HospitalInspections.org

Based on hospital policy review, medical record reviews, physician and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure necessary stabilizing treatment for an emergency medical condition by failing to provide within the capabilities of the staff and facilities available at the hospital, for stabilizing treatment as required to stabilize the medical condition for 1 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #11).

~ Cross refer to §489.24(d)(1) Necessary Stabilizing Treatment for Emergency Medical Conditions, Tag A2407.

2. The hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure an appropriate transfer by failing to ensure the receiving hospital had available space and qualified personnel for the treatment of the individual; and by failing to ensure the receiving hospital had agreed to accept transfer of the indvidual and to provide appropriate medical treatment for 1 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #11).

~ Cross refer to §489.24(e)(1)-(2) Appropriate Transfer, Tag A2409.

Based on hospital policy review, medical record reviews, physician and staff interviews the hospital's Dedicated Emergency Department (DED) physician failed to ensure necessary stabilizing treatment for an emergency medical condition by failing to provide within the capabilities of the staff and facilities available at the hospital,stabilizing treatment as required to stabilize the medical condition for 1 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #11).

The findings include:

Review of Hospital Policy and Procedure titled "EMTALA: Treatment Of Patients With Emergency Medical Conditions" last revised 07/05/2016 revealed "A. 5. If the qualified medical person determines that an emergency medical condition exists, appropriate treatment shall be offered to stabilize the patient's condition."

"Hospital A (Rex Hospital ) closed DED medical record review on 03/01/2017 for patient (Pt) #11 revealed a 54-year-old female that presented via law enforcement on Involuntary Commitment to the DED on 01/28/2017 at 1455 with a chief complaint of hallucinations. Review revealed the patient was placed in a DED room at 1457. Review revealed first provider contact was at 1529. Review of Nursing Triage Note at 1534 revealed Patient #11 was unsure why she was brought to the hospital. Review revealed the patient's family stated "pt has multiple medical problems including mental health issues, and last night she 'ran away' from home and checked herself into a hotel where she was hallucinating that people were going in and out of her hotel room and her sisters were under her bed. ...Family reports pt was supposed to go to (Hospital B name) per her PCP (primary care physician), but was sent here by the magistrate". Review of nursing notes at 1539 revealed vital signs as follows: Oral temperature 98.1; Heart Rate 95; Respirations 14; Blood Pressure 118/79 in left arm; and oxygen saturation 99% on room air. Review revealed discharge vital signs at 1841 as follows: Oral temperature 98.6; Heart Rate 87; Respirations 16; Blood Pressure 121/72 in left arm; and oxygen saturation 98% on room air. Further review revealed Patient #11 was identified as a falls risk related to confusion and that fall precautions were initiated. Review of triage nursing notes at 1541 revealed the patient's acuity (ESI) level was a 2 (Urgent). Further review revealed no documentation of suicidal or homicidal ideations. Record review revealed a psychiatric consult order was placed by the DED physician at 1542 and consult was called by phone at 1546. Review revealed a psychiatric nursing assessment was completed by the primary DED registered nurse at 1545. Psychiatric nursing assessment revealed Patient #11 was alert and oriented to person, place, time and date; follows commands; general attitude: apathetic, defensive; general appearance: disheveled (malnourished); mental status: unremarkable with no delusions noted and no appearance of responding to internal stimuli, does have impaired judgment and insight. Record review revealed a note documented by a patient relations advocate at 1652 with information related to Patient #11's recent visit to Hospital B where she was treated medically and consulted by psychiatry. Note revealed the family was upset and wanted the patient taken to Hospital B but due to the magistrate's order on involuntary commitment papers, the patient was transported to Hospital A by law enforcement. The patient relations advocate discussed the family's wishes with charge nurse, house supervisor and physician and attempted to arrange a lateral transfer to Hospital B. Note revealed request was met with resistance from Hospital B and care was provided by Hospital A. Note revealed the family was made aware that the patient would be treated at Hospital A. Further review of patient relations advocate note revealed the psychiatrist consulted the patient and spoke with the family. Note revealed the involuntary commitment was lifted and family was encouraged to follow-up with Hospital B if further medical or psychiatric evaluation was necessary. Note revealed psychiatrist was at the bedside talking with the patient while completing the examination. Note revealed the psychiatrist would speak with the family separately.

