HospitalInspections.org

Based on document review and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to follow the CAH's policies and did not provide an appropriate medical screening examination, stabilizing treatment or appropriately transfer 1 ED patient (Patient #1) who presented to the ED with an emergency, out of 61 cases selected for review from November 2010 to March 2011. The CAH administrative staff identified an average of 534 emergency department visits per month.

Failure to provide an appropriate exam, stabilizing treatment or appropriate transfer could potentially result in disability, loss of limb, or death in a patient with an emergency.

Findings include:

1. Review of the medical record revealed a 43 year old patient (# 1) presented to the ED by ambulance on 12/22/10 at 12:58 PM. Upon arrival to the ED, the nurse documented patient (#1) stated he "took a bunch of Kepra and Tegretol" at approximately 9:30 AM. The patient's wife found him and reported the patient was impaired last night - all week. The patient's wife reported some of her soma and amitriptyline pills were gone. The ED physician was in the ER on patient arrival. At 1:55 PM, the ED nurse documented the social worker was present.

At 2:30 PM, the social worker documented the patient's wife reported the patient OD [overdosed] all week and today threatened to shoot himself. The social worker documented the patient's assessment included the patient's gait as unsteady; posture as slouched and shaky; motor as tremors, slow/retarded; mood as despairing, depressed, and stupor; affect as flat; speech as mumbled and whispered; perception as paranoid; thoughts as disoriented, suicidal, and 'wants to die'; sensorium as stupor; orientation as disoriented. The social worker documented the evaluation of the patient's suicide risk included a prior attempt and use of guns, the patient verbalized suicidal ideations and a plan - the family locked up the guns.

The social worker documented summary of findings as patient appears very depressed and reports he wants to die. The social worker recommended inpatient admission, as he was a danger to self and that the patient needed court committal to an inpatient mental health facility.

The ED physician examined the patient and documented the patient stated he took some pills and had a shot gun that he was waving around. There was a threat or a concern of doing harm to himself and others, but he was quieted down and brought into the Emergency Room for treatment. The ED physician documented the patient's urine drug of abuse screen was positive for tricyclic antidepressants. At 4:00 PM the ED physician consulted with the CAH's "on call" physician (as required by the CAH's transfer policy) and at 4:28 PM documented the name of the physician at Hospital B accepting Patient # 1's transfer. At 6:24 PM (time of transfer) the medical record showed Patient # 1's oxygen saturation had dropped to 88% and his blood pressure decreased with a concomitant increase in his heart rate.

2. Review of [Hospital B's] medical record for Patient #1 revealed CAH ED RN A gave report to Hospital B staff that Patient # 1 was leaving per law enforcement, patient ambulates on own with a slightly staggering gate.

The admission note from Hospital B showed the patient was unable to stand or walk, had slurred speech, and had a hard time sitting up.

3. During an interview on 3/15/11 at 10:00 AM, ED Registered Nurse (Registered Nurse) A reported that Patient #1 presented by ambulance with chief complaint that he took pills. RN A stated the patient was responsive and cooperative and a social worker came to talk to the patient due to his suicide attempt. RN A stated she did not contact Poison Control per the CAH policy/procedure prior to Patient # 1's transfer since they did not know what and how many pills he actually took.

RN A acknowledged it would be standard of practice to contact Poison Control when a patient came into the ED with a drug overdose.

4. During an interview on 3/10/11 at 3:15 PM, the Chief Nursing Officer stated it is their policy/procedure to call Poison Control when a patient comes into the ER with a drug overdose.

5. During an interview on 3/14/11 at 7:45 PM, ED Physician A stated the ED staff always call Poison Control for a patient with an overdose but does not recall if the ED staff called Poison Control for Patient #1.

6. During an interview on 3/10/11 at 3:15 PM, the Director of Emergency Department/EMS, the Chief Nursing Officer and the Director of Quality Services revealed the CAH had the capability to perform a Tegretol level and monitor patients that had overdosed in the ICU.

7. During an interview on 3/15/11 at 1:30 PM, the Chief Nursing Officer reported the CAH had a 2 bed intensive care unit and staff capable of providing comprehensive monitoring of critically ill adult patients including drug overdose cases. Review of the 12/22/10 inpatient census for the Intensive Care Unit revealed 2 available beds (census of 0 patients).

8. During an interview on 3/10/10 at 11:50 AM, Physician B, the CAH's 12/22/10 on-call physician, stated ED Physician A did not tell him what combination of drugs Patient #1 ingested and agreed to the transfer of Patient #1 to Hospital B without knowing what combination of drugs the patient had ingested. Physician B also reported, after review of Patient #1's medical record, Physician A did not identify all the potential problems for Patient #1 who had taken an overdose of medications.

