HospitalInspections.org

27303

1. Review of the medical record revealed patient #1 first presented to the Emergency Department (ED) on 5/28/10 at 12:24 PM. At 12:24 PM, ED Triage nurse A handwrote on the "Emergency Department Triage Form" patient #1's "Reason for visit: open wounds to buttocks, states [he/she] wants to kill [him/herself]." ED Triage nurse A also checked "Yes" to the question, "Suicide: Are you currently thinking about hurting yourself?"

On 5/28/10 at 12:36 PM, Physician's Assistant (PA) B handwrote on the "Skin Rash/Insect Bite/Abscess Emergency Physician Record" that patient #1 (located in ED room 10) "denies being suicidal. States [he/she] said this to nurses because [he/she] was angry; states [he/she] is always depressed because of health situation (confined to wheelchair) but not wanting to kill [himself/herself]."

At 12:50 PM, ED nurse B performed a suicide risk screening on patient #1, and patient #1 scored 12/14 points. According to the form, if the patient scores greater than 5 points, "Call Security and institute Suicide Precautions". At 1:30 PM, ED nurse B handwrote on the "Nursing Documentation Emergency Department" form in the nurses notes, "[Patient] states [he/she] wants to 'kill myself ' ' I took an overdose [of medication] 2 days ago but it didn't work.' ..."

At 4:16 PM, PA A handwrote on the "Emergency Department Physician Progress Note ..." "... Upon getting discharged from the [Emergency Department], it was told by Case Management Employee [Case Manager C ' s name] that [patient] was in parking lot trying to get hit by car, and also told [him/her] that [he/she] had scalpels at home that [he/she] is going to cut [his/her] throat when [he/she] gets home. Patient had previously told me that [he/she] was depressed for a long time because of [his/her] medical condition but stated that [he/she] was not actively suicidal .... Roommate came to [ED] and has given more info: states [patient] attempted suicide by overdose [with] pain medicine about 1 week ago; family was so concerned that they were going to have [him/her] committed after this holiday weekend; ..."

ED Physician B handwrote on the "Emergency Department Physician Progress Notes ..." "...[patient # 1] not eating, does not care if [he/she] lives. Tried to kill self 1 [week] ago by overdosing on pain medication. Has held knife to throat, driven wheelchair in street trying to get hit by car ...."

The medical record revealed no documentation PA A, or ED Physician B, obtained a psychological evaluation of patient #1, or contacted the health system's mental health unit until after patient #1 was discharged, and wheeled his/her wheelchair into traffic, attempting to cause a car to strike him/her.

2. Review of the policy, "Transfer and Emergency Examination EMTALA (Emergency Medical Treatment and Active Labor Act)", revised 4/22/10, revealed in part, "Mental Health Examination at Trinity Terrace Park Emergency Department ... All patients presenting to the dedicated emergency department at Terrace Park with a primary complaint of a mental health issue will be assessed by a [Mental Health Center at Hospital B] psychiatric nurse or masters level counselor for the mental health component of the emergency medical screening examination .... The ED physician staff will notify the [Mental Health Center at Hospital B] of the need for a mental health professional at Terrace Park ED. The mental health professional will examine the patient at Terrace Park under the direction and supervision of the ED physician."

3. During an interview on 6/7/10 at 11:45 AM, Physician's Assistant A stated he/she normally asks suicidal patients simple questions regarding if the patient wanted to commit suicide, and if the patient planned on committing suicide. Patient A had initially told the nurses he/she wanted to kill himself/herself, but recanted the statement during Physician's Assistant A's interview with patient A. Physician's Assistant A offered patient #1 the opportunity to talk with a mental health evaluator from the mental health unit at Hospital B, but patient #1 didn't feel he/she needed to talk to the mental health evaluator.

4. Review of the statutorily mandated QIO physician review of patient #1's medical record revealed the hospital failed to provide an appropriate and sufficient medical screening examination to an individual who presented to the hospital ED requesting care for open wounds to the buttock and plans for self harm.

5. During an interview on 6/8/10 at 3:50 PM, Mental Health Examiner F stated the ED physicians or PAs normally request the assistance of mental health examiners when assessing patients with thoughts of killing themselves. Mental Health Examiner F stated they would expect the ED physician or PAs to ask the mental health examiners to evaluate a patient with thoughts of suicide, especially if the patient had recently attempted suicide. Mental Health Examiner F stated they were available at the time patient #1 came to the ED, and would have seen the patient if they knew patient #1 was in the ED. " I wish I had known about [him/her] earlier. It may have changed things, and prevented that outcome."

Based on document review, and staff interview, the hospital failed to provide an appropriate medical screening exam for 1 patient (patient #1), who presented to the emergency department (ED) requesting care, out of 30 cases selected for review from May 2010. The hospital ED staff identified an average of 1,446 emergency department visits per month.

Failure to provide an appropriate medical screening exam could potentially result in patients with an emergency medical condition not receiving appropriate care, leading to disability, loss of limb, or death.