Review of an electronic Psychiatric Consultation Note documented at 1822 revealed the patient has a history of psychosis and multiple medical conditions. Review revealed the patient was involuntary committed by her family after she 'ran away' on 01/27/2017 and was hallucinating in her hotel. Further review of psychiatric consult note revealed "Pt (patient) was seen in ED (Emergency Department). She appears to be drowsy. She understands that she is in the hospital, but not sure how she got here. She saw her mom and sister, and had no difficulty recognizing them, and stated that she wants to go home with them. But she also agreed that she needs to go to (Hospital B name) for a checkup first. Of note, she was just released from (Hospital B name) about 2 weeks ago after a month long stay for failure to thrive. Spoke with mom and sister, who are at the hospital, and filed the IVC. They said that pt got upset yesterday, without a clear trigger. She then insisted that she needs to go to a hotel. After family refused to take her anywhere because they worried about her safety, pt somehow made a neighbor drive her to a hotel last night. This morning, pt caller her mom from the hotel, and was completely incoherent. Mom and sister tracked the number back to Embassy Suite, and called the hotel. The hotel staff reported that pt has been calling the front desk complaining 'people were in and out of her room', or 'hiding under her bed' all night. Family stated that pt often have similar kind of complaint due to visual hallucinations. Family worried that pt has not been taking her meds and is unable to take care of herself. Thus, they called pt's PCP and the PCP office advised to file IVC and get the pt to an ED. However, family said that they strongly prefer to go to (Hospital B name) since they know the pt very well both medically and psychiatrically from her recent lengthy hospitalization. Both mom and sister feel very comfortable to drive pt there themselves, as hospital to hospital transfer is very challenging and can take days even if it is successful. In fact, the pt's mom insisted that is what she would like to do. Thus, we discussed with the pt together afterward again, and pt confirmed that she would like to go home with her mom and sister, and agreed that they are going to check up with (Hospital B name) first. Past Psychiatric History: Previous diagnoses: psychosis, likely from medical conditions. Hospitalizations: no psych ... Social History Narrative ...Lives with mom and sister ...Review of Systems (ROS) - Psychological ROS: positive for - tired. ...Mental Status Exam: General/Appearance: Appears stated age and malnourished Behavior: Cooperative but irritable at times. ...Speech/Language: paucity Mood: Anxious Affect: Anxious, Constricted and Depressed ...Perceptual disturbances: family reported AVH (auditory verbal hallucinations) last night Orientation: to person and place Attention: Able to fully attend without fluctuations in consciousness Concentration: Distractible Memory: impaired Insight: Impaired Judgment: Impaired Impulse Control: Fair Test Results: ...No results found for this or any previous visit (from past 24 hours) ..." Further review of psychiatric consultation revealed "Assessment: ...Currently, pt feels tired and not actively hallucinating. Family feels that it would be at the best interest of the pt, if she could go to (Hospital B name) ... Since pt has been calm and cooperative currently, and fully agreed to go with her family (sister and mom), and family feel comfortable to drive her directly to [Hospital B name] (mom will sit in the back with the pt, and sister will drive), and family appears to be very reliable, the risks of self-harm or harming other during transportation is low. Thus, IVC is lifted. Pt will be going to (Hospital B name) directly from (Hospital A name), with her family. Risk Assessment: A thorough evaluation has been completed of risk and protective factors including, but not limited to these risk factors, psychosis, and these protective factors, supportive family. In my judgment the patient is at a chronically elevated risk of dangerousness to self (and/or others), but is not an acutely elevated risk. It is important to note that future behaviors cannot be accurately predicted. Safety Concerns: None at present time ...Plan-Lifted IVC so that family will be able to take her directly to (Hospital B name), as they strongly prefer that hospital given pt has recently been there for over one month. Family feel that the staff and doctors there are already familiar with her case, and would be able to perform better care. After carefully assessing the risks of transfer by family, I feel the benefits overweight the risks for doing so. Thus, IVC is lifted. Family is given the information for refile IVC if needed, and they plan to drive directly to (Hospital B's name) ED". Rex Hospital failed to ensure that stabilizing treatment was provided as required that was within the capability of the hospital on 1/28/2017 for Patient #11.

