HospitalInspections.org

On the days of the EMTALA (Emergency Medical Treatment And Labor Act) survey based on observations, record reviews, interviews, review of the hospital's emergency department policies and procedures, review of the hospital's emergency department policies and procedures, review of the hospital's central log, review of the hospital's emergency department's on - call lists from October 2018 through April 2019, review of the hospital's Governing Body and Medical Staff Bylaws,and review of the hospital's personnel education and competency files, the following deficiencies were cited:


The findings are:

1. Cross Reference to A 2404: Based on observational tours of the ED review of medical records, policy and procedures, on-call schedules, Medical staff Bylaws, and staff interviews it was determined the hospital failed to have an effective system in place to ensure that designated on call psychiatrists for the emergency department responded to psychiatric consult requests from the emergency department physician in accordance with the hospitals Bylaws to provide further evaluation and/or treatment needed for 2 (#30, and#37) of 46 sampled patients.

2. Cross Reference to A 2406: Based on observations, medical record reviews, Policy and Procedure reviews, Obstetrics and Gynecology Department Rules and Regulations review, on -call schedules, Medical Staff General Rules and Regulations, Medical Staff By-Laws, Labor and Delivery Triage competency forms and staff interviews it was determined the facility failed to ensure that obstetrical patients presenting to the hospital's emergency department with gestation 20 weeks or greater received an appropriate medical screening examination to rule out an emergency medical condition by a qualified medical personnel approved by the governing board for 2 (#23, & #41) of 2 patient obstetrical charts reviewed for care and services with a potential to affect every patient presenting to the hospital's emergency department.

Cross Reference to A 2409: Based on review of patient medical records, review of the hospital's policies and procedures, review of the hospital's bed census reports, review of the hospital's on-call schedules, and staff interviews, it was determined the hospital failed to provide medical treatment within its capacity to minimize the risks to the individuals' health for 2 (Patient #37 and #46) of 46 sampled patients that resulted in an inappropriate transfer of these individuals and posed an immediate and serious threat to the individual's health and safety.

Based on observational tours of the ED review of medical records, policy and procedures, on-call schedules, Medical staff Bylaws, and staff interviews it was determined the hospital failed to have an effective system in place to ensure that designated on call psychiatrists for the emergency department responded to psychiatric consult requests from the emergency department physician in accordance with the hospitals Medical Staff Bylaws to provide further evaluation and/or treatment needed for 2 (#30, and#37) of 46 sampled patients with identified emergency psychiatric medical emergencies.

The findings were:

Observational Tour

On 4/15/2019, during the observational tour of the emergency department, the Emergency Department(ED) Director escorted the survey team to an area away from the main emergency department with approximately 9 rooms. The ED Director stated the rooms were still part of the ED and medical and psychiatric patients could be held in the rooms until the patient received a psychiatric evaluation for up to 24 hours or later. The ED Director reported the psychiatrist on-call had 24 hours to evaluate the patient for psychiatric emergency conditions. The ED Director stated this was an overflow area for the ED. The ED Director reported that the psychiatric patient was monitored via video camera and sitters in this area.


Medical Staff Bylaws

On 4/17/2019, review of the hospital's "Medical Staff Bylaws, Governance, Structure, and Function of the Medical Staff", dated November 28, 2017, section "2.3. Responsibilities of Membership", page 13, revealed, "In addition, all members who have joined the medical staff after January 1, 2015 must assist the Hospital in fulfilling its responsibilities for providing emergency and charitable care, including without limitation service call coverage, in accordance with policies passed by the MEC (Medical Executive Committee) and/or Board."

Medical Staff General Rules and Regulations

On 4/17/2019, review of "Medical Staff General Rules And Regulations (RR)", approved as policy February 9, 2015, RR 1.000 "Organization Responsibilities Of The Medical Staff", RR 1.010 Active Medical Staff, reads, "C. Each member of the Medical Staff, in his absence, shall arrange coverage for his hospitalized patients. In cases of emergent/urgent clinical situations, contact with the member of the Medical Staff shall be established. The on-call physician shall present to the emergency department within thirty (30) minutes to evaluate the patient in emergency situations."

Policy and Procedures

Review of the hospital's policy, titled, "Subject: EMTALA: Transfer - Patient Medical Screening Exam. page 5 of 12, Manual: Administrative", reads, "Physician Evaluation: The patient's emergency medical condition is to be evaluated by a physician in accordance with level of acuity. On - Call Physician means a member of RMC Medical staff whose name appears on the roster of physicians on - call to respond to properly communicated requests to provide further medical examination and/or treatment for the stabilization of an emergency medical condition and agrees to accept the patient on behalf of the hospital. If immediate evaluation is not necessary, but follow- up care is required, the on-call physician is responsible for providing follow - up in the time frame designated by the ED. If requested by the ED/treating physician, the on-call physician shall present to the ED within 30 minutes to evaluate the patient. The on-call physician rosters are to be maintained by Medical Staff Services for a five (5) year period. Note: Any surgical department that allows the on-call physician to perform elective procedures, must have made back up arrangements."


