HospitalInspections.org

Based on medical record review, document review and interview, the hospital does not meet the emergency needs of patients. Specifically, all patients presenting to the emergency department (ED) with behavioral health issues, including suicidal ideation, do not receive a coordinated psychiatric consultation evaluation communicated between services.

See Tag A-1103

Based on policy review, document review, medical record review, and interview, the facility failed to ensure there was communication and coordination between the Emergency Department (ED) and Psychiatric Services designed to meet the needs of patients requiring a psychiatric evaluation in the ED for 3 of 3 Patients (Patient #1, # 12 and #15).
Specifically, there is no evidence of the content of the consult telephone call between the Psychiatric Assessment Officer (PAO) and Staff Psychiatrist, there are no documented recommendations or consult notes from the Psychiatrist, and there are no documented communications between the ED Physician and the Psychiatrist regarding the coordination of care and psychiatric evaluation. There is no evidence of a re-assessment by the ED Physician prior to the discharge of patients.

Failure to meet the emergency needs of patients in accordance with acceptable standards of practice can delay treatment and/or contribute to an adverse patient outcome.

Findings Include:

Review of policy "Emergency Medicine Unit Structure Standard" manual approved on 10/2020 revealed multiple specialty consultants are available to support Emergency Department (ED) patient care. On-call changes are maintained on a daily, weekly, or monthly basis. Consultants are to communicate with the ED provider and the nursing staff regarding patient management and provide appropriate documentation to help guide patient care. Consultants are to discuss the plan of care with the ED provider, update the patient/family as necessary, and provide appropriate direction to the nursing staff.

Review of policy "Behavioral Health Inpatient Mental Health Admission" last revised 08/2021 indicates it is ultimately the responsibility of the admitting Psychiatrist to determine if a patient meets criteria for admission, as well as whether the patient requires voluntary (9.13) or involuntary (9.39) Emergency Admission. Emergency (9.39) Admission standard: reasonable cause to believe that the person has mental illness for which immediate observation, care and treatment is appropriate and which is likely to result in serious harm to him/herself or others. The 'likelihood of serious harm" means: A substantial risk of physical harm as manifested by threats of or attempts at suicide or bodily harm or other conduct demonstrating that the person is dangerous to him/herself.

Review of Staff (D), Psychiatric Assessment Officer (PAO)/ LMSW Job description revealed the Licensed Clinical Evaluator (CE) responsibilities include:
-Manages all telecommunication collaboration with internal and external customers and documentation relevant to psychiatric patient admission, treatment, discharge, or transfer.
- Consults with Team Leader, Manager and/or Psychiatrist On-call to implement most appropriate treatment and dispositional plan. Reviews every person evaluated with the Psychiatrist to determine most appropriate treatment and disposition.

Review of Staff (N), Psychiatrist personnel file revealed privileges granted for Psychiatry from 08/31/2021 to 08/31/2023 to perform patient assessments, medical screen examinations (MSE) and Diagnosis/Consultation/Clinical Supervision, and coordination of care & medication therapy.

Review of Staff (G), ED Physician personnel file revealed Joint ED and General privileges are granted from 07/31/2022 to 07/31/2024. No Psychiatry privileges were noted.