Review of electronic DED Provider Note documented at 1824 revealed patient #11 presented with a chief complaint of Involuntary Commitment and hallucinations. Further review revealed patient had multiple medical problems including Lupus, Sjogren's (systemic autoimmune disease that affects the entire body with dry eyes & dry mouth), Crohn's disease and required Total Parenteral nutrition (TPN) through an indwelling port. Documentation revealed patient had recent hospitalization at Hospital B for failure to thrive. Review revealed the patient checked into a hotel on 01/27/2017 to get away from her sister and mother. Review revealed the family were concerned about the patient's increasing depression and paranoia so they took out Involuntary Commitment papers. Review revealed the patient had no acute issues other than her port being accessed for one week due to home health nurse unable to disconnect. Review of physician's documented physical examination revealed "General: Chronically ill-appearing thin framed black female. She is awake and conversant. ...Psych: Mental status is fairly normal and affect depressed, normal speech pattern and content. ED COURSE & MEDICAL DECISION MAKING: Labs reviewed (per interview MD #1 reviewed previous record from Hospital B) ... This is a 54-year-old female brought in by police under IVC (Involuntary Commitment) which was taken out by her family. From medical standpoint the patient seems overall fairly stable. I consulted our psychiatrist who evaluated the patient and spoke with the family. After this, the psychiatrist is recommended the patient's IVC be lifted. The psychiatrist has done this and the patient was discharged with the family. Diagnosis: #1 psychosis #2 depression #3 lupus #4 Crohn's disease." Review revealed no available documentation of labs or x-rays ordered during this visit.

Record review revealed patient #11 was assigned a disposition of discharge by the DED provider at 1923. Review revealed the patient's "After Visit Summary" (discharge instructions) was printed at 1930. Discharge nursing notes at 1946 revealed patient #11 was discharged via wheelchair with family and documentation of a pain assessment with a score of "5" on a scale of 0-10 (10 being worst, 0 being no pain). Further review of discharge notes at 1947 revealed discharge instructions and follow-up care were discussed with patient and the patient verbalized understanding. Review of discharge nursing notes documented at 1947 revealed "Pt (patient) discharged at this time, respirations even & unlabored, ambulatory to and from the wheelchair with a steady gait, NAD (no acute distress) noted, mother at side. Pt verbalizes understanding of discharge instructions and verbalizes conditions which necessitate return to the ED or calling 911, as well as warning signs for possible condition deterioration. Pt's mother verbalizes intention to take the patient to (Hospital B name) for IVC (involuntary commitment)."

Review of After Summary Visit (discharge instructions) dated 01/28/207 revealed documentation of follow-up information for family medicine physician that included physician's name and address, vital signs during the visit, procedures/test performed during visit, diagnosis, provider name that saw patient in the DED, telephone numbers for National Suicide Hotlines and NC Crisis lines and home care patient instructions for psychosis diagnosis. Further review of After Summary Visit dated 01/28/2017 at 1945 revealed a signature page with documentation that patient and mother refused to sign discharge instructions.

Review of medical record from Hospital B for Patient #11 revealed a "Call In Referrals" was received on 01/28/2017 at 1316 (38 minutes prior to patient arriving at Hospital A) from MD #5 to RN #6 with reason for referral "acute psychotic break". Review revealed Pt #11 arrived in the ED on 01/28/2017 at 2022 with complaint of IVC (Involuntary Commitment). Further review revealed Pt #11 arrived by private vehicle, escorted by her mother, at Hospital B on 01/28/2017 at 2102 with a chief complaint "Altered Mental Status (Patient's mother reports that her daughter's PCP wants her to have a psych (psychiatric) evaluation due to change in behavior)". Review of Emergency Department Provider Notes dated 01/28/2017 at 2102 revealed " ...Family apparently completed IVC paperwork feeling that she was not safe. Police picked patient up and apparently Crisis was on diversion and (Hospital A name) was up for the next patient evaluation. Patient was taken to (Hospital A name), but repeatedly stated that she wanted to come to (Hospital B name) as she had recently been admitted here and all her records were here. Psychiatrist saw her in the ER (Hospital A) and with repeated requests by patient and mom agreed to lift IVC so she could come here ..." Review revealed nursing documentation at 2145 the patient was unwilling to provide discharge paperwork from (Hospital A name) when asked. Review of record revealed Involuntary Commitment Papers were completed by Emergency Department Physician and sent to the magistrate's office on 01/29/2017 at 0225. Review revealed Pt #11 was admitted to observation on 01/29/2017 at 0358 awaiting Psychiatric Bed Placement.

