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Based on review of medical records, Medical Staff Rules and Regulations, Emergency Department (ED) policies and procedures, Emergency Department Logs, Police Report and staff interviews, the facility failed to provide stabilization treatment and/or appropriate transfer for an individual that presented to the emergency department seeking treatment for one (#3) of twenty (20) sampled patients.

Findings include:

Cross refer to A2407 as it relates to failure to provide an appropriate stabilizing treatment.

Cross refer to A2409 as it relates to failure to affect an appropriate transfer.

Based on review of medical records, Emergency Department (ED) policies and procedures, Police Report, physician, and staff interviews, Atlanta Medical Center failed to provide stabilization treatment as required that was within the capability and capacity of the hospital for one (#3) of twenty sampled patients who presented to the ED with homicidal thoughts, combative with family seeking treatment.

Findings include:

Review of the facility's policy entitled, "EMTALA -Screening, Stabilization and Transfer of Individuals with Emergency Medical Condition", revised December 2010, revealed if an individual "comes to the Emergency Department" the Hospital will provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as required to "stabilize" the emergency medical condition, or
1. if after a medical screening examination, it is determined that an individual has an emergency medical condition, the hospital shall:
a. Within the capability and capacity of the staff and facilities available the Hospital (including coverage available through the Hospital's on-call roster), provide treatment necessary to stabilize the individual, at which time the individual may be discharged; or
b. admit the individual to the Hospital in order to stabilize the individual: or

Record review for patient #3 revealed the patient presented to Atlanta Medical Center with a parent on 11/23/2013 at 10:22 p.m. The parent reported that patient #3 was combative with a grandparent, was cursing, and out of control at home.

Patient #3 was triaged at level 2 indicating an "emergent" condition, (Triaged - (classification of patient acuity that characterizes the degree to which the patient's condition is life- or limb- threatening, and whether immediate treatment is needed to alleviate symptoms with 5 levels: 1-5, level 1 Resuscitation, level 2 Emergent, level 3 Urgent, level 4 Non-urgent, level 5 Referred).

Patient #3 received a medical screening examination, history and physical by a qualified medical professional ED physician #2. Physician #2 documented patient #3, mood was angry, combative, and uncooperative was pacing in the triage area with hands clenched in a fist. Continued review revealed patient #3 was having thoughts of homicide directed towards family member.

Review of the physician ' s notes for patient #3, dated 11/23/2013 revealed the following:
--at 10:36 p.m. revealed that patient #3, was combative and punched the parent twice in the chest. The security guard and local law enforcement were notified;
--at 10:37 p.m. and 10:52 p.m. patient #3 had homicidal thoughts directed at the parent and grandparent. Patient #3 was uncooperative, combative behavior, cursing and punched parent twice in the chest; Hospital security called to restrain patient.
--at 10:53 p.m. the physician completed a history/physical revealing that patient #3, has a history of Schizophrenia, Bipolar disorder, Seizures medically treated with Risperdal (medication used to treat schizophrenia, bipolar disorder) and Topamax ( medication to prevent seizures), however, patient #3 was not taking the medication. Patient #3 arrived to the ED with agitation, combative, hit the parent, was in a physical altercation with security; local law enforcement was notified; when law enforcement arrived to the ED, they handcuffed patient #3, and took the patient away.
---at 22:54 " Psych: Positive for combative and agitated. Actively fighting. "

--at 22:55 MDM (Medical decision making) " Differential diagnosis: psychosis secondary to noncompliance ... Patient has an emergent medical condition.
--at 22:57 Disposition Summary: Problem is an acute exacerbation. Symptoms have worsened " .

The hospital's Security incident report date 11/23/2013 (10:29 pm.-10:58 p.m.) was reviewed. The report specified in part, at 10:29 p.m. ... security guard received a call for RN, who was in the Emergency Room (RN) Triage office, reporting that a person (#3) was getting loud in the Triage Office. I, Sergeant, responded to the call. As I was walking down the Fast track hall, EVS personnel said she saw the person (#3) push a nurse. I continued to the location and found Patient #3, the person in question, In the Triage Office with S/O Security Officer) 502 and SO/504. I moved to the side entrance of the Triage Office ... and asked S/O 504 what was going on. She told me that the patient (#3) was aggravated and was reported to have pushed his grandmother into a wall. He was talked into getting his blood pressure check, but started getting aggravated again. I told S/O 504 and S/O 502 to glove up. At this point S/O 505 arrived on the scene. Patient #3, his father, his mother, Nurse and RN were in the office as well. When the RN tried to put an identification band on Patient #3, he resisted. He acted angry ...He then tried to push his father, and I got him to return to his seat. After that, he swung and punched his mother in the face. Me and S/O 505 placed Patient #3 on the ground. I told S/O 504 to tell base to contact the local Police. Me and S/O 505 held him until the local police arrived. "

