HospitalInspections.org

Based on record review and interview the hospital failed to be in compliance with 42 CFR ?489.20 (l) of the provider's agreement which requires that hospitals comply with 42 CFR ?489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

1) Failing to maintain an accurate and complete central (patient) log on each individual who came to the Emergency Department, as defined in ?489.24(b), seeking assistance, whether the patient refused treatment, was refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged. (see findings at A2405)

2) Failing to have documentation of a Medical Screening Examination for patient #3 for his 01/05/13 at 1:46 a.m. presentation to the Emergency Room via ambulance service "a". The hospital has no medical record or documentation that patient #3 was brought to the emergency room. (see findings at A2406)

3) Failing to have documentation of a Medical Screening Examination for patient #3 for his 01/05/13 at 3:46 p.m. presentation to the Emergency Room via ambulance service "a". The hospital has no medical record or documentation that patient #3 was brought to the emergency room. Emergency Room staff refused to see patient #3 and had him removed from the ER by police. (see findings at A2406)

4) Failing to have documentation of a Medical Screening Examination for patient #3 for his 12/10/12 presentation to the Emergency Room. (see findings at A2406)

5) Failing to have documentation of a Medical Screening Examinations for 6 patients (#8, #9, #11, #12, #13, #19) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24) presentation to the Emergency Room as per policy. (see findings at A2406)

Based on record reviews and staff interviews, the hospital failed to maintain an accurate and complete central (patient) log on each individual who came to the Emergency Department, as defined in ?489.24(b), seeking assistance, whether the patient refused treatment, was refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged as evidenced by:

1) failing to have documented evidence on the central log on each individual who came to the Emergency Department to contain the name of the individual seeking assistance and the disposition recorded on the "Patient Logs" as per the EMTALA Central Log policy for 2 (#3 on 01/05/13 at 1:46 a.m., #3 on 01/05/13 at 3:46 p.m., #7 on 12/26/12 visit) of 21 (#1 - #21) sampled patients.

Findings:

1)
FIRST VISIT OF PATIENT #3 ON 01/05/13 AT 1:46 a.m.

Review of the first run report by ambulance service "a" revealed in part: "Incident 10531911. Date: 01/05/2013. Patient: (patient #3). Complaint: Behavioral ...Origin: 1609 Orchid St. Lake Charles, LA ...Destination: LCMH ...Patient found: pt was sitting in a carport talking to pd (police department) and was in just his underwear ...History of Present Illness ...Description: pt was sleeping in his mother shed and had been for days pt had stop taking his meds pt was in just his underwear sitting outside ....Past Medical History: psychiatric, bipolar ...Observation and Exam. Secondary Conditions for Ambulance Transport: Hallucinations, Paranoia ...Vitals ...BP (blood pressure) 185/113 ...Dispatch Time: Clock Start 01:30 (1:30 a.m.) ...Arrive at Hospital: 01:46 (1:46 a.m.)."

Review of a statement from ambulance service "a" crew member S19 revealed the following: "...Incident # 10531911. (ambulance service "a") Crew: S18/S19 (Unit 402). Patient: (patient #3). To Whom It May Concern: On January 5, 2012, my partner and I transported patient (#3) to the Lake Charles Memorial ER from his residence in Lake Charles. We arrived at the hospital with the patient at 1:46 a.m. I was the medic responsible for riding in the module of the ambulance with the patient and I completed the medical record. When we entered the LCMH-ER with the patient, I was instructed by an ER staff nurse that the patient was being triaged and that I should bring him to the ER lobby. My partner and I brought him to the ER lobby, had him sit in a chair, I gave his demographic information to the ER admit clerk, and my partner and I departed the hospital. Respectfully, (S19)...".

Review of a statement from S15 (ambulance service "a" supervisor) revealed the following: "Incident # 10531911. (ambulance service "a") Crew: (S18)/(S19) (Unit 402). Patient: (patient #3). To Whom It May Concern: On January 5, 2013, Unit 402 transported (patient #3) from his residence to the Lake Charles Memorial Hospital ER. CAD (Computer Aided Dispatch) tracking by GPS (global positioning satellite) shows that they arrived at LCMH at 01:46:34 (1:46 a.m.). Respectfully, (S15)...".

In an interview on 01/23/13 at 2:00 p.m. with S1CNO she was shown a copy of the ambulance run report indicating patient #3 was brought to LCMH ER at 1:46 a.m. on 01/05/13. S1CNO stated she "would have to look into it."

In an interview on 01/23/13 at 2:05 p.m. with S1CNO and S21ER Tech it was confirmed by S21ER Tech that patient #3 was not registered in the computer at all for 01/05/13.

In a follow up interview on 01/24/13 at 11:36 a.m. with S1CNO and S2RN, ER Director both confirmed that the hospital has no record of patient #3 being at the ER for either of his two ambulance arrivals on 01/05/13.

