HospitalInspections.org

Based on observations, medical record reviews, contract reviews, hospital policy and procedure, Medical Staff Rules and Regulations, credential and personnel files, and staff interviews, the hospital failed to ensure that appropriate medical screening examinations were provided within the capability of the hospital's Emergency Department (ED), to include the ancillary services (Psychiatric Services) of Qualified Medical Personnel routinely available in the Emergency Department to determine whether or not an emergency psychiatric condition existed for 7 of 9 psychiatric patients' medical records reviewed (Patient #7, #17, #19, #6, #22, #23, and #24). Additionally, the hospital's Medical Staff Rules and Regulations failed to state that Licensed Professional Counselors were determined qualified to conduct psychiatric screening examinations.

Findings include:

Cross Refer to findings in Tag A-2406.

Based on observations, medical record reviews, contract reviews, hospital policy and procedure, Medical Staff Rules and Regulations, credential and personnel files, and staff interviews, the hospital failed to ensure that appropriate medical screening examinations were provided within the capability of the hospital's Emergency Department (ED), to include the ancillary services (Psychiatric Services) of Qualified Medical Personnel routinely available in the Emergency Department to determine whether or not an emergency psychiatric condition existed for 7 of 9 psychiatric patients' medical records reviewed (Patient #7, #17, #19, #6, #22, #23, and #24). Additionally, the hospital's Medical Staff Rules and Regulations failed to state that Licensed Professional Counselors were determined qualified to conduct psychiatric screening examinations.

The findings are:

Hospital A's Contract
On 07/21/2020 at 2:00 PM, review of the hospital's contract , titled, "Psychiatric Assessment Team Services Agreement", revealed, "This Service Agreement (the "Agreement") is made and entered into to be effective March 5, 2018 by and between Hospital (A)(hereinafter referred to as "Hospital") and Hospital (B) (hereinafter referred to as "Provider"). Whereas, Hospital (A) provides emergency care service in it emergency department (the "Emergency Department") and inpatient units that require, from time to time, the services of qualified psychiatric clinicians (e.g. mental health clinicians, social workers, and/or psychologists) (here in after referred to collectively as the "Assessment Team") to perform psychiatric and mental health consultatively assessments (hereinafter referred to as the "Services").
1. Services To Be Provided By The Provider
1.2.1 ......members of the Assessment Team will provide triage, assessment, evaluation, documentation, and recommend disposition for chemically dependent and/or psychological patients.
1.2.6 report to Hospital (A) via phone within one (1) hour of notification or request for a psychological and mental health assessment and onsite the day of notification if during agreed time. It is anticipated by the parties that coverage by the Assessment Team will be available Monday - Friday from 8:00 a.m. through 6 p.m.; ......."

Medical Staff Bylaws
Review of Hospital A's Medical Staff Bylaws approved by Medical Staff 02/01/2000 and approved by Board of trustees 02/02/2000 and last revised 05/08/2018, reads, Article B 2 Medical Records, "Other individuals, such as Nurse Practitioners, Physician Assistants, or Midwives, who are permitted to provide patient care services independently may perform the medical screening and history and physical examination, if granted such privileges and if the findings, conclusions,and assessment of risk are confirmed or endorsed by a qualified Practitioner prior to operative, invasive, diagnostic or therapeutic intervention or within 24 hours, whichever occurs first. Review of Article E 8 , reads in part, .....The medical screening exam under Article B 2 may be performed by a qualified RN (Registered Nurse)under the orders of and in telephone contact with the obstetrical physician. There was no approval granted by the Governing Body and/or Medical Staff Bylaws for a Clinical Assessment Coordinator(CAC) or Licensed Professional Counselor to perform the psychiatric Medical Screening Examination for patients presenting to Hospital A's emergency department for patients with psychiatric complaint/illnesses, when the Emergency Department(ED) physician requested a psychiatric consultation.


