HospitalInspections.org

Based on document review, record review, policy review and interview the Hospital failed to ensure the emergency medical treatment and labor act (EMTALA) requirements were met by failing to provide stabilizing treatment to a patient who presented to the emergency department seeking medical care for an emergency medical condition (EMC). Failure to provide stabilizing treatment places patients at risk for unidentified emergency medical conditions resulting harm and injury up to an including death.

Findings Include:


The hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking emergency medical care. (Refer to tag A2407)

Based on record review, document review and interview the Hospital failed to provide stabilizing treatment for 1 of 20 patients (Patient 1) who presented to the emergency department seeking medical care. Failure to provide stabilizing treatment has the potential to place patients at risk for deterioration of the emergency medical condition (EMC) causing harm or injury up to and including death.

Findings Include:

Review of a document titled, "Medical Staff Rules and Regulations" revised on 04/14/2011 showed, " ...Patients discharged from the ER will be provided with discharge instructions and, as needed, advised to obtain follow-up care with their primary care physician. If the patient does not have a primary care physician, the patient will be referred to the on-call physician. The patient shall be advised that, if he or she cannot obtain follow-up care or his or her condition worsens, the patient may return to the Emergency Room for care ...Emotionally ill / alcohol abuse / drug abuse patients shall receive: i. Medical Screening ii. Evaluation by Southwest Guidance Center or a Psychiatric consult, as ordered ..."

Review of a hospital policy titled, "EMTALA" revised 11/2022 showed, " ...To Stabilize" or "Stabilize" or "Stabilized" means: 1. With respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or discharge of the individual from the Hospital ... 2. The hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below ...E. Individuals Who Have An Emergency Medical Condition 1. If, after a medical screening examination, it is determined that an individual has an emergency medical condition, the Hospital must a. Within the capability and capacity of the staff and facilities available at the hospital (including coverage available through the hospital's on-call roster), provide treatment necessary to stabilize the individual, at which time the individual may be discharged; or b. Admit the individual to the hospital in order to stabilize the individual; or c.
If stabilization of the individual is beyond the capabilities or capacity of the hospital, arrange for appropriate transfer of the individual to another medical facility in accordance with this policy ..."

Patient 1

Review of Patient 1's, medical record showed, a 57-year-old, presented to the Emergency Department (ED) on 08/19/24 at 12:50 PM by private vehicle. Patient 1 was triaged at an Emergency Severity Index (ESI) 2 (Patients are very ill and at high risk. The need for care is immediate and an appropriate bed needs to be found. Usually, rather move to the next patient, the triage nurse determines that the charge nurse or staff in the patient care area should be immediately alerted that they have an ESI level 2). Chief complaint " ...[Staff] His behavior has been getting worse, He is hitting and scratching people. He was trying to wrap the seatbelt around his neck today. We want to get him evaluated ..."

Review of a document titled, "Emergency Department Physician Documentation" dated 08/19/24 at 3:53 PM showed, "Chief complaint: Mental Health Emergency Time Seen by Provider: 08/19/24 13:15 [1:15 PM] ...male with history of intellectual deficiency and behavior disorder brought to emergency department severe agitation screaming and yelling emergency department. Patient require physical and chemical restraint ...Patient agitation become under control with total 10 mg Zyprexa IM [intramuscular] ...I requested screening with [Community Mental Health agency] and patient signed out to night shift physician on shift change apparently patient apparently screen and discharge ..."

Review of a document titled "ED Notes" dated 08/19/24 at 1:19 PM showed, "Pt [sic] assisted in to bed with by x5 asst. [sic] Soft wrist restraints applied per [Staff I] and Zyprexa [atypical antipsychotic that may be used to treat adults and adolescents aged 13 and older with schizophrenia or bipolar I disorder] 5 mg IM given in left: deltoid. Pt [sic] continues to holler out. Lights dimmed to try to help the patient rest."