Findings include:

1. Review of the medical record revealed patient #1 first presented to the Emergency Department (ED) on 5/28/10 at 12:24 PM. At 12:24 PM, ED Triage nurse A handwrote on the "Emergency Department Triage Form" patient #1's "Reason for visit: open wounds to buttocks, states [he/she] wants to kill [him/herself]." ED Triage nurse A also checked "Yes" to the question, "Suicide: Are you currently thinking about hurting yourself?"

On 5/28/10 at 12:36 PM, Physician's Assistant (PA) B handwrote on the "Skin Rash/Insect Bite/Abscess Emergency Physician Record" that patient #1 "denies being suicidal. States [he/she] said this to nurses because [he/she] was angry; states [he/she] is always depressed because of health situation (confined to wheelchair) but not wanting to kill [himself/herself]."

At 12:50 PM, ED nurse B performed a suicide risk screening on patient #1, and patient #1 scored 12/14 points. According to the form, if the patient scores greater than 5 points, "Call Security and institute Suicide Precautions". At 1:30 PM, ED nurse B handwrote on the "Nursing Documentation Emergency Department" form in the nurses notes, "[Patient] states [he/she] wants to 'kill myself ' 'I took an overdose [of medication] 2 days ago but it didn't work.'... "

At 4:16 PM, PA A handwrote on the "Emergency Department Physician Progress Note ..." "... Upon getting discharged from the [Emergency Department], it was told by Case Management Employee [Case Manager C's name] that [patient] was in parking lot trying to get hit by car, and also told [him/her] that [he/she] had scalpels at home that [he/she] is going to cut [his/her] throat when [he/she] gets home. Patient had previously told me that [he/she] was depressed for a long time because of [his/her] medical condition but stated that [he/she] was not actively suicidal .... Roommate came to [ED] and has given more info: states [patient] attempted suicide by overdose [with] pain medicine about 1 week ago; family was so concerned that they were going to have [him/her] committed after this holiday weekend; ..."

ED Physician B handwrote on the "Emergency Department Physician Progress Notes ..." "...[patient] not eating, does not care if [he/she] lives. Tried to kill self 1 [week] ago by overdosing on pain medication. Has held knife to throat, driven wheelchair in street trying to get hit by car ...."

The medical record revealed no documentation PA A, or ED Physician B, obtained a psychological evaluation of patient #1, or contacted the health system's mental health unit until after patient #1 left the ED, and wheeled [his/her] wheelchair into traffic, attempting to cause a car to strike [him/her].

2. Review of the policy, "Transfer and Emergency Examination EMTALA (Emergency Medical Treatment and Active Labor Act)", revised 4/22/10, revealed in part, "Mental Health Examination at Trinity Terrace Park Emergency Department ... All patients presenting to the dedicated emergency department at Terrace Park with a primary complaint of a mental health issue will be assessed by a [Mental Health Center at Hospital B] psychiatric nurse or masters level counselor for the mental health component of the emergency medical screening examination .... The ED physician staff will notify the [Mental Health Center at Hospital B] of the need for a mental health professional at Terrace Park ED. The mental health professional will examine the patient at Terrace Park under the direction and supervision of the ED physician."

3. During an interview on 6/7/10 at 11:45 AM, Physician's Assistant A stated he/she normally asks suicidal patients simple questions regarding if the patient wanted to commit suicide, and if the patient planned on committing suicide. Patient A had initially told the nurses he/she wanted to kill himself/herself, but recanted the statement during Physician's Assistant A's interview with patient A. Physician's Assistant A offered patient A the opportunity to talk with a mental health evaluator from the mental health unit at Hospital B, but patient A didn't feel he/she needed to talk to the mental health evaluator.

4. Review of the "Daily Events" log for 5/28/10, written by Security Officer D, revealed from 1:00 PM to 3:00 PM, Security Officer D was "Patient Sitting ED ...Uncompliant patient. Also suicidal." Security Officer D monitored the patient in ED room 10, the room ED staff placed patient #1.

5. Review of the "Daily Events" log for 5/28/10, written by Security Officer E, revealed from 3:05 PM to 6:10 PM, Security Officer E "[was] Patient Sitting ED ...Watching ...patient suicidal in ER [room] 10. [He/She] tried leaving and rolling [himself/herself] into on coming vehicles in the parking lot after being discharged so [he/she] was brought back to the [ED]. Originally here for medical reasons. [He/She] was very verbally abusive to staff and threatening to harm [himself/herself] and others."

6. Review of the statutorily mandated QIO physician review of patient #1's medical record revealed the hospital failed to provide an appropriate and sufficient medical screening examination to an individual who presented to the hospital ED requesting care for open wounds to the buttock and plans for self harm.

7. During an interview on 6/8/10 at 3:50 PM, Mental Health Examiner F stated emergency department physicians normally call the mental health examiners to evaluate patients with thoughts of killing themselves, especially if the patient had recently tried to kill themselves.