HospitalInspections.org

Based on document review and staff interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure a medical screening exam to determine whether or not an emergency medical condition existed, appropriate to the individual's presenting signs and symptoms, was provided for an individual with psychiatric complaints who presented to the emergency department. (A-2406)

2. The Hospital failed to ensure that 1:1 care was provided for a patient at risk for suicide, to prevent the patient from eloping. (A-2407)

Based on document review and interview, it was determined that for 1 of 6 (Pt #1) clinical record reviewed for individuals who presented to the Hospital's emergency department (ED) with psychiatric complaints, the Hospital failed to ensure a medical screening exam to determine whether or not an emergency medical condition existed, appropriate to the individual's presenting signs and symptoms, was provided for an individual with psychiatric complaints who presented to the emergency department.

Findings include:

1. On 11/30/2021, the Hospital's policy titled, "EMTALA [Emergency Medical Treatment and Labor Act]" was reviewed. The policy required, "...IV. Policy: If an individual comes to the Emergency Department... The Hospital shall provide a medical screening examination... examination of the patient by the Qualified Medical Person required to determine within reasonable clinical confidence whether an emergency medical condition does or does not exist. The examination should be tailored to the patient's complaint, and depending on the presenting symptoms, the medical streening examination may represent a spectrum ranging from a simple process involving a brief history and physical examination, to a complex process that also involves performing ancillary studies and procedures. 3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred..."

2. On 11/29/2021, Pt. #1's clinical record was reviewed. Pt. #1 presented to the Emergency Department (ED) on 10/27/2021 at 4:52 PM. Pt #1 arrived to the ED from a nursing home via ambulance with a petition for involuntary psychiatric admission, sent from the nursing home.

- Pt #1's Facesheet (patient's demographics) included that Pt #1 was assigned a legal guardian, and the guardian's name and contact telephone number were listed.

- Pt #1's clinical record included the petition for [psychiatric] involuntary/judicial admission, sent with Pt #1 from the nursing home to the ED, completed and signed by the Social Worker at the nursing home and dated 10/27/201. The petition included, " ...I assert that [Pt. #1] is: a person with mental illness who; because of his or her illness is reasonably expected, unless treated on an inpatient basis to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed ...in need of immediate hospitalization for the prevention of such harm ...[Pt. #1] is a female with a diagnosis of Adult Failure to Thrive, Schizoaffective disorder - bipolar type, Schizoaffective - depressive type and restlessness and agitation ...[Pt. #1] is in need of immediate hospitalization to prevent harm to herself and others."

-The ED nursing note, dated 10/27/2021 at 7:29 PM, authored by a Registered Nurse (E #2), included, "1900 [7:00 PM] brought to er [emergency room] for psych [psychiatric] evaluation with petition from nursing home. pt is very aggressive to staff. throwing tray and linen to nursing home staffs. upon arrival, pt refused to be touched for vital signs and tried to hit er tech. unable to get vital signs and unable to redirect. md aware." The triage note documented Pt #1's acuity: 2 - Emergent.

- Pt #1's vital signs, obtained at 8:01 PM, were stable: temperature - 36.6, pulse - 76, respiratory rate - 16, blood pressure - 138/70, oxygen saturation - 96% on room air.

- The ED Physician's (MD #1) note, dated 10/27/2021 at 8:44 PM, included, "Chief Complaint: psych evaluation. History of Present Illness: "...presents with flight of ideas and labile behavior. She is yelling at staff and asking to "get the [profanity] out." Hx [history] of similar presentation. Project impact [contracted psychiatric assessment service] attempted to evaluate but the patient is not cooperative and history is difficult to discern. I attest that all medical, family, social, surgical, allergy histories available to me have been reviewed and unless noted are noncontributory to today's presentation. No additional modifying factors/ Acute on chronic severe issues. Review of Systems [ROS]: Additional ROS info: Except as noted in the above ...all other systems have been reviewed and are negative or noncontributory." The physical exam included, "Able to ambulate. Partial right mid-foot amputation... Neurologic: A/Ox3 [alert and oriented to person, place, time]. Psychiatric: Labile screaming at staff and claiming security is molesting her."

- MD #1's laboratory test orders, dated and timed 10/27/2021 at 7:56 PM, included Rapid COVID test; urinalysis; alcohol level; urine drug screen; complete blood count; and a comprehensive metabolic panel. However, the clinical record indicated that none of these lab tests were completed.

- MD #1's medication orders, dated and timed 10/27/2021 at 8:31 PM, included Benadryl (antihistamine) 50 mg IM (intramuscular injection); Ativan (anti-anxiety) 2 mg IM; and Haldol (antipsychotic) 5 mg IM. However, the clinical record indicated that none of these medications were given to Pt #1.