Physician interview on 03/02/2017 at 0850 with MD #1, the MD who completed the MSE on Pt #11 at Hospital A, revealed the patient came to the DED after being Involuntary Committed by her family for auditory hallucinations. Interview revealed the patient was lucid, talking and stated she didn't know why she was at the hospital. Interview revealed the patient has no acute complaints, vital signs were stable and patient was mentally competent to make decisions. Interview revealed the DED provider reviewed the patient's previous hospitalization and lab results in Care Everywhere system. Interview revealed patient was medically cleared and psychiatrist was notified for consult. Interview revealed the family were upset that the patient was not taken to Hospital B as requested. Interview revealed DED physician told family he did not see a need for patient transfer or admission to Hospital B but he would try and see if Hospital B would accept patient as a transfer at family request. "I spoke with hospitalist at (Hospital B name) about family's request for transfer, but (Hospital B name) denied patient transfer." Interview revealed "I felt the patient was stable for discharge home." Interview revealed after psychiatric consult and Involuntary Commitment lifted, "the patient was discharged home and was not directed by me to go to (Hospital B name)."

Physician interview on 03/02/2017 at 1330 with MD #2, the MD who completed the psychiatric consultation at Hospital A, revealed the patient was not having active hallucinations during his assessment. Interview revealed the patient had no Psychotic Diagnosis. Interview revealed the patient had symptoms of psychosis related to her delirium from chronic medical conditions. Interview revealed the family preferred to take patient back to Hospital B where she had been previously hospitalized for approximately a month. Interview revealed "I did feel some pressure from the family to lift the Involuntary Commitment, but I would not have released her if she was actively hallucinating. The patient was calm with no hallucinations and wanted to go home with her family. The patient knew what she wanted to do." Interview revealed at the time of the Involuntary Commitment removal the patient was "stable to discharge home with follow-up with primary care provider". Interview revealed no follow-up was arranged as patient had been set up with outpatient follow-up appointment from her previous hospitalization at Hospital B.

Staff interview on 03/02/2017 at 0938 with RN #3 (Registered Nurse) revealed she was the nurse that discharged patient #11 from Hospital A. Interview revealed the patient stated "I don't want to be here". Interview revealed the patient was drowsy. Interview revealed the family stated she had been this way for a couple of months. Interview revealed the patient was assisted with getting dressed for discharge. Interview revealed the patient transferred from the stretcher to the wheelchair with minimal assistance and was able to ambulate with assistance to the bathroom. Interview revealed "I felt she was okay to send home with family and home health." Interview revealed the patient's mother said she was going to take the patient to Hospital B and have her Involuntary Committed again. Interview revealed the mother did not express her reasons for having the patient Involuntary Committed. Interview revealed the mother was comfortable with the patient being discharged from Hospital A.

Staff interview on 03/02/2017 at 1140 with PRA #4 (Patient Relations Advocate) for Hospital A, revealed "my job is to tie everything together between the magistrate, the DED physician and the psychiatrist". Interview revealed Involuntary Commited patients are set up on a "round robin" schedule from the magistrate's office, meaning they are rotated around the area hospitals. Interview revealed the family was not aware the patient was going to be brought to Hospital A as they had requested the magistrate send patient to Hospital B. Interview revealed the family were very insistent that the patient go to Hospital B where they were familiar with her medical and psychiatric problems. Interview revealed after input from DED physician, psychiatrists, charge nurse and house supervisor, a transfer to Hospital B was attempted, but Hospital B refused to accept the patient. Interview revealed the police department offered to take patient to Hospital B, but patient had already been checked in at Hospital A and "I thought it would be a violation if sent to (Hospital B name)". Interview revealed the patient was medically cleared and psychiatrist released the Involuntary Commitment after assessing patient. Interview revealed the psychiatrist met with the family and the patient to discuss decision and plan.