Patient Record Reviews
Patient #7
On 07/21/2020 at 11:00 AM, review of Patient #7's chart revealed the patient presented to the hospital's Emergency Department(ED) via ambulation with parent at 11:03 AM on 4/20/2020 with a chief complaint of "dad states behavioral problems at home, aggressive with mom. has tried to run away. Dad States "he's fine until he doesn't get his way." The triage level was documented as 2- Emergent. (The triage scale is based on 1 - 5 with 1 being the most serious requiring the most resources.) The ED Physician documented "intermittent bouts over the past 3 to 4 months (dating to the time his mother succumbed . . .) of both physically and verbal violent behaviors towards family members, school officials and law enforcement." The ED Physician ordered a psych(psychiatric) evaluation and security was ordered on 04/20/2020 at 11:54 AM. On 04/20/20 at 11:54 AM, documentation showed the patient was evaluated by Licensed Professional Counselor(LPC) #1. There was no documentation in the medical record to indicate that a psychiatrist evaluated patient #7 on 4/2020. There was no approval by the Governing Body for a Licensed Professional Counselor to conduct/perform the psychiatric screening examination.
History and Physical
"Narrative History of Present Illness: 7- year- old male with no previously diagnosed psychiatric or behavioral condition is brought in by his father for intermittent bouts over the past 3 to 4 months (dating to the time his mother succumbed to yet unidentified chronic illness) of both physically and verbal violent behaviors towards family members, school officials and law enforcement. Father states that the child has repeatedly run away and has had to have been brought back by law enforcement. Dad claims that all episodes appear to be triggered by him "not getting his way". He has been seen 2-3 times by a counselor in Florence with whom I have spoke this morning who claims that he is being referred to a psychiatrist urgently for further evaluation. Clinical Impression: Oppositional defiant disorder, Agitation."

Review of Systems - Peds(Pediatrics)
"Complete review of systems negative except as per HPI (History and Physical)."

Evaluation by LPC #1
On 4/20/20 at 11:54 AM, a physician order for a psych(psychiatric) evaluation and security was ordered. On 04/20/2020 at 1:26 PM, LPC #1 documented, "pet (Psychiatric Assessment Team) has been consulted and at this time, pet has staffed the case with dr. ...... and at this time he states that the pt (patient) has been out of control with no relief.. dr.....spoke with the counselor and she has been trying to get the pt in to see a psychiatrist. this has not happened at this time. pet has called hospital(Hospital C) (where patient was transferred to) and the pt has been accepted under the care of dr ..... ....".

Discharge
The ED Physician wrote transfer orders for Patient #7 on 04/20/2020 at 2:35 PM to Hospital C via private owned vehicle accompanied by the patient's father.


Patient #17
On 07/21/2020 at 3:00 PM, review of Patient #17's chart revealed the patient presented to the ED on 06/04/2020 at 3:01 PM via a private vehicle accompanied by family. Patient #17's triage level was documented as 2- Emergent, and the patient's chief complaint was Suicidal Thoughts and Depressed Mood. The Triage Nurse documented the patient was a high suicide risk. The Triage Nurse documented "pt brought in via pov(private owned vehicle) with family, pt states over the last week has been having suicidal thoughts about cutting her wrist with a razor blade." On 06/05/2020 at 7:00 AM, an order was placed for a consult with the Psych Evaluation Team (PET). On 06/08/20 at 11:29 AM, documentation showed the patient was evaluated by Licensed Professional Counselor(LPC) #1. There was no documentation that a psychiatrist evaluated the patient throughout the patient's stay in the emergency department. There was no approval by the Governing Body or Medical Staff for Licensed Professional Counselors to conduct the psychiatric medical screening examination. There was no documentation that the hospital made any contacts for placement of the patient until 06/08/2020 when LPC #1 evaluated the patient. During an interview with the Director of Nursing on 7/22/2020 at 11:00 AM, the Director stated, "They (nursing staff) don't always document when they fax the papers to inpatient facilities". There was no documentation in the medical record to indicate that a psychiatrist was involved in the patients care.
History and Physical
Documentation dated 06/04/2020 at 3:09 PM by ED Physician #1 revealed, "This is a 35-year-old Caucasian female. She states she has a lifelong history of what sounds to be bipolar disorder. She has had increasing depression over the past several days and has had thoughts of self harm. She is planning to cut her wrist with a razor or knife she says she has access to same. She has scars on both wrist where she is attempted to cut her wrist in the past. She has no recent history of COVID-19 exposure. She reports she is compliant with her medications.
Psychiatric/psychosocial problems and conditions: anxiety, depression, suicide attempt.

