HospitalInspections.org

Based on document review, observation, and staff interview, the Acute Care Hospital's administrative staff failed to:

1. Ensure that there was adequate staffing to meet the safety needs of behavioral health patients including 15-minute safety checks and keeping patients safe from objects that could cause self or injury to others. Please refer to A-0392.

2. Ensure the clinical staff monitor patients after the administration of medications for potential adverse effects and therapeutic benefit. Please refer to A-0405.

The cumulative effect of these deficient practices resulted in the hospital's inability to ensure the safe and effective delivery of care to all patients.

Based on medical record review, hosptial policy review, observation and staff interviews, the Hospital's administrative staff failed to ensure the Behavior Health Unit (BHU) had adequate nursing staff to provide supervision and monitoring of 9 of 9 sampled patients (Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #17).

Failure to ensure that there was adequate nursing staff to provide supervision and monitoring of behavioral patients placed patients at risk for unsafe behavior including potential harm to themselves or others.

Findings include:

1. Review of the policy "General Safety," last revised 10/2023, revealed in part, " ...All patients will have direct observation by staff members through the hospitalization ...Safety rounds will be conducted by staff ...Patients may be directly visualized more often as determined by nursing assessment or provider recommendation."

2. Review of the BHU staffing ratio grid revealed the unit should have 1 nurse, 1 mental health technician (MHT) and a Recreational Therapist (RT) for up to 6 patients during the day shift ( no specific times given for what hours this was supposed to cover). The BHU staffing grid specified the unit should have 1 nurse, 2 MHTs and a RT during the day shift. At night, the BHU staffing grid specified 1 nurse and 1 MHT should be present.

2. During observation of the BHU on 9/28/2023 from 12:00 PM until 2:35 PM revealed 3 staff members (RN EE, RN FF (orientating) and Recreational Therapist) present on the unit. The unit staffing did not include a MHT. The unit had 8 patients (Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, and Patient #16) and the admission of a new patient (Patient #17) to the floor by various staff members. All patients admitted to the BHU had a physician order for 15-minute safety checks due to being a danger to themselves or others.

3. The Surveyor's observation of the BHU on 9/28/2023 from 12:00 PM until 2:35 PM revealed the following:

a. On 9/28/2023 at 12:30 PM the Surveyor was left alone with Administrative staff at the nurses' station and noted the nursing station had an open concept that allows staff to pass through from one side of the hall to the other. Half doors were unlocked and able to easily open by pushing a button on the bottom of the door latch. There was a desk in the nurses' station used for charting that contained pencils, pens, paper clips and scissors on top of the desk in an organizer. Each drawer throughout the station was unlocked. The patients had easy access to sharp objects or projectiles. Administrative staff were only present at the nurses' station to accompany the Surveyor during observation periods and did not normally staff the nurses' station.

b. On 9/28/2023 at 1:10 PM, during a tour of the BHU, Patient #17's assigned room revealed a lead pencil sitting on the bed.

c. On 9/28/2023 at 1:50 PM Patient #17 was observed sitting alone in the dining room with a lead pencil.

d. On 9/28/2023 from 12:00 PM until 1:30 PM BHU staff did not perform 15 minute safety checks.

4. A BHU nursing assessment documentation, dated 9/28/2023 at 1:02 PM, revealed Patient #17 was a court ordered admission for a suicidal attempt. Patient #17 was a high suicide risk with history of multiple hospitalizations due to suicide attempts. Further documentation revealed the patient was a moderate risk for violent and impulsive behavior.

The evidence of the Surveyors observation revealed the BHU staff failed to provide appropriate safety monitoring of Patient #17.

5. On 9/18/23 at 2:00 PM, during an interview, RN TT reported problems with not having enough staff for the BHU and only having 2 staff persons. RN TT reported hospital administrative staff only had RN TT and the RT scheduled to work on 9/20/23 with 7 patients on floor. RN TT explained how difficult it had been to work with just 2 people in the BHU with an open nurses station and
one person had to stay with the patients at meal times. RN TT reported when a patient discharged, they did not have anyone to staff the nurses station. RN TT reported when they had 3 staff scheduled to work, hospital administration staff frequently took one of the three to work on another unit. RN TT reported hospital administration directed them to call the House Supervisor if they needed assistance, but the House Supervisor was not always available. RN TT explained Saturday (9/16/23) they had visitors in BHU to manage with the patients and they called the House Supevisor to get assistance, but no one was available. RN TT explained recently when a patient started screaming and punching doors, they called for assistance, but no one was available to come. RN TT reported another time, they could not get anyone to come assist in the BHU for 20 to 25 minutes. RN TT explained they had a patient that required 1:1 supervision and they were short-staffed. Hospital Administration staff had a maintenance man sit with the patient that required 1:1 supervision.

5. During an interview on 9/18/2023 at 2:35 PM with Security II revealed they observed the BHU with no staff members at the nurses' station. Security II verified this was a safety risk in which patients could easily access objects that could cause injury and harm. Security II stated the BHU consistently only had 2 staff members monitoring up to 8 patients. Because of this risk Security II increased their walk through to provide a security check 4 to 6 times throughout the week of the BHU.

6. Review of the medical records of all 9 patients (Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, and Patient #17) that received in-patient services on the BHU, dated 10/3/2023 and 10/4/2023, revealed the healthcare practitioner responsible for the treatment of each of the patients had ordered 15-minute safety checks on all 9 patients, but the medical records lacked documentation that the BHU staff consistently performed the 15-minute safety checks.