- MD #1's medical decision making note, documented at 8:34 PM, included, " ...Security to remove the patient [Pt. #1]." The reexamination/reevaluation included, "CPD [Chicago Police Department] escorted patient [Pt. #1] out of the ER and off hospital property." The assessment/plan included, "1. Labile personality - orders: discharge patient [Pt. #1]."

-The Physician order, dated 10/27/2021 at 8:39 PM, signed by MD #1, included an order to discharge home. Pt #1 was discharged on 10/27/2021 at 8:41 PM to self.

- MD #1's MSE lacked review of the petition for [psychiatric] involuntary/judicial admission sent with Pt #1; review of the patient's history that included Pt #1 was from a nursing home and had a Guardian who was responsible for being informed and consenting to/refusing Pt #1's treatment; a psychiatric evaluation; and completion of ordered labs and medication administration to determine whether or not an emergency medical condition existed prior to discharging Pt #1.

- The ED physician note, authored by MD #1, dated 10/27/2021 at 11:02 PM (post patient discharge note), documentation included, "[Nursing home] called patient apparently had petition for psychiatric placement. Was not reported to night staff or myself. CPD contact to find patient and return them to the ED."

3. The Hospital's incident report regarding Pt #1, dated 10/27/2021, included documentation that Pt. #1 was "accidentally discharged", without knowledge of psychiatric petition and certification from the nursing home.

4. On 11/29/2021 at 1:38 PM, an interview was conducted with an Emergency Department Physician (MD #1). MD #1 stated that he performed a medical screening examination, Pt. #1 was alert and oriented to person, place, and time and was discharged upon Pt. #1's request. MD #1 stated that he was not made aware that Pt. #1 was from a nursing home with a petition for a psychiatric evaluation until after Pt. #1 was discharged. MD #1 stated that he was not made aware that Pt. #1 had a guardian until today (11/29/2021). MD #1 stated that it is the responsibility of the Emergency Department staff to review the patient record when a patient comes from another Facility.

Based on document review and interview, it was determined that for 1 of 1 suicidal patient (Pt. #3) who eloped from the Emergency Department (ED), the Hospital failed to ensure further medical examination and treatment to stabilize the medical condition, inlcuding adequate monitoring of the patient, was provided prior to the patient leaving the Hospital, in order to prevent injury to self or others.

Findings include:

1. On 11/30/2021, the Hospital's policy titled, "EMTALA [Emergency Medical Treatment and Labor Act]" was reviewed. The policy required, "...IV. Policy: If an individual comes to the Emergency Department...B. 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 facility in accordance with the procedures set forth below...Medical screening Examination...2...The examination should be tailored to the patient's complaint...3. Monitoring must continue until the individual is stabilized or appropriately admitted or transferred..."

2. On 12/1/2021, the Hospital policy titled, "Constant Observer Assessment, Implementation, and Discontinuation," revised 9/2019, was reviewed. The policy required, "IV. Procedure... A. Assessment of Patient... e. Constant Observer [one staff member to one patient observation] is ordered by a physician for behavioral health... Suicidal and/or homicidal ideation and or gestures or hopelessness..."

3. On 11/30/2021, Pt. #3's clinical record was reviewed. Pt. #3 arrived in the ED on 7/26/2021, with complaints of alcohol intoxication and drug overdose. A Behavioral Health Case Management note, dated 7/26/2021 at 5:01 PM, included, "... Patient gave verbal consent to contact therapist. When contacted, therapist stated that Patient has been drinking for at least 12 hours, that Patient already might have taken some pills and that Patient has been making statements that it is time to join his recently deceased partner. CW [Crisis Worker] conferred with RN... and MD... and both agree that Patient requires immediate hospitalization for safety and stability."

- Pt. #3's Medical Screening Exam, dated 7/26/2021 at 8:00 PM, included, "... Per EMS [Emergency Medical Services], patient's therapist states patient... endorses suicidal thoughts, has been drinking for the past 24 hours and may have taken some pills... Patient eloped from the ED..." Pt. #3's ED clinical record lacked documentation of an order for patient safety monitoring.

- Pt. #3's Disposition Document, dated 7/26/2021 at 6:27 PM, included, "Left against medical advise [AMA]." Pt. #3's clinical record lacked an Against Medical Advise form.

4. On 12/1/2021 at 9:30 AM, an interview was conducted with the ED Manager (E #1). E #1 stated that Pt. #3's gurney was in the ED hall so staff could easily observe Pt. #3. E #1 did not know why Pt. #3's disposition was AMA instead of elopement. E #1 stated Pt. #1 should have been on one to one monitoring.