Patient Charts

Patient #37
Medical Record review revealed that Patient #37 presented to the facility via Advanced Life Support/Emergency Medical Services (ALS/Ambulance) on April 1, 2019. Review of the "Patient Information" sheet, the section titled "ENCOUNTER INFORMATION" revealed the patient was a 74 year old who was registered in the emergency department at 7:12 p.m., and patient type was "Emergency" and the Admit Reason: was for "Physical Aggression." Documentation by the triage nurse revealed the patient was triaged at an ESI (Emergency Service Index) level was listed at 3- Urgent. The patient's Vital Sign was listed as Oral Temperature: 36.5; Pulse Rate: 68; Respiratory Rate: 16, Blood Pressure: 210/101 (normal blood pressure (Ideal Blood Pressures) 100/65-120/80); Oxygen saturation: 99% on room air. The patient was seen by the ED (Emergency Department) physician on 4/1/2019 at 10:26 p.m. Documentation by the ED physician revealed in part, History of Present illness: The patient presents with psychiatric problem and agitation. The onset was 5 hours ago. The course/duration of symptoms is constant. Character of symptoms angry, paranoid agitated, denies suicidal thoughts. Self-injury: none. The exacerbating factor is none. The relieving factor is none. Risk factors consist of age and psychosis. Prior episodes: rare. Therapy today: prescription medications including geodone (medication used to treat certain mental mood disorders) prior to discharge from hospital today. Associated symptoms: denies fever, denies chills, denies nausea, denies vomiting, denies headache, denies dizziness, denies chest pain, denies shortness of breath, denies abdominal pain, and denies altered vision. Pt. (patient) sent to ED by nursing facility ...just today became a resident at. Per facility, pt. biting, punching and injuring other residents. Pt is alert and oriented x 4. ...reason did this because...is a preacher. Denies SI/HI (suicidal ideations/homicidal ideations), but endorses auditory hallucinations; unable to specify if these are command hallucinations. Pt. states ...not on any medications although ...was discharged today from tRMC (The Regional Medical Center of Orangeburg and Calhoun) on Geodon. Attempting to reach nursing facility to further collateral information on pt's (patient's) behavior ... Review of symptoms ...Psychiatric Symptoms: Delusional, hallucinations, irritability, no anxiety, no depression, no mania, not suicidal, not homicidal, no eating disorder, no substance abuse ...Physical Examination: Vital Signs ...04/01/2019 6:00 EDT- Temperature: 36.8; Peripheral Pulse Rate:65;Respiratory Rate: 18; Blood Pressure: 161/93 ...Oxygen Saturation- 93% Room Air ...General: Alert, no acute distress, Not ill-appearing, ...Psychiatric: Mood and affect: not anxious, not depressed, not hostile, not non-communicative, not flat, not paranoid, Behavior: Relaxed, not uncooperative, not belligerent, Judgement: Impaired by abnormal thoughts, Abnormal/Psychotic thoughts: Hallucinations (auditory, not visual) flight of ideas, not suicidal, not homicidal, not obsessive, not tangential. Review of ED physician orders dated 4/1/2019 at 10:12 p.m., revealed the ED physician electronically ordered, "When Medically clear, contact Behavioral Health. Further review revealed that the ED physician electronically ordered a 10:12 p.m., "Consult to Psychiatry ...Routine, (Name of On-call Psychiatrist), acute behavioral disturbance, psychosis, agitation and assaulting of nursing home staff~(approximately) 1 d (day) after discharge from the hospital. The patient's suicide risk was 7. Medical Decision Making: Rationale: Unable to obtain collateral information got specifically why patient was brought back to the ED except for secondhand information form EMS. Actively attempting to contact nursing facility who report pt. was violent towards other residents. Pt. endorses auditory hallucinations for provider but is otherwise pleasant and cooperative. Denies any somatic symptoms at this time. Most recent inpatient bloodwork ~16 hours ago unremarkable ...Orders. Urine drug screen, Urinalysis Comprehensive, White Blood Cell Count,(red blood cell count, Hemoglobin , Hematocrit-Low) ...Blood Urea Nitrogen (Low) ...BUN/Creatinine Ratio (Low) ...Calcium Level Total (Low) ...Albumin Level (low) ...Albumin/Globulin Ratio (low) ... Reexamination/Reevaluation: Time: 04/01/2019 22:34 (11:34 PM). Course: Nurse has attempted to contact nursing facility multiple times ...using multiple numbers but has been unable to get through to the facility to obtain collateral information. Given alleged report pt. will be held overnight for psych(psychiatric) eval (evaluation) in the am. Pt is voluntary and willing to stay overnight in the hospital. Pt is A/O (awake/oriented) x4. Time: 04/02/201900:07 (12:07 AM) Course: Pt. is no longer making sensical statements, statements have increased grandiosity. Pt. Less directable and unable to specify why he is here. Geodon ordered for treatment of psychosis. Pt. wandering around emergency department and refusing treatment, becoming a danger to staff and other patients. Pt. will need to be placed on Psychiatric hold. Impression and Plan: Agitation or violent behavior- History of psychosis ...Disposition: Admit: Time 04/02/2019 00:00 (12 midnight) to Observation Unit. TO CDU (Clinical Decision Making Unit) for further psychiatric workup and evaluation .... Notes: Pt will need involuntary commitment given more and more disorganized and non-directable, with more tangential thoughts and agitation. This note was electronically signed by the ED physician on 04/02/2019 at 01: 23 a.m.
A review of the Progress Notes-Nurse dated 4/2/2019 at 0429 (4: 29 a.m.), Documentation by an RN revealed, Referral's Faxed to 2 acute care hospitals, one with a geriatric psychiatric unit, and 3 Psychiatric Behavioral Health hospitals.

Review of the progress note, "Psych daily f/u (follow-up)" dated 4/2/2019 at 7:46 a.m., documentation by the on-call psychiatrist revealed in part, "History of Present illness. Pt. #37 is a 74 year old ...with a history of dementia and psychosis, brought into the emergency room by police officer with the complaint of left sided facial pain right knee pain bilateral leg and ankle swelling after a fall. Pt fell yesterday and hit hi face during the fall. The patient also reports intermittent shortness of breath. Patient has chronic right knee pain with weather changes. He denies any injury ...recently diagnosed with psychosis and dementia by (this) on- call psychiatrist. He also has left lower extremity edema. The patient was Discharged on 4/1/2019 and represented to the ED later that day for agitation ....Psychiatry is being consulted for: Medical Management and behaviors. 03/30/2019 PROGRESS NOTE- Pt. was laying down comfortably in bed. No acute events overnight. Pt. continued to repeat that his name is "Patient #38" ...He was oriented to person but not to place, time and situation. Pt. was poor historian due to underlying psychosis w/ (with) delusions. 03/31/2019 PROGRESS NOTE- Pt. laying down comfortable in bed. No acute events overnight. Only PRN (as needed) med taken was acetaminophen-hydrocodone 325mg -5mg. 1 tab no reported medication SE (side effects). 04/1/2019 PROGRESS NOTES-Discussed patient with charge nurse. No Psychiatric acute events noted since last visit. No prn meds (medications) required Patient's sleep and appetite are adequate. Pt refused medications stating, "He cannot take that stuff and drive" the nurse educated the patient on medications and re-oriented pt. Pt. still refused. 04/2/2019 PROGRESS NOTES Patient was discharged to nursing home on yesterday morning. He was readmitted to the ED for agitation along with biting, punching and injuring other residents. When asked why he did it he said "because he is the preacher." Patient has been receiving Geodon 20 mg BID (twice a day) long with he go 10 mg IM (intramuscular) @ 00:38 (12:38 a.m.) Now he resides in the CDU. Mental status exam: Appearance: adequately groomed, appropriately dressed; Behavior: Cooperative, eye contact is adequate; Motor: no psychomotor agitation noted, Speech: normal rate and volume; Mood agitated. Though process: Non-linear, incoherent, irrelevant. Thought content: denied SI/HI, denies AVH (audio visual hallucinations). Alert/Oriented to person. Not oriented to place, time, location. Insight: Limited. Judgement: poor. Impulsive Intelligence: within normal range. PE (Physical Examination) General: Alert, no acute distress, Not ill-appearing ...Cardiovascular: Regular rate and rhythm, No murmur, no edema. Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal ...Neurological: Alert and oriented to person place, time and situation, normal sensory observed, normal motor observed, normal speech observed, normal coordination observed. DIAGNOSTIC IMPRESSION: Axis -1 Neurocognitive d/o (disorder) with behavioral concern, Axis 2- deferred, Axis 3- as per hospital course, Axis 4- moderate to severe, Axis 5 GAF 35. The Emergency Documentation note was electronically signed by the on-call psychiatrist on 4/2/2019 at 08:56. The on-call psychiatrist was consulted by the ED physician on 4/1/2019 at 10:12 p.m., but the psychiatric consult was not completed until 4/2/2019 at 7:46 am (9 hours later after the initial psychiatric consult was ordered). Review of the hospital's on call list of psychiatrist for the ED revealed there was a psychiatric on for 4/1/2019 for the hospital ED.

Patient #30

Medical record review revealed that patient #30 (a 16 year old) arrived to the hospital's ED on 4/1/2019 at 4:19 PM via BLS/Ambulance. The triage nurse documented the patient's Chief Complaint was, "Pt. was home alone when he sent several text to mother that "life is not worth living anymore". Pt. will not talk in in triage. Pt asked questions with no response. Pt nodded yes to wanting to her (sis) hurt himself. No plan noted or voiced. The patient was triaged as an ESI of 3 -Urgent. The patient's VS on arrival to the ED were: Temperature Oral: 36.6; Heart Rate: 80; Blood Pressure: 104/72; Respiratory Rate: 17, and oxygen saturation was 98% on room air. The patient's suicide risk score was documented as 13. The patient was evaluated by a Physician's Assistant (PA) on 4/1/2019 at 4:57 p.m. The PA documented in part, "History of Present illness: The patient presents with depression. The course/duration of symptoms is constant. Character of symptoms depressed. Self-injury: none. The exacerbating factor is family problems. The relieving factor is none ...The patient presents with Mother for Depression ...Mother is concerned because patient's father passed and patient has been very sad about it. He has never been treated for Depression in the past. Attempted to go to Mental Health but was not able to get in. Patient will not answer my questions verbally. Only shakes head or nods. He denies any medical complaints ... Review of symptoms: Constitutional symptoms: Negative except as documented in HIP (History of Present Illness). The Physical Examination conducted by the ED PA revealed in part, "Psychiatric: Mood and effect: non communicative. The section of the note titled "Medical Decision Making" revealed the following, "Differential Diagnosis: Anxiety, Depression, suicide risk, drug abuse. All laboratory test and urinalysis and Urine drug testing ordered were reviewed by the PA. The PA documented, that Patient #30 was medically cleared and was "Awaiting Psych disposition."