Review of the local law enforcement report (dated 11/23/2013) p.m. revealed receiving a call from Atlanta Medical Center because a mentally ill (patient #3) was fighting with the parent and security in the triage room at the hospital. The report indicated that patient #3 had pushed the grandparent into the wall earlier that day and was brought to the hospital to be seen and treated by a physician. Patient #3 was previously diagnosed with schizophrenia but has run out of medication and has been acting out recently. Continued review of the report revealed that while in the ED, patient #3 attacked the parent twice. After the second time the security officers tried to gain control of the patient and fought with patient #3 until they were able to subdue him/her.

Interview on 1/16/14 at 11:05 a.m. Registered Nurse (RN) #2, the Nurse Supervisor, and security revealed that the RN was called to triage patient #3. The nurse supervisor came to the triage area patient #3 was secured by security. RN #2, reported security had spoken with patient #3 and the parent who stated that patient #3, had hit them twice. The security guard stated patient #3 had also hit the security guard in the triage area. The security guard had already contacted local law enforcement for back up and the ED physician had also called the local law enforcement.

The nurse supervisor revealed the incident happened during the triage process. The Nurse Supervisor stated that when the local law enforcement officer arrived to the ED, patient #3 was still yelling, cursing at the parent and staff. The Nurse Supervisor reported the security guard had restrained patient #3 from hitting the parent, and when local law enforcement arrived, patient #3 was handcuffed. The Nurse Supervisor stated asking local law enforcement where patient #3 was going, and was informed that the patient was under police custody due to assaulting the parent.

Interview on 1/16/14 at 11:45 a.m. with the security manager revealed that on 11/23/2013 at 10:29 p.m. security was called by the triage nurse who stated security was needed in the triage area. The security manager explained four security guards responded to the call. The security manager reported that security was informed by the triage nurse that patient #3 was combative toward the staff and parent. The security manager stated that patient #3 refused to wear an arm band, tried to leave the room and was in the process hitting the parent in the face. The security guard grabbed and restrained patient #3 and ordered the operator to contact local law enforcement. Local law enforcement arrived, spoke with ED staff, handcuffed patient #3, then transferred the patient.

Interview on 1/16/14 at 12:15 p.m. the ED physician #2 revealed being familiar with patient #3, who was brought to the ED by a parent due to agitation. The ED physician #2, stated that patient #3, was aggressive, was detained by security as local law enforcement entered the ED. The local law enforcement witnessed patient #3, being aggressive, and angry.

The ED physician continued to reveal local law enforcement was asked about keeping patient #3 at Atlanta Medical Center however, law enforcement stated patient #3 was too aggressive. The ED physician continued to reveal, patient #3, needed to be treated, with medical sedation or restrained to prevent harm to self and/or others, however no treatment was rendered to patient #3, due to the patient being under the jurisdiction of local law enforcement.

Interview on 1/17/14 at 10:05 a.m. RN #3 and the triage nurse revealed that patient #3 cursed the parent after the parent explained to the nurse why they were seeking treatment. The RN #3 stated patient #3 arrived with a parent and a male friend to the triage room. The male friend was standing in the room until patient #3 hit the parent and then the male friend intervened. The male friend and patient #3 began to struggle and then patient #3 hit the parent a second time and the nurse called security. Continued interview revealed that security arrived in the ED, patient #3, hit the parent third time and hit security. Local law enforcement arrived while patient #3 was still arguing, then patient #3 started struggling with the security. RN #3 stated that local law enforcement did not ask for any assistance. Review of the Local law enforcement report dated 11/23/2013 revealed that the local law enforcement staff did ask the hospital staff for assistance with patient #3. As this was verified by review in the Local law enforcement report which revealed in part, " Local law enforcement while at Atlanta Medical Center, requested from the ED staff a secure room for patient #3 to provided safety for the patient and others until the physician could treat the patient. The Atlanta Medical Center ED staff responded that since patient #3 had attacked hospital employees and was behaving violently they would not be able to treat the patient. Local law enforcement requested from the triage nurse again, if they could take patient #3 to a room that they used for mentally ill patients and commit patient #3 with a 1013 (an in-voluntary admission- 72 hour hold in a psychiatric ward resulting from the display of self-declaration of intending to harm themselves or others). The triage nurse and the administrator refused to treat the patient due to violent behavior." The RN #3 further stated that local law enforcement did not ask for a 1013, medication or treatment for patient #3, prior to taking the patient away in handcuffs. The nurse explained there was no discussion related to stabilization treatment for patient #3's combative behavior.

