HospitalInspections.org

A. Based on medical record review, staff interview and review of facility document, it was determined that the facility failed to implement its policy "AES [Affiliated Emergency Services]- Assessment Guidelines For The Detox [detoxification] Patient."

Findings include:

Reference: Facility policy, "AES- Assessment Guidelines For The Detox Patient" states: "...5. If a detox is not required, and patient is not exhibiting symptoms which require inpatient detoxification/medical management, patient will be referred to community based outpatient treatment."

1. Review of Medical Record #1 on 8/25/20, revealed the following:

a. Patient #1 presented to the Emergency Department (ED) on 7/13/20 at 2203 with a complaint of "Detox."

b. A Nursing Note dated 7/13/20 at 2240 states: "...Crisis called and ___ [he/she] stated -____[he/she] would call ___ [his/her] supervisor to see if pt [patient] can still be accepted into detox ...pt was instructed to follow up tomorrow for a detox bed. Pt left..."

c. On the "Chart Summary" in the section identified as "Patient Discharge Information," the line marked "Referrals" was blank.

d. Upon interview with Staff #4, it was confirmed that Patient #1 was not referred to a community based outpatient treatment.

2. Review of Medical Record #9 on 8/25/20, revealed the following:

a. Patient #9 presented to the ED on 7/29/20 at 1527 with a complaint of "Requesting Detox."

b. Patient #9 was discharged "home" at 1554.

c. On the "ED Chart," in the section identified as "Patient Discharge Information," the line marked "Referrals" was blank.

d. Upon interview with Staff #4, it was confirmed that Patient #9 was not referred to a community based outpatient treatment.

B. Based on medical record review, staff interview and review of policy and procedure, it was determined that the facility failed to implement a policy regarding patient rights.

Findings include:

Reference: Facility policy, "Consent for Admission and Treatment" states: "...2. If the patient lacks decision making capacity and is unable to sign the consent due to his/her condition (i.e. unconscious, confused or an emergent condition), and the consent cannot be obtained from the next of kin, domestic partner or guardian, the Registration Associate will document on the consent form the reason why ..."

1. Review of Medical Record #13 revealed the following:

a. Patient #13 presented to the ED on 4/2/20 at 1918 with a complaint of "Gunshot wound."

b. The "ED Provider Documentation" states: "...Progress Note: It was deemed necessary to intubate pt [patient] due to proximity of GSW [Gunshot wound] to airway."

c. On the Facesheet, the emergency contact information included a name, address and telephone number of Patient #13's spouse.

d. A physician's order dated 4/2/20 at 1745 states: "transfer to ___ [name of hospital]."

e. On the "Transfer Certification" form, in box seven (7), subheading "Patient Consent to Transfer," on the line marked "Patient signature or signature of responsible person on behalf of patient," a signature was identified by Staff #4 as belonging to a registered nurse. On the line marked "Witness" a signature was identified by Staff #4 as belonging to the same nurse who signed the consent to transfer.

f. There was no evidence that the facility attempted to contact Patient #13's spouse to obtain a consent to transfer.

2. The above findings were confirmed by Staff #4.

Based on a review of policy and procedure, review of the emergency department on-call schedules for the time frame of 2/1/20 through 7/31/20 and interview with administrative staff, it was determined that the hospital failed to maintain an on-call list of physicians available to provide treatment necessary after initial examination to stabilize individuals with emergency medical conditions.

Findings include:

Reference: Policy and procedure "Emergency Medical Treatment and Active Labor Act EMTALA states: ".....
PROCEDURE:
I. Emergency Department
.....
6. Administrative Requirements
A. On-Call Physicians
A list of on-call physicians for each major clinical service provided by the hospital is to be maintained in the Emergency Department. All on-call physicians are to respond by telephone within 30 minutes as per Rules and Regs [Regulations] of the medical staff. For all patients, the Emergency Room physician and the on-call physician will then agree on a response time for an in-person visit, if indicated.
....."

1. Review of the Psychiatry Call Schedules revealed:

a. 2/1/20/to 2/29/20:

(i) The "Psych [Psychiatric] Inpat [Inpatient] Consults" section listed the name of Staff #13, an APN (Advance Practice Nurse), for 2/1 and 2/2.

(ii) The "Psych Inpat Consults" section listed the name of Staff #15, an APN, for 2/14, 2/15, 2/16, and 2/20.

(iii) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #13, an APN, for 2/1, 2/2, and 2/6.

(iv) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #14, a DPN (Doctor of Nursing Practice), for 2/12 and 2/28.

(v) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #15, an APN, for 2/15 and 2/16.