SECOND VISIT OF PATIENT #3 ON 01/05/13 AT 3:46 p.m.

Review of the second run report revealed in part: "Incident 10533092. Date: 01/05/2013. Patient: (patient #3). Complaint: PSYCH ...Origin: 2429 Anita Dr. Lake Charles, LA ...Destination: LCMH ...Patient Found: PT found outside talking to police ...History of Present Illness ...Description: Police called (ambulance service "a") for a psych pt that needed to be evaluated. Police state the pt was walking around a neighborhood pointing at people and saying bizarre things. Pt states he takes psych meds but he ran out. Pt also states he smoked some marijuana...Past Medical History...Psychiatric...Observation and Exam...Secondary Conditions for Ambulance Transport: Unmanageable behavior, Restraints; to prevent harm to self/others, hallucinations...(no vital signs documented)...Response to Treatment...Additional Narrative: During transport to the hospital the pt would talk to himself and say bizarre things and laugh. Pt refused vitals and pt refused to talk to me. Once we arrived at the ED we brought the pt inside and was assigned a psych room. Enroute to the psych room the pt would constantly say bizarre things and at one point he took his shoes off and threw them at a doctor. Once we put the pt in the psych room a nurse came in and said he was "banned" from this hospital and that he could not be seen here. Police were called to ED and the pt was escorted out of the ED. We then had to transport the pt to (hospital "b") (Inc # 10533190). Dispatch Time: Clock Start 15:26 (3:26 p.m.)...Arrive at hospital 15:46 (3:46 p.m.)."

Review of a statement from S16 (ambulance service "a") revealed the following: "...Incident # 10533092. (ambulance service "a") Crew: (S16/S17) (Unit 403). Patient: (patient #3). To Whom It May Concern: On January 5, 2013, my partner and I transported patient (patient #3) to the Lake Charles Memorial Hospital ER. We arrived at the hospital with the (patient #3) at 3:46 p.m. I was the medic responsible for riding in the module of the ambulance with the patient and I completed the medical record. When we entered the LCMH-ER with the patient, we were instructed by a staff ER nurse to take the patient to one of the "psych" rooms. As we were wheeling the patient toward the Psych room, (patient #3) took off his shoes and threw them at the doctor. My partner and I entered the Psych room and placed (patient #3) on the bed. At that point a female staff member, I am not sure if she was a doctor or a nurse practitioner, entered the room and said this patient was "banned" from LCMH and would not be seen in their facility. Hospital security was contacted and instructed to escort (patient #3) into the parking lot. The local police department was contacted to intervene once in the parking lot. The police officer that responded asked my partner and me if we would transport (patient #3) to (hospital "a") in Lake Charles which we did without further incident. Kindest Regards, (S16)...".

In an interview on 01/23/13 at 2:05 p.m. with S1CNO and S21ER Tech it was confirmed by S21ER Tech that patient #3 was not registered in the computer at all for 01/05/13.

During the same interview S1CNO was asked if any part of her investigation revealed that patient #3 was "banned" from the ER. She stated only as it relates to being dropped from a physicians service after an ICU (intensive care unit) stay.

In a follow up interview on 01/24/13 at 11:36 a.m. with S1CNO and S2RN, ER Director both confirmed that the hospital has no record of patient #3 being at the ER for either of his two ambulance arrivals on 01/05/13.

Patient #7: (12/26/12 visit):

Review of the "Patient Log" revealed no documented evidence Patient #7 was at the Emergency Department on 12/26/12.

Review of the medical record revealed Patient #7 arrived at the emergency department (ED) on 12/26/12 at 01:20 (1:20 a.m.). Review of the "Face Sheet" indicated the patient's (#7's) chief complaint was Psyc (Psychiatric) Evaluation.

Review of the "Clinical Report-Nurse" dated/timed 12/26/12 1:20 (1:20 a.m.) revealed Patient #7 was triaged at 01:22 (1:22 a.m.) with a chief complaint of bizarre behavior with the onset today (Pt uncle call 911 because pt was acting weird and hallucinating).

Further review of the "Clinical Report-Nurse" revealed Patient #7 was brought to a treatment room at 01:26 (1:26 a.m.) via (per) a stretcher on 12/26/12.

Review of the "Mental Health Assessment" form revealed Patient #7 assessed at 01:35 (1:35 a.m.) with no documented evidence of what time the assessment was completed by the Mental Health Specialist- the date and time that the specialist signed the form was left blank.

Review of the "Clinical Report-Physicians/Mid Levels, dated/timed seen on 12/26/12 02:11 (2:11 a.m.) revealed the "patient (#7) deserted prior to completion of the medical and psyc (psychological) exam (examination)" as documented by the physician.

Further review of the "Clinical Report-Nurse" revealed the "Disposition/Discharge" section indicated the patient's (#7's) "blood pressure, heart rate, respiratory rate, and temperature pain level) were unable to obtain due to patient not present. The patient (#7) left prior to discharge education provided. (Patient left emergency room (ER) after assessment by ER physician, left prior to signing discharge papers" at 0235 (2:35 a.m.) on 12/26/12.