7. On 9/29/2023 from 6:45 AM through 4:00 PM observation of the BHU, revealed CNA HH conducted 15 minute safety checks by looking through a frosted window (each patients ' room had a frosted window) in which a small portion of the frosting had been removed. This method of observation provided CNA HH with a very limited view of each patient's entire room. This surveyor followed CNA HH while they completed 15-minute safety check rounding. The surveyor observed Patients #9, Patient #11, Patient #14, and Patient #16 were in their rooms with the door closed. CNA HH completed the 15 minute safety check on these patients by looking through the small clear section in the window. The surveyor looked through the same small clear section of the window while following CNA HH. The surveyor was only able to see a partial view of Patient #9, Patient #11, Patient #14, and Patient #16 due to a wall obstruction within these rooms. The surveyor was unable to determine whether the patient was in possession of a sharp object or projectile or if the patient had harmed themselves with this limited view.

8. During an interview on 9/27/2023 at 2:38 PM, the Recreational Therapist (RT) reported having to perform certified nursing assistant/mental health technician (CNA/MHT) duties in addition to RT duties due to being short-staffed. The duties of CNA/MHT included performing 15-minute safety checks, monitoring patients, performing scheduled vitals, passing meals, snacks, and assisting in activities of daily living (ADL's which can be bathing, eating and mobility). The RT explained that this was difficult to perform along with their other normal recreational therapy duties which included exercise therapy class, music therapy class, relaxation therapy, and board/drawing therapy. The Recreational Therapist further revealed that they would document that they performed the 15 minute safety checks on the scheduled time regardless if the checks were late or missed. The RT reported he had to reduce the number of therapuetic groups offered to patients due the BHU being short-staffed.

9. During an interview on 9/18/2023 at 7:15 PM with Psychiatric Physician O revealed Administration approached Psychiatric Physician O and requested them to cut back or get rid of the 1:1 observations of patients, because the Hospital did not have the staff available to perform them. Psychiatric Physician O further revealed the RT on the BHU had been doing more than their job requirements due to staffing issues.

10. During an interview on 9/19/2023 at 8:41 AM with ARNP T revealed a concern about short staffing on the BHU, especially with the multiple acuities, which increased a risk for patient safety.

11. During an interview on 9/27/2023 at 1:57 PM with Clinical Education Coordinator OO revealed, they left the Director role of the BHU because it was too difficult to cover for staff that did not come in and the unit was constantly short staffed.

Based on medical record review, hospital policy review and staff interviews, the Hospital's administrative staff failed to ensure clinical staff monitored a patient after the administration of medications for potential adverse effects and therapeutic benefit for 1 of 49 sampled patients (Patient #1).

Failure to monitor the therapeutic benefit and clinical symptoms related to adverse effects placed a patient at risk to receive unnecessary medications without therapeutic benefit and at risk for the development of an undetected severe adverse medication reaction.

Findings include:

1. Review of the policy, "Medication Administration Process," effective 12/2022, revealed in part, "...Documentation occurs in the medication administration record ...a patient's response to therapy as applicable, and any intolerances or adverse reactions a patient may experience."

2. Review of the medical record for Patient #1, an elderly patient, revealed the following:

a. On 7/17/2023 at 5:29 PM, Patient #1 arrived at the Emergency Department (ED) with a family member due to an alteration in the patient's mental status and a reported history of dementia. Patient #1 independently walked into the ED with a family member and no assistive devices.

b. On 7/17/2023 at 5:47 PM, ED nursing documentation revealed that soon after arriving in the ED, Patient #1 became confused and required "line of sight" monitoring from ED staff. ED staff immediately moved the patient from the waiting room into a room in the ED and performed a triage assessment.

c. On 7/17/2023 at 8:04 PM, ED Physician C wrote a one-time order for Haloperidol (an antipsychotic medication associated with an impaired ability to swallow, adverse neurological and cardiac risks effects including arrhythmias and rapid heart rate, and an increased mortality risk in elderly patients with dementia) 5 milligrams (mg) intramuscular (IM) injection and Diphenhydramine (an antihistamine medication that caused increased sedation when given in conjunction with Haldol) 50 mg IM. ED Physician C documented the reason for ordering the medication was due to the patient's agitation. On 7/17/23 at 8:04 PM, an ED nurse documented they gave the first dose of Haloperidol 5 mg IM to the patient. The medical record did not include information which indicated staff attempted to provide the appropriate dementia care measures (repositioning, distraction, or reassessment) prior to medicating the patient. On 7/17/2023 at 8:15 PM, ED nursing documentation revealed the ED nurse gave the patient Diphenhydramine 50 mg IM. The medical record lacked documentation that the clinical staff assessed the patient's response to Haloperidol and Diphenhydramine.

d. On 7/18/2023 at 6:00 AM, ED Physician C ordered Haloperidol 5 mg, one tablet by mouth every 6 hours while the patient was awake. The medical record lacked evidence of a reason for why the physician ordered the medication and lacked documentations that the patient was displaying any symptoms (such as agitation, delusions or hallucinations) that would necessitate the administration of an antipsychotic.

e. On 7/18/2023 at 10:00 AM, ED nursing documentation revealed Patient #1 had developed generalized weakness and a slow gait. Patient #1 required assistance with ambulation.

f. On 7/18/2023 at 11:30 AM, ED nursing documentation revealed the patient was awake and the nurse gave a Haloperidol 5mg tablet. The medical record lacked evidence that the patient was displaying any symptoms that would necessicate the administration of an antipsychotic.

g. On 7/18/2023 at approximately 12:57 PM, ED Physician E ordered a one-time Haloperidol 5 mg IM injection and Diphenhydramine 25 mg IM injection. ED Physician E documented the patient had an altered mental status, but did not have any documentation to support why the physician ordered the one-time dose of Haloperidol and Diphenhydramine IM.

h. On 7/18/2023 at 1:35 PM, ED nursing documentation revealed an ED nurse gave Haloperidol 5 mg IM injection and Diphenhydramine 25 mg IM injection. ED documentation by the patient's nurse included an assessment of the patient's confusion, but lacked documentation of unmanageable behaviors, such as agitation, threatening behaviors or unsafe behaviors, that would warrant the use of Haloperidol. The medical record lacked documentation of the patient's therapeutic response to the medications or if the patientt was experiencing any adverse effects from the Haldol and Diphenhydramine.