Review of the "CERTIFICATE OF LICENSED PHYSICIAN EXAMINATION OF CHILD IN NEED OF EMERGENCY ADMISSION" for patient #30 dated April 1, 2016 at 5:00 p.m. was completed in TRMC emergency department. The further review of involuntary commitment (IVC) papers revealed in part, "1. I the undersigned licensed physician, has examined the above named child am of the opinion the said child is in need of treatment and in need of emergency admission. Further review of the IVC papers revealed that because of the patient's symptoms and specific examples of behavior, and type of serious harm thought probable if the child is not immediately hospitalized. Review of an electronic order dated 4/1/2019 at 4:36 p.m., revealed that an order was entered, When medically clear, contact Behavior Health." An electronic order was entered into the computer on 4/1/2019 at 5:18 p.m., to "Consult the Social Worker, because the patient was "At risk for suicide." An electronic order for Consult to Psychiatry dated 4/1/2019 at 7:40 p.m., was sent to the on call psychiatrist from the ED physician. The order in detail specified, 4/1/2019 7:40 P.M ... Today, (Name of on-call physician)Pt. Stating doesn't want to live anymore, denies pain, hearing voices." A review of the physician's electronic orders revealed that on 4/1/2019 at 6:51 p.m., "Patient will need continuous monitoring 1:1 not indicated at this time. Review of the "Psych consult ED was performed by the on-call psychiatrist on 4/2/2019 at 8:01 a.m. Further review revealed that a psychiatric examination was conducted by the on-call psychiatrist approximately 13 hours after the initial request was made by the ED physician on 4/1/2019 at 7:40 p.m. Review of the transfer form revealed that Patient #30 was transferred to a Behavioral Health Hospital by Law Enforcement on 4/2/2019 at 3:45 p.m.


Interviews

An interview was conducted with the Nursing Director of the Emergency Department on 4/16/2019 at 2:57 p.m. He stated that when it is determined a patient in the emergency department has an emergency psychiatric condition, a psychiatric consult is put in, and the psychiatrist has 24 hours to come in and perform the psychiatric evaluation for that patient in the ED.

On 4/17/2019 at 1120 AM, the Medical Staff Chief (Physician (21) of the hospital's psychiatric unit was interviewed related to the hospital's on call responsibilities. Physician 21 verified the hospital has a physician on call for the emergency department for psychiatric evaluations every day for 24 hours a day. Physician 21 verified the psychiatric on call schedules from October 2018 through April 2019 were correct. Physician 21 confirmed that he/she has 24 hours to evaluate the psychiatric patients in the ED after the emergency department physician has determined that no emergency medical condition exists. Physician 21 further stated that the ED physicians place an order in the computer as a routine psychiatric consult and stated that physicians have 24 hours to conduct routine psychiatric evaluations in the ED. MD,#21 stated that a stat consult is to be answered in 4 hours and routine consults are to be seen in 24 hours. MD #21 stated the ED physician rules out an emergency medical condition, and then requests a psychiatric evaluation. When asked if he/she was aware that the Medical Staff Bylaws and ED policy stated the on - call physician is to present to the ED within 30 minutes to evaluate the patient, Physician 21 stated he/she thought it had always been 24 hours. He further stated that when the Emergency Department psychiatric consults come in we treat them as routine consults, and the patients are stabilized by the medications.


39310

Based on the review of the Emergency Department (ED) Central Log and interview, the hospital failed to ensure the emergency department maintained a Central Log for individuals presenting to the hospital's emergency department seeking assistance, Review of the hospital's emergency department Central Log for November 2018, December 2018, January 2019, February 2019, March 2019, and April 2019 revealed no data was recorded in the emergency department's Central Log for the discharge disposition for 5 patients on the emergency department's Central Log.

The findings are:

On 4/18/2019 at 5:30 p.m., random review of the hospital's emergency department Central Log from November 2018 through April 2019 revealed the hospital failed to capture the patient's discharge disposition for 1 patient who presented to the ED on 11/19/2018 at 15:59, 2 patients who presented to the hospital's ED on 1/12/2019 at 15:58 p.m. and 18:42 p.m., and 2 patient's who presented to the ED on 2/28/2019 at 14:30 p.m. and 21:29 p.m. for care. On 4/18/2019 at 5:30 p.m., random review of the hospital's ED Central Log also revealed that the patient's discharge diagnosis was not recorded for 87 patients listed on the hospital's ED Central Log from November 2019 through April 2019. On 4/18/2019 at 5:45 p.m., Manager 1 reported the hospital's Central Log is not monitored for accuracy.

Based on observations, medical record reviews, Policy and Procedure reviews, Obstetrics and Gynecology Department Rules and Regulations review, review of on - call schedules, review of Medical Staff General Rules and Regulations, review of Medical Staff By-Laws, review of Labor and Delivery Triage competency forms and staff interviews, it was determined the facility failed ensure that obstetrical patients presenting to the hospital ' s emergency department with gestation 20 weeks or greater received an appropriate medical screening examination to rule out an emergency medical condition by a qualified medical personnel approved by the governing board for 2 (Patient #23 and Patient #41) of 5, patient obstetrical charts reviewed for care and services. The facility failed to ensure that Medical Staff ByLaws, Medical Staff General Rules and Rules and Regulations, and Obstetrical Gynecology Department Rules and Regulations identified and approved Obstetrical Registered Nurses as qualified to conduct/perform medical screening examinations.

The findings are:


Patient Charts

Patient 41
On 4/18/19 at 2:00 p.m., review of the closed record for Patient 41 revealed the 24 year old patient presented to the hospital's Emergency Department (ED) on 3/11/19 at 2:30 p.m. with complaints of abdominal pain and vaginal bleeding. The hospital's ED staff notified the obstetrical department on 3/11/19 at 2:30 p.m. that a patient presented to the ED with a possible intra-uterine pregnancy (IUP) 21? weeks with abdominal pain and bleeding. The patient was sent from the hospital's emergency department to the obstetrical unit for a medical screening examination. Documentation in the patient's chart revealed the patient was a 24 year old with complaints of abdominal pain and bleeding. The patient was examined by a labor and delivery registered nurse and a telephone order was obtained to collect a urine specimen for human Chorionic Gonadotropin (hCG) test, drug screen, comprehensive urinalysis, and pelvic ultrasound. The result of the urine hCG were obtained at 3/11/19 at 15:06 and was reported as negative. A pelvic ultrasound was done 3/11/19 at 15:48 p.m., and the findings were: "Impression - No intrauterine pregnancy or focal pelvic abnormality identified". On 3/11/19 at 16:10 p.m., the registered nurse notified the patient that she was not pregnant. Documentation by the registered nurse revealed, "Patient and mom agrees that maybe she was starting her period....Patient and mom ambulated off unit with no difficulty." There was no documentation that a medical screening examination was performed by a physician or other qualified medical personnel. The findings were verified by Registered Nurse 1 at 2:00 p.m. on 4/18/2019 at the time of review of the patient's chart.