Psychiatric: not homicidal, anxious, depressed, suicidal ideation.
Clinical impression: Major depression, Suicidal ideation
Suicide risk prevention
Review of the Columbia Suicide Screening dated 06/04/2020 at 3:11 PM revealed,
" 1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? yes"
" 2. In the past month, have you actually had any thoughts of killing yourself? Yes"
"3. In the past month, have you been thinking about how you might do this? Yes"
"4. In the past month, have you had these thoughts and had some intention of acting on them? Yes"
"5. In the past month, have you started to work out the details of how to kill yourself? Do you intend carry out this plan? Yes"
"6. In your lifetime, have you ever done anything, started to do anything, or prepared to do anything to end your life? Yes"

Nurse Progress Notes dated:
"06/05/20 at 5:11 PM: Called over to see Pt due to Pt laying in bed and scratching her arm with her fingernails. All Pts plastic utensils have been removed from the room. No bleeding seen at this time but Pt has the letter Z in her arm."
"06/05/20 at 6:50 PM: Called over to see Pt again due to Pt trying to cut her arm again. Found Pt had pulled a small piece of metal out of her mask and trying to cut her arm. .....".
"06/07/20 at 9:48 PM: Patient refused all medications. Withdrawn, refuses to talk."
"06/08/20 at 2:57 PM: Occupational Therapy: Security notified that patient was trying to cut herself with straw from dinner tray. Dinner tray removed from room. Patient states that she is having urges to harm herself. States she still does not want to taker her medications."

Licensed Professional Counselor (LPC) #1 Progress Note dated 06/08/2020 at 11:29 AM revealed "PET (Psychiatric Evaluation Team) Pt remains suicidal at this time, she has past attempts to harm herself and has been con-compliant with treatment at this time.. clinical has been faxed to Hospital D and at this time the patient has been accepted for admission ....".

Physician Progress Notes
ED Physician #1 recorded a progress note labeled "Psychiatric Progress Note", dated 06/06/20 at 08:26 AM, that reads, "35 year old she still reports she is suicidal. Last night she obtained a piece of metal from her mask that she is waiting for COVID protection she scratched her wrist with same at this time I am unable to discharge her to home. She must have further attempts at commitment."
ED Physician #1 recorded a progress note labeled "Psychiatric Progress Note", dated 06/07/2020 at 10:32 AM, that reads, "Patient reports she is still having suicidal thoughts and she is scheduled for outpatient surgery tomorrow for chronic cutaneous abscesses in her groin. Administration will discuss with surgeon tomorrow concerning the necessity of this procedure. "

Patient #17 had PART 1 Affidavit For Involuntary Emergency Hospitalization For Mental Illness And Order Of Detention forms completed for the patient dated 06/04/20, 06/05/20, 06/06/20, and 06/07/20. Patient #17 was transferred to Hospital D on 06/08/20 at 1:35 PM via police transport.


Patient #19
On 7/21/2020 at 14:30 PM, review of Patient #19 emergency department chart revealed the patient presented to the emergency department via ambulance on 05/22/2020 at 6:26 PM. Chief Complaint recorded as "pt called ems(Emergency Medical Service) and law enforcement but won't say why."
Triage
Patient triaged on 05/22/2020 6:27 PM with a level 2 - emergent.
History And Physical
ED Physician #3 documented the patient's history and physical on 05/22/2020 at 6:47 PM. "A 24-year-old patient presents to the ED department via police for psychiatric evaluation. The patient refuses to speak to me. I gave her a pen and piece of paper and she wrote me a short letter describing her problem. I will dictate the note below: "I wonder if my grandma made me eat my baby. Also I may have been kidnapped by someone. I think I am not sure maybe I am not sure." Home medications include Haldol and Cogentin. Review of systems: Unable to obtain due to: Altered mental status. Affidavit for Involuntary Emergency Hospitalization for Mental Illness and Order of Detention Part I was signed on 5/22/2020 for harm thought possible, self neglect and inability to care for self." ED Physician #3 ordered a "Consult for the Psych Evaluation Team" on 5/22/2020 at 10:00 PM. Psychiatric Extended Stay ED Q12H(Every 12 hours) and security at bedside." There was no documentation that a psychiatrist evaluated the patient during the patient's stay in the ED. There was no approval by the Governing Body for a Licensed Professional Counselor (LPC) to do the psychiatric screening by the Governing Body. "Psychiatric: flight of ideas, abnormal judgement/insight, acute psychosis". Narrative Decision Making reads, "Schizophrenia, psychosis, toxic ingestion".