The medical record lacked evidence the patient received any further doses of Haloperidol or Diphenhydramine and lacked any documentation to explain why. On 7/20/2023 at 9:00 AM, Patient #1's ED physician discontinued the scheduled Haloperidol 5 mg every 6 hours while the patient was awake.

i. On 7/18/2023 at 5:12 PM, nearly 24 hours after presenting to the ED, the on-call Psychiatrist examined Patient #1. The on-call psychiatrist recommended an inpatient psychiatric admission for the patient once the ED staff stabilized the patient's medical problems. The psychiatrist also recommended Haloperidol 2 mg every 4 hours for agitation, instead of 5 mg every 6 hours. The psychiatrist recommended to avoid Diphenhydramine, if possible, since this medication could have worsened the patient's confusion and agitation. The final recommendation was to start Risperidone 0.25 mg two times a day.

The medical record lacked documentation that ED Physicians followed the recommendations made by the on-call psychiatrist to change patients medications and admit the patient to the psychiatric unit.

j. On 7/19/2023 at 8:00 AM, ED nursing documentation revealed the patient had a decreased level of consciousness, would respond only to noxious stimuli and was mumbling inappropriate words and jumbled phrases.

k. On 7/19/2023 at 9:23 AM, ED nursing documentation revealed the nurse assessed the patient was lethargic, at risk for aspiration. The ED nurse contacted ED Physician E.

l. On 7/19/2023 at 10:41 AM, Physical Therapist D documented the completion of an evaluation assessment. The assessment revealed the patient was weak, unsteady on the feet and required a maximum assist of two with ambulation and transfers.

m. On 7/19/2023 at 11:48 AM, Occupational Therapist documented the completion of an evaluation assessment. The assessment revealed the patient was sedated and unable to follow directions.

n. On 7/19/2023 at 4:52 PM, a speech therapy evaluation revealed the speech therapist performed a bedside swallow test, and the patient failed the test. The speech therapist ordered that the patient remain NPO.

3. On 8/2/23 at 12:31 PM, during an interview, Registered Nurse (RN) Case Manager A reported the patient received 3 doses of Haldol and 2 doses of Benadryl. (RN) Case Manager A asked ED Physician C to quit giving the patient Haloperodol on 7/18/2023 at 2:21 PM due to a lack of documented behaviors and no justification to give the medication.

4. During an interview on 8/9/2023 at 5:30 PM with ED Physician I revealed, there were no psychiatric medications that were best for the elderly, but giving Haloperidol (Haldol) and diphenhydramine (Benadryl) were something that should not be done first. Staff may try Geodon and Seroquel (both antipsychotic medications) first but did not want to give Haldol right off. ED Physician I explained that staff should first try to talk to the patient, redirect them and address the patient's behavioral issues. ED Physician I reported that if the results for all diagnostic/laboratory tests had not been obtained, ED Physician I did not like giving that much medication. ED Physician I explained the need to have the psychiatric evaluation done prior to the administration of antipsychotic medication. The on-call Psychiatrist needed to see the patient at their baseline prior to the sedating effects of medications like Haloperidol. ED Physician I reported the amount of Haloperidol Patient #1 received was not needed.

5. During an interview on 8/15/2023 at 2:00 PM with ED Physician E revealed Patient #1 had an unusual amount of Haldol administered and would not have given that much.

Hospital staff failed to evaluate the therapeutic benefits and potential adverse effects of the administration of Haloperidol and Diphenhydramine on the patient. ED staff gave Patient #1 multiple doses of Haloperidol and Diphenhydramine resulting in extreme somnolence, in which Patient #1 could not swallow, was unable to walk, or turn without assistance of two staff members.

Based on document review and staff interviews, the Hospital's administrative staff failed to ensure that:

The integration of the Emergency Department (ED) with the other services of the hospital such as the ICU, equipment, personnel, and the behavioral health unit to ensure patient care was provided within an acceptable timeframe to promote the health and safety of 3 of 49 patients (Patient #1, Patient #2, and Patient #3). Please refer to A-1103.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to separately and independently meet the emergency needs of patients at the Hospital.

Based on policy/procedure review, medical record review and interviews, the Hospital failed to ensure the integration of the Emergency Department (ED) with the services of the hospital such as ICU, equipment, and behavior health unit to ensure patient care was provided within an acceptable timeframe to promote the health and safety of 3 of 49 patients (Patient #1, Patient #2, and Patient #3) selected for review.

Failure to have all hospital departments integrated with emergency services caused a delay in treatment and placed patients at risk for worsening of their medical condition and, potentially, death.

Findings include:

1. Review of policy, "EMTALA- Medical Screening and Treatment of Emergency Medical Conditions", approved 11/28/2022, revealed in part, " ...if a medical screening examination reveals an Emergency Medical Condition (EMC), then the Hospital must provide stabilizing treatment within its capacity and capabilities (including on-call physician services and ancillary services) necessary to stabilize the patient or must appropriately transfer the patient to another facility. Admission as an inpatient may be required as part of the stabilizing treatment. Once a patient is admitted as an inpatient in good faith, EMTALA is satisfied; however, the Hospital continues to have responsibility to meet patient emergency needs in accordance with the Medicare Conditions of Participation."

2. Review of the medical record for Patient #1, an elderly patient, revealed the following:

a. On 7/17/2023 at 5:29 PM, Patient #1 arrived at the Emergency Department (ED) with a family member due to an alteration in the patient ' s mental status. Patient #1 independently walked into the ED with a family member and no assistive devices.

b. On 7/17/2023 at 5:47 PM, ED nursing documentation revealed that soon after arriving in the ED, Patient #1 became confused and required "line of sight" monitoring from ED staff. ED staff immediately moved the patient from the waiting room into a room in the ED and performed a triage assessment.