Patient 23
On 4/18/19 at 3:00 p.m., review of Patient 23's emergency department chart revealed the patient presented to the hospital's Emergency Department (ED) on 4/5/19 at 15:39 p.m. and was escorted to the obstetrical unit on 4/5/19 at 18:15 p.m. where an obstetrical admission history and assessment was started 4/5/19 at 18:13 p.m.. Staff(Registered Nurse) obtained the patient's vital signs, ordered labs and obtained the results, performed a vaginal examination at 16:07 p.m. that revealed cervical dilation 2 centimeters (cms) cervical effacement 70. At 17:30 p.m., documentation showed the registered nurse called the physician and an order was received to check the cervix in 30 minutes. Documentation showed the physician was notified at 18:02 p.m. that the patient's cervix was at 3 cms, and the registered nurse received an order to admit the patient. On 4/18/2019 at 3:15 p.m., in an interview with Registered Nurse 1, during review of the patient's chart, Registered Nurse 1 stated, "The physician called at midnight to check on the patient. He probably came in and saw where she wasn't progressing, so he sent her home". The patient was discharged on 4/6/19 at 9:45 a.m., but there was no evidence that a medical screening examination was performed by a physician or other qualified medical personnel. On 4/18/2019 at 3:15 p.m., Registered Nurse 1 verified the findings.

On 4/18/19 at 3:00 p.m., review of Patient 23's chart for the second presentation to the emergency department revealed the patient again presented to the hospital's Emergency Department (ED) on 4/7/19 at 8:08 a.m. and was taken to the hospital's obstetrical unit where the Registered Nurse performed the patient's medical screening examination. Documentation in the patient's chart revealed, "Cervical dilation was 3 cms and cervical effacement was 30. There was no leaking fluid, fetal movement was present, and no urge to push". At 8:43 a.m., the Registered Nurse called the physician and orders were received to discharge the patient home with instructions. Documentation revealed there was no medical screening examination performed by a physician or other qualified medical personnel. On 4/18/2019 at 3:15 p.m., Registered Nurse 1 verified the findings, and stated, "It doesn't look like a doctor saw her until she was actually admitted (third presentation to ED) to have the baby."



1. Medical Screening Examination

Policy and Procedure
The facility's policy titled, "EMTALA: Transfer-Patient Medical Screening Examination, (No policy Number), revealed in part, "Purpose: To guide all personnel in complying with the requirements of federal law the Emergency Medical Treatment and Labor Act (EMTALA), Title 42 USC Section 1395 dd.et. seq., including medical screening and stabilization of the individual who presents at RMC's "Emergency Department." ...EMERGENCY MEDICAL CONDITION (EMC): A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate attention could reasonably be expected to result in: Placing the health of the individual ...in serious jeopardy; serious impairment of bodily functions, or Serious dysfunction of any bodily organ or part; Acute alcohol and drug intoxication (substance abuse). A psychiatric condition where it is determined that the individual is a substantial danger to himself and others." ...MEDICAL SCREENING EXAMINATION includes: When an individual comes to the RMC [ED/OB urgent care center(s) or within 250 yards of the main hospital building] and a request is made on the individual's behalf for examination or treatment of a medical condition, a qualified medical personnel is to provide an appropriate medical screening examination within the Emergency Department's capability to determine whether or not an emergency medical condition exists."

Medical Staff Bylaws
On 4/17/2019, review of the hospital's "Medical Staff Bylaws, Governance, Structure, and Function of the Medical Staff", dated November 28, 2017, section "2.3. Responsibilities of Membership", page 13, revealed, "In addition, all members who have joined the medical staff after January 1, 2015 must assist the Hospital in fulfilling its responsibilities for providing emergency and charitable care, including without limitation service call coverage, in accordance with policies passed by the MEC (Medical Executive Committee) and/or Board."

Medical Staff General Rules and Regulations
On 4/17/2019, review of "Medical Staff General Rules And Regulations (RR)", approved as policy February 9, 2015, RR 1.000 "Organization Responsibilities Of The Medical Staff", RR 1.010 Active Medical Staff, reads, "C. Each member of the Medical Staff, in his absence, shall arrange coverage for his hospitalized patients. In cases of emergent/urgent clinical situations, contact with the member of the Medical Staff shall be established. The on-call physician shall present to the emergency department within thirty (30) minutes to evaluate the patient in emergency situations." Further review revealed " A. Active Medical Staff members shall be required to accept responsibilities for patients applying for Emergency Department services who are without a personal physician who is a member of the Active Medical Staff. All patients applying for emergency services who do not have a physician on the Active Medical Staff shall be assigned to members of the Active Medical Staff who are on-call in the department to which the illness of the patient indicates assignment."


II. Obstetrical Medical Screening Examination (20 or more weeks gestation)
On 4/15/2019 at 2:14 p.m., an observational tour was conducted in the hospital's obstetrical unit with the Director of the Obstetrical Unit (OB Director). Observations revealed the administrative area where obstetrical patients with a gestation at or greater than 20 weeks are transported to from the hospital's emergency department or for those obstetrical patients at or greater than 20 weeks who bypass the emergency department and report directly to the obstetrical unit for care. Observations of the Obstetrical Units primary obstetrical examination room and of the secondary obstetrical examination room was conducted. During the tour, the OB Director reported that obstetrical patients presenting for care report to the administrative area on the obstetrical unit first where the patient's demographic as well as the patient's chief complaint is captured. The OB Director stated that no insurance information is obtained at that time. The OB Director reported the Medical Screening Examination is performed by the Labor and Delivery Registered Nurses. The OB Director stated that every labor and delivery nurse receives special training to perform the medical screening examination on obstetrical patients at or greater than 20 weeks. The OB Director stated that when the registered nurse completed the patient's medical screening examination, the registered nurse called the on call obstetrical physician and relayed the findings of the patient's medical screening examination to the physician on call for the obstetrical service. On 4/15/19 at 2:30 p.m., the OB Director stated, "A labor and delivery registered nurse who has been trained to perform a medical screening examination can train another labor and delivery registered nurse to perform a medical screening examination. This procedure hasn't been approved by the hospital's Governing Body."


Obstetrical Call Schedules
On 4/16/2019 at 11:00 a.m., an obstetrical on-call physician schedule for February 2019, March 2019, and April 2019 was presented to the survey team. Review of the obstetrical on - call schedules revealed an obstetrical physician was scheduled on call for the hospital each day of the month for February 2019, March 2019, and April 2019.

Governing Body
On 4/17/2019 and 4/18/2019, review of the hospital's Governing Body and Medical Staff Bylaws revealed there was no approval by the hospital's governance for Registered Nurses in the Labor and Delivery department to conduct medical screening examinations for obstetrical patients 20 weeks or greater gestation who presented to the hospital's emergency department requesting services.


Obstetrics and Gynecology Department Rules and Regulations
The facility's Obstetrics and Gynecology Department Rules and Regulations, last reviewed 10/9/2007, was reviewed. The Obstetrical and Gynecology Medical Staff Department Rules and Regulations revealed in part, "Medical Staff ...2. Medical Screening Examination. a. The pregnant individual (greater than 29 weeks gestational age) presenting at Her Place: A medical screening will be provided by an obstetrician (his or her designee) or a 'qualified' registered nurse* b. if the medical screening examination is completed by a 'qualified registered nurse*, the registered nurse is to consult with the obstetrician regarding clinical findings, status and appropriate disposition. *'qualified' registered nurse is one who has successfully completed the following required training: 1) Completion of Her Place skills checklist; 2) Successful completion (a minimum score of 85%(percent)) of the following modules: a) Antepartum Fetal Monitoring; b) Intrapartum Fetal Monitoring; c) Oxytocin Infusions for induction/Augmentation of labor." Review of this Obstetrics and Gynecology Rules and Regulations revealed that the Chairman, Obstetrics/Gynecology Department, Chief of Medical Staff, or the Chairman of the Board of Trustees had not signed, dated or approved L&D (Labor and Delivery) nurse to perform/conduct medical screening examinations.


