HospitalInspections.org

Based on finding at A2406, the facility failed to ensure compliance with CFR 489.24.

Based on interview and record review, the facility failed to ensure an appropriate medical screening examination was conducted to rule out a psychiatric emergency for 1 of 45 sampled patients (Patient #11).

Findings include:

Patient #11 presented to the Emergency Department (ED) via an ambulance on 07/27/08 at 12:14 AM with a chief complaint of Depression and Anxiety.

The Nursing Physical Assessment dated 07/27/08 at 1:40 AM documented "...The patient appears to have altered thought processes (UNCOOPERATIVE)..."

The Nursing Progress Notes dated 07/27/08 at 2:13 AM documented "...Refused to use urinal. Physically confrontational..."

The Physician Clinical Report dated 07/27/08 at 12:14 AM documented "Chief Complaint - Delusional and Paranoid. This started yesterday. He has exhibited a sudden behavior change reported by the spouse. The patient has been angry and had mood swings and insomnia. No situational problems. Has no been eating or sleeping. The patient has had persecution delusions. The symptoms are described as severe. No injury is present."

The physician's clinical impression was "Acute psychosis with delusions."

Patient #11 was placed on a legal psychiatric hold 07/27/08 at 2:15 AM by a registered nurse due to "Patient states he's very depressed and anxious." The patient was medically cleared by the ED physician on 07/27/08 at 2:30 AM. The ED physician certified the patient has a mental illness and was a danger to self or others on 07/27/08 at 2:30 AM due to "Patient is acutely psychotic."

There was no documented evidence the patient had a psychiatric evaluation to rule out a psychiatric emergency condition.

On 07/27/08 at 4:40 AM, the facility completed a "Suicide Risk Factor Scale" which indicated a total score of 7. If the total score of 12 or greater, then the facility would initiate a case management referral for further assessment.

Patient #11 was transferred from the ED to a psychiatric hold area on 07/27/08 at 5:25 AM. The nursing progress note documented the patient was placed on suicide precautions with every 15 minute checks performed, clothing and valuables were removed. The psychiatric holding area was monitored with cameras and patient belongings were given to security. The patient reported moderate restlessness and anxiety. The patient reported moderate depression, denied suicidal ideation or plan, denied anger, headache or difficulty breathing. The patient's affect appeared normal, the patient appeared agitated with hyperactive body language.

On 07/27/08 at 7:04 AM, nursing documented the patient was calm and resting quietly.

On 07/27/08 at 9:10 AM, nursing documented the patient reported anxiety and restlessness. The patient was awaiting evaluation. The patient was Spanish speaking only and translation by security identified the patient had flight of ideas, confused and delusional "does not want to contaminate the world."

On 07/27/08 at 1:00 PM, nursing documented "Patient was found face down in bed to eat lunch at 12:45 PM and found 2 socks stuck to his mouth and patient was not responsive called code."

The ED physician pronounced the patient death on 07/27/08 at 1:00 PM.

There was no documented evidence the patient was checked every 15 minutes for safety.

On 08/05/10 at 1:25 PM, Employee #6 indicated the patient was placed on suicide precautions and every 15 minute checks when admitted to the psychiatric hold area. Employee #6 indicated there was no documentation the every 15 minutes checks were done in the patient's chart. There was no expectation the licensed nurse would enter a note in the computerized charting system everytime the 15 minute check was done. The licensed nurse could complete an hourly summary which would document the 15 minute checks where done. Employee #6 indicated the every 15 minute check could be a visual check and not a hands on check. Employee #6 indicated it was standard practice in the ED that when a patient was placed on a legal psychiatric hold, suicide precautions should be initiated and every 15 minute checks were based on patient needs.

On 08/06/10 at 10:35 AM, Employee #3 indicated there was no documentation the every 15 minute checks were being done. The camera in the psychiatric hold area was rotating and was not constantly on the patient.

The patient was placed on a legal psychiatric hold and the patient was certified as a danger to self or others due to being acutely psychotic. The record lacked documented evidence a psychiatric evaluation was completed to rule out a psychiatric emergency condition. The record lacked documented evidence the patient was appropriately monitored for safety, after the licensed nurse documented the patient was placed on suicide precautions and monitored every 15 minutes.