The ED nurse assessment revealed the patient's temperature, pulse, respirations, and blood oxygen saturation levels were within normal limits.

c. On 7/17/2023 at 6:14 PM, ED Physician E ordered a urinalysis (UA) and culture, due to suspected urinary tract infection. The ED nurse did not collect a urine specimen for analysis until 7/18/2023 at 10:03 AM, a delay of approximately 16 hours. The medical record lacked documentation of why there was a delay in the collection of the UA.

d. On 7/17/2023 at 6:37 PM, review of laboratory testing revealed the following results: Troponin I high sensitivity (Troponin I HS, a protein released into the bloodstream during a heart attack) was within normal limits 6.4 (normal range measured 0.00-14.9 picograms per milliliter, pg/mL), the creatinine level (a lab test used to determine kidney function) was elevated at 1.22 (normal range measured 0.6-1.1 milligrams per deciliter, mg/dL), the glomerular filtration rate (GFR, a lab test used to determine how well the kidneys filter blood) was low at 45 millimeters per minute (normal range measured 60-89 mm per minute for an elderly patient).

The medical record lacked evidence that the ED physician ordered intravenous (IV) fluids to promote normal kidney function, or ordered monitoring of the patient's intake (amount of oral or IV fluids) and output (amount of urine produced, over a set period of time).

e. On 7/17/2023 at 8:04 PM, ED Physician C wrote a one-time order for Haloperidol (an anti-psychotic medication) 5 milligrams (mg) intramuscular (IM) injection and Diphenhydramine (an antihistamine medication that caused increased sedation when given in conjunction with Haldol) 50 mg IM. ED Physician C documented the reason for ordering the medication was due to the patient ' s agitation. At 8:04 PM, an ED nurse gave the patient Haloperidol 5 mg IM. The medical record did not include information which indicated staff attempted to provide the appropriate dementia care measures (repositioning, distraction, or reassessment) prior to medicating the patient.

f. On 7/17/2023 at 8:05 PM, Patient #1 underwent a computed tomography scan (CT scan is a special type of x-ray) of the head which revealed normal results.

g. On 7/17/2023 at 8:15 PM, ED nursing documentation revealed the ED nurse gave the patient Diphenhydramine 50 mg IM. The medical record lacked documentation of the patient's response to Haloperidol and Diphenhydramine.

h. On 7/17/2023 at 10:05 PM, ED staff performed an Electrocardiogram (EKG records the electrical signals in the heart) on the patient and the results were normal.

i. On 7/17/2023 at 10:20 PM, review of the results of a repeat Troponin I HS level revealed the rate had nearly doubled to 15.6 pg/mL (the patient's level at 6:37 PM was 6.4 pg/mL). The medical record lacked documentation of any further laboratory testing or cardiology consultation orders at the time.

j. On 7/18/2023 at 6:00 AM, ED Physician C ordered Haloperidol 5 mg, one tablet by mouth every 6 hours while the patient was awake.

k. On 7/18/2023 at 10:00 AM, ED nursing documentation revealed Patient #1 had developed generalized weakness and a slow gait. Patient #1 required assistance with ambulation.

l. On 7/18/2023 at 11:30 AM, ED nursing documentation revealed the patient was awake and the nurse gave the Haloperidol 5 mg.

m. On 7/18/2023 at an unknown time, laboratory results revealed the patient had a UTI.

n. On 7/18/2023 at 12:27 PM, ED nursing documentation revealed ED nursing staff gave Patient #1 a 500 mg Cephalexin (antibiotic) capsule to start the treatment of the UTI.

o. On 7/18/2023 at approximately 12:57 PM, ED Physician E ordered a one-time Haloperidol 5 mg IM injection and Diphenhydramine 25 mg IM injection. ED Physician E documented the patient had an altered mental status, but did not have any documentation to support why the physician ordered the one-time dose of Haloperidol and Diphenhydramine IM.

p. On 7/18/2023 at 1:35 PM, ED nursing documentation revealed an ED nurse gave Haloperidol 5 mg and Diphenhydramine 25 mg IM injection. ED documentation by the patient's nurse included an assessment of the patient's confusion, but lacked documentation of unmanageable behaviors, such as agitation, threatening behaviors or unsafe behaviors, that would warrant the use of Haloperidol. The medical record lacked documentation of the patient's therapeutic response to the medications.

The medical record lacked evidence the patient received any further doses of Haloperidol or Diphenhydramine and lacked any documentation to explain why. On 7/20/2023 at 9:00 AM, Patient #1's ED physician discontinued the scheduled Haloperidol 5 mg every 6 hours while the patient was awake.

q. On 7/18/2023 at 5:12 PM, nearly 24 hours after presenting to the ED, the on-call Psychiatrist examined Patient #1. The on-call psychiatrist recommended an inpatient psychiatric admission for the patient once the medical staff stabilized the patient's medical problems including the UTI. The psychiatrist also recommended Haloperidol 2 mg every 4 hours for agitation, instead of 5 mg every 6 hours. The psychiatrist recommended to avoid Diphenhydramine, if possible, since this medication could have worsened the patient's confusion and agitation. The final recommendation was to start Risperidone 0.25 mg two times a day.