Hospital Policy and Procedure
On 4/18/2019, review of the Hospital's policy and procedure, titled, "Pre-Admission Assessment", reads, " ....Policy: Obstetrical patients, 20 weeks or greater gestation, presenting for assessment are to be triaged in ED by nurse and if patients has complaints of labor symptoms (ROM, vaginal bleeding, cramps or back pain), the patient should be taken to "Her Place"(Obstetrical Unit) via wheel chair or stretcher for evaluation by a qualified Intrapartum RN ....
1. The patient is to be evaluated by an Intrapartum RN according to the following criteria.
A. Brief history as to onset and type of symptoms.
B. Vital signs (TPR, BP, FHT) (Temperature, Blood Pressure, Fetal Heart Rate)
C. Abdominal palpation for uterine tonus and size.
D. Fetal Fibronectin Swabbing if 22 weeks IUP-35 completed weeks IUP. (Must be done before any digital or ultrasonic vaginal exam).
E. Vaginal exam for dilation, effacement, presentation, station, and status of membranes. (Unless otherwise contraindicated) E. Blood glucose finger stick on any OB patient who is on insulin or an oral agent for diabetes.
F. Any other pertinent data relevant to the patient ' s condition.

2. The patient 's prenatal record (if available) is to be reviewed by the Intrapartum RN for prenatal course and risk factors.

3. A twenty minute fetal heart monitor tracing is to be obtained to document fetal status, when applicable. The heart monitor tracing may be done concurrently with the history and physical assessment.

4. The attending/service physician is to be notified within 20 minutes of the results of the assessment, vital sign and FHR (Fetal Heart Rate) interpretation when applicable ....".

On 4/18/2019, review of the Hospital's policy and procedure, titled, "Extended Nursing Roles - Validation of Competencies", reads, "Purpose: To identify extended nursing roles in the medical screening of obstetrical patients. To provide a mechanism for validating nursing competency in extended roles.
Policy: Continuing education programs are offered to all licensed nursing staff in order to meet requirements for practicing extended nursing roles. Education programs include: a. Electronic fetal monitoring course b. Antenatal testing course c. Annual observation by UBE/Clinical Coordinators.
Procedure:
1. Validation of theoretical knowledge is determined by a passing score of an examination following completion of fetal monitoring class.
2. Staff members who fail may re-test with a second written examination. If a failing score is obtained on the second testing the staff is required to repeat the fetal monitoring class.
3. Validation of clinical experience is to be documented by an approved preceptor. The period of supervised clinical experience necessary to obtain minimal competency may vary with the individual.
4. The annual performance appraisal is to be utilized to validate and document continued competency and increased clinical skills in the extended role areas. In addition, annual competencies will be required based on volume and risk assessments.
5. Reference to "qualified" nursing staff in other Obstetrical policies is defined as a licensed nurse who has met the above stated criteria.".

Interviews

On 4/16/2019 at 4:00 p.m., the Director of the Emergency Department and the Director of Quality submitted the "Psychiatry Call Schedule" for November 2018, December 2018, January 2019, February 2019, March 2019, and April 2019 revealed a psychiatrist was scheduled for the ED on - call every day. The hospital's OB on call schedule for October 2018, November 2018, December 2018, January 2019, February 2019, March 2019, and April 2019 revealed an OB-GYN(Obstetrician - Gynecology) physician was scheduled for the ED every day. When asked how the on call schedules for the hospital's emergency department functioned, the ED Director stated it was a 24 hour on call schedule. When informed of the hospital's 30 minute reporting requirement, the ED Director stated that the psychiatrist has 24 hours to screen the patient's after the emergency department requested a psychiatric evaluation. The ED Director stated when the ED physician completes the medical screening examination and clears the patient but determines that the patient requires an evaluation by a psychiatrist to determine if a psychiatric emergency condition exists, the psychiatric patient is placed in a room on hold to wait for the psychiatrist to evaluate the patient.


On 4/17/2019 at 10:20 AM, in an interview with the Director of Quality related to the extended training requirements for registered nurses performing the medical screening examinations for those patients presenting to the hospital's emergency department with a 20 week or greater gestational age, the Director of Quality verified the electronic fetal monitoring course, antenatal testing course, and annual observations by Clinical Coordinators, were required by all of their labor and delivery registered nurses, and were the same educational requirements written in the hospitals policy for the labor and delivery unit and were the same requirements for all labor and delivery nurses.


On 4/17/2019 at 10:50 AM, an interview was conducted with Medical Doctor 21(Medical Director - Inpatient Psychiatric Services) and Medical Doctor 2(Emergency Services). Medical Doctor 21 verified that he and another psychiatrist are on the hospital's on - call schedule for consult in the hospital's ED for 24 hours. MD 21 stated the on call schedule for the ED for April 2019 is correct. MD 21 stated that the ED physicians do not call the psychiatrist on call for an evaluation. MD 21 stated a routine consult for a psychiatric evaluation is placed in the computer, and the patient(s) are held in the emergency department until the psychiatric evaluation is completed. MD 21 stated that a stat consult is to be answered in 4 hours and routine consults are to be seen in 24 hours. MD 2 stated the ED physician rules out an emergency medical condition, and then requests a psychiatric evaluation.




39310

On 4/18/2019, the hospital submitted the following skills check list as competencies to perform the medical screening examination for registered nurses in labor and delivery. The competency check list was titled, Labor Triage Competency Skills Check list.
Labor Triage Competency Skills Checklist
Labor and Delivery completed skills checklist
Fetal Fibronectin collection
Amnisure collection
Accurate Vaginal Exams
Obtaining Vaginal Cultures
MD Unattended Delivery
Collection of Patient Information
Assessment of signs and symptoms of labor
Accurately identifies abnormal results ( labs, vaginal exams, FHR (Fetal Heart Rate) abnormalities)
Accurately reports information to physician
Administration of outpatient injections.

The Labor Triage Competency check off sheets were reviewed.
On 11/19/17: Labor and Delivery (L&D)Registered Nurse 1 checked off on labor triage competency
On 11/21/17: L&D Registered Nurse 2 checked off on labor triage competency
On 12/04/17: L&D Registered Nurse 3 checked off on labor triage competency
On 12/09/17: L&D Registered Nurse 4 checked off on labor triage competency
On 01/04/18: L&D Registered Nurse 5 checked off on labor triage competency
On 02/12/18: L&D Registered Nurse 6 checked off on labor triage competency

Hospital policy and procedure, titled, EMTALA: Transfer - Patient Medical Screening Exam, Page 3 of 12, Manual:Administrative, reads, "Emergency Department and Urgent Care Center(s): The on duty physician or physician extender (NP/PA) will perform a MSE. [Note: Triage by a RN is not considered a MSE.] The pregnant individual (greater than 20 weeks gestation) presenting for a non - obstetrical chief complaint will be evaluated in the ED or urgent care center."
"Her Place: A MSE will be provided to the individual (greater than 20 weeks gestation) by an obstetrician or "qualified RN" defined as one who has successfully completed the following training: Completion of Her Place skills checklist (Intrapartum and Antepartum) and Successful completion (minimum score of 80%) of a Fetal Monitoring Course. When the MSE is completed by the RN, the RN is to consult with the obstetrician regarding the clinical findings/status and appropriate disposition. The facility failed to provide a documented evidence that Obstetrical RN's were qualified to perform MSE for obstetrical patients who present to the ED and/or L&D unit.