The facility failed to ensure that their policy and procedure related to stabilizing treatment was followed as evidenced by failing to provide appropriate treatment to stabilize patient #11's psychiatric condition on 1/28/2017. As patient #11 arrived to Hospital B on 1/28/2017 at 8:22 PM, and Involuntary Commitment Papers were completed by the ED physician on 1/29/2017 at 2:25 AM. The Patient was admitted to observation at Hospital B on 1/29/2017 awaiting psychiatric placement.
NC00124830

Based on hospital policy review, medical record reviews, physician and staff interviews the hospital's Dedicated Emergency Department (DED) physician failed to ensure an appropriate transfer by failing to ensure the receiving hospital had available space and qualified personnel for the treatment of the individual; and by failing to ensure the receiving hospital had agreed to accept transfer of the individual and to provide appropriate medical treatment for 1 of 7 sampled patients that were transferred with an EMC to other acute care hospitals (Patient #11).

The findings include:

Review of Hospital Policy and Procedure titled "EMTALA: Treatment Of Patients With Emergency Medical Conditions" last revised 07/05/2016 revealed "C. Discharge or Transfer When Emergency Condition Exists ...4. ...The receiving medical facility must have available space and qualified personnel for the treatment of the patient, and prior to transfer, must have agreed to accept the transfer of the patient and agreed to provide appropriate medical treatment."

Hospital A closed DED medical record review on 03/01/2017 for patient (Pt) #11 revealed a 54-year-old female that presented via law enforcement on Involuntary Commitment to the DED on 01/28/2017 at 1455 with a chief complaint of hallucinations. Review revealed the patient was placed in a DED room at 1457. Review revealed first provider contact was at 1529. Review of Nursing Triage Note at 1534 revealed Patient #11 was unsure why she was brought to the hospital. Review revealed the patient's family stated "pt has multiple medical problems including mental health issues, and last night she 'ran away' from home and checked herself into a hotel where she was hallucinating that people were going in and out of her hotel room and her sisters were under her bed. ...Family reports pt was supposed to go to (Hospital B name) per her PCP (primary care physician), but was sent here by the magistrate". Review of nursing notes at 1539 revealed vital signs as follows: Oral temperature 98.1; Heart Rate 95; Respirations 14; Blood Pressure 118/79 in left arm; and oxygen saturation 99% on room air. Review revealed discharge vital signs at 1841 as follows: Oral temperature 98.6; Heart Rate 87; Respirations 16; Blood Pressure 121/72 in left arm; and oxygen saturation 98% on room air. Further review revealed Patient #11 was identified as a falls risk related to confusion and that fall precautions were initiated. Review of triage nursing notes at 1541 revealed the patient's acuity (ESI) level was a 2 (Urgent). Further review revealed no documentation of suicidal or homicidal ideations. Record review revealed a psychiatric consult order was placed by the DED physician at 1542 and consult was called by phone at 1546. Review revealed a psychiatric nursing assessment was completed by the primary DED registered nurse at 1545. Psychiatric nursing assessment revealed Patient #11 was alert and oriented to person, place, time and date; follows commands; general attitude: apathetic, defensive; general appearance: disheveled (malnourished); mental status: unremarkable with no delusions noted and no appearance of responding to internal stimuli, does have impaired judgment and insight. Record review revealed a note documented by a patient relations advocate at 1652 with information related to Patient #11's recent visit to Hospital B where she was treated medically and consulted by psychiatry. Note revealed the family was upset and wanted the patient taken to Hospital B but due to the magistrate's order on involuntary commitment papers, the patient was transported to Hospital A by law enforcement. The patient relations advocate discussed the family's wishes with charge nurse, house supervisor and physician and attempted to arrange a lateral transfer to Hospital B. Note revealed request was met with resistance from Hospital B and care was provided by Hospital A. Note revealed the family was made aware that the patient would be treated at Hospital A. Further review of patient relations advocate note revealed the psychiatrist consulted the patient and spoke with the family. Note revealed the involuntary commitment was lifted and family was encouraged to follow-up with Hospital B if further medical or psychiatric evaluation was necessary. Note revealed psychiatrist was at the bedside talking with the patient while completing the examination. Note revealed the psychiatrist would speak with the family separately.