The medical record lacked documentation that ED Physicians were aware of the recommendations made by the on-call psychiatrist to change patients medications and admit the patient to the psychiatric unit.

r. On 7/18/2023 at 9:00 PM, ED nursing documentation revealed the patient experienced an increased heart rate of 90 beats per minute and BP of 181/79 (nearly 24 hours after the patient's Troponin I HS level had doubled). The patient remained boarded in the ED without orders for inpatient admission or examination by the hospital's on-call cardiologist to assess the patient's heart function.

s. On 7/19/2023 at 12:30 AM, ED staff gave a one-time bolus (single dose given over a short time) of Normal Saline intravenously (IV) (30 hours after the ED physician received results of the patient ' s abnormal laboratory testing results).

t. On 7/19/2023 at 8:00 AM, ED nursing documentation revealed the patient had a decreased level of consciousness, would respond only to noxious stimuli and was mumbling inappropriate words and jumbled phrases. The ED nurse had assessed the patient ' s blood pressure which measured 190/111 and a heart rate of 95 beats per minute.

u. On 7/19/2023 at 9:10 AM, nearly 12 hours after experiencing uncontrolled high blood pressure with no stabilizing treatment, the ED physician ordered an IM injection of Hydralazine 10 mg (used to treat high blood pressure).

v. On 7/19/2023 at 9:23 AM, ED nursing documentation revealed the nurse assessed the patient was lethargic, at risk for aspiration and had an elevated high blood pressure. The ED nurse notified ED Physician E.

w. On 7/19/2023 at 9:55 AM, ED nursing documentation revealed nursing staff gave the patient 1000 mg/50 ml Ceftriaxone (antibiotic) IV to treat the UTI per physician orders.

x. On 7/19/2023 at 10:41 AM, Physical Therapist D documented the completion of an evaluation assessment. The assessment revealed the patient was weak, unsteady on the feet and required a maximum assist of two with ambulation and transfers.

y. On 7/19/2023 at 11:48 AM, Occupational Therapist documented the completion of an evaluation assessment. The assessment revealed the patient was sedated and unable to follow directions.

z. On 7/19/2023 at 12:55 PM, Hospitalist H (a physician consultant for inpatient services and provided medical management to ED patients at this hospital) completed an initial examination (nearly 40 hours after the patient presented to the ED). Hospitalist H documented, "Awaiting placement to extended care facility, case management is following." Hospitalist H did not document plans for an inpatient admission as recommended by the on-call psychiatrist or follow-up with the on-call psychiatrist.

aa. On 7/19/2023 at 3:52 PM, Hospitalist H ordered the patient to have nothing by mouth (NPO).

bb. On 7/19/2023 at 4:52 PM, a speech therapy evaluation revealed the speech therapist performed a bedside swallow test, and the patient failed the test. The speech therapist ordered that the patient remain NPO.

cc. On 7/20/2023 at 9:06 AM, ED nursing documentation revealed the nurse assessed the patient to continue to have nothing by mouth due to a choking risk. The ED nurse documented they started an IV bolus of Normal Saline per physician order.

dd. On 7/20/2023 at 2:20 PM, ED staff performed a second EKG which showed a septal infarct (a heart attack). The patient remained boarded in the ED without orders for inpatient admission, further examination or treatment by the hospital's on-call cardiologist or the on duty Hospitalist.

ee. On 7/20/2023 at 2:36 PM, Speech Therapy (ST) ordered thickened liquids, a pureed diet and medications in applesauce.

ff. On 7/20/2023 at 6:00 PM, ED nursing documentation revealed Patient #1 experienced an irregular pulse with a heart rate of 124 beats per minute and an elevated BP of 188/84. The medical record lacked documentation of any intervention by ED staff or by the on duty Hospitalist.

gg. On 7/20/2023 at 11:00 PM, ED nursing documentation revealed the patient continued to have an elevated blood pressure that measured 175/80 with a heart rate of 93 beats per minute. The medical record lacked documentation of any intervention to treat the elevated blood pressure.

hh. On 7/21/2023 at 5:08 AM, ED nursing documentation revealed the nurse assessed the patient had an elevated blood pressure that measured 174/82. The medical record lacked documentation of any further assessments of the patient's blood pressure.

ii. On 7/21/2023 at 6:13 AM, review of ED Physician C's progress notes revealed Patient #1 was still in the emergency room and there was a plan for the patient to remain there for the foreseeable future until placement (nursing home). ED Physician C documented the patient did not have any acute events, the patient appeared alert and pleasantly confused. The patient did not have any other complaints. The patient's heart rate and rhythm was regular. ED Physician C further documented Patient #1 was medically stable.

jj. On 7/21/2023 at 12:00 PM, Hospitalist H ordered IV fluids, Normal Saline at 15 ml per hour.

kk. On 7/21/2023 at 12:58 PM, Hospitalist H ordered the patient to be placed in observation status on the medical/surgical floor. Hospitalist H documented the reason for the observation status was due to the patient's confusion, inability to care for him/herself, not eating or drinking and UTI treatment.

ll. On 7/22/2023 at 9:30 AM a repeat CT of head, findings/impression were as follows:
Age-related changes with no acute intracranial pathology. Ventriculomegaly most likely part of the atrophy process, less likely any NPH (Normal Pressure Hydrocephalus, a brain disorder in which excess cerebrospinal fluid accumulates in the brain's ventricles, causing thinking and reasoning problems, difficult walking, and loss of bladder control) clinically.

mm. On 7/22/2023 at an unknown time, Hospitalist H documented the patient had altered mental status, likely in the setting of delirium, advancing dementia, UTI, and unable to rule out NPH. Hospitalist H documented the plan to transition the patient to comfort measures only after discussion with the patient's power of attorney (POA) for healthcare decisions.

nn. On 7/24/2023 at 8:58 AM, the medical record included documentation of the pronouncement of Patient #1's death.

3. Review of the ED on call schedule from 7/17/2023 through 7/24/2023 revealed there was a cardiologist and psychiatrist on call during these times.