9. Review of the policy titled "EMTALA Policy - Emergency Examination/Medical Screen & Transfer Policy", dated reviewed/revised 1/10, revealed in part, "Any individual who presents to the dedicated emergency department of Greater Regional Medical Center and who requests, or on whose behalf a request, for examination or treatment for a medical condition is made, shall receive a medical screening examination . . . within the capacities of GRMC, including ancillary services routinely available to the hospital emergency department to determine whether or not a emergency medical condition exists. . . Transfer to another acute care medical facility is appropriate only after the completion of a medical screening examination and the physician has determined that: the emergency medical condition has been stabilized. . . . Contracted Physician's providing coverage will consult the "on call" physician about the patient to be transferred. The contracted physician in attendance at the time of transfer will document on the ER record that the "on call" physician was consulted and concurs with the transfer. . . . The transportation must be effected through use of qualified personnel and transportation equipment, including necessary and medically appropriate life support measures and documented as such. . . ."

Review of the policy titled "Treatment of Intentional or Accidental Poisoning/Overdose", dated reviewed/revised 4/09, revealed in part, "Policy: To provide emergency care to patients presenting with intentional overdose or accidental poisoning. Procedure: ER Staff will contact the Iowa Statewide Poison Control Center . . . for recommended treatment of poisonous substance or overdose patients. It will be documented on the ER record that Poison Control was contacted. Poison Control recommendation for treatment and monitoring of patient must be documented on ER record. Any faxed information received from the Poison Control Center will become part of the patient's ER chart. ER staff will notify on call ER physician of recommendation of Poison Control and proceed as directed by Physician."

Review of the policy/procedure titled "Patients Treated in the Emergency Department", dated reviewed/revised 4/09, revealed in part, "Other services provided by Greater Regional Medical Center on a 24 hour basis and are integrated with the Emergency Department are laboratory, radiology services, the operating room, obstetrics, and intensive care unit."

The CAH ED staff failed to follow these policies and did not contact Poison Control for recommendations to monitor and treat a patient (# 1) who had overdosed, failed to provide stabilizing treatment within their capabilities including an incomplete assessment by the on call physician responsible for concurring with the transfer, and failed to ensure Patient #1's safe transfer.

Refer to tag A 2406, A 2407, and A 2409 for further details.

Based on document review and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to provide an appropriate medical screening examination for 1 ED patient (Patient #1) who presented to the ED, out of 61 cases selected for review from November 2010 to March 2011. The CAH administrative staff identified an average of 534 emergency department visits per month.

Failure to provide an appropriate exam could potentially result in disability, loss of limb, or death in a patient with an emergency.

Findings include:

1. Review of the medical record revealed a 43 year old patient (# 1) presented to the ED by ambulance on 12/22/10 at 12:58 PM. Upon arrival to the ED at 12:58 PM, the nurse documented patient (#1) stated he "took a bunch of Keppra and Tegretol" at approximately 9:30 AM. The patient's wife found him and reported the patient was impaired last night - all week. The patient's wife reported some of her soma and amitriptyline pills were gone. The ED physician was in the ER on patient arrival. At 1:55 PM, the ED nurse documented the social worker here.

AT 2:30 PM, the social worker documented the patient's wife reported the patient OD [overdosed] all week and today threatened to shoot himself. The social worker documented the patient's assessment included the patient's gait as unsteady; posture as slouched and shaky; motor as tremors, slow/retarded; mood as despairing, depressed, and stupor; affect as flat; speech as mumbled and whispered; perception as paranoid; thoughts as disoriented, suicidal, and 'wants to die'; sensorium as stupor; orientation as disoriented. The social worker documented the evaluation of the patient's suicide risk included prior attempt and method of guns, the patient verbalizes suicidal ideations and plan - the family locked up guns.
The social worker documented summary of findings as patient appears very depressed and reports he wants to die. The social worker recommended inpatient admission, as he was a danger to self. Patient needs court committal to inpatient mental health facility.

The ED physician examined the patient and documented the patient stated he took some pills and had a shot gun that he was waving around. There was a threat or a concern of doing harm to himself and others, but he was quieted down and brought into the Emergency Room for treatment. The ED physician documented the patient's urine drug of abuse screen was positive for tricyclic antidepressants. At 4:00 PM the ED physician consulted with the CAH's "on call" physician (as required by the CAH's transfer policy) and at 4:28 PM documented the name of the physician at Hospital B accepting Patient # 1's transfer. At 6:24 PM (time of transfer) the medical record showed Patient # 1's oxygen saturation had dropped to 88% and his blood pressure decreased with a concomitant increase in his heart rate.

Patient #1's medical record showed ED staff failed to contact Poison Control to obtain information regarding Keppra, Tegretol, Amitriptyline, and Soma overdose or to obtain the necessary lab tests to determine the amount of medications, including Tegetrol, the patient had ingested.

