HospitalInspections.org

Based on interview and record review, the hospital 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 in that, 1 of 20 patients (Patient #1) who presented in the emergency department on the day of 05/14/19 with a chief complaint of psychotic episode did not receive psychological screening and stabilized prior to discharge.


Cross Refer to Tag A2406 - §489.24(a) and 489.24(c) Medical Screening Exam

Based on observation, record review, and interview, the facility failed to ensure a patient presenting to the Emergency Department (ED) with aggressive behavior via EMS (emergency medical services) with a history of bipolar and anxiety received appropriate psychological screening and stabilizing treatment prior to discharge. Patient arrived in handcuffs with the police. A review of the medical charts revealed 1 (#1) of 20 patient records failed to have the appropriate psychological screening and stabilizing treatment prior to discharge. The facility failed to follow their own policy.

A review of the ED record revealed Patient #1 was a 55-year-old female who presented to the Emergency Department (ED) at 10:47 AM and arrived via ambulance in handcuffs and in police custody. Patient had a history of bipolar and anxiety. During the patients encounter with the EMS personnel, the patient received 2 IM (intramuscular) injections of Versed 5 mg.


This deficient practice had the likelihood to cause harm in all patients presenting to the ED with psychological complications.


Findings include:

During an observation tour of the ED after 11:00am on 05/28/2019, the facility was noted to have a room called the "safe room" designated for psychiatric patients. The room was monitored by a camera and was over a distance of 20 feet from the nursing station. In an interview, Staff #3 confirmed every psychiatric patient had a sitter provided. (an employee from the hospital)

A review of Patient's #1 record revealed the following:

ED Chief Complaint: 5/14/2019 arrived 10:40 AM

"Pt was at doctor's office and had a psychotic episode. Per EMS, pt. bit someone at the doctor's office. Currently pt is sleeping. 10 mg versed given by Rockwall EMS. Pt being escorted by Rockwall PD and she is currently in handcuffs on arrival."

ED Provider Notes: 5/14/2019 10:47 AM

"Chief Complaint: Aggressive Behavior
First Provider Contact Date and Time: 05/14/2019 10:48 AM

HPI
10:48 AM: Patient #1 is a 55y.o. female with h/o bipolar and anxiety who comes to the ED via EMS for aggressive behavior. As per police officer, pt was at her PCP getting her blood work done for seizure workup, when she bit the nurse's arm. The police were called afterwards and found pt in the exam room, curled up and red in the face. Pt yelled expletives towards the officers and asked to be left alone. The officers asked pt to turn around and quietly go with them. Pt got up from the bed and began to kick one of the officers, after which she was placed under arrest and taken to this ED via EMS. Was given 10 mg Versed en route.
Unable to get pt history due to being under the influence of Versed, but pt appears to be resting comfortably.

Pt was seen in this ED on 04/23/19, with similar combative sx. Was given Versed at the time as well and sent to Garland Behavioral Health.

Present medication list:

BACLOFEN (LIORESAL) 10 mg. TAKE ONE TABLET BY MOUTH THREE TIMES A DAY
CARIPRAZINE (VRAYLAR) 3 Take 3 mg by mouth every day for bipolar. Pt to stop Risperidone.
DEPAKOTE Take 1 Tab (250 mg total) by mouth Take only as directed by physician, for:
Mania associated with Bipolar Disorder, take 250 mg. in morning and 500 mg. at bedtime
DULOXETINE (CYMBALTA) Take 1 Cap (30 mg total) by mouth every day
ESTRADIOL CESTRACE): 2
FOLIC ACID (FOLVITE) 1 MG TABLET daily
MEDROXYPROGESTERONE Take 2.5 mg by mouth
MELATONIN 3 MG TABLET Take by mouth at bedtime
MIRTAZAPINE (REMERON) 7.5 MG TABLET TAKE ONE TABLET BY
MOUTH EVERY NIGHT AT BEDTIME FOR MAJOR DEPRESSIVE Disorder
MIRTAZAPINE (REMERON) TAKE ONE TABLET BY
7.5 MG TABLET MOUTH EVERY NIGHT AT BEDTIME FOR MAJOR DEPRESSION


Physical Exam:
Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Eyes: Conjunctivae and EOM are format. Right eye exhibits no discharge. Left eye exhibits no discharge.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes.
She has no rales.
Abdominal: Soft. She exhibits no distension. There is no tenderness. There is no rebound and no guarding.
Musculoskeletal: Normal range of motion. She exhibits no edema.
Neurological: She is alert and oriented to person, place, and time.
Skin: Skin is warm and dry. No erythema.
Nursing note and vitals reviewed.