Columbia Suicide Screening
Documentation on the Columbia Suicide scale by the Registered Nurse showed "No Suicide Risk."

Nurse Progress Notes
On 05/22/2020 at 8:02 PM, the Registered Nurse(RN) documented "Patient is unable to verbalize her feelings to the MD (Medical Doctor), she has been given paper and pen to record her thoughts."

On 05/23/20 at 6:00 PM, the RN documented "Called over by security stating pt's head was bleeding. Arrived to find pt. sitting on the floor with a laceration to the back of her head bleeding. Pt. screaming, "He pushed me." Security stating pt. slipped on a blanket she was wrapped up in, hitting the back of her head on the counter. Bleeding controlled at this time. Pt. moved to ED hallway and cleaned up, Noted to have a 4.5 CM (Centimeter) laceration to the back of her head. Pt remains alert and oriented. Pupils remain equal and reactive. NP (Nurse Practitioner) at bedside to see pt."

On 5/24/2020 at 2:20 PM, the RN documented " Pt discharged at this time and grandfather here to pick pt up."

Affidavit for Involuntary Emergency Hospitalization for Mental Illness and Order of Detention Part I dated 5/22/2020 for harm thought possible, self neglect and inability to care for self.

Nurse Practitioner(NP) Note
The NP recorded a progress note dated 05/23/2020 at 7:04 PM that reads, "Around 1600 (4:00 PM), patient was noted yelling and security was standing in front of the patient. Per patient, she was pushed by the security guard hitting her head on the metal portion of the counter in her room. Patient with a 4 1/2 CM laceration noted to the posterior head, she denies any loc (loss of consciousness). bleeding controlled. On 5/23/20 at 8:3 PM, the NP recorded" CT(Computerized Tomography) Head is negative for any acute finding per radiologist report."

Discharge
Ed Physician #3 recorded the following on 05/24/2020 at 2:20 PM, "Narrative Medical Decision Making: We were able to verify social support system at home patient appears to be less psychotic at this point with a history of chronic schizophrenia. There is no homicidal ideation currently. Patient's family was educated to maintain safe environment or if there is any concerns occurrences of worsening hallucinations or onset of any self-destructive behavior with any suicidal or homicidal ideation patient return to the ED for further evaluation." Patient #19 never received a psychiatric evaluation from admission on 05/22/2020 - 05/24/2020 although a psychiatric consult was ordered on 05/22/2020.


Patient #6
On 7/21/2020 at 3:00 PM, review of Patient #6's chart revealed the patient presented to the hospital's Emergency Department (ED) on 4/26/2020 at 4:59 PM via ambulance. Patient was triaged as a Level 2 - emergent based on the patient's chief complaint as " Pt. ambulatory with EMS with alleged overdose. Over 6 hours last night, pt. took 6 milligrams (mgs) Zanaflex x(times) 2, 1 mg. Xanax x 8, and 5 milliliters (mls) Hydrocodone syrup. Pt. denies SI (Suicidal Ideation), states "I was just trying to take enough to get some sleep." Pt. states hx (history) of Depression. Pt denies any complaints at this time."
History and Physical
ED Physician #1 performed the patient's history and physical on 4/26/2020 at 5:03 PM . ED Physician documented "This is a 40-year-old Caucasian female. She has a history of depression and chronic back pain. She takes Zanaflex and Xanax on a regular basis. Today she reports she took 3 mgs of Xanax and a Zanaflex this morning. She awoke this afternoon and took 4 mgs of Xanax additional Zanaflex tablet. Also report she took 5 mgs of hydrocodone elixir. She reports she took this in order to obtain some sleep she states that she is not suicidal and has no plan of self harm. She reports this is an accidental overdose and she was not planning to harm herself."

Addendum: By ED Physician #1 at 9:05 PM: "labs unremarkable and patient is alert and doing well and again denies any desire to harm herself - Will discharge."

Addendum on 4/26/2020 at 9:32 PM by ED Physician #I: "I was shown a Facebook page that was the patient's and clearly was a suicide note, and this is clearly an intentional overdose. I spoke with the patient, and she did not deny this, but still says she is not currently suicidal. I believe the best thing would be to hold her for further evaluation and possible admission since she is clearly depressed also."

Clinical Impression: Accidental Overdose; Suicide attempt; Overdose. Security at bedside for Suicide monitoring. Consult Psych Evaluation Team On 04/26/2020 at 9:27 PM. PET Team (Clinical Assessment Coordinator ) notified on 4/26/2020 at 9:28 PM.