2. During an interview on 3/15/11 at 10:00 AM, CAH ED Registered Nurse (Registered Nurse) A reported that Patient #1 presented by ambulance with chief complaint that he took pills. RN A stated the patient was responsive and cooperative and a social worker came to talk to the patient due to his suicide attempt. RN A stated she did not contact Poison Control per the CAH policy/procedure since we did not know what and how many pills the patient actually took.

RN A acknowledged it would be standard of practice to contact Poison Control when a patient came into the ED with a drug overdose.

3. During an interview on 3/14/11 at 7:45 PM, ED Physician A stated the ER staff always call Poison Control for a patient with an overdose but does not recall if the ER staff called Poison Control for Patient #1. Physician A stated if it was not documented in the patient's medical record that a Tegretol level was not done, then he did not order one.

4. According to the statutorily mandated QIO physician peer review completed on 3/25/11, the hospital failed to provide patient #1 with an appropriate exam.

Based on review of policies/procedures, patient medical records, documents, and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to provide stabilizing treatment within its capabilities prior to transferring a patient (patient # 1) with an unstable emergency medical condition. The CAH administrative staff identified an average of 534 emergency room visits per month.

Failure to provide stabilizing treatment within the CAH's capabilities for a patient with an unstable emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications including death.

Findings include:

1. Review of the medical record revealed a 43 year old patient (# 1) presented to the ED by ambulance on 12/22/10 at 12:58 PM. Upon arrival to the ED at 12:58 PM, the nurse documented patient (#1) stated he "took a bunch of Kepra and Tegretol" at approximately 9:30 AM. The patient's wife found him and reported the patient was impaired last night - all week. The patient's wife reported some of her soma and amitriptyline pills were gone. The ED physician was in the ER on patient arrival. At 1:55 PM, the ED nurse documented the social worker here.

At 2:30 PM, the social worker documented the patient's wife reported the patient OD [overdosed] all week and today threatened to shoot himself. The social worker documented the patient's assessment included the patient's gait as unsteady; posture as slouched and shaky; motor as tremors, slow/retarded; mood as despairing, depressed, and stupor; affect as flat; speech as mumbled and whispered; perception as paranoid; thoughts as disoriented, suicidal, and 'wants to die'; sensorium as stupor; orientation as disoriented. The social worker documented the evaluation of the patient's suicide risk included prior attempt and method of guns, the patient verbalizes suicidal ideations and plan - the family locked up guns.
The social worker documented summary of findings as patient appears very depressed and reports he wants to die. The social worker recommended inpatient admission, as he was a danger to self. Patient needs court committal to inpatient mental health facility.

The ED physician examined the patient and documented the patient stated he took some pills and had a shot gun that he was waving around. There was a threat or a concern of doing harm to himself and others, but he was quieted down and brought into the Emergency Room for treatment. The ED physician documented the patient's urine drug of abuse screen was positive for tricyclic antidepressants. At 4:00 PM the ED physician consulted with the CAH's "on call" physician (as required by the CAH's transfer policy) and at 4:28 PM documented the name of the physician at Hospital B accepting Patient # 1's transfer. At 6:24 PM (time of transfer) the medical record showed Patient # 1's oxygen saturation had dropped to 88% and his blood pressure decreased with a concomitant increase in his heart rate.

2. Review of information obtained by the surveyor from the Iowa Statewide Poison Control Center on 3/16/11 at 3:06 PM revealed the following:

a. Laboratory/Monitoring - Monitor mental status, pulse oximetry and initiate continuous cardiac monitoring. Obtain an initial carbamazepine [Tegretol] serum concentration every 4 hours until the concentration has peaked and is clearly declining. Obtain an EKG upon initial evaluation and repeat every hour following a significant overdose. Patient #1's medical record lacked documented evidence the ED staff obtained a Tegretol level or performed an EKG.

b. Treatment Overview - Absorption can be prolonged as long as 24 hours after a large overdose or an ingestion of a sustained-release formulation. Toxicity typically resolves within 48 hours, however, large ingestions with prolonged absorption may have a longer course.

The CAH's ED staff failed to admit Patient #1 to the CAH's ICU for close monitoring and serial Tegretol levels as recommended by the Poison Control Center.

3. During an interview on 3/16/11 at 3:06 PM, the Director of Iowa Poison Control Center stated the Poison Control Center is available 24 hours a day, 7 days a week, 365 days per year for consultation. The Poison Control Center staff can readily recognize drug to drug interactions and provide expert consultation for recommendations for appropriate stabilizing treatment.

4. During an interview on 3/10/11 at 3:15 PM, the Chief Nursing Officer stated it is policy/procedure to call Poison Control when a patient comes into the ER with a drug overdose.