Based on review of patient medical records, review of the hospital's policies and procedures, review of the hospital's bed census reports, review of the hospital's on-call schedules, and staff interviews, it was determined the hospital failed to provide medical treatment within its capacity to minimize the risks to the individuals' health for 2 (Patient #37 and Patient #46) of 46 sampled patients.


The findings were:


Hospital Policy and Procedure
The facility's Policy and Procedure, titled, "EMTALA: Transfer -Patient Exam Medical Screening" (No Policy Number), the policy specified, in part, "Purpose to guide all personnel in complying with the requirements of federal law regarding Emergency Medical Treatment and Labor Act (EMTALA), title 41 USC section 1395 dd. met. saq., including medical screening and stabilization of the individual who presents at RMC's "Emergency Department" ... APPROPRIATE TRANSFER TO A MEDICAL FACILITY OCCURS: When the transferring hospital provides the medical treatment with its capacity which minimizes the risk of the individuals health." ...ON-CALL PHYSICIAN means a member of RMC Medical Staff whose name appears on the roster of physicians on-call to respond to properly communicated requests to provide further medical examination and/or treatment for the stabilization of an emergency medical condition."

The hospital's policy, titled, "Admission/Exclusion Continued Stay/Discharge Criteria, Department: Psychiatry" (No Policy Number), was reviewed. The policy revealed, in part, "It is the policy of the Behavioral Health Unit to provide the most appropriate level of psychiatric care in the least restrictive and age appropriate environment utilizing the following criteria. Treatment is offered without regard to race, color, religion, sex, national origin, sexual orientation, age, physical disability, payer source or socioeconomic status. The provider has the responsibility to admit or discharge a patient based on medical necessity and achievement of treatment goals. Admission Criteria: (Intensity of Service): 1. The patient must require intensive, comprehensive, multimodal treatment with medical supervision and coordination 24 hours a day. 2. The patient needs 24 hour nursing or medical supervision for safety to protect self or others, psychiatric diagnostic evaluation, potential severe side effects of psychotropic medications associated with medical or psychiatric comorbidities and/or changes in psychotropic medications. 3. The acute psychiatric symptoms and behaviors being evaluated and treated must require active treatment, including a combination of services such as intensive nursing and medical intervention, psychotherapy, occupational recreational and active therapy. The intensity and frequency of these therapies and interventions exceed those services available in outpatient setting. Admission Criteria (Severity of Illness): 1. The patient poses a threat to self-requiring 24 hour professional observation: 1.1 Suicidal ideation or gesture within 72 hours prior to admission. 1..2. Accrual threatened self-injury mutilation within 72 hours prior to admission- 1.3 Chronic and continuing self- destructive behavior that poses immediate threat to life or limb. 2. The patient poses a threat to others requiring 24 hour professional observation: 2.1 Assault behavior threatening others within 72 hours of admission. 2.2 Significant verbal threat to the safety of others within 72 hours of admission ... 3. Acute disordered/bizarre behavior or psychomotor agitation or retardation that interferes with individual's ability to function with activities of daily living at a less intensive level of care during evaluation and treatment. 4. Cognitive impairment (disorientation or memory loss) due to an acute Axis 1 disorder that endangers the welfare for the patient or others. 5. A mental disorder that causes the inability to maintain adequate nutrition or self-care, lack of reliable family/community support or essential care so that the patient cannot function in a less intensive level of care during evaluation and treatment. 6. A mental disorder causing major disability in social, occupational, educational and/or interpersonal functioning that is leading to life threatening or dangerous functioning and can only be addressed in an acute patient setting. 7. Failure of outpatient psychiatric treatment so the patient requires 24 hour professional observation and care. Reasons for failure of outpatient treatment may include: increase severity of symptoms, non- compliance with medications due to severity of symptoms, inadequate clinical response to psychoactive medications. 8. Adults 18 years of age or older who meet admission criteria and who have DSM V diagnosis may be admitted to the Behavioral Health Center with a provider order. 9. The admission criteria are applied consistently to all patients regardless of payer sources or reimbursement. 10. The severity and acuity of symptoms along with the likelihood of patients' response to treatment combined with the requirement for an intensive, 24 hour level of care are the significant factors in determining the medical necessity of admission for inpatient psychiatric treatment ... Exclusionary Criteria ...7. Patients who actively manifest or have historically manifested on prior behavioral health unit admission behaviors that preclude their ability to be safely managed in the Psych IP (In Patient) unit. This would include actively violent patients with violence directed toward hospital staff and history of hospitalizations in forensic units. If there is concern regarding the level of violence or the potential threat of violence, then either the MH social worker or the Provider will have the Final say."

Patient #37
Medical Record review revealed that Patient #37 presented to the facility via Advanced Life Support/Emergency Medical Services (ALS/Ambulance) on April 1, 2019. Review of the "Patient Information" sheet, the section, titled, "ENCOUNTER INFORMATION" revealed the patient was a 74 year old who was registered in the emergency department at 7:12 p.m., and patient type was "Emergency" and the Admit Reason: was "Physical Aggression." Documentation by the triage nurse revealed the patient was triaged at an ESI (Emergency Service Index) level at 3 - Urgent. The patient's Vital Signs were listed as: Oral Temperature: 36.5; Pulse Rate: 68; Respiratory Rate:16, Blood Pressure: 210/101 (normal blood pressure (Ideal Blood Pressures) 100/65-120/80); Oxygen saturation: 99%(percent) on room air.

The patient was seen by the ED (Emergency Department) physician on 4/1/2019 at 10:26 p.m.. Documentation by the ED physician revealed, in part, "History of Present illness: The patient presents with psychiatric problem and agitation. The onset was 5 hours ago. The course/duration of symptoms is constant. Character of symptoms angry, paranoid agitated, denies suicidal thoughts. Self-injury: none. The exacerbating factor is none. The relieving factor is none. Risk factors consist of age and psychosis. Prior episodes: rare. Therapy today: prescription medications including Geodon (medication used to treat certain mental mood disorders) prior to discharge from hospital today. Associated symptoms: denies fever, denies chills, denies nausea, denies vomiting, denies headache, denies dizziness, denies chest pain, denies shortness of breath, denies abdominal pain, and denies altered vision. Pt. (patient) sent to ED by nursing facility ...just today became a resident at. Per facility, pt.(patient) biting, punching, and injuring other residents. Pt is alert and oriented x(times) 4. ...reason did this because...is a preacher. Denies SI/HI (suicidal ideations/homicidal ideations), but endorses auditory hallucinations; unable to specify if these are command hallucinations. Pt. states ...not on any medications although ...was discharged today from TRMC (The Regional Medical Center of Orangeburg and Calhoun) on Geodon. Attempting to reach nursing facility to further collateral information on pt's (patient's) behavior ... Review of symptoms ...Psychiatric Symptoms: Delusional, hallucinations, irritability, no anxiety, no depression, no mania, not suicidal, not homicidal, no eating disorder, no substance abuse ...Physical Examination: Vital Signs ...04/01/2019 6:00 EDT- Temperature: 36.8; Peripheral Pulse Rate:65; Respiratory Rate:18; Blood Pressure: 161/93 ...Oxygen Saturation- 93% Room Air ...General: Alert, no acute distress, Not ill-appearing, ...Psychiatric: Mood and affect: not anxious, not depressed, not hostile, not non-communicative, not flat, not paranoid, Behavior: Relaxed, not uncooperative, not belligerent, Judgement: Impaired by abnormal thoughts, Abnormal/Psychotic thoughts: Hallucinations (auditory, not visual) flight of ideas, not suicidal, not homicidal, not obsessive, not tangential.