Review of the Medical Record from Rochester General Hospital (RGH) for Patient #1 revealed:
- Emergency Department (ED) Triage Note dated 03/18/2022 at 12:43 AM by Staff (F), RN revealed according to EMS, Patient #1 told his family that he was going to take pills to kill himself and then walked out of the house. They do not know what he took. Patient #1 is currently suicidal.
- Suicide Screen Triage note dated 12:43 AM by Staff (F), RN revealed Patient # 1 responded "yes" to having thoughts of killing himself within the past twenty-four (24) hours.
- On 03/18/2022 at 01:48 AM, Patient #1 was transferred to the Crisis Intervention Unit (CIU- Psychiatric ED area) and was received by Staff (E), RN for a mental health arrest (MHA) and being suicidal.
- ED note on 03/18/2022 at 02:10 AM by Staff (E), RN revealed Patient #1 was pacing around room, bumping into walls, and soft intentionally hitting head on wall.
- Drug Screen Urine Results dated 03/18/2022 at 03:13 AM revealed Patient #1 was positive for opiates (drug used for pain relieve and anesthesia, include heroin and fentanyl) and benzodiazepines (sedative/ depressant drug).
- On 03/18/2022 at 05:43 AM, Staff (G), ED Physician discharged Patient #1.
- ED Psychiatric Evaluation dated 03/18/2022 at 06:14 AM by Staff (D), PAO revealed Patient #1's legal status at arrival was a 9.41 (NYS Mental Hygiene law allows a police officer to take into custody any individual for evaluation if the person is conducting themselves in a manner which is likely to cause harm to themselves or others). Patient #1 reports there was a verbal altercation where he expressed that he "should just take all the pills and end his life". Patient #1 stated "things just get said during arguments and that he has not acted on any suicidal thoughts in years". Upon chart review it was found that Patient #1 has a history of suicide attempts and multiple accidental overdoses as well as inpatient admissions. The Collateral Report information received from Patient #1's mother indicates ongoing issues for several years. Patient #1 will often do this and then downplay the situation to be able to return home. The mother reported in January that Patient #1 sold a part of his computer, then overtook medications to end his life, was seen at another facility, and discharged. Upon arriving home, Patient #1 told her that she should have known he wanted to kill himself because he sold his computer. Patient #1 has a history of inpatient chemical dependency treatment as recent as last week, which he did not complete. Patient #1 is at moderate risk for acute/chronic suicide, low risk for acute/chronic violence, moderate risk for acute/chronic overdose. He is at low risk for acute re-admission but moderate risk for chronic re-admission. Patient #1 states he does not wish to be dead currently or in the past 3 months. He denies having specific active suicidal thoughts. Patient #1 has attempted suicide by overdose on multiple occasions. Patient #1 denies any suicide attempts within the last 3 months, however, his mother reports that his ED visit at SMH (01/10/22) was a suicide attempt. Patient #1 presents at a chronic elevated risk for suicides, violence, and overdose due to poor coping skills and his continued substance abuse. Patient #1 has a history of inpatient admission, most recently 02/2021 with a long-standing history of behavior and substance abuse. Patient #1 ' s mother states he also sold the same part yesterday and is concerned for the safety of Patient #1. Patient #1 should continue to utilize chemical dependency (CD) treatment as clinically appropriate as well as outpatient mental health services, as they are the least restrictive form of treatment based on current symptoms. Discharge home and follow safety plan, attend outpatient appointments as scheduled. Staff (D) consulted with Staff (N), Psychiatrist over the phone.
- On 3/18/2022 at 06:28 AM, Patient #1 was discharged home via taxi.
There is no documentation of the time or content of the consult telephone call between Staff (D), PAO and Staff (N), Psychiatrist, there is no documented recommendations or consult note from Staff (N), Psychiatrist, and there is no documented communication between Staff (G), ED Physician and Staff (D), PAO or between Staff (G) ED Physician or Staff (N), Psychiatrist regarding the coordination of care and psychiatric evaluation for Patient #1. There is no documentation of a re-assessment by Staff (G), ED Physician prior to the discharge for Patient #1.