LPC #1 Progress Note
LPC #1 documented on 04/27/2020 at 2:21 PM that "The patient presents stating that she was not trying to kill herself and that she took the overdose to try and sleep. The patient suffers from depression and states that her care and her mental status has gotten worse. The patient wanted to state that she was stable and ready to go home. However, her husband reported to staff that she had made a Facebook post that her attempt was intentional and that she was trying to harm herself and that she wanted to die. Clinical Assessment Coordinator has faxed clinical to Hospital D and at this time it has been determined that the patient needs further stabilization inpatient. The patient has been accepted."

Discharge
On 4/27/2020 at 2:54 PM, the patient was transferred via police escort to Hospital D. There was no documentation that a psychiatrist evaluated the patient. There was no approval by the Governing Body or Medical Staff for a Licensed Professional Counselor (LPC) to do the psychiatric screening examination.



Patient #22
On 7/22/2020 at 1:00 PM, review Of Patient 22's chart revealed the 33 year old patient presented to the ED on 05/23/2020 at 5:47 PM "via ambulance for self inflicted lacerations to bilateral ankles. HX (History) Bipolar, Off medications, Patient states was attempting to kill himself. Calm and Cooperative." The patient was triaged as a level 2- emergent.
History and Physical
On 05/23/2020 at 6:04 PM, the ED physician documented "Narrative of present illness: Patient is a 33-years-old Caucasian male who presents to the ED after self inflicted lacerations to his ankles bilaterally. Patient states that this is done in an effort to kill himself. Patient denies any history of preop prior suicidal attempts or suicidal ideation. Review of systems: All systems negative except as marked. Psych: Reports: stress, depression, suicidal ideation. There are 2 lacerations on the medial ankles bilaterally that are approximately 3 cm long and adjacent to the Achilles tendon. The left 1 is quite deep however does not extend into the Achilles tendon. The patient is neurovascularly intact and there is no tendon laxity. Number of sutures: 13, other (total of 13, 5 on the right and 7 on the left.) . Results/Interpretation: labs reviewed and normal except (Positive for marijuana)".

Physician orders included but were not limited to: "Consult Clinical Assessment Coordinator ONCE order was placed at 5/25/2020 at 7:00 AM. Then a Notify Clinical Assessment Coordinator NOW order was placed on 5/23/202 at 8:15 PM. Notify security completed on 5/23/2020 at 7:09 PM. Psychiatric Extended Stay ED Q12H(Every 12 hours), Security at bedside continuous and Suicide Monitoring orders noted in the system on 5/23/20 at 8:14 PM. Labs ordered: Alcohol Ethanol Blood Stat, CBC(Complete Blood Count) w(with) Diff(Differential) Stat ,Comprehensive Metabolic Panel Stat, Drug screen Comprehensive, Urine Stat, Thyroid Stimulating Hormone Stat and UA(Urine) w Microscopic if indicated Stat. Medications listed: Ativan 1 MGs PO (by mouth) X1ED(Times 1 Emergency department) STA(Stat), Nicotine 21 mgs patch X1ED STA, Trileptal 1200 mgs PO X1ED STA. Scheduled medications as follows: Trileptal 1200 mgs daily SCH(Scheduled), Trileptal 600 mgs daily SCH and Trileptal 600 mgs PO(by mouth) daily after lunch."

Nurse Progress Notes
Review of the nurse progress note dated 5/24/2020 at 9:22 AM revealed "Pts wife called at this time stating she would bring the phone up here to prove that Pt was sending text messages to people telling them bye. Wife continues to state she had talked to her lawyer this morning who told her to call the ER(Emergency room) and let them know, he has tried this in the past, and really needs to be sent somewhere. "

Review of the nurse progress note dated 5/24/20 at 7:32 PM revealed "wife notified that husband ready to be discharge. Wife refused to pick him up. Patient states he needs his cell phone and clothes, County deputy call to go by residence to pick up cell and clothes. Wife notified, wife states he does not have anything at her house. Wife stated that she would get clothes and phone ready for officer. "

Affidavit for Involuntary Emergency Hospitalization for Mental Illness and Order of Detention Part I dated 5/23/2020 and 5/24/2020 for "cut, bilateral ankles w/razor,states he was trying to kill himself, states he needed attention".
Psychiatric Evaluation: There was no documentation of a psychiatric evaluation in the patient's chart.

