HospitalInspections.org

A2400
Based on record review and interview the facility failed to abide by the provider's agreement that required a hospital to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements, citing 1 of 20 patients (Patient #1) that presented to the emergency department (ED) on 3/16/2021.

Findings included

Cross Refer to Tag 2409

Based on record review and interview, the facility failed to initiate and secure an appropriate transfer to a higher level of care for 1 of 20 patients (Patient #1) who presented to the emergency room on 3/16/2021 after a suicide attempt.

Findings included

Patient #1 was allowed to leave the initial hospital with police. The patient was taken for further psychiatric evaluation by the police to a second hospital which provides psychiatric inpatient care.

The facility's process of waiting for Behavioral Health Assessors to evaluate and place the patient contributed to Patient #1's delayed care and treatment.

There was no physician discharge or transfer order for Patient #1.

There was no accepting hospital/physician obtained for permission to transfer Patient #1.

There was no transfer documentation for Patient #1.

There was no physician to physician report for Patient #1.

There was no documentation of risks and benefits of transfer for Patient #1.

There was no medical record sent with Patient #1.

The facility's printed records for Patient #1 reflected,

"~ 3/16/2021 17:58 (PM) ...Arrival: (Named Ambulance) EMS ...

~ Orders Placed: 18:12 Self- Harm Precautions; Direct Observation Harm to Self and Others...Suicide Risk Level: High ...

~ ED (Emergency Department/ER/Emergency Room) Provider Notes by Personnel #6 at 3/16/2021 19:00 (PM)...presenting with suicidal ideation and attempt. Per EMS...doesn't have anything to live for...tried to cut her wrist with a knife but could not go deep enough...drinking wine and taking some Tylenol...denies taking a large amount...reports desire to end her life...protective custody per police ...past medical history: Bipolar 1 disorder, depressed...review of systems...positive for self-injury, suicidal thoughts, thought of violence. High stress level and depressed mood. Negative for agitation. The patient is nervous/anxious...

Physical Exam...appears distressed...Tachycardia...alert and oriented to person, place, and time...Laceration noted...superficial laceration to left wrist, approx. 2 cm (centimeters), does not appear amenable to suturing...Psychiatric: Her mood appears anxious. Her speech is rapid and/or pressured. She is agitated. Cognition and memory are impaired. She expresses impulsivity. She exhibits a depressed mood. She expresses suicidal ideation. She expresses suicidal plans...

18:40 (PM) discussed with poison control...awaiting remainder of labs...(Behavioral Health Assessor) consult...19:00 (PM) ETOH (Alcohol level) 193 (High)...will require 4 hour Tylenol level either way...

19:45 (PM) Patient agitated, requesting to leave, currently on a APOW (apprehension without warrant) with police, pt awake, alert, oriented, but agitated and cursing. Threatening staff, nursing removed patients IV (intravenous catheter), Police now on scene discussing with patient regarding emergency detention order, pt continues to decline treatment here and requesting to leave, police to take in custody to (second hospital)...Patient left with a disposition of law enforcement...

~ ED Notes by Personnel #8 at 3/16/2021 19:48 (PM)...Patient became aggressive and Bowing up to sitter...(Personnel #6) at bedside and explained process of behavioral health assessment and gave orders for IV Ativan. Patient refusing Ativan at this time unless it is going to knock me out I don't want it. Patient states I have been here for hours and they haven't done a f***ing thing. I want to leave. I am not sitting here any longer and waiting for whatever help they say is coming...

Three (named) PD officers at bedside explaining to patient that she is under emergency detention and processes related to psych evaluation. Patient states I want my belongings and I want to walk out of here...

Patient states then take me to jail because I don't want to be here. I am a saucy Italian girl and I would rather be in jail than to have to put up with this s**t that isn't helping. All I want is help and they won't do anything...Patient given ultimatum by (named) police said if she is refusing care at this hospital they would take her to (names second hospital)..."

During a return call/interview on 3/29/2021 ending at 7:50 PM, Officer #2 was asked if he was given Patient #1's medical records to give to the second hospital/ or patient discharge paperwork. Officer #2 stated, "No, I was not provided any paperwork. Nothing was given to us. I did transport her to (named second hospital)."

During a telephone interview on 3/30/2021 at 3:12 PM, Personnel #6, Physician was asked what the Emergency Detention Order means. Personnel #6 stated, "For us - considering her psychiatrically - essentially she can't leave or be able to leave until she isn't a harm to self or others."

Personnel #6 was asked if she completed a Medical Screening examination on Patient #1 to determine the existence of any emergency medical condition including psychiatric issues on 3/16/2021. Personnel #6 stated, "Yes. Completed - I felt the patient needed further Psych eval - we use Behavioral Health - to determine. We were still waiting for that (eval) to be done when they started telling me she was refusing care.

Charge came and said she refused care, but that we were not able to force her to stay. Charge told me that if she (Patient #1) agreed to go to (named second hospital), it would be fine. On a protective order, she can't go home. I said we can't just let her leave. Charge said we can't keep her here. I said I think we are supposed to.

Police showed up. Police explain to her she couldn't leave - have to be psychiatrically cleared - unless you want to go to (named second hospital) - she was under the protective order and it would still be in effect for (named second hospital). They said it was like a transfer. They said it would be fine."

Personnel #6 was asked if Patient #1 was psychologically cleared for discharge, admission, or transfer on 3/16/2021. Personnel #6 stated, "definitely thought she would need some kind of inpatient psychiatric care."

The facility's 1/06/2020, effective date "Care of Patients with Behavioral Health Emergencies - ED" required, "Involuntary detention order - the practice of using legal means as part of the Texas law to commit a person to psychiatric facility or the like

against their will or over their protests for observed behavior constituting a clear and present danger to the individual and or others. This may include actual or attempted substantial self-injury, attempted or inflicted serious bodily harm to another, acting in a manner that indicates a person may not be able to care for him herself without assistance, attempting suicide or showing high risk of suicide...Apprehension by Peace Officer without Warrant (APOWW) - enacted by and on active duty a licensed peace officer...Medical clearance - the process required to reach the point, with reasonable clinical confidence, at which remaining medical problems are treatable on an outpatient, non-emergent basis. This is the point at which it is

medically appropriate to discharge the patient from either the ED or transfer to a psychiatric facility."