Intakes: GA00135824

2409- inappropriate transfer

Based on reviews of the Emergency Department Transfer log, medical records, Security Incident Report, Local law enforcement report, policy and procedure, and interview the hospital failed to ensure that their policy and procedure was followed by failing to provide an appropriate transfer for and individual who had not been stabilized prior to transfer for one (#3) of 20 sampled patients..

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Findings include:

Review of the facility's policy entitled, "EMTALA -Screening, Stabilization and Transfer of Individuals with Emergency Medical condition", revised December 2010 revealed, the hospital will arrange for transfer of the individual to another medical facility if the medical condition is not within the capability and capacity of the staff and facilities. Continued review of the policy revealed a decision regarding patient transfer may be made by either patient request or physician certification. " a. The Hospital shall, within its capability, provide medical treatment that minimizes the risks to the individual ' s health. ... b. A representative of the receiving facility must confirm that: (1) The receiving facility has available space and qualified personnel to treat the individual; and (2) The receiving facility agrees to accept transfer of the individual and to provide appropriate medical treatment. c. " The hospital shall send the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (20 records related to the individual ' s emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnosis; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; (8) the written patient consent or physician certification of transfer ... d. The transfer shall be affected through appropriate trained professional and transportation equipment, including the use of necessary and medically appropriate life support measures during transfer. The physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer. "

Record review for patient #3 revealed the patient presented to the facility's ED with a parent and male friend on 11/23/2013. The parent reported that patient #3 was combative with a grandparent, was cursing, and out of control at home. Patient #3 was assessed in triage to be at level 2-Emergent. Further review revealed that at 10:55 p.m. revealed in part, " MDM (Medical Decision making) diagnosis: psychosis: secondary to noncompliance ... ED course patient taken away by (local) Police... patient was taken away by (local) Police to higher level of care to (name of receiving hospital). " Review of the ED record dated 11/23/2013 revealed patient #3, left the Atlanta Medical Center ED at 10:57 p.m.

Review of the facility's transfer log for the month of 11/2013, revealed no evidence that patient #3 was transferred to an appropriate facility.

The hospital' s Security Incident Report dated 11/23/2013 was reviewed. The report revealed the local police handcuffed patient #3 and took charge of the patient. They took patient #3 and his parents to name of receiving hospital. Review of patient #3 ' s medical record and the Security incident report verified the facility staff was aware of the name of the receiving hospital and location as to where patient #3 was being transferred to by the local police department. There was no documentation to indicate/verify that the receiving hospital was notified or agreed to accept patient #3 on 11/23/2013.

Interview on 1/16/14 at 12:15 p.m. the ED physician #2 revealed being familiar with patient #3, who was brought to the ED by a parent due to agitation. The ED physician #2, stated that patient #3, was aggressive, was detained by security as local law enforcement entered the ED. The local law enforcement witnessed patient #3, being aggressive, and angry. During this interview it was revealed that when they have patients that were too aggressive the local police would be called in and assesses the patient. There was no documentation of a written physician certification of transfer in the medical record for patient #3 on 11/23/2013.

A review of the Local law enforcement report dated 11/23/2013 revealed in part, " I transported Patient #3 to the receiving hospital and turned him over to the care of the psychiatric ward with a 1013 form. Patient #3's mother followed me there and waited in the waiting room to speak to the doctor about his illness."

Review of the receiving hospital ED record dated 11/23/2013, revealed that patient #3, arrived to the ED at 11:48 p.m. via law enforcement escort. Per the record the patent had been triaged at another facility, became combative with nursing and security staff, local law enforcement was notified, placed the patient in handcuffs however did not place patient #3 in custody. Law enforcement reported that staff from the previous hospital instructed them to take the patient to a different hospital because they didn't have psych services, even though they are a 911 receiving facility. Continue review revealed, patient #3, was agitated, aggressive, hyperactive, actively hallucinating and combative. Review of the EM (emergency medicine) work-up Medical Decision Making: the ED physician documented, " Patient with psychosis and erratic behavior. Unable to care for himself. " The patient ' s condition was listed as " guarded " Documentation by the ED nurse revealed also that Patient #3 was " Exhibiting erratic behavior...Restraints in place. " Patient #3 was medically cleared and discharged on 11/24/2013 at 10:24 a.m. The facility failed to provide an appropriate transfer of patient #3 on November 23, 2014 as evidenced by failing to contact a representative at the receiving hospital to confirm that the facility had available space and qualified personnel to treat the patient. The hospital failed to contact a representative at the receiving hospital that agreed to accept patient #3 to provide appropriate medical treatment. The hospital also failed to send the receiving hospital copies of pertinent medical records. Additionally, the hospital failed to document/provide a written physician certification of transfer for patient #3 as stated in their policy and procedure.
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