Review of an electronic Psychiatric Consultation Note documented at 1822 revealed the patient has a history of psychosis and multiple medical conditions. Review revealed the patient was involuntary committed by her family after she 'ran away' on 01/27/2017 and was hallucinating in her hotel. Further review of psychiatric consult note revealed "Pt (patient) was seen in ED (Emergency Department). She appears to be drowsy. She understands that she is in the hospital, but not sure how she got here. She saw her mom and sister, and had no difficulty recognizing them, and stated that she wants to go home with them. But she also agreed that she needs to go to (Hospital B name) for a checkup first. Of note, she was just released from (Hospital B name) about 2 weeks ago after a month long stay for failure to thrive. Spoke with mom and sister, who are at the hospital, and filed the IVC. They said that pt got upset yesterday, without a clear trigger. She then insisted that she needs to go to a hotel. After family refused to take her anywhere because they worried about her safety, pt somehow made a neighbor drive her to a hotel last night. This morning, pt caller her mom from the hotel, and was completely incoherent. Mom and sister tracked the number back to Embassy Suite, and called the hotel. The hotel staff reported that pt has been calling the front desk complaining 'people were in and out of her room', or 'hiding under her bed' all night. Family stated that pt often have similar kind of complaint due to visual hallucinations. Family worried that pt has not been taking her meds and is unable to take care of herself. Thus, they called pt's PCP and the PCP office advised to file IVC and get the pt to an ED. However, family said that they strongly prefer to go to (Hospital B name) since they know the pt very well both medically and psychiatrically from her recent lengthy hospitalization. Both mom and sister feel very comfortable to drive pt there themselves, as hospital to hospital transfer is very challenging and can take days even if it is successful. In fact, the pt's mom insisted that is what she would like to do. Thus, we discussed with the pt together afterward again, and pt confirmed that she would like to go home with her mom and sister, and agreed that they are going to check up with (Hospital B name) first. Past Psychiatric History: Previous diagnoses: psychosis, likely from medical conditions. Hospitalizations: no psych ... Social History Narrative ...Lives with mom and sister ...Review of Systems (ROS) - Psychological ROS: positive for - tired. ...Mental Status Exam: General/Appearance: Appears stated age and malnourished Behavior: Cooperative but irritable at times. ...Speech/Language: paucity Mood: Anxious Affect: Anxious, Constricted and Depressed ...Perceptual disturbances: family reported AVH (auditory verbal hallucinations) last night Orientation: to person and place Attention: Able to fully attend without fluctuations in consciousness Concentration: Distractible Memory: impaired Insight: Impaired Judgment: Impaired Impulse Control: Fair Test Results: ...No results found for this or any previous visit (from past 24 hours) ..." Further review of psychiatric consultation revealed "Assessment: ...Currently, pt feels tired and not actively hallucinating. Family feels that it would be at the best interest of the pt, if she could go to (Hospital B name) ... Since pt has been calm and cooperative currently, and fully agreed to go with her family (sister and mom), and family feel comfortable to drive her directly to [Hospital B name] (mom will sit in the back with the pt, and sister will drive), and family appears to be very reliable, the risks of self-harm or harming other during transportation is low. Thus, IVC is lifted. Pt will be going to (Hospital B name) directly from (Hospital A name), with her family. Risk Assessment: A thorough evaluation has been completed of risk and protective factors including, but not limited to these risk factors, psychosis, and these protective factors, supportive family. In my judgment the patient is at a chronically elevated risk of dangerousness to self (and/or others), but is not an acutely elevated risk. It is important to note that future behaviors cannot be accurately predicted. Safety Concerns: None at present time ...Plan-Lifted IVC so that family will be able to take her directly to (Hospital B name), as they strongly prefer that hospital given pt has recently been there for over one month. Family feel that the staff and doctors there are already familiar with her case, and would be able to perform better care. After carefully assessing the risks of transfer by family, I feel the benefits overweight the risks for doing so. Thus, IVC is lifted. Family is given the information for refile IVC if needed, and they plan to drive directly to (Hospital B's name) ED".