Medical Decision Making
MDM
Due to pt being given Versed en route to ED, will interview pt after she wakes up.
Differential Diagnosis: Alcohol intox, drug abuse, electrolyte abnormality, anemia

Rechecks/ED Course/Consults:

12:02 PM: Pt is awake and alert. Is refusing CT scan, CT scan was discontinued, Pt has no signs of head trauma.
12:09 PM: Rechecked Pt, who states she was brought to ED by police after being handcuffed. She denies biting the nurse, but states she tried. Denies SI, HI.
12:22 PM: Pt discharged in care of police."

A review of the ED Notes:

Staff #5 documented 05/14/19 at 11:00 AM

"Handcuffs removed by Rockwall pd."


Staff #5 documented 05/14/19 at 12:04 PM

"Pt denies suicidal thoughts and homicidal thoughts. When pt asked the question if she had any more suicidal thoughts Pt stated "I'm gonna punch someone if they ask me that question one more time"


Staff #8 documented 05/14/19 at 12:20 PM

"Pt in waiting room bathroom being verbally and physically aggressive. MD, house supervisor, security, ED manager/director, and Rockwall PD notified. Pt medically cleared and discharged per MD. Awaiting PD arrival to remove pt from department."


Staff #8 documented 05/14/19 at 12:23 PM

"Pt witnessed leaving ED waiting room entrance by staff. Ambulatory and in no acute distress."



Staff #6 documented 05/14/19 at 12:11 PM

"@1211 Called PD to notify that patient left - an officer is on the way.

@ 1227 PD called to see if patient was discharged. MD had printed papers, but patient left prior to receiving the paperwork. PD on scene."


Staff #8 documented 05/14/19 at 14:42 PM

"Vanna, RN from Facility B called regarding pt care in ED. Answered questions and gave report on ED care."

A review of the patient's consents revealed no signed consent (patient left the facility). The discharge instruction sheet was not signed by the patient.


A review of the EMS Patient care record revealed the following:

"*10:24 AM Versed 5 mg intramuscular (IM)
*10:26 AM Versed 5 mg intramuscular (IM)

On scene the staff reported the patient arrived at the clinic for psychiatric follow-up and collapsed onto bed. Staff reported seizure activity with stridor respirations and that patient had psychotic episodes. Patient was physical and verbally combative with periods of screaming and crying. Patient wanted husband called. Husband did not answer phone. It was obvious that the patient was in emotional distress. EMS attempted to convince patient to transport and be evaluated. Patient became verbally combative and Rockwall police were called. Patient was placed in protective custody. Patient received Versed 5 mg in left deltoid due to being a danger to others during transport. Patient was lifted by 3 men and secured to the cot. Patient did not respond to medication, so she received an additional 5 mg of Versed in right deltoid."


A review of the Rockwall police report revealed the following:


"This is a summary of events that occurred on Tuesday, May 14, 2019 at approximately 10:15am. I, Officer #22 (badge #1032) along with Officers #23 (badge #946) and Officer #24 (badge #1011) were dispatched to a medical call at Texas Health Family Care,1005 Ralph Hall Pkwy, regarding _____ (Patient #1).

Upon arrival we spoke to a firefighter on scene who stated Patient #1 was at the location seeking medical attention for an unknown problem. Patient #1 became irate and belligerent with the hospital staff and bit a Medical Assistant. I spoke to assistant who stated he did not want to pursue charges against _______ (Patient #1).