Review of ED physician orders dated 4/1/2019 at 10:12 p.m. revealed the ED physician electronically ordered, "When Medically clear, contact Behavioral Health." Further review revealed that the ED physician electronically ordered a 10:12 p.m., "Consult to Psychiatry ...Routine, (Name of On-call Psychiatrist), acute behavioral disturbance, psychosis, agitation and assaulting of nursing home staff~(approximately) 1 d (day) after discharge from the hospital." The patient's suicide risk level was 7. Medical Decision Making: Rationale: Unable to obtain collateral information got specifically why patient was brought back to the ED except for second hand information from EMS(Emergency Medical Services). Actively attempting to contact nursing facility who report pt. was violent towards other residents. Pt. endorses auditory hallucinations for provider but is otherwise pleasant and cooperative. Denies any somatic symptoms at this time. Most recent inpatient blood work ~16 hours ago unremarkable ...Orders. Urine drug screen, Urinalysis Comprehensive, White Blood Cell Count,(red blood cell count, Hemoglobin , Hematocrit-Low) ...Blood Urea Nitrogen (Low) ...BUN/Creatnine Ratio (Low) ...Calcium Level Total (Low) ...Albumin Level (low) ...Albumin/Globulin Ratio (low) ... Reexamination/Reevaluation: Time: 04/01/2019 22:34 (11:34 PM). Course: Nurse has attempted to contact nursing facility multiple times ...using multiple numbers but has been unable to get through to the facility to obtain collateral information. Given alleged report pt. will be held overnight for psych(psychiatric) eval (evaluation) in the am. Pt is voluntary and willing to stay overnight in the hospital. Pt is A/O (awake/oriented) x 4. Time: 04/02/201900:07 (12:07 AM) Course: Pt. is no longer making sensical statements, statements have increased grandiosity. Pt. Less directable and unable to specify why he is here. Geodon ordered for treatment of psychosis. Pt. wandering around emergency department and refusing treatment, becoming a danger to staff and other patients. Pt. will need to be placed on Psychiatric hold. Impression and Plan: Agitation or violent behavior- History of psychosis ...Disposition: Admit: Time 04/02/2019 00:00 (12 midnight) to Observation Unit. TO CDU (Clinical Decision Making Unit) for further psychiatric workup and evaluation .... Notes: Pt will need involuntary commitment given more and more disorganized and non-directable, with more tangential thoughts and agitation." This note was electronically signed by the ED physician on 04/02/2019 at 01: 23 a.m.

Review of the Progress Notes - Nurse dated 4/2/2019 at 0429 (4: 29 a.m.), Documentation by an RN revealed, Referral's Faxed to 2 acute care hospitals, one with a geriatric psychiatric unit, and 3 Psychiatric Behavioral Health hospitals.

Review of the progress note, "Psych daily f/u (follow-up)" dated 4/2/2019 at 7:46 a.m., documentation by the on-call psychiatrist revealed in part, "History of Present illness. Pt. (#37) is a 74 year old ...with a history of dementia and psychosis, brought into the emergency room by police officers with the complaint of left sided facial pain, right knee pain, bilateral leg, and ankle swelling after a fall. Pt fell yesterday and hit his face during the fall. The patient also reports intermittent shortness of breath. Patient has chronic right knee pain with weather changes. He denies any injury ...recently diagnosed with psychosis and dementia by (this) on- call psychiatrist. He also has left lower extremity edema. The patient was Discharged on 4/1/2019 and re-presented to the ED later that day for agitation ....Psychiatry is being consulted for: Medical Management and behaviors.

03/30/2019 PROGRESS NOTE- Pt. was laying down comfortably in bed. No acute events overnight. Pt. continued to repeat that his name is "Patient (#37)" ...He was oriented to person but not to place, time, and situation. Pt. was poor historian due to underlying psychosis w/ (with) delusions. 03/31/2019 PROGRESS NOTE- Pt. laying down comfortable in bed. No acute events overnight. Only PRN (as needed) med taken was acetaminophen-Hydrocodone 325 mgs (milligrams)- 5 mgs. 1 tab no reported medication SE (side effects).

04/1/2019 PROGRESS NOTES-Discussed patient with charge nurse. No Psychiatric acute events noted since last visit. No prn(as needed) meds (medications) required Patient's sleep and appetite are adequate. Pt refused medications stating, "He cannot take that stuff and drive". The nurse educated the patient on medications and re-oriented pt. Pt. still refused.

04/2/2019 PROGRESS NOTES Patient was discharged to nursing home yesterday morning. He was readmitted to the ED for agitation along with biting, punching, and injuring other residents. When asked why he did it, he said "because he is the preacher." Patient has been receiving Geodon 20 mgs BID (twice a day) along with 10 mgs IM (intramuscular) @ (at)00:38 (12:38 a.m.). Now he resides in the CU. Mental status exam: Appearance: adequately groomed, appropriately dressed; Behavior: Cooperative, eye contact is adequate; Motor: no psychomotor agitation noted, Speech: normal rate and volume; Mood agitated. Though process: Non-linear, incoherent, irrelevant. Thought content: denied SI/HI, denies AVH (audio visual hallucinations). Alert/Oriented to person. Not oriented to place, time, location. Insight: Limited. Judgement: poor. Impulsive Intelligence: within normal range. PE (Physical Examination) General: Alert, no acute distress, Not ill-appearing ...Cardiovascular: Regular rate and rhythm, No murmur, no edema. Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal ...Neurological: Alert and oriented to person place, time and situation, normal sensory observed, normal motor observed, normal speech observed, normal coordination observed. DIAGNOSTIC IMPRESSION: Axis -1 Neuro-cognitive d/o (disorder) with behavioral concern, Axis 2- deferred, Axis 3- as per hospital course, Axis 4- moderate to severe, Axis 5 GAF 35. The Emergency Documentation note was electronically signed by the on-call psychiatrist on 4/2/2019 at 08:56.

The on-call psychiatrist was consulted by the ED physician on 4/1/2019 at 10:12 p.m., but the psychiatric consult was not completed until 4/2/2019 at 7:46 am (9 hours later after the initial psychiatric consult was ordered. Review of the hospital's on call list of psychiatrist for the ED revealed there was a psychiatric on call for 4/1/2019 for the hospital ED.

PLAN/RECOMMENDATIONS: Pt is on ICP. 1. Continue with efforts to medically stabilize patient. 2. Continue Ziprasidone (GEODON is an antipsychotic medication) 10 mg prn up to qid (4 times a day) for disruptive behavior not responding to verbal limit setting. 3. Referrals faxed to the following: Names of 2 acute care hospitals, one with a geriatric psychiatric unit, and 3 Psychiatric Behavioral Health hospitals. 4. Appreciate this interesting consult opportunity.

Review of the facility's Inter-facility Transfer Record dated 4/2/2019 revealed Patient #37 was accepted at the acute care hospital with the geriatric psychiatric unit. The form also listed that Patient #37 was transported to an acute care hospital with the geriatric unit at 2:27 p.m. via basic life support ambulance. The AUTHORIZATION FOR TRANSFER form dated 4/2/2019 listed Patient #37 diagnosis as "Psychiatric Problem/Agitation." The REASON FOR TRANSFER: was checked, as "service that patient requires is not available at TRMC."