Review of electronic DED Provider Note documented at 1824 revealed patient #11 presented with a chief complaint of Involuntary Commitment and hallucinations. Further review revealed patient had multiple medical problems including Lupus, Sjogren's (systemic autoimmune disease that affects the entire body with dry eyes & dry mouth), Crohn's disease and required Total parenteral nutrition (TPN) through an indwelling port. Documentation revealed patient had recent hospitalization at Hospital B for failure to thrive. Review revealed the patient checked into a hotel on 01/27/2017 to get away from her sister and mother. Review revealed the family were concerned about the patient's increasing depression and paranoia so they took out Involuntary Commitment papers. Review revealed the patient had no acute issues other than her port being accessed for one week due to home health nurse unable to disconnect. Review of physician's documented physical examination revealed "General: Chronically ill-appearing thin framed black female. She is awake and conversant. ...Psych: Mental status is fairly normal and affect depressed, normal speech pattern and content. ED COURSE & MEDICAL DECISION MAKING: Labs reviewed (per interview MD #1 reviewed previous record from Hospital B) ... This is a 54-year-old female brought in by police under IVC (Involuntary Commitment) which was taken out by her family. From medical standpoint the patient seems overall fairly stable. I consulted our psychiatrist who evaluated the patient and spoke with the family. After this, the psychiatrist is recommended the patient's IVC be lifted. The psychiatrist has done this and the patient was discharged with the family. Diagnosis: #1 psychosis #2 depression #3 lupus #4 Crohn's disease." Review revealed no available documentation of labs or x-rays ordered during this visit.

Record review revealed patient #11 was assigned a disposition of discharge by the DED provider at 1923. Review revealed the patient's "After Visit Summary" (discharge instructions) was printed at 1930. Discharge nursing notes at 1946 revealed patient #11 was discharged via wheelchair with family and documentation of a pain assessment with a score of "5" on a scale of 0-10 (10 being worst, 0 being no pain). Further review of discharge notes at 1947 revealed discharge instructions and follow-up care were discussed with patient and the patient verbalized understanding. Review of discharge nursing notes documented at 1947 revealed "Pt (patient) discharged at this time, respirations even & unlabored, ambulatory to and from the wheelchair with a steady gait, NAD (no acute distress) noted, mother at side. Pt verbalizes understanding of discharge instructions and verbalizes conditions which necessitate return to the ED or calling 911, as well as warning signs for possible condition deterioration. Pt's mother verbalizes intention to take the patient to (Hospital B name) for IVC (involuntary commitment)."

Review of After Summary Visit (discharge instructions) dated 01/28/207 revealed documentation of follow-up information for family medicine physician that included physician's name and address, vital signs during the visit, procedures/test performed during visit, diagnosis, provider name that saw patient in the DED, telephone numbers for National Suicide Hotlines and NC Crisis lines and home care patient instructions for psychosis diagnosis. Further review of After Summary Visit dated 01/28/2017 at 1945 revealed a signature page with documentation that patient and mother refused to sign discharge instructions.

Review of medical record from Hospital B for Patient #11 revealed a "Call In Referrals" was received on 01/28/2017 at 1316 (38 minutes prior to patient arriving at Hospital A) from MD #5 to RN #6 with reason for referral "acute psychotic break". Review revealed Pt #11 arrived in the ED on 01/28/2017 at 2022 with complaint of IVC (Involuntary Commitment). Further review revealed Pt #11 arrived by private vehicle, escorted by her mother, at Hospital B on 01/28/2017 at 2102 with a chief complaint "Altered Mental Status (Patient's mother reports that her daughter's PCP wants her to have a psych (psychiatric) evaluation due to change in behavior)". Review of Emergency Department Provider Notes dated 01/28/2017 at 2102 revealed " ...Family apparently completed IVC paperwork feeling that she was not safe. Police picked patient up and apparently Crisis was on diversion and (Hospital A name) was up for the next patient evaluation. Patient was taken to (Hospital A name), but repeatedly stated that she wanted to come to (Hospital B name) as she had recently been admitted here and all her records were here. Psychiatrist saw her in the ER (Hospital A) and with repeated requests by patient and mom agreed to lift IVC so she could come here ..." Review revealed nursing documentation at 2145 the patient was unwilling to provide discharge paperwork from (Hospital A name) when asked. Review of record revealed Involuntary Commitment Papers were completed by Emergency Department Physician and sent to the magistrate's office on 01/29/2017 at 0225. Review revealed Pt #11 was admitted to observation on 01/29/2017 at 0358 awaiting Psychiatric Bed Placement.