4. During an interview on 8/10/2023 at 2:00 PM, ED Physician C could not provide information as to why the testing for a UTI was delayed. ED Physician C did not realize the patient failed the swallow test during the speech therapy evaluation on 7/19/23. ED Physician C could not explain why Patient #1 was not admitted as an inpatient as recommended by the on-call psychiatrist.

5. During an interview on 8/9/2023 at 5:30 PM with ED Physician I revealed, there were no psychiatric medications that were best for the elderly, but giving Haloperidol (Haldol) and diphenhydramine (Benadryl) were something that should not be done first. Staff may try Geodon and Seroquel (both antipsychotic medications) first but did not want to give Haldol right off. ED Physician I explained that staff should first try to talk to the patient, redirect them and address the patient's behavioral issues. ED Physician I reported that if the results for all diagnostic/laboratory tests had not been obtained, ED Physician I did not like giving that much medication. ED Physician I explained the need to have the psychiatric evaluation done prior to the administration of antipsychotic medication. The on-call Psychiatrist needed to see the patient at their baseline prior to the sedating effects of medications like Haloperidol. ED Physician I reported the amount of Haloperidol Patient #1 received was not needed.

6. During an interview on 8/15/2023 at 10:00 AM with Hospitalist H revealed Patient #1 did not meet inpatient criteria because their blood pressure and labs were stable.

7. During an interview on 8/15/2023 at 11:00 AM with Hospitalist Q revealed there were a few instances in which there was not a bed available on the medical surgical floor and at this time there was no ICU services or step down unit. Hospitalist Q remarked the provider looked to other hospitals to transfer patients that need those services. ED physicians requested Hospitalists to assist with medication management, monitor the patients while in ED for medical deterioration and to assist with the request a transfer to another facility.

The evidence in the medical record showed the hospital failed to ensure the integration of the ED with other departments in the Hospital. Patient #1 presented to the ED with concerns regarding an alteration in mental status change related to the possible worsening of the patient ' s dementia. There were multiple delays in examining and treating the patient's urinary tract infection, evaluating the kidney function, fluid balance, controlling the patient's high blood pressure, and rapid heart rate. The medical record lacked documentation of a timely consultation by Speech Therapy and no evaluation by Dietary.

8. Review of Patient #2's medical record revealed the following:

a. On 1/12/2023 at 2:26 PM, ED documentation revealed Patient #2 arrived at the ED by police escort. The police reported to ED staff indicated they had 3 encounters with Patient #2 that day indicated that the patient was a danger to the patient and others.

b. On 1/12/2023 at 2:30 PM, ED documentation revealed a triage assessment of the patient. The assessment revealed the patient was agitated with altered mental status. The vital signs including temperature, pulse and respiration were within normal limits, with the exception of a borderline elevated blood pressure at 134/82.

c. On 1/12/2023 at 6:48 PM, ED Physician J documented Patient #2's general appearance was filthy, unclean, and cachectic (meaning general state of ill health with marked weight loss). Patient #2 had multiple scars and bruises from drug use. The patient was agitated and anxious. The patient ' s Troponin I HS (a protein released into the bloodstream during a heart attack) results was elevated and measured 32.4 and 33.5 at the 2 hour interval (normal range was 0.0-19.8 picograms per milliliter pg/mL); the Hematocrit (Hct-red blood cells) was 36.3 percent (the normal range was 41.9- 50.9%; low red blood cells can cause, dizziness, irregular heart rhythms, weakness, chest pain and shortness of breath); the alanine transaminase (ALT) was 95 U/L (test for liver function normal 4-36 unit per liter U/L; which revealed liver damage) and aspartate transferase (AST) was 95 units (test for liver function normal 14-20 units). ED Physician J documented the patient was positive for alcohol, Benzodiazepines (medication used to relieve anxiety). ED staff gave Patient #2 2 mg of Ativan (medication to relieve anxiety) and 50 mg of Benadryl to reduce aggression. The physician ordered the continuation (patient had been ordered to take them at home prior to the ED visit) of the following medications to treat ongoing cardiac issues related to high blood pressure and chest pain: Norvasc and Metoprolol.

The medical record lacked evidence of an order for an EKG or a cardiology consult to address the patient ' s elevated Troponin levels.

d. The medical record revealed hospital staff performed CT scans of the head on 1/12/2023 at 11:15 PM and the chest on 1/13/2023 at 12:29 AM. The medical record lacked documentation of a CT of the abdomen. The CT scans of the head revealed the patient had no changes from the previous CT performed at Hospital K on 12/13/2022. The CT of the chest revealed the patient continued to have nodules and lesions on the lungs (related to a previously diagnosed fungal lung infection which required antibiotic treatment) that had decreased in size from the CT scan performed by Hospital K on 12/9/2022, but was still present.

The medical record lacked evidence ED staff provided treatment for the patient ' s ongoing fungal lung infection.

e. Due to Patient #2 ' s multiple outbursts, ED Staff placed the patient in physical restraints 20 times in a secured room and gave the patient the following medication between 1/12/2023 through 1/17/2023 to calm the patient down:

Diphenhydramine HCL 50 mg IM:
1/12/2023 at 3:00 PM
1/13/2023 at 9:16 PM
1/14/2023 at 6:23 PM
1/15/2023 at 2:27 PM
1/15/2023 at 11:44 PM
1/17/2023 at 10:30 PM

Haloperidol IM:
1/13/2023 at 1:20 AM 2 mg
1/13/2023 at 2:45 PM 2 mg
1/13/2023 at 3:14 PM 10 mg
1/14/2023 at 6:23 PM 10 mg
1/14/2023 at 9:21 PM 5 mg
1/14/2023 at 11:23 PM 5 mg
1/15/2023 at 2:18 PM 10 mg
1/15/2023 at 2:54 PM 10 mg
1/15/2023 at 8:57 PM 5 mg
1/15/2023 at 11:44 PM 5 mg
1/17/2023 at 2:54 PM 10 mg