The ED-Note by the Physician/Midlevel (PA-Physician Assistant) dated 4/2/2019 at 11:37 AM was reviewed. The PA documented in part, "Basic Information- Addendum: time of addendum: 04/02/2019 11:35, Pertinent History, CDU psych hold rounds. Medical Decision Making: Documents reviewed: Emergency department records. Physical Examination: Nurse reports no issues. Pt. has no complaints. Resting in bed in no distress. Reexamination/Reevaluation: Vital signs 04/02/2019 8:42 EDT Temperature 36.6; Peripheral Pulse rate; 75; Respiratory Rate: 18; Blood Pressure 158/85. Impression and Plan: Will continue current PSYCH treatment while waiting for placement/disposition. The note was electronically signed by the PA on 4/2/2019 at 11:37 a.m..

Review of the facility's Bed Census dated April 1, 2019 revealed the facility had 1 psychiatric bed available; and on April 2, 2019 revealed the facility had 3 psychiatric beds available.
A review of the facility's on-call schedule for psychiatry verified that on April 1, 2019 and on April 2, 2019, a psychiatrist was on call for the ED.


Patient #46
The medical record for Patient #46 revealed the patient presented to the hospital's ED on 4/3/2019 at 11:17 a.m., via ALS (Advance Life Support/EMS (Emergency Medical Services). Review of the Nurse's triage noted dated 4/3/2019 at 11:17 am revealed the patient's chief complaint was, " ...Patient called suicide hotline. Suicide hotline called ems. Patient not wanting to answer questions. Patient said he called the hotline because "I don't want to be here anymore" The patient's ESI (Emergency Severity Index) was listed as a 2 - Emergent. The patient's vital signs were listed as: Oral Temperature- 37.1; Heart rate: 105 (normal heart rate 60-100); Respiratory Rate - 22; Blood Pressure: 153/77 and 98% on room air.

Review of the ED Note-Physician/Midlevel note, documentation by the ED physician revealed the patient was seen/evaluated on 4/3/2019 at 11:43 a.m. The physician documented the history regarding the patient was limited because the patient refused to answer questions. The History of Present illness, revealed in part, "the patient presents with psychiatric problem and suicidal ideation. The course/duration of symptoms is constant. Character of symptoms depressed suicidal thoughts. The exacerbating factor is family problems. Risk factors consist of suicide risk. Prior episodes none. Therapy note today: none ...Pt. will not communicate with me ...Per the tech, whom pt. will talk to, he's been having depression x 5 months due to family issues. Pt indicates pain in the chest with his hand when asked if anything is bothering him, but will not specify if it's emotional or physical pain. Review of Systems: Additional review of systems information: Unable to obtain due to: Uncooperative patient. ..General: alert, no acute distress, morbid obesity, not ill-appearing ...Cardiovascular: Tachycardia (fast heart rate) ...Psychiatric: Appearance: Adequately groomed; Mannerisms: Non-communicative: tries to avoid eye contact; Speech: refuses to speak; Mood: depressed; Thought content and process: Called suicide hotline today; Hallucinations: No external evidence of hallucinations during exam; Insight: Poor; Judgement: Poor; Intelligence: Unable to determine ...Medical Decision Making: Differential Diagnosis: Suicide Risk. Put on Psych hold papers based on circumstances. Will medically clear and no AMI and have psychiatry evaluate."

The Certificate of Licensed physician for Emergency Admission dated 4/3/2019 at 11:45 a.m., completed in the ED revealed that Patient #46, "Is mentally ill and because of this mental condition CURRENTLY POSES A SUBSTANTIAL RISK, or physical harm to self and others to the extent that INVOLUNTARY EMERGENCY HOSPITALIZATION is recommended."

The physician orders revealed, "Consult to Psychiatry: 04/03/2019 11:43 a.m., Routine. (On-call physician name), acute behavioral disturbance." Laboratory tests, EKG(Electrocardiogram), Chest X-Ray, and urinalysis were ordered and results reviewed by the ED physician. The patient was re-evaluated/re-examined by the ED physician. The patient was positive for a Urinary Tract Infection(UTI) and an antibiotic was ordered. The ED physician documented that Patient #46 was medically cleared for a psychiatric evaluation. Further documentation revealed the Impression and Plan was UTI, Suicidal Ideation Depression. Plan: "dispo" (disposition) per psychiatry. The note was electronically signed by the ED physician on 04/03/2019 at 15:32.

The Psych consult ED- note revealed that an evaluation was performed by the on-call physician on 4/32019 at 12:31 p.m. Documentation of the Mental Status Examination revealed, appearance: poorly groomed, hospital garb; Behavior: passively cooperative, adequate eye contact; Motor: no psychomotor agitation noted; Speech: nl(normal) rate and volume; Mood depressed; Affect: Blunt; Thought Process: linear, content, relevant; Thought Content : Denied SIHI, denies AVH (Audio Visual Hallucinations), no active delusions AOX4; Judgment: Poor ,Impulsive: Intelligence: within normal range. A physical examination was completed. The diagnostic impression was: Axis 1- Major Depression with SI; Axis -2 Deferred; Axis3: per ED ROS; and Axis 4- moderate to severe. The plan/ recommendations were listed as, 1. Stabilize patient medically, 2. Optimize psych psychotropic medications; 3. Evaluate for discharge disposition placement. This note was electronically signed by the psychiatrist on 4/4/2019 at 10:07 a.m.

Review of the transfer form for Patient #46 revealed the patient was accepted to a (name of Behavioral Health Hospital) on 4/4/2019 at 1:27 p.m. The reason for transfer was listed as, "Service that patient requires is not available at TRMC." The patient was transferred to the named behavioral health hospital via law enforcement.

A review of the facility's Bed Census dated April 3, 2019 revealed that 3 psychiatric beds were available on 4/3/2019. A review of the facility's on-call schedule for psychiatry verified that on April 3, 2019 and on April 4, 2019, a psychiatrist was on call for the ED

Interviews
An interview was conducted on 4/15/2019 at 11:05 a.m. with the interim Director of Nursing (#23). The Interim Director of Nursing stated that we do not accept psychiatric patients who have violent tendencies.

On 4/17/2019 at 11:20 a.m., the Medical Staff Chief Physician (21) of the hospital's psychiatric unit was interviewed. Physician 21 reported the hospital's psychiatric inpatient unit does not admit patients exhibiting violent behaviors. When asked what was difference in the management between a psychiatric patient in the ED exhibiting violent behavior, and a patient in the inpatient psychiatric unit who exhibits violent behaviors? Physician 21 reported that staff can move the patient to the observation room and put additional staff with the patient. Physician 21 also stated that if patient becomes violent or is identified as having a history of violence, it is in our policy as an exclusionary criteria, and we do not admit the patient (s) to the psychiatric unit. He stated that if a patient attacks someone, "Zero tolerance", and we will call the Sheriff.

An interview was conducted on 4/18/2019 at 1: 40 p.m. with the Nurse Manager (#24) of the Behavioral Health Unit (BHU). She stated that some exclusionary reasons for not admitting a patient to the BHU from the hospital's ED would be, if the patient has previous history of aggressive behavior, substance abuse, or used an assistive device.

An interview was conducted with ED Director #1 on 4/18/2019 at 1:51 p.m. regarding Patient #46. The ED Director stated that Patient #46 presented to the TRMC emergency room because he was punching other patients. The ED Director also stated that Patient #46 was not a candidate for admission to TRMC's Behavioral Health Unit because the patient was combative.

The facility failed to admit 2 (Patient #37 and Patient #46) psychiatric patients to their inpatient Behavioral Health Unit for psychiatric services when the hospital's BHU had the capacity (Psychiatric Beds) and the capability (Psychiatrists) to admit these 2 patients, to minimize the risks of these individuals health.