HospitalInspections.org

This condition is not met as evidenced by:

Based on review of medical records, hospital policies and procedures, staff interviews and video, the Governing Body is not maintaining its responsibilities for the oversight and operation of all services provided by the hospital as evidenced by the severity of the deficiencies listed below and non-compliance with the Conditions of Participation: 482.13 Patient's Rights.

Findings include:

Observations, interviews, review of medical records and policies and procedures, the facility failed to ensure that patient care services provided at the Emergency Department met generally acceptable standards of professional practice. Specific reference is made to the use of restraints in the Emergency Department, "physical holding for forced medications" and the services provided by the hospital security staff.

The deficiencies are cited regarding a patient death and the hospital's use of chemical and physical restraint to a patient who was not a physical threat prior to the initiation of such restraints. There was no evidence that a policy and procedure was in effect to address the use of chemical restraint and physical holding for forced medications. The Emergency Department staff did not implement the facility's policy "that all alternative interventions were considered" prior to the initiation of chemical restraints by staff.
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Based on record review and staff interview, the Governing Body failed to exercise sufficient oversight of the Emergency Department Services to ensure that Emergency Room systems and processes were developed, implemented and evaluated that ensured proper use of restraints.

Findings include:

The Emergency Room staff did not provide to patients requiring restraints safe care that met the regulatory requirements in the Condition of Patient Rights.

(See A-092, A-131, A-154, A-165, A-167, A-168, A-187, A-194, A-196, A-206, A-396 and A-1104).
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Based on review of medical records, hospital policies and procedures, staff interviews and video and observations, it was determined that the Governing Body did not ensure: 1) the Emergency Department staff appreciated the patient's right to refuse treatment. Although Patient #10 repeatedly refused to have his blood drawn and he never became a physical threat, he was physically held by the staff for forced medication and subsquently expired and 2) the Governing Body did not provide oversight to ensure that current policies and procedures pertaining to the application of the restraint were documented and effectively implemented.

1) Findings include:

Review of the medical record revealed that Patient #10 presented to the Emergency Department on 03/04/10 at 3:47AM with a chief complaint of depression and not taking his medications. His past medical history included bipolar disease and asthma. His vital signs were blood pressure: 156/103, pulse: 99, respirations: 20, temperature: 97.6 and Oxygen saturation rate: 96 on room air. At 4:00AM the patient ambulated with a steady gait to the treatment area. The nursing assessment documented that the patient appeared comfortable, was cooperative, alert and oriented x 3 and in no acute distress. The psychosocial assessment documented that the patient denied visual, auditory, tactile hallucinations and homicidal ideation. The patient appears depressed with a flat affect. The patient admitted to suicidal ideation and his plan for suicidal ideation was to smash his car. The Suicide Risk Assessment Tool identified the patient as a low risk. The patient became agitated, belligerent, threatening staff, refusing to have his blood drawn. Security was called. At 5:13AM Ativan 4mg IM, Haldol 5mg IM and Benadryl 50mg IM was ordered and administered while several security guards restrained the patient face down on the floor. The patient ceased movement and was in respiratory arrest. ACLS was implemented without success and at 5:34AM the patient was pronounced dead.

Review of the patient takedown video tape on 03/09/10 at 1:35PM revealed the gowned patient walking in his room then lying on the stretcher. The patient is standing in the doorway with his elbows resting on the door jams. A black gloved hand is then observed pointing, then waving, in front of the patient's face. The black gloved hand lies on the patient's chest and briefly slides up to the patient's neck then back down to his chest. Multiple people are in the room struggling with the patient. The patient is being held face down, kneeling with his upper body leaning over the stretcher. A person darts into the room behind the patient's buttock and extends his arm. This person stands and leaves the room. (We were told this was a physician giving the patient an injection.) The struggle continues to the floor. The patient is prone on the floor with a large man lying perpendicular across the patient's upper back. Someone is crouching near the patient's head. Someone has their knee on the patient's left hip with their arms extended out leaning on the first large person's back. The patient is kicking his legs. The patient stops moving and the people around the patient get up. Someone places a towel/sheet on the floor near the patient and uses their foot to move the towel/sheet. The patient's legs from the knees down are darkened. The patient is rolled over. His face is darkened. Two people walk toward the patient. The patient is lifted to the stretcher and wheeled out of the room.