Addendum ED Discharge Dispo(Disposition): Charted at 5/24/20 at 8:46 PM.
Clinical Impression: Suicide Attempt. Laceration of foot. Disposition: Inpatient Psych Facility 65 Condition: Good Return to work: Suicide Risk Prevention Instructions: Laceration Repair Care transferred: 7:20 PM (Patient was reexamined. He has no thoughts of harming himself or others. Patient agrees to follow up with his mental health.) Discharged to home.


Patient #23
On 7/22/20 at 2:30 PM, review of Patient 23's chart revealed the patient presented to the Emergency Department on 6/26/2020 at 2:07 PM by ambulance[sic] or police on pick up papers related to hallucinations. Triage was conducted at 2:08 PM and a triage level of 2- emergent was assigned. The patient's chief complaint was hallucinations.
History and Physical
The ED Physician conducted the patient's history and physical on 6/26/2020 at 2:14 PM. Ed Physician documented: "Subjective Assessment: pt brought in by police on pick up papers r/t(related/to) hallucinations. Chief Complaint: Behavior Health. Narrative History of Present illness: 41-year-old male. Long history of psychiatric issues. Has been adherent to his medication per report. Has been hearing voices and seeing things that he recognizes as hallucinations. He has also been threatening his mother. Sent to us by behavioral health after their evaluation. Psychiatric: not suicidal, not homicidal, auditory hallucinations, visual hallucination. Security at bedside continuous and Suicide Monitoring Q1H". On 6/26/20 at 2:30 PM, a consult was placed for Psych Evaluation Team STAT ED. Labs ordered at 3:17 PM and 3:21 PM as follows: "Alcohol Ethanol Blood Stat, CBC w Diff Stat ,Comprehensive Metabolic Panel Stat, Drug screen Comprehensive, Urine Stat, Thyroid Stimulating Hormone Stat and UA w(with) Microscopic if indicated Stat". "Psychiatric Extended Stay ED Q 12H" order placed at 6/26/20 at 8:23 PM. On 6/26/20, orders placed for Security at bedside continuous and Suicide monitoring Q1H. On 6/26/20 at 11:12 PM, order entered for Lorazepam (Ativan) 1 mg by mouth. On 6/26/20 at 11:17 PM, the dose was documented as administered by Registered Nurse (RN).

Discharge
On 6/27/20 at 10:45 AM, Patient #23 was transferred to Hospital D via police escort. There was no documentation that Patient #23 received a psychiatric screening evaluation as ordered.


Patient #24
On 07/22/2020 at 2:25 PM, review of Patient #24's chart revealed the patient presented to the ED on 7/17/2020 at 5:39 PM. Review of the Triage notes revealed "Pt. was brought in by police due to climbing halfway up cell tower in his grandparent's yard, stating, "I' m going to kill myself." Pt. states he came to the ED to get Xanax, 120 tabs of them for his nerves and stressing. Arrival mode: Police. Triage level was 2- Emergent.
History and Physical
ED Physician documented the patient's history and physical on 7/17/2020 at 5:50 PM as "Patient climbing tower to try and jump and kill himself, patient made statement of this to his grandparents. Patient also has machete. Review of Systems: Unable to obtain due to uncooperative.

Physician Orders
ED status HOLD on 7/17/2020 at 6:40 PM. Consult for Psych Evaluation Team (PET), suicide assessment CONTINUOUS, and suicide monitoring Q1H orders placed 7/17/2020 at 6:41 PM. 07/17/2020 at 8:31 PM, Security made aware of need for urine sample. A cup and urinal is at the door.

Psychiatric
There was no documentation of a psychiatric screening evaluation or assessment in Patient #24's chart.

Nurse Notes
On "7/17/2020 at 6:20 PM, Pt. searched and placed in paper scrubs by security, then moved to a room. Part I and Part II, Affidavit for Involuntary Emergency Hospitalization, signed on 7/17/2020 at 6:00 PM.

Discharge
On 7/18/2020 at 11:25 AM, Pt. #24 was transferred to Hospital E.


Interviews
ED Director
On 7/22/2020 at 10:00 AM, in the conference room, the ED Director stated, "The charge nurse or the primary nurse have a reference guide with phone numbers and fax numbers to all the psychiatric treatment centers. The nurses will call and attempt to find placement on the weekends when the PET is not available."