As I and Officer #23 arrived into the medical room, _______ Patient #1 was sitting on the observation table with her head down and against the wall. She was yelling at everyone to get out of the room and to leave her alone. Nurse Practitioner was in the room as well and she advised me that ________ (Patient #1) was suffering from schizophrenia. Nurse Practitioner, also said that______ (Patient #1) made statements that she wanted to go to heaven and for it to all be over.
Officer #23 then attempted to ask _______ (Patient #1) a question to which she replied, "I'm not answering anymore fucking questions". Every attempt to speak to_________ ( Patient #1) seemed to agitate her even more. As Officer #23 continued to attempt to talk to_______ (Patient #1) she became irate and continued to scream and yell at officers to get out of the room. Officer #23 again asked ________ Patient #1 if she needed medical attention. _______ (Patient #1) then became extremely agitated and threatened to jump out of the window. She then stood up on the table as officers began to approach her. Officer #23 requested _______ (Patient #1) to come down off the table and place her hands behind her back. ________ (Patient #1) then stood straight up on the table and backed herself into the corner. As officers went to assist ________ (Patient #1) off the table, she attempted a feeble kick at me with her left leg. I was able to grab a hold of her left leg and left arm while Officer #23 grabbed hold of her right arm and right leg. We then placed _________ (Patient #1) onto the floor. While we had ________ (Patient #1) on the floor we attempted to place her in handcuffs. During this time,__________ (Patient #1) attempted to bite Officer #23 and kick at emergency responders. Once we had ________ (Patient #1) in handcuffs, we tried to stand her up and she continued to kick at hospital staff. At this point, EMS personnel gave ________ (Patient #1) a shot of a sedative to calm her down. _________ (Patient #1) was then transported by EMS to Facility A for further medical treatment and psychological evaluation. ________ (Patient #1) was released to hospital staff.

At approximately 12:14pm myself, Officers #23 and #24 were dispatched to Facility A regarding ________ (Patient #1) leaving the hospital without being discharged. Upon arrival we observed _________ (Patient #1) walking away from the ER entrance. As we made contact with her she became extremely agitated and yelling at us to leave her alone. _________ (Patient #1) informed us that she had been discharged from the hospital. Officers then had dispatch contact the hospital to confirm whether or not she had in fact been discharged. The hospital confirmed with dispatch that __________ (Patient #1) had not been discharged. We then informed Patient #1 she had not been discharged and she needed to return inside for discharge.

Officers escorted _________ (Patient #1) who walked without assistance, back into the ER. In the ER, hospital staff had not communicated clearly with each other as to whether or not _______ (Patient #1) was discharged. One staff member said she had been and another said she had not been discharged.

At this point, ________ (Patient #1) began screaming and cursing in the ER lobby. Hospital staff advised they were going to release her because she was medically cleared and was highly aggressive towards the staff. They advised they were not going to have a psych evaluation performed because she had not told them she was suicidal, based on the totality of the circumstances (bit medical assistant, threatened to jump out of a window) she was determined be a danger to herself and others. At this time, myself and Officer #24 placed _________ (Patient #1) into protective custody. I and Officer #23 then transported ________ (Patient #1) to Facility A for further psychological evaluation without incident.

An Application for Emergency Detention and a NTBHA referral form was completed and will be submitted with this report."


During an interview on 05/28/19, after 6:00 PM, Staff #15 (ED physician) reported he did not order a psychological evaluation. Staff #15 stated, "I thought the patient was being taken into custody of the police department. If I would have known that the police were taking Patient #1 to a psychiatric facility I would ordered the psychological evaluation and transferred the patient. I medically cleared Patient #1 and did not order the psychological evaluation, because the patient expressed no suicidal ideation or hallucinations."

An interview with Staff #5 on 05/28/19 about the 05/14/19 incident revealed that she could not remember much about the occurrence except remembering Patient #1 being in the lobby screaming and yelling with a very aggressive behavior toward the staff.

An interview with Staff #2 on 05/28/19 verified with medical records at Facility A, that Facility A never received a request from Facility B about Patient #1.


A review of the facility policy titled, "Medical Screening Examinations and patient transfers" revealed the following:

"4.1.6 Providing stabilizing treatment to persons with an Emergency Medical Condition. An Emergency Medical Condition is considered stabilized when the Emergency Medical Condition has been resolved although the underlying medical condition may persist. For purposes of a transfer, the patient may be considered stabilized if no material deterioration of the Emergency Medical Condition is likely, within reasonable medical probability, to result from or occur during the transfer. (Refer to Section 5.0 below for the definition of stabilized.)

A psychiatric patient may be considered stable when he or she is protected and prevented from injuring or harming him/herself or others.

4.3. 7 Psychiatric patients. Calls from other facilities or physicians seeking authorization to transfer a psychiatric patient to Hospital should be routed to the Texas Health Resources Behavioral Health Transfer Center."



A review of Patient #1's medical record revealed no psychological screening prior to the patient being released into police custody.

An interview with Staff #2 and #3 on 05/28/19 confirmed the ED Provider Notes and ED Notes did not document that Patient #1 received appropriate psychological screening and stabilizing treatment prior to discharge in police custody.