Interview on 03/10/10 at 10:20AM with Staff Member #7 revealed at 4:30AM when she went into the patient's room to draw the blood the patient refused to have his blood drawn and stated "I know my rights." Staff Member #7 stated "I explained to the patient you lose your rights when you threaten to take your life. I left the room and the attending physician said something like 'you know he can't refuse.' A half an hour later I returned to draw the blood and the patient refused, stating 'you're not drawing bloods'. I left to get to get physician." She stated she did not feel threatened by the patient.

Interview on 03/10/10 at 2:00PM with Staff Member #11 revealed suicidal or homicidal patients can't refuse treatment, blood work. Staff Member #11 stated "the nurse told me he did not want to give blood. I went to his room and told him we need your blood and urine to medically clear you. During the de escalating process I could not offer oral medication because I can't give medication until I have the blood work and urine results. I don't know what I'm treating. He did not swing. He was a verbal threat. Not a physical threat. He was psychotic and needed treatment. I instructed security to hold him so he could be given the med. I watched as they held him on the bed. He was fighting. They held him down on the floor. He was flipped over and he was blue."

Interview on 03/10/10 at 11:15AM with Staff Member #3 revealed the patient was between the door and the doorway, red faced and screaming verbal threats at the physician. He waved his finger in front of the patient's face because he was threatening the physician. The black glove is a police issue glove that protects from body fluids and needle punctures. He entered the room because the patient was threatening the doctor. He was there to protect the staff and himself. He received Crisis Prevention and Intervention Training. He was aware of the procedure to take a patient down with the under the arm maneuver. It was a split second decision not to use the under the arm maneuver. When the patient was rolled over there was blood was coming out of his mouth and nose.

Interview on 03/12/10 at 9:25AM with Staff Member #4 revealed "I was called over the radio. When I got to the ED there were 10 people in the hallway. The patient was not giving blood. I went up to the door. The patient was red in the face and a large man. He was blocking the doorway. One arm was extended to the wall and the other extended arm was on the door. He was in an aggravated stance. The patient was getting more uppity. He was yelling "no one is taking my blood. I'll get a lawyer." Usually I offer food, talk to the patient, but it was mandatory to take his blood. I said to the patient how about we take your blood later. He calmed down and his face was less red. Someone yelled get the blood now. The patient became incited. His face was beyond red. I thought he was going to stroke out. He grabbed the door tighter. I'm thinking lets throw the protocol out the window, let's wait. If we dropped drawing the blood, I believe the patient would have sat in the room. He was not a problem prior to this. We don't want the patient or staff to get hurt. They were afraid he would get out of the room. The four of us looked at each other. The patient moved the door open, puffed out his chest, as to say come and get me. The four of us got the patient to the stretcher. The patient rolled back to the ground with the security guard. I leaned down on his left buttock. The patient said something like I had enough, ok guys. We released the patient I said thank God (out loud). He was a big guy. We got up. We were waiting for him to get up. He never got up. He was put on the stretcher and wheeled to the trauma room. I was told about one half hour later that he died. I said I could not believe it, he was dead. During the stuggle the patient was yelling screaming, "I'm going to F ... ing kill you." Then it got quiet. This was not right. He was not a watch. This did not need to happen. We could have waited for the blood. It would not have killed him. He's dead now. I felt we should have walked away defuse the situation. Call the psychiatrist, to talk to the patient. I spoke to the Night Supervisor. She has thirty (30) years psych experience from Pilgrim State. I talked to her already. She said she would intervene if a doctor says go in and security says no. If I get in trouble, who cares. She doesn't care if she gets in trouble either. The patient died. This will never happen again."

The medical record documentation was contradictory to what was observed in the video and ascertained on interview.

2) Findings include:

Based on record review and interviews during an on site survey from 03/09/10 to 03/15/10, five (5) of twenty-five (25) medical records revealed that the Emergency Room physician did not document a medical condition to justify implementation of chemical and physical restraint (See A-154).

Review of records revealed there was no documented evidence that the Emergency Room staff considered less restrictive measures prior to the use of chemical restraints. (See A-165).