Registered Nurse 2
A face to face interview was conducted in the conference room on 07/22/20 at 10:00 AM with Emergency Department (ED) Registered Nurse (RN) 2. RN 2 was asked to explain the process for evaluating the psychiatric population in the ED, and reported "We evaluate, the Medical Doctor (MD) talks with the patient, and we collect labs if ordered. We make sure Part I of the hold papers are filled out if we have to place a patient on hold on the weekend. We do hourly rounds once admitted and place the patient in paper scrubs, and security wands them for any contraband. The psychiatric patients usually go to room 9 initially, and then we may move them to room 14, 15, 16 or 17. I take the monitor, basket, blood pressure cuff, and anything I can remove from the walls out of the room. Security sits outside the door." When asked about the Medical Screening Examination (MSE), RN 2 stated, "The MD does the psychiatric evaluation and the MD places the orders." RN 2 was asked to explain the process on the weekends if the emergency department has a patient with psychiatric issues that requires placement, and RN 2 explained, "The nurse who has that patient will attempt to get them placed. We will notify the MD if there are any changes in behaviors. The MD assesses the patient once a day. The ED MD writes orders for any psychiatric medications." When asked if the Clinical Assessment Coordinator (CAC) ever writes for medications or other orders in the patient's chart, RN 2 replied, "No, the CAC writes notes in the chart but no orders."

Licensed Professional Counselor #1
On 7/22/2020 at 10:15 AM, an interview via telephone was conducted with Licensed Professional Counselor #1 (LPC), also known as the Clinical Assessment Coordinator(CAC), in the conference room. LPC #1 reported that she is a professional counselor who has contracted at Hospital A for three years. LPC #1 stated, "I'm a Licensed Professional Counselor (LPC), and I'm waiting on the Board to tell me if I need another class." LPC #1 reported her role in the emergency department is to ".....call or text the Charge Nurse (CN) or in some cases the Nursing Supervisor to see if the Emergency Department (ED) has any psychiatric patients that I need see. If they do, I come to the facility. First, I go to the physician. I check with the CN, and the primary nurse for the patient. I go to the computer and look at notes and laboratory results. I use a clinical assessment tool and the full Columbia-Suicide Severity Rating Scale (CSSR). I am a contracted employee employed by Hospital B. I have contracts with this facility and a neighboring facility. I work Monday through Friday only. If a patient presents over the weekend, the ED physician decides if the patient needs to be held in the ED over the weekend or discharge the patient. If a patient comes in over the weekend, the physician will conduct the assessment and decide to hold or safely discharge the patient. If the physician feels he/she cannot safely discharge the patient, the physician will hold the patient in the emergency department and initiate Part I papers for a 23 hour hold. The physician in the ED re-assesses the patient every day and decides if another 23 hour hold or Part I paperwork needs to be filled out. On Monday, I check to see if the ED has anyone on a 23 hour hold in the ED." When asked if anyone covers the emergency department on weekends, vacation, or sick leave, LPC #1 replied, "No, it is me or no one. I will try to be available remotely if there is something I can help with or any resources they need, they call me." LPC #1 was asked if he/she has access to a Psychiatrist to assist her with recommendations, and LPC #1 replied, "If I need them (Psychiatrist), I can call Hospital B's psychiatry group. Of course, they only make recommendations. They obviously are not going to prescribe medications or anything else on a patient they have not and cannot see".

LPC #1 Credential/Personnel File
On 7/22/20 at 10:30 AM, a request was made for the credentialing and training file for LPC #1. The Director of Nursing (DON) stated, "We don't have a credentialing or personnel file." When asked if LPC #1 had been approved by the Governing Body as a Qualified Medical Professional(QMP) to perform the psychiatric evaluations, the Director of Nurses stated, "No. We don ' t have approval from the Board, just a contract with Hospital B. We don ' t have psychiatrists here."

ED Physician Credential Files
The Emergency Department Director stated on 07/21/2020 at 9:20 AM that "The ED physician does the psychiatric Medical Screening Exam (MSE)." When asked if the ED physicians had psychiatric background or were credentialed to conduct psychiatric screenings, and if the ED Physicians were approved by the Governing Body to perform a psychiatric screening examinations for psychiatric patients presenting to the ED, the ED Director stated, "No, they're not psychiatrists."