(vi) The "Psych Inpat Consults" section listed the name of Staff #16, an APN, for 2/23 and 2/29.

(vii) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #16, an APN, for 2/24 and 2/29.

b. 3/1/20 to 3/31/20:

(i) The "Psych Inpat Consults" section listed the name of Staff #14, a DPN, for 3/1.

(ii) The "Psych Inpat Consults" section listed the name of Staff #15, an APN, for 3/14 and 3/15.

(iii) The "Psych Inpat Consults" section listed the name of Staff #13, an APN, for 3/21 and 3/22.

(iv) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #14, a DPN, for 3/1, 3/12, and 3/19.

(v) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #13, an APN, for 3/5, 3/20, 3/21, 3/22, and 3/26.

(vi) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #15, an APN, for 3/14, 3/15, and 3/25.

c. 4/1/20 to 4/30/20:

(i) The "Psych Inpat Consults" section listed the name of Staff #14, a DPN, for 4/11 and 4/12.

(ii) The "Psych Inpat Consults" section listed the name of Staff #15, an APN, for 4/18 and 4/19.

(iii) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #14, a DPN, for 4/2, 4/10, and 4/11.

(iv) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #13, an APN, for 4/8, 4/16, and 4/28.

(v) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #15, an APN, for 4/17, 4/18, 4/19, and 4/28.

d. 5/1/20 to 5/31/20:

(i) The "Psych Inpat Consults" section listed the name of Staff #13, an APN, for 5/15, 5/16, 5/17, and 5/25.

(ii) The "Psych Inpat Consults" section listed the name of Staff #14, a DPN, for 5/29 and 5/30.

(iii) The "Psych Inpat Consults" section did not include an entry for 5/31/20.

(iv) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #13, an APN, for 5/5, 5/12, 5/15, 5/16, 5/17, 5/20, and 5/25.

(v) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #14, a DPN, for 5/29, 5/30, and 5/31.

e. 6/1/20 to 6/30/20:

(i) The "Psych Inpat Consults" section listed the name of Staff #13, an APN, for 6/20 and 6/21.

(ii) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #14, a DPN, for 6/4 and 6/15.

(iii) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #13, an APN, for 6/11, 6/20, 6/21, 6/24, and 6/29.

f. 7/1/20 to 7/31/20:

(i) The "Psych Inpat Consults" section listed the name of Staff #14, a DPN, for 7/3, 7/4, and 7/5.

(ii) The "Psych Inpat Consults" section listed the name of Staff #13, an APN, for 7/25 and 7/26.

(iii) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #13, an APN, for 7/2, 7/9, 7/16, 7/24, 7/25, 7/26, and 7/30.

(iv) The "Psych Call 4 pm - 8 pm" section listed the name of Staff #14, a DPN, for 7/3, 7/4, 7/5, 7/13, and 7/23.

2. Staff #4 and Staff #7 agreed with the above findings.

Based on review of one (1) of twenty (20) medical records, review of hospital policies and procedures, and interviews with administrative staff, it was determined that the hospital failed to provide an appropriate medical screening exam within the hospital's emergency department to determine whether or not an emergency condition exists.

Findings include:

Reference: Facility policy, "Emergency Department Evaluation and Discharge of Patients" states: "...A. All patients will be assigned an Emergency Severity Index priority level by a registered nurse on arrival... C. All patients presenting to the Emergency Department, will be evaluated by Emergency Department Physician..."

1. Review of Medical Record #1 on 8/24/20 revealed the following:

a. Patient #1 presented to the ED on 7/13/20 at 2203 with a complaint of "detox."

b. A Nursing Progress Note dated 7/13/20 at 2240 states: "pt [patient] was called several times by triage nurse with no answer. ____ [name of nurse] notified me that ___ [Patient #1] had been in the bathroom for too long. I went with security ___ [name of security] and ____ [name of security] and pt found in bathroom holding ___ [his/her] rt [right] wrist with toilet paper, puncture wound noted with slight oozing, when asked where the needle was, __ [he/she] said __ [he/she] threw it out. ___ [name of staff] Crisis called and __ [he/she] stated ___[he/she] would call her supervisor to see if pt can still be accepted into detox as a prescreened pt. After speaking to supervisor, pt was instructed to follow up tomorrow for a detox bed. Pt left ambulatory with steady gait awake, alert ..."

c. There was no evidence that Patient #1 was triaged or received a Medical Screening Exam (MSE).

(i) There was no evidence that Patient #1 was encouraged to stay to be triaged and receive an MSE.

d. Upon interview at 1145, Staff #2 confirmed that Patient #1 did not receive an MSE.

2. These findings were confirmed by Staff #4, Staff #5 and Staff #7.