and compulsive, hearing voices, felt like people are "messing with him", complained of delusions and hallucinations, and altered sleeping habits. The patient stated a recent diagnosis of schizophrenia and bipolar disorder, however had not been started on any medication. The patient was cooperative with the assessment, however stated having a hard time trusting anyone right now.

ED Physician P documented on 10/3/16 at 9:40 PM the patient agreed to admission however at 9:45 PM Patient #2 decided not to stay and signed AMA (Against Medical Advice) paperwork. Physician P documented Patient #2 was provided with a local mental health area number and was able to understand the instructions. The medical record did not contain any evidence that the risks to the patient at the time of his refusal to stay for treatment were explained or identified what the risks were, or any evidence indicating staff attempted to keep the patient from leaving prior to stabilization of his emergency medical condition. The medical record contained multiple entries indicating the patient was psychotic and delusional, a danger to himself, and that his mental state vacillated back and forth.

The medical record lacked evidence the on call psychiatrist was contacted to evaluate Patient #2's mental/psychotic disorder and paranoid/fear of harm to self.

Record review revealed the census on the Behavioral Medicine Unit (BMU) on 10/3/17 was 7 patients. The unit had 7 open beds.

Review of the local law enforcement's "Call For Service Record", showed documentation which specified that patient # 2 called 911 from the hospital on 10/3/16 at 9:58 pm and advised that "he did not want to stay there." In a second entry on 10/3/16 at 11:27 pm, "Subject [patient # 2] decided to stay for the time being."

On 10/4/16 at 2:15 AM, nursing staff documented in the medical record that Physician P was made aware of the incident.

The medical record lacked evidence that ED Physician P re-assessed Patient # 2's emergent medical until 4:51 AM on 10/4/16. Physician P documented in an "Addendum" note that the hospital was attempting to locate placement for the patient since he decided to stay and report will be given to the oncoming physician (ED Physician T) since no placement was located on this shift. Further documentation by ED Physician P indicated the patient was very resistant to receiving any kind of medicines and "flip-flopped" on the issue several times during the time in the ED.

On 10/4/16 at 8:52 AM, nursing staff documented the patient was voicing concerns about hearing voices, believed staff from the lab poisoned Patient #2 with a lab draw and certified nursing assistant (CNA) staff were trying to "kill" Patient #2.

Review of local law enforcement's "Call For Service Record", showed documentation which specified that patient # 2 called 911 from the hospital a second time on 10/4/16 at 1:57 am.

On 10/4/16 at 9:36 AM, nursing staff documented on-call Psychiatrist Q was paged to evaluate the patient because Patient #2 called 911 and said people at the hospital were "here" to hurt Patient #2.

On 10/4/16 at 10:25 AM, nursing staff documented St. Anthony Regional Hospital Behavioral Medicine Unit (BMU) Department was contacted for bed placement and was denied because the patient was "not appropriate" for the unit. The medical record did not specify the criteria used to determine the patient was not appropriate for admission to the hospital's psychiatric unit.

Review of the hospital's "Admission and Exclusion Criteria to Psychiatric Program" last revised on 4/7/2015 specified in part, "Inpatient hospitalization may be indicated or contraindicated, under the following circumstances:" "1. Inclusion Criteria, a. When the patient demonstrates that, as the result of a mental disorder, he or she presents a danger to himself/herself or other." "b. When documentated outpatient treatment has failed due to the severity of the patient's symptoms, or is unavailable." ... "d. When the patient's orientation, perception, memory, intellect, or judgments are severely impaired due to a mental disorder."

Review of the clinical records revealed the census on the BMU on 10/4/17 was 7 patients. The unit had 7 open beds.

The medical record did not contain evidence that on-call Psychiatrist Q responded to the page or came to the ED to provide further examination or treatment to stabilize Patient #2's emergency medical condition or that the hospital lacked the necessary capabilities to stabilize the patient's psychiatric emergency.

On 10/4/16 at 10:40 AM, nursing staff documented on-call Psychiatrist Q was consulted to evaluate the patient due to difficulty finding placement.

The medical record lacked evidence that on-call Psychiatrist Q responded to the request for consult or came to the ED to provide further examination or treatment to stabilize the patient's emergency medical condition.

According to the medical record review between 11:30 AM to 3:38 PM on 10/4/16 the patient demonstrated alternating states of anxiety, absence of agitation, irritability, and paranoia.

Review of vital signs dated 10/3/16 to 10/4/16 revealed Patient #2's blood pressure varied from 174/118 to 142/98 over the course of the ED .

On 10/4/16, ED Physician T documentated an addendum entry at 2:36 PM which included in part, "Assumed care at 0600 (6:00 AM on October 4. Patient definitely demonstrating some psychotic behavior with pronounced paranoia and does appear to present a danger to self and others and therefore a 48 hour hold was obtained and arrangements made for transfer to an appropriate facility...patient will go with the sheriff...patient does have hypertension and therefore was given Toprol XL 100 milligrams (mg) here in the emergency department prior to transfer."

Documentation in the medical record showed that ED nursing staff contacted 10 Psychiatric Hospitals for bed placement from the time the patient presented to the ED on 10/3/16 until 10/4/16 (19 hours) when the patient transferred at 3:58 PM to a 12 bed psychiatric hospital approximately 1.5 hours from Patient #2's home. Arranging for the transfer and the time taken for the transport inappropriately delayed stabilizing treatment for patient # 2's emergency medical condition.


During an interview on 10/27/16 at 1:45 PM, ED Physician P stated because the patient wouldn't accept anything to calm down there was very "little" he could do from a psychiatric perspective beside "talk" the patient "down". Physician P said the patient voiced an interest in being evaluated by a psychiatrist and the hospital began making inquiries for a psychiatric bed for Patient #2. When asked what symptoms the patient experienced while he was providing emergent medical care, Physician P said the patient was hypervigilant (an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats, also accompanied by a state of increased anxiety) and paranoid. When asked if he was aware what the census was on the hospital BMU and if there was a bed available for Patient #2, Physician P stated emphatically, "They got some hard and fast rules on that unit about if a patient is violent or has a history of violence they won't take them." Patient #2 needed help and I did the best I could for the patient.

During an interview on 11/1/16 at 12:25 PM, the Medical Director of BMU (Psychiatrist Q) said since the hospital did not have a security detail they would not admit patients that have been violent in the past 5 years or are violent when they are in the ED or had a history of assaultive behaviors to their families or to their ED staff. When asked if this was a hospital policy for the 5 year history of violent behavior that would exclude patient's from being admitted to the psychiatric unit, Psychiatrist Q stated he was not aware of a policy but it was hospital protocol and staff checked the "Court on Line" web site to determine if a patient had a history of violence "routinely". When asked if he recalled being paged to the ED to evaluate Patient #2 on 10/4/16, Psychiatrist Q replied, "They may have called me to come see the patient but I was working on the unit and when I got back to them they didn't need me because the patient was being transferred to another hospital."

During an observation on 11/1/16 at 1:05 PM, Staff A, Nursing Director of BMU demonstrated how staff access the Iowa Court on Line. At the time of the observation the surveyor requested Staff A to complete a check for Patient #2. During an interview at 3:05 PM, Staff A said she did not find any evidence of a violent record for Patient #2.

Review of Credential files revealed Psychiatrist Q was privileged to provide psychiatric services to patients on 2/16 by the Medical Staff and Governing Board.