5. During an interview on 3/10/11 at 3:15 PM, the Director of Emergency Department/EMS, the Chief Nursing Officer and the Director of Quality Services revealed the CAH has the capability to perform a Tegretol level and monitor patients that have overdosed in the ICU.

6. During an interview on 3/15/11 at 1:30 PM, the Chief Nursing Officer revealed the CAH had a 2 bed intensive care unit capable of providing comprehensive monitoring to critically ill adult patients including drug overdose cases. Review of the 12/22/10 inpatient census for the Intensive Care Unit revealed 2 available beds (census of 0 patients).

7. During an interview on 3/10/11 at 11:50 AM, the Emergency Room Medical Director stated the medical treatment of a patient that presented to CAH's ED with a possible Tricyclic overdose would include admission to the CAH's ICU for close observation.

8. During an interview on 3/10/10 at 11:50 AM, Physician B, the CAH's 12/22/10 on-call physician, stated ED Physician A did not tell him what combination of drugs Patient #1 ingested and agreed to the transfer of Patient #1 to Hospital B without knowing what combination of drugs the patient ingested. Physician B also reported, after review of Patient #1 medical record, Physician A did not identify all the potential problems for Patient #1 who had taken an overdose of medications.

9. During an interview on 3/15/11 at 10:00 AM, CAH ED Registered Nurse (Registered Nurse) A reported that Patient #1 presented by ambulance with chief complaint that he took pills. RN A stated she did not contact Poison Control per the CAH policy/procedure since staff did not know what and how many pills the patient actually took. RN A acknowledged it would be standard of practice to contact Poison Control when a patient came into the ER with a drug overdose.

10. During an interview on 3/14/11 at 7:45 PM, ED Physician A stated the ER staff always call Poison Control for a patient with an overdose but does not recall if the ER staff called Poison Control for Patient #1.

11. According to the statutorily mandated QIO physician peer review completed on 3/25/11, the hospital failed to provide patient #1 with stabilizing treatment and failed to admit the patient to an available ICU bed for close monitoring.

Based on review of policies/procedures, documents, patient medical records, and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to arrange an appropriate transfer for an individual (Patient # 1) with an unstable emergency medical condition as required. The hospital identified an average of 18 emergency room transfers per month.

Failure to arrange an appropriate transfer for a patient with an unstable emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications including death.

Findings include:

1. Review of the medical record revealed a 43 year old patient (# 1) presented to the ED by ambulance on 12/22/10 at 12:58 PM. Upon arrival to the ED at 12:58 PM, the nurse documented patient (#1) stated he "took a bunch of Kepra and Tegretol" at approximately 9:30 AM. The patient's wife found him and reported the patient was impaired last night - all week. The patient's wife reported some of her soma and amitriptyline pills were gone. The ED physician was in the ER on patient arrival. At 1:55 PM, the ED nurse documented the social worker here.

At 2:30 PM, the social worker documented the patient's wife reported the patient OD [overdosed] all week and today threatened to shoot himself. The social worker documented the patient's assessment included the patient's gait as unsteady; posture as slouched and shaky; motor as tremors, slow/retarded; mood as despairing, depressed, and stupor; affect as flat; speech as mumbled and whispered; perception as paranoid; thoughts as disoriented, suicidal, and 'wants to die'; sensorium as stupor; orientation as disoriented. The social worker documented the evaluation of the patient's suicide risk included prior attempt and method of guns, the patient verbalizes suicidal ideations and plan - the family locked up guns. The social worker documented summary of findings as patient appears very depressed and reports he wants to die. The social worker recommended inpatient admission, as he was a danger to self. Patient needs court committal to inpatient mental health facility.

The ED physician examined the patient and documented the patient stated he took some pills and had a shot gun that he was waving around. There was a threat or a concern of doing harm to himself and others, but he was quieted down and brought into the Emergency Room for treatment. The ED physician documented the patient's urine drug of abuse screen was positive for tricyclic antidepressants. At 4:00 PM the ED physician consulted with the CAH's "on call" physician (as required by the CAH's transfer policy) and at 4:28 PM documented the name of the physician at Hospital B accepting Patient # 1's transfer. At 6:24 PM (time of transfer) the medical record showed Patient # 1's oxygen saturation had dropped to 88%, his blood pressure decreased with a concomitant increase in his heart rate and that he was transported to Hospital B in a car by law enforcement.

Patient #1's medical record showed ED staff failed to contact Poison Control and failed to treat and stabilize the changes in his oxygen saturation, blood pressure and heart rate prior to transporting to Hospital B.

2. According to the statutorily mandated QIO physician peer review completed on 3/25/11, the hospital failed to arrange an appropriate transfer. The patient required transport in an ambulance that had advanced life support capabilities, including immediate access to medications, cardiac monitoring, oxygen, and life support equipment.