Review of a document titled "ED Notes" dated 08/20/24 at 4:03 PM showed, " ... Patient was screened by [Community Mental Health agency] and a safetly [sic] plan was made. This nurse went to speak with the [Patient Representative] about the patient and his safetly [sic] plan...[Patient Representative] explained that they couldn't take him back due to him being a safety risk to himself and safe [sic]. This nurse explained to the worker that this was understood but placement to [Mental Health Hospital] would not be appropriate due to his IDD [Intellectual disability] diagnoses per [Community Mental Health agency]. [Patient Representative] stated "[Mental Health Hospital] said that we were not to take him back until his mental health needs were met." This nurse explained to [Patient Representative] that this was not a mental health facility and that we have done everything we can to the best of our ability ..."

Review of a document titled "Mental Health Screening Form" dated 08/20/24 at 4:25 PM showed " ...III. Presenting Problem. Client is a 57-year-old male who was brought to the ED yesterday for physical aggression and self-abusive behavior. At the ED, client had to be chemically and physically restraint. Client was seen in the ED on 08/14/24 for verbal and physical aggression and self-abusive behavior and also required restraint however for a shorter duration. He was diverted back to [home] with a safety plan. Client has been unable to maintain with a safety plan. Yesterday, client wrapped a seat belt around his neck. Client has superficial abrasions on his face due to his self-abusive behavior. He scratched and hit staff members and hospital workers. Client has been throwing items and has been destructive to property. Client's current presentation is a change in his baseline level of functioning ..."

Further review of the "Mental Health Screening Form" showed, " ... both reports a significant change in clients functioning and symptoms. Client's current behaviors are outside of his baseline level of functioning. They expressed significant concern about the ability to maintain client safety and the safety of others. A safety plan has not been successful in maintaining client at a lower level of care. Client does meet criteria for inpatient hospitalization as client presents as current risk of harm to self, current risk of harm to others, and current destruction of property. Client does pose an imminent risk of harm to self or others as evidenced by clients acting out, physically aggressive behaviors directed towards self and others. Client will be referred for involuntary inpatient hospitalization as client lacks capacity to make an informed decision regarding care and treatment and is likely to cause harm to themselves or others in the foreseeable future. Written report will be provided to the ED for their records ..."

Review of a document titled, "State Hospital Application for Emergency Admission (for Observation and Treatment)" dated 08/20/24 at 4:25 PM showed, " ...I will file a petition seeking involuntary commitment of this person with the District Court of no later than close of business day on 08/21/24. I believe this patient to be a mentally ill person subject to involuntary commitment for care and treatment as defined in KSA 59-2946 (F) and is likely to cause harm to self or others if not immediately detained ..."

During an interview on 09/10/24 at 4:30 PM Staff B, CNO stated, " ...I wasn't aware of the court hold. Our gap here is we didn't read the paperwork from the Mental Health screener, and patient was already discharged ..."

During an interview on 09/10/24 at 6:25 PM Patient Representative (PR) 2, Licensed Masters Social Worker (LMSW) stated, " ...I had pulled a safety plan from a previous chart in case we were going to go that way just to be prepared to and that's not the way we went so the safety plan wasn't used ... and the last I knew we were waiting for placement at [Mental Health Hospital] the form was sent to the County Attorney and the County Attorney decided not to file the because [Patient 1] had been released back to his home ... the hospital didn't want to keep him there while they waited placement because it was a pretty long wait list ...the evaluation was faxed to the hospital at 5:34 PM ..."

During an interview on 09/11/24 at 9:30 AM PR 1, stated, " ...the client was in active psychosis not at baseline he was being very aggressive violent verbally explosive and so his provider recommended that we send him to the emergency room for evaluation so that they could get him into [Mental Health Hospital] so we did that we took him to the emergency room and they sedated him with medication he was sedated with medication and also physically restrained in four point restraints ... so he was sedated couldn't answer questions for the screener ... we were told that there was a waiting list and [Mental Health Hospital] confirmed that they received the referral and that he was 13th on the list and the emergency room told us we had to come get him so they discharged him ..."

Although there was significant concern about Patient 1's ability to maintain safety and the safety of others, safety plan had not been successful in maintaining at a lower level of care and Patient 1 met criteria for inpatient hospitalization as he posed an imminent risk of harm to self or others as evidenced by acting out, physically aggressive behaviors directed towards self and others, Patient 1 was discharged home on 08/20/24 at 5:53 PM.