The Emergency Room physicians failed to effectively implement the facility's Restraint Policy when ordering restraints on combative patients resulting in inappropriate monitoring or/and no monitoring (See A-168).

The Emergency Room staff failed to document the use and/or discontinuation of restraints applied to patients in the Emergency Department (See A-187).

The Emergency Room staff failed to effectively implement the hospital's Informed Consent Policy regarding the patient's right to refuse treatment (See A-131).

The hospital did not ensure the Restraint Policy reflected the current standard of practice (See A-167).

The hospital failed to ensure that all of the Emergency Room staff and security guards received in depth training for the application of restraints to the patient who exhibits violent or self destructive behavior (See A-194, A-196).
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Based on record review and staff interviews, the Emergency Room staff failed to implement the facility's policy on informed consent regarding a patient right to refuse treatment.

Findings include:

Review of the Administration Policy titled: "Informed Consent" dated 1/07, revealed that "if the patient expressly objects to treatment, consent to treatment cannot be implied."
See also the Emergency Doctrine.

On interview between 03/09/10 & 03/15/10, Emergency Room Staff Members #6, #7 and #11 stated that the patient refused to have his blood drawn stating "I know my rights" he was told that "you lose your rights when you threaten to take your own life."

However, during an interview on 03/09/10 at 3:00PM with Staff Member #5 they stated a "psychiatric patient has the right to refuse blood work" and if they refuse you walk away. You can't get the blood from the patient until they are ready to give it to you. You leave them alone and document the refusal to have blood drawn. They have the right to refuse any treatment. Sometimes we have to go to court to have the judge decide the treatment. Usually the judge orders treatment and the patient usually accepts treatment. But if the patient still refuses treatment we could not treat them. You document the refusal and wait them out."
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Based on record review and interviews during an on site survey from 03/09/10 to 03/15/10 five (5) of twenty-five (25) medical records revealed that the Emergency Room physician did not document a medical condition to justify implementation of chemical and physical restraint.

Findings include:

Review of the medical record for Patient #12 revealed the patient presented to the Emergency Room by ambulance on 10/20/09 at 4:02PM, after being found lying in the road with a head laceration. The triage note documented that the patient was intoxicated, non-cooperative and had an alcohol like odor on his breath. The physical examination documented that the patient was confused, disoriented, was started on intravenous fluids and was medicated with Ativan 2 mg intravenous push at 4:37PM.

Blood work, a urine for toxicology and CAT scan of the head was obtained at 6:08PM which revealed atrophy and degenerative disc disease. At 6:34PM, the patient tried to get out of bed saying he wanted to go home. The nurse documented that he could not leave until sober or he had a responsible ride home and the patient received an additional 2 mg of Ativan with 5 mg of Haldol. After administration of the medication the head laceration was cleaned and the patient required an additional staff member to assist and distract the patient. The patient slept until 1:10AM on 10/21/09 and was discharged home with outpatient referrals accompanied by a family member.

Review of the medical record for Patient #41 revealed that the patient was brought to the Emergency Room on 10/16/09 at 9:55PM by ambulance after drinking and cutting her left wrist. The nurse documented that the patient appeared depressed, had suicidal ideation, was intoxicated, crying, combative, uncooperative and anxious. The patient was medicated with intravenous Ativan, Haldol and Benadryl, prior to repair of the laceration at 11:00PM. The nurse's notes then documented that the patient was resting quietly on 10/17/09 at 12:55AM, 1:55AM, 3:29AM and 5:15AM. At 7:11AM the patient had stable vital signs, was in no distress and awaiting a psychiatric evaluation. The patient remained in the Emergency Room and was alert, easily arousable and tolerated a diet. At 8:25AM the Emergency Room physician ordered Ativan 4 mg intravenously with no evidence of a reassessment. The patient was psychiatrically evaluated at 1:38PM and discharged home with outpatient follow-up.

Review of the medical record for Patient #43 revealed that the patient presented to the Emergency Room at 8:51AM on 10/02/09 with a history of seizures and depression stating she wants to die. After appropirate triage the patient was examined by the Emergency Room physician who noted a 1 cm abrasion with swelling of the tongue and a history of seizures, sickle cell, bipolar disease, depression with suicide attempts and hallucinations. Intravenous fluids were administered and blood studies obtained. At 10:18AM Ativan 1 mg IVP was ordered and administered with no documented symptoms to indicate the need for the intervention.