Physician interview on 03/02/2017 at 0850 with MD #1, the MD who completed the MSE on Pt #11 at Hospital A, revealed the patient came to the DED after being Involuntary Committed by her family for auditory hallucinations. Interview revealed the patient was lucid, talking and stated she didn't know why she was at the hospital. Interview revealed the patient has no acute complaints, vital signs were stable and patient was mentally competent to make decisions. Interview revealed the DED provider reviewed the patient's previous hospitalization and lab results in Care Everywhere system. Interview revealed patient was medically cleared and psychiatrist was notified for consult. Interview revealed the family were upset that the patient was not taken to Hospital B as requested. Interview revealed DED physician told family he did not see a need for patient transfer or admission to Hospital B but he would try and see if Hospital B would accept patient as a transfer at family request. "I spoke with hospitalist at (Hospital B name) about family's request for transfer, but (Hospital B name) denied patient transfer." Interview revealed "I felt the patient was stable for discharge home." Interview revealed after psychiatric consult and Involuntary Commitment lifted, "the patient was discharged home and was not directed by me to go to (Hospital B name)."

Physician interview on 03/02/2017 at 1330 with MD #2, the MD who completed the psychiatric consultation at Hospital A, revealed the patient was not having active hallucinations during his assessment. Interview revealed the patient had no Psychotic Diagnosis. Interview revealed the patient had symptoms of psychosis related to her delirium from chronic medical conditions. Interview revealed the family preferred to take patient back to Hospital B where she had been previously hospitalized for approximately a month. Interview revealed "I did feel some pressure from the family to lift the Involuntary Commitment, but I would not have released her if she was actively hallucinating. The patient was calm with no hallucinations and wanted to go home with her family. The patient knew what she wanted to do." Interview revealed at the time of the Involuntary Commitment removal the patient was "stable to discharge home with follow-up with primary care provider". Interview revealed no follow-up was arranged as patient had been set up with outpatient follow-up appointment from her previous hospitalization at Hospital B. The Hospital failed to ensure that the receiving hospital had available space and qualified personal for treatment of Patient $11 on 1/28/2017. The hospital also failed to ensure that the receiving hospital had agreed to accept and provide to provide appropriate medical treatment to Patient #11 on 1/28/2017.

Staff interview on 03/02/2017 at 0938 with RN #3 (Registered Nurse) revealed she was the nurse that discharged patient #11 from Hospital A. Interview revealed the patient stated "I don't want to be here". Interview revealed the patient was drowsy. Interview revealed the family stated she had been this way for a couple of months. Interview revealed the patient was assisted with getting dressed for discharge. Interview revealed the patient transferred from the stretcher to the wheelchair with minimal assistance and was able to ambulate with assistance to the bathroom. Interview revealed "I felt she was okay to send home with family and home health." Interview revealed the patient's mother said she was going to take the patient to Hospital B and have her Involuntary Committed again. Interview revealed the mother did not express her reasons for having the patient Involuntary Committed. Interview revealed the mother was comfortable with the patient being discharged from Hospital A.

Staff interview on 03/02/2017 at 1140 with PRA #4 (Patient Relations Advocate) for Hospital A, revealed "my job is to tie everything together between the magistrate, the DED physician and the psychiatrist". Interview revealed Involuntary Committed patients are set up on a "round robin" schedule from the magistrate's office, meaning they are rotated around the area hospitals. Interview revealed the family was not aware the patient was going to be brought to Hospital A as they had requested the magistrate send patient to Hospital B. Interview revealed the family were very insistent that the patient go to Hospital B where they were familiar with her medical and psychiatric problems. Interview revealed after input from DED physician, psychiatrists, charge nurse and house supervisor, a transfer to Hospital B was attempted, but Hospital B refused to accept the patient. Interview revealed the police department offered to take patient to Hospital B, but patient had already been checked in at Hospital A and "I thought it would be a violation if sent to (Hospital B name)". Interview revealed the patient was medically cleared and psychiatrist released the Involuntary Commitment after assessing patient. Interview revealed the psychiatrist met with the family and the patient to discuss decision and plan.

NC00124830