Haloperidol tablet by mouth:
1/17/2023 at 8:40 AM 5 mg

Lorazepam IM (an antianxiety medication):
1/14/2023 at 11:33 PM 1 mg
1/15/2023 at 8:57 PM 1 mg
1/15/2023 at 11:44 PM 2 mg

Olanzapine Tablet (an antipsychotic) by mouth:
1/17/2023 at 8:40 AM 15 mg
1/17/2023 at 8:50 PM 10 mg

Chlordiazepoxide Capsule (a sedative) by mouth:
1/17/2023 at 8:50 PM 25 mg

f. On 1/13/2023 at 7:10 PM, On-Call Psychiatrist RR documented the evaluation of the patient through telehealth services and the recommendation that Patient #2 was safe to go home. On-Call Psychiatrist RR placed the patient on 15 mg of Zyprexa twice daily (an antipsychotic medication used to treat mental health conditions).

The medical record lacked documentation that the ED physicians or the Hospitalist addressed Patient #2 ' s multiple medical concerns related to abnormal laboratory test results for heart and liver function. Patient #2 ' s behaviors remained uncontrolled and the patient ' s psychiatric condition remained unstable (as demonstrated by frequent violent behavior outbursts) prior to and after the addition of Zyprexa to the patient ' s medication regimen.

g. On 1/15/2023 at 7:16 PM, On-Call Psychiatrist RR evaluated the patient through telehealth and ordered Haloperidol tablets, 3 mg by mouth every 6 hours. On-Call Psychiatrist RR ordered the continuation of as needed medications (Haloperidol, Diphenhydramine, Lorazepam, and Geodon).

h. On 1/17/2023 at 12:14 PM, On-Call Psychiatrist M evaluated the patient through telehealth services and ordered Haloperidol tablets, 5 mg by mouth every 6 hours.

i. On 1/17/2023, review of complete chemistry panel (CMP) results revealed an elevated AST 111 (normal 13-33 U/L); elevated ALT 69 (normal 11-47 U/L); an elevated total ALK phosphatase 210 (normal 36-113 U/L, a test used to determine liver function and indicated the patient ' s liver was functioning abnormally); a low Albumin 3.5 (3.7-4.7 g/dl, test results which indicated the patient was potentially malnourished).

j. On 1/18/2023 at 8:38 AM the On-Call Psychiatrist SS ordered the reduction of Zyprexa from 15 mg to 5 mg by mouth twice a day for two days. The On-Call Psychiatrist SS documented the need for ED staff to obtain an EKG, if the patient allowed, due to climbing liver (LFT) test results in order to rule out medical delirium.

The medical record lacked documentation ED physicians ordered or attempted to obtain an EKG until 2/7/2023.

k. On 1/20/2023 at 8:11 AM, ED Physician L ordered a gastroenterologist consultation due to elevated liver function test results.

The medical record lacked documentation of a gastroenterologist evaluating the patient until 2/16/2023. The medical record lacked documentation of a reason for the delay in the evaluation.

l. On 1/21/2023 at 8:08 PM, Psychiatrist O documented Patient #2 had been agitated when out of seclusion and continued to have episodes of aggressiveness that were seemingly unprovoked at times. The patient appeared to have some healing wounds/sores and was cachectic in appearance. Psychiatrist O documented Patient #2 was not appropriate for an inpatient psychiatric unit due to the patient's symptoms not resulting from a primary psychiatric disorder. Psychiatrist O documented the patient would not have been able to participate in any portion of the treatment program offered on the psychiatric unit due to the patient's severe cognitive deficits. Patient #2's underlying medical issues caused serious brain damage which resulted in a lack of ability to reason, comprehend, rationalize, communicate meaningfully, etc. and caused the patient's aggression. Patient #2 behavioral-based symptoms were a sequela from their prior stroke. The patient ultimately received medications only to help palliate the symptoms. Psychiatrist O documented the patient was not safe to discharge due to serious concerns about safety for the patient and others.

m. Review of the medical record from 1/12/2023 to 3/24/2023 revealed the ED staff continued to board the patient in the ED for 71 days before ED staff transferred the patient to another facility. ED staff placed Patient #2 in Non-Violent Restraints 46 times and Violent Restraints/Seclusion Room 151 times due to aggressive behavior, attempted elopements, violent outbursts and behaviors that place the patient at risk to self and others. A total of 7 different on-call psychiatrists evaluated the patient from 1/13/2023 to 3/24/2023, and they completed a total of 32 psychiatric evaluations on the patient.

n. On 1/22/2023 at 10:32 AM, Hospitalist H ordered a speech therapy evaluation to evaluate the patient ' s swallowing ability.

o. On 1/23/2023 at 3:52 PM, a speech therapy evaluation included documentation the speech therapist placed Patient #2 on a pureed diet due to the patient pocketing food and medication.

The medical record lacked documentation that explained the delay in speech therapy completing the evaluation (completed more than 24 hours after the physician ordered the evaluation and 13 days after admission to the ED). The medical record lacked documentation and an order for a dietary consult.

p. On 2/7/2023 at 6:40 PM, ED documentation Patient #2 complained of chest pain. Hospital ED staff performed an EKG on 2/7/2023 at 6:57 PM which revealed the patient had an abnormal heart rhythm. ED staff also completed lab tests related to cardiac function as follows: a Troponin HS I with a result of 33.5 (high and indicative of abnormal heart function); and, a CMP with abnormal results of ALT 69 and an AST of 111 (both high and indicative of abnormal liver function).

q. On 2/14/2023 at 12:51 PM, Hospitalist H documented, based on ejection fraction studies completed at Hospital K (prior to this ED visit), Patient #2 had an ejection fraction of less than 30% (test that shows the heart's ability to pump blood throughout the body, normal range is 50-70%).

r. On 2/16/2023, at an undocumented time, the Gastroenterologist evaluated Patient #2 for elevated LFTs and weight loss. The Gastroenterologist ' s evaluation revealed the patient had gained some weight, was less sedated and there was no further indication for a gastroenterologist evaluation.