Review of the medical record for Patient #46 revealed that the patient presented to the Emergency Room on 03/11/10 at 7:50PM and the triage nurse documented that the patient stated he had increased alcohol intake and was "not feeling right". The patient had a past medical history of Bipolar Disorder with ETOH and Drug Abuse. The nursing assessment documented that the patient was alert, oriented, anxious and admitted to suicidal ideation but was with out a plan. The nurse documented that the patient stated "I just don't feel right, having odd thoughts" and that "I might" hurt self and placed the patient on suicide and elopement precaution. The patient had an intravenous placed at 8:27PM and blood studies were obtained. The physician documented that the patient has had multiple visits for ETOH abuse in the past, was "not feeling right" and wants to see psychiatrist. The patient was then medicated at 3:26AM with intravenous Ativan but there is no documented reason. The patient remained in the Emergency Room awaiting a psychiatric evaluation for ten (10) hours until 6:10AM on 03/12/10, at which time he was evaluated and cleared for discharge home with outpatient follow-up. The patient complained of increased anxiety and was medicated orally at 8:30AM with good effect then discharged at 10:00AM.

Review of the medical record for Patient #14 revealed that this patient presented to the Emergency Room on 10/20/10 at 16:46 accompanied by EMS. The patient was triaged at 16:46 with the chief complaint of intoxication. The Security Log record revealed that at 16:55 the security officers responded to assist the ED staff with placing a two-point restraint and medication for this patient. However, there was no documented evidence of an order for the restraint or any subsequent monitoring flow sheet. The Medication Administration Record revealed that Ativan 2mg IV and Haldol 5mg IV were both administered concurrently at 17:15 with no documented reason. These interventions occurred prior to documented evidence of a physician's evaluation.

Review of the medical record for Patient #9 revealed that the patient was triaged at 8:27AM on 02/15/10 and was sent to the ER for evaluation after assaulting an employee at the group home. The nurse documented that the patient appeared comfortable, cooperative, in no acute distress but was combative with care. The patient was evaluated by psychiatry at 2:41PM who documented that the patient required inpatient treatment and the patient remained in the Emergency room awaiting a bed. The Medication Administration Record documented that the patient received intramuscular Ativan 2 mg, Haldol 5 mg and Benadryl 50 mg at 3:01PM with no documented reason.

There is no documented evidence that the Emergency Room physician implemented the hospital policy entitled "Restraints" dated 7/09 which states "the order for the restraint will include the indications and reasons for use" and less restrictive measures were considered.
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Based on record review there was no documented evidence that the Emergency Room staff considered the use of less restrictive measures prior to the use of the chemical restraint.

Findings include:

Review of the medical record for Patients #9, #10, # 12, #14, #41 and #46 revealed there was no documentation by the physician or nursing staff prior to the administration of medication given to control the patient behavior and no documentation of the patient's plan of care.

See 482.13 and 482.55.
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Based on review of the Restraint Policy the hospital failed to 1) establish a procedure for the implementation and education of staff on items listed in Section #13 (Education) and 2) follow it's own policy in that the Restraint Policy documents "the facility never to use chemical restraints" there is evidence with the review of the medical records that several patients where chemically restrained.

Findings include:

1) Interview with Staff Members #7, #8, #10 and #13, revealed that they were aware of the policy but had not been provided the the above education or any additional policies addressing the use of restraints.

2) See A-154.

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Based on record review the hospital did not ensure that the Emergency Room physician effectively implemented the restraint policy. The Emergency Room physician failed to order a restraint/failed to order the correct restraint for the patient and as a result the patient was inappropriately monitored.