Review of the fax from Strong Memorial Hospital (SMH) on 03/18/2022 at 05:06 AM (part of the RGH medical record) for a previous hospital visit which occurred on 01/10/22 revealed the following:
- The SMH CPEP Clinical Evaluator (CE) Note dated 01/10/2022 at 02:31 PM revealed Patient #1 presents with mental hygiene transfer for chief complaint of drug overdose. Patient #1 took fourteen (14) Xanax and then called 911. He denies suicidal ideation, homicidal ideation and endorses the suicide attempt. Patient #1 denies auditory or visual hallucinations. Patient #1 reports taking Xanax (sedative), but without the intent to die, just took too many. Patient #1 is requesting to be discharged.
- A Behavior Health Safety Plan dated 01/10/2022 at 02:30 PM was developed.
- The SMH Physician Provider noted dated 01/11/2022 at 05:29 AM revealed, Patient #1's history is consistent with what was provided by the collateral evaluator. Patient #1 was evaluated once he was clinically sober and is working with outpatient providers on improving coping strategies. Patient #1 is not exhibiting any acute psychiatric symptoms meeting acute/ involuntary psychiatric admission criteria. In my clinical opinion, based on the documented information, assessments, and multidisciplinary consultation, at this time a psychiatric hospitalization or extended observation of Patient #1 is not indicated, because he denies suicidal ideation, homicidal ideation, violence ideation and is not exhibiting any psychiatric symptoms meeting acute/ involuntary psychiatric admission criteria. Patient # 1 was informed of returning to the nearest ED if feeling acutely unsafe and agreed. Patient #1 was discharged after interventions and referrals were completed. Family and current providers were informed of disposition.
There is no documentation that this medical record from SMH for Patient #1 was reviewed by any of the RGH ED providers on 03/18/22.

Review of the Medical Record for Patient #12 revealed no documentation of the content of the consult telephone call between Staff (DD), PAO and Staff (GG), Psychiatrist, no documented recommendations or consult note from Staff (GG), Psychiatrist, and no documented communication between Staff (HH), ED Physician Assistant (PA) and Staff (DD), PAO or between Staff (HH) ED PA or Staff (GG), Psychiatrist regarding the coordination of care and psychiatric evaluation for Patient #12. There is no documentation of a reassessment by the ED PA prior to the discharge for Patient #12.

Review of the Medical Record for Patient #15 revealed no documentation of the content of the consult telephone call between Staff (II), PAO and Staff (JJ), Psychiatrist, no documented recommendations or consult note from Staff (JJ), Psychiatrist, and no documented communication between Staff (FF), ED Physician and Staff (JJ), Psychiatrist regarding the coordination of care and psychiatric evaluation for Patient #15. There is no documentation of a reassessment by the ED Physician prior to the discharge for Patient #15.

Telephone interview on 11/02/2022 at 01:22 PM with Staff (B), Director of Behavior Health Services revealed a psychiatrist is on site Monday to Friday. The PAO will call the Psychiatrist, who makes recommendations. The PAO gives the recommendations to the ED Provider who ultimately can discharge or admit the patient. No note is completed by the Psychiatrist. The ED Provider will fill out the disposition section in the system, which is the standard process for ED patients.

Telephone Interview on 11/03/22 at 08:48 AM with Staff (D), Psychiatric Assessment Officer (PAO) revealed she telephoned Staff (N), Psychiatrist to determine Patient #1's disposition from a psychiatric position.

Telephone Interview on 11/03/2022 at 02:37 PM with Staff (N), Psychiatrist revealed once a patient with psychiatric issues is medically cleared, the PAO reviews patient information with the psychiatrist and the ED provider separately. Staff (N) "never sees patients, writes notes, or co-signs the PAO note". Staff (N) "only has contact with the ED Provider if the patient is being admitted. The ED Provider will write the discharge order and change the disposition. I trust the PAO to evaluate". Staff (N) never does telemedicine and trusts the PAO to evaluate patients.

Interview on 11/04/2022 at 01:06 PM with Staff (A), RN Senior Director of Regulatory Compliance revealed Staff (N), Psychiatrist provides consult services, is privileged at the hospital, and a member of the RGH staff. The care to Patient #1 is viewed as a consult.

Interview on 11/04/2022 at 02:45 PM with Staff (K), RN Compliance revealed Patient #1 died of a drug overdose on 03/20/2022.

Interview on 11/04/2022 at 03:01 PM with Staff (A), RN Senior Director of Regulatory Compliance verified the findings.