9. During an interview on 8/10/2023 at 1:30 PM, Psychiatrist O explained the ED was not an appropriate place to keep Patient #2. The ED did not have a conducive environment to provide consistent care. Psychiatrist O explained, part of the problem in the ED was that it used a service for behavioral health patients in which the ED staff contacted the on-call psychiatrists through a tele-health program. The psychiatrists did not have admitting privileges. When ED staff needed to consult an on-call psychiatrist, ED staff would dial up a tele-psychiatrist and they would get a different psychiatrist each time. Due to the patient getting a different psychiatrist each time, the hospital was unable to provide consistency in providing medical care and treatment.

The patient presented to the ED with concerns regarding behavior health issues, symptoms of malnourishment, abnormal cardiac and liver function and ongoing fungal lung infection. The evidence in the medical record revealed the hospital failed to ensure the integration of the ED with other departments in the Hospital. There were multiple delays in communication, care coordination, examination and treatment of the patient's fungal/bacterial lung and urinary tract infections; malnourishment, fluid balance, and controlling the patient's high blood pressures and rapid heart rate. The medical record lacked documentation of a dietary consult, on-going PT/OT evaluations, on-going psychiatric consults, and cardiology consultation. Patient #2 had been boarded in the ED for 2 months without attempts to provide the patient with consistent care in a safe environment reducing triggers caused by over stimulation.

10. Review of Patient #3's medical record revealed the following:

a. On 7/22/2023 at 10:48 PM Patient #3 arrived in the ED accompanied by family members. Patient #3's chief complaints were pain, unable to breathe, and stomach spasms. The patient further explained the patient had a stomach tube for oral intake placed on 7/21/2023.

b. On 7/22/2023 at 11:24 PM ED staff triaged Patient #3 and documented that there were green contents in the gastric (stomach) tube. The patient complained of lower abdominal pain of a 7 (0-10, 0 was no pain and 10 was severe pain) and reported a weight of 74 pounds. ED staff assessed the patient ' s vital signs were within normal limits, except for an elevated BP of 145/104. ED staff documented the patient ' s medical history included diagnoses of alcohol abuse, acute pancreatitis, abnormal weight loss, and cachexia.

c. Starting on 7/22/2023, between 11:40 PM and 1:56 AM on 7/23/2023, ED Physician X ordered a chest x-ray, CT scan of the abdomen and the following laboratory tests: UA, CMP, complete blood count (CBC) with differential, red blood count (RBC), white blood cell count (WBC), platelets, lipase (lab test used and basic metabolic panel (BMP). ED Physician X ordered Tylenol, Morphine (narcotic pain reliever to treat severe pain), Bentyl (medication used to treat irritable bowel syndrome) Zosyn (antibiotic) and Metronidazole (used to treat the patient ' s abdominal infection) IV and Protonix. ED Physician X requested a consultation with the Hospitalist.

The medical record lacked evidence ED Physician X completed an examination of the patient.

d. On 7/23/2023 at 1:56 AM, a CT scan of the abdomen revealed indication of pancreatitis (inflammation of the pancreas) with a pseudocyst (collection of pancreatic fluid) adjacent to the stomach and surrounding the gallbladder. The CT scan revealed a possible peritonitis (infection in the abdomen) due to a perforated bowel.

e. The lab results revealed Patient #3 anemic, a hemoglobin of 7.0 g/dL (results from a lack of red blood cells or dysfunctional red blood cells in the body. This leads to reduced oxygen flow to the body's organs, normal is 12.1- 15.1 grams per deciliter), a low potassium levels, albumin (test for malnutrition normal 3.5-5.5) of 2.5, a Lipase (problem with pancreas, normal levels 24-151 U/L) of 101, and erythrocyte sedimentation rate (ESR) of 6.8 (high levels show a presence of inflammation).

f. On 7/23/2023 at 6:30 AM, ED documentation revealed Hospitalist TT completed an initial physician examination of the patient. Hospitalist TT reported the patient had left upper quadrant abdominal pain, rated at a 9 intensity (with 10 being the worst pain) level. The patient reported slight nausea and abdominal cramps. Hospitalist TT concluded the patient had severe acute pancreatitis and evidence of chronic pancreatitis.

g. A Hospitalist consultation note completed by Hospitalist TT, dated 7/23/2023, revealed the hospital did not have a gastroenterologist or any general surgical capabilities until at least Monday, 7/24/2023. The consultation note included documentation that the ED provider spoke with another acute care hospital, Hospital B, regarding a referral for an inpatient admission, but Hospital B had to put the patient on a waiting list.

The medical record lacked evidence ED staff attempted to appropriately transfer the patient to another acute care hospital ED with the capability to treat the patient ' s EMC.

h. On 7/24/2023 at 10:15 AM, ED Physician R ordered and performed a lower extremity venous doppler ultrasound (special diagnostic test used to assess the blood flow in large arteries and veins) for both legs due to swelling and color change. ED Physician R documented the patient did not have a deep vein thrombosis in either leg.

i. On 7/24/2023 at 4:51 PM ED Physician R documented the inability to feel a pulse in Patient #3 ' s feet. ED Physician R documented a consultation with a vascular surgeon via telephone. ED Physician R documented the consulting vascular surgeon advised that the patient had a low flow state (poor perfusion). ED Physician R documented the consulting vascular surgeon indicated there was no concern for an emergent procedure or the need for an emergent CTA (special x-ray with dye to see more detail).
The medical record lacked documentation of an ED Physician ordered any other diagnostic tests to identify or treat the perfusion concern identified in the patient '