Findings include:

Review of the medical record for Patient #9 revealed that the patient was triaged at 8:27AM on 02/15/10 and was sent to the Emergency Room for evaluation after assaulting an employee at the group home. The nurse documented that the patient appeared comfortable, cooperative, in no acute distress but was combative with care. The patient was evaluated by psychiatry at 2:41PM, who documented that the patient required inpatient treatment and the patient remained in the Emergency Room awaiting a bed. The Medication Administration Record documented that the patient received intramuscular Ativan, Haldol and Benadryl at 3:01PM, but there is no nursing note indication the reason or the effectiveness of the medication. The nurse's notes then documented that the patient was alert and oriented times three with soft restraints in place at 7:59PM. The nurse's notes document at 8:30PM that the leg restraints and Posey vest were removed but that the patient still required wrist restraints for trying to run out of the hospital. The nurse then documented at 6:21AM on 02/16/10 that the patient remained in wrist restraints due to being uncooperative and stating she wanted to leave, the patient was also on 1:1 observation. The patient remained in the Emergency Room and became combative again at 10:18AM, attempting to kick and punch. The patient was then documented to be awake and cooperative at 6:00PM. The patient remained in the Emergency Room until 02/17/10 when a bed became available and the patient was admitted to the psychiatric unit. The standardized physician's order sheet contained in the medical record dated 02/15/10 at 3:00PM documents that the patient was placed on Level I - Medical Surgical Restraints incorrectly as required by the facility's policy and incorrectly documents the type of restraint used. The Medical Surgical Unit - Level 1 - Restraint / Seclusion Flow Sheet documents the patient was placed on 1:1 and monitored every thirty (30) minutes from 3:00PM on 02/15/10 to 7:00AM on 02/16/10 but there is no further monitoring documented.

Review of the medical record for Patient #4 revealed that the patient presented with his mother to the Emergency Room at 6:17AM on 10/21/09 stating that the patient was drinking, became agitated throwing things outside and had been discharged two (2) weeks early from another psychiatric center. The nurse documented that the patient was anxious and refusing to change. The patient was seen by the Emergency Room physician who documented that the patient presented for evaluation of Alcohol Abuse. The Security Department Incident Report documented that the patient was refusing to change and that after two (2) hours of trying to get him to change the patient was restrained on his bed so the ER staff issued medication. The medical record documented that the patient was verbally and physically abusive toward staff and that attempts to curb his behavior was ineffective. The physician documented that patient required chemical and/or physical restraints for safety however there is no order for restraints or monitoring after the patient was then held down and medicated intramuscularly. The patient was then seen by psychiatry and admitted to the inpatient psychiatry unit with psychosis.

Review of the medical record for Patient #8 revealed that the patient presented to the Emergency Room by ambulance accompanied by the police and his friend at 9:41PM on 03/9/10. The patient was agitated and irrational, reportedly drinking and smoking "weed". The patient was documented to be yelling and combative requiring handcuffs. The nurse documented that the patient was cursing, verbally and physically threatening to the staff. The nursing documentation reveals that the patient required one (1) to three (3) additional staff members to assist in holding the patient during the application of oxygen, a cardiac monitor and placement of a urinary catheter which was discontinued after the urine specimen was obtained. The physician documented that the patient was verbally and physically abusive toward the staff, exhibiting behavior that was dangerous to self and others and that attempts to curb his behavior was ineffective. Then patient was then medicated intravenously with Ativan, Haldol and Benadryl however there is no order for restraints documented in the medical record. The physician then documented that the patient was more calm and cooperative at 10:26PM and that his mother stated he did not have a psychiatric history but was told top leave her house due to hanging out with "gangs". The nurse documented that the patient was awaiting sobriety and a psychiatric evaluation at 11:00PM and again at 6:55AM. The patient was then evaluated by psychiatry at 9:28AM on 03/10/10 and cleared for discharge with outpatient follow up twelve (12) hours later.

Review of the medical record revealed that Patient #1 presented to the Emergency Room at 4:16PM on 12/24/09 by EMS after being found wondering in a store. The physician documented at 4:26PM that the patient has a past medical history Alcohol Abuse, Depression and Anxiety. The physician then documents at 9:50PM that the patient became severely agitated, combative, screaming and yelling. The physician documented that chemical sedation was ordered for patient safety, that security was called who restrained the patient and the patient was medicated intravenously with Ativan, Haldol and Benadryl. There are no physician's orders for restraints contained in the medical record and no documented monitoring of the patient as required. The Security Department Incident Report documented that security was called to assist the nurse in administering medication and that on arrival the patient was already restrained in a vest. The security officer documented that the patient was combative and while swinging at staff hit the side rail with his left elbow. The patient was then placed on 1:1 supervision. The physician examined the patient and ordered an x-ray of the elbow which revealed a fracture and a splint was allied. The patient was seen by the orthopedist at 10:45PM and a long arm case was applied. The patient was then discharged the next morning with follow-up as an outpatient.

The "Patient Care Standard: Restraint" policy dated 7/2009 documents that the use of physical restraints requires a written order and includes type, duration indication criteria for release and requires the monitoring of a patient while restrained (Level Two) to be continuous in person observation with every fifteen (15) minute and the observation to include vital signs, circulation with range of motion, nutrition, hydration, hygiene and readiness for discontinuation. There was no documented evidence that the physician implemented this policy.
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Based on record review the Emergency Department (ED) staff failed to document the use or discontinuation of restraint applied prior to the patient presenting to the ED.

Findings include:

Review of the medical record for Patient #3 revealed the patient presented to the Emergency Room by ambulance on 02/24/10 at 10:12PM. The nurse documented that the patient arrived in handcuffs but there was documentation in the medical record for the removal or continuation of the restraints.

Review of medical record for Patient #14 revealed that the patient presented to the Emergency Room on 10/20/10 at 4:46PM. The Security Log record revealed that at 4:55PM, the security officers responded to assist the ED staff with placing a two-point restraint and medicating of this patient. There was no documented evidence of an order for the restraints or any subsequent monitoring of the restraints.

Review of medical record for Patient #16 revealed that this patient presented to the Emergency Room on 11/11/09 at 10:43 accompanied by SCPD. The patient's chief complaint was homicidal ideation. The Security Log record revealed at 1055, the security officers "responded to assist the ED staff with placing a four-point restraint and medication for this patient." The patient is combative and cannot provide any additional history. There was a physician's order for the four-point restraint at 1130 however there was no documentation that the restrained patient was monitored. At 1515, the nurse documented "the 4 point leather restraints removed and patient placed in bilateral hand restraints for patient safety." There was no physician order or monitoring for wrist restraints.

Review of medical record for Patient #15 revealed that this patient arrived accompanied by EMS in the ED at 1754 on 10/12/09 for evaluation of suicidal ideation and overdose. The patient was intoxicated and combative. There was a physician's order for the Level II Behavioral management restraint at 1830. The Medication Administration Record revealed that at 1850, Ativan and Haldol IV were administered concurrently to the patient. There was no documented evidence that the restrained patient was monitored and the time the restraint was discontinued.

Review of the hospital's policy entitled "Patient Care Standard: Restraint" dated 7/2009 documents that the use of physical restraints requires a written order.
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Based on review of hospital employees' personnel files, the hospital did not ensure that each staff member with direct patient contact completed education and training on the proper and safe use of restraints.

Findings include:

Review of four (4) of four (4) security staff personnel files on 03/11/10, revealed no documented evidence of recent inservice education on the use of restraints.

In nine (9) of ten (10) employee personnel files, there was no evidence of more in depth training for patients who exhibit violent or self destructive behavior.

Interviews conducted with hospital staff on 03/10/10 and 03/11/10 confirmed the above findings.
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Based on the review of the personnel files for four (4) security officers; it was revealed they did not have the necessary and required training to demonstrate competency in the safe application of restraints and provision of care for a patient in restraints.

Findings include:

In four (4) of four (4) hospital security personnel files reviewed on 03/11/10, the prerequisite credential requirement for the job title of security officer was a NYS Department of State security guard license, which were current and verified in Staff Members #1, #2, #3 an #4 files. However, the records revealed no evidence of a documented training program demonstrating knowledge and competency in the safe application of restraints.
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Based on interview and review of four (4) of four (4) security officers personnel files revealed the facility failed to ensure that the security guards received training in CPR and first aid.

Findings include:

Review of the personnel files on 03/11/10, for Staff Members #1, #2, #3 and #4 revealed there was no evidence of first aid or CPR training.
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Based on record reviews and staff interviews the hospital failed to ensure the nursing staff in the Emergency Department assessed, developed or revised the nursing care plans for patients that presented to the Emergency Room who required chemical or physical restraints as evidenced by the citations in Patients' Rights.

Findings include:

Review of the medical records for Patients #7, #9, #10, #12, #14, #41 and #46 revealed there was no documentation reflecting the use of restraints in the patient's plan of care.

This was confirmed with the facility staff.
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Based on record review and interviews between 03/09/10-03/15/10, the hospital did not ensure that fifteen (15) out of forty (40) patients received a timely psychiatric evaluation and disposition within six (6) hours as per the hospital policies (Patients #18, #36, #22, #28, #2, #8, #7, #19, #20, #26, #30, #34, #35, #41 and #46).

Findings include:

Review of Patient #36's medical record revealed the patient was brought to the Emergency Department by the police on 09/09/09 at 2:05PM with a chief complaint of hearing voices and suicidal ideation. The patient was diagnosed with Suicidal Ideation 09/10/09 at 12:25PM the psychiatric consultation was performed, twenty-two and one-half (22 1/2) hours after the patient arrived at the Emergency Department.

Review of Patient #22's medical record revealed that the patient was brought to the Emergency Department on 10/04/09 at 2:10PM by ambulance after drinking and cutting herself. The patient had a chief complaint of hearing voices and suicidal ideation. The patient was diagnosed with Suicidal Ideation. On 10/05/09 at 9:18AM the psychiatric consultation was performed, nineteen (19) hours after the patient arrived at the Emergency Department.

Review of Patient #2's medical record revealed on 11/22/09 at 9:36PM the patient was brought to the Emergency Department in police custody after threatening his family. The patient was diagnosed with Bipolar Disorder. At 11:59PM the physician's note revealed the patient was medically cleared and waiting for "psychiatric evaluation in the AM." Although the patient was medically cleared on 11/22/09 at 11:50PM, the psychiatric evaluation was not performed until 11/23/09 at 10:00AM, ten (10) hours after the patient was medically cleared and eleven and one-half (11 1/2) hours after the patient presented to the Emergency Department.

Review of Patient #8's medical record revealed on 03/09/10 at 9:41PM the patient was escorted to the Emergency Department in handcuffs by the police. The patient was diagnosed with Multiple Drug Abuse. On 03/10/10 at 6:38AM the physician's note documented the patient "has not received psychiatric evaluation and disposition." At 9:28AM the physician's note documented patient "awaiting psychiatric evaluation. Dr. M on his way." At 10:05AM a psychiatric evaluation was performed and at 10:40AM the patient as discharged home. Although the patient presented to the Emergency Department on 03/09/10 at 9:41PM the patient was not evaluated by psychiatry until 03/10/10 at 10:05AM, twelve (12) hours after the patient presented to the Emergency Department.

Review of Patient #7's medical record revealed on 02/13/10 at 12:06AM the patient presented to the Emergency Department with a chief compliant of hearing voices, and paranoid, uncooperative and combative behavior. At 3:17AM and 7:41AM the nurse's notes documented the patient was awaiting "a psychiatric evaluation in the AM." At 6:18AM and 6:40AM the physician documented the patient was awaiting "psychiatric evaluation and disposition." At 11:50AM the psychiatric evaluation was performed, twelve (12) hours after the patient presented to the Emergency Department.

Review of the hospital policy entitled "Emergency Department - Subject: Provision of Care," dated 11/07 documented that "all Emergency Department patients will have a decision regarding their disposition (admission or discharge) made within six (6) hours."

Review of the hospital policy entitled "Emergency Department- Subject: Psychiatry - Emergency Department Joint policy," dated 11/07 documented when a patient has been assessed to not have any acute medical conditions and it is determined by the Emergency Department physician that the patient is in need of psychiatric services the psychiatric nurse practitioner and/or psychiatrist is to be notified. If the psychiatric nurse practitioner is not available the Emergency Department physician iss to call the on-call psychiatrist directly.

On 03/11/10 at 2:00PM an interview with Staff Member #13 revealed every morning between 6:00AM and 7:00AM, when the psychiatrist comes to the Emergency Department, the charge nurse tells the psychiatrist which patients are waiting for a psychiatric consultation. The psychiatrist sees the patients in priority order.