During interviews on 01/29/13 from 11:20 a.m. through 11:34 a.m., S1CNO (chief nursing officer) and S2RN, ED Director (registered nurse, emergency department) confirmed Patient #7 arrived at the emergency department on 12/26/12 at 01:20, was brought to a treatment room at 01:26, was seen by the Mental Health Specialists from 01:35 to 02:00, was seen by a physician at 02:11, and was identified missing at the time documented for disposition/discharge at 02:35. S2RN, ED Director verified there was no documented evidence of Patient #7's visit to the department from 01:20 through 02:35 on 12/26/12 on 12/26/12 on the "Patient Log" (Central Log) dated 12/26/12 as per policy.

Review of the policy titled, "EMTALA-Central Log", with no policy number, approval date, Manual: Emergency Center, Date issued: April 2012, page 1 of 2, with no last reviewed and/or revised dates, presented as the hospital's current "Central Log" policy on 01/29/13 at 1:55 p.m. by S1CNO (chief nursing officer) revealed its purpose was to track the care provided to each individual who comes to the hospital seeking assistance. Each hospital must maintain a central log on each individual who comes to the Emergency Department. The central log must contain the name of the individual seeking assistance and the disposition.

During an interview on 01/29/13 at 1:30 p.m., S1CNO confirmed the above findings. S1CNO indicated the "Central Log" in the ED is inaccurate. S1CNO further indicated the hospital failed to maintain a log for each individual who presents to the ED as identified above as per the "EMTALA Central Log" policy. S1CNO stated the hospital failed to follow the permitted dispositions/discharges documented on the "Patient Logs" from 01/01/13 through 01/18/13 as per the "EMTALA Central Log" policy.

26458


Based on record review and interview the hospital failed to provide Medical Screening exams to patients who came to the emergency room for 8 (#3 for 2 visits, #8, #9, #11, #12, #13, #19) of 21 (#1 - #21) sampled patients and 1 (#R1) of 24 (#R1 - #R24) random sampled patients as evidenced by:

1) failing to have documentation of a Medical Screening Examination for patient #3 for his 01/05/13 at 1:46 a.m. presentation to the Emergency Room via ambulance service "a". The hospital has no medical record or documentation that patient #3 was brought to the emergency room.

2) failing to have documentation of a Medical Screening Examination for patient #3 for his 01/05/13 at 3:46 p.m. presentation to the Emergency Room via ambulance service "a". The hospital has no medical record or documentation that patient #3 was brought to the emergency room. Emergency Room staff refused to see patient #3 and had him removed from the ER by police.

3) failing to have documentation of a Medical Screening Examination for patient #3 for his 12/09/12 presentation to the Emergency Room.

4) failing to have documentation of a Medical Screening Examination for patient #3 for his 12/10/12 presentation to the Emergency Room.

5) failing to have documentation of a Medical Screening Examinations for 6 patients (#8, #9, #11, #12, #13, #19) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24) presentation to the Emergency Room as per policy.

Findings:

1)

FIRST VISIT OF PATIENT #3 ON 01/05/13 AT 1:46 a.m. This visit to the ED is not mentioned as part of the incident reported by LCMH.

Review of the first run report revealed in part: "Incident 10531911. Date: 01/05/2013. Patient: (patient #3). Complaint: Behavioral...Origin: 1609 Orchid St. Lake Charles, LA...Destination: LCMH...Patient found: pt was sitting in a carport talking to pd (police department) and was in just his underwear...History of Present Illness...Description: pt was sleeping in his mother shed and had been for days pt had stop taking his meds pt was in just his underwear sitting outside...Past Medical History: psychiatric, bipolar...Observation and Exam. Secondary Conditions for Ambulance Transport: Hallucinations, Paranoia...Vitals...BP (blood pressure) 185/113...Dispatch Time: Clock Start 01:30 (1:30 a.m.)...Arrive at Hospital: 01:46 (1:46 a.m.)."

Review of a statement from ambulance service "a" crew member S19 revealed the following: "...Incident # 10531911. (ambulance service "a") Crew: S18/S19 (Unit 402). Patient: (patient #3). To Whom It May Concern: On January 5, 2012, my partner and I transported patient (#3) to the Lake Charles Memorial ER from his residence in Lake Charles. We arrived at the hospital with the patient at 1:46 a.m. I was the medic responsible for riding in the module of the ambulance with the patient and I completed the medical record. When we entered the LCMH-ER with the patient, I was instructed by an ER staff nurse that the patient was being triaged and that I should bring him to the ER lobby. My partner and I brought him to the ER lobby, had him sit in a chair, I gave his demographic information to the ER admit clerk, and my partner and I departed the hospital. Respectfully, (S19) ..."

Review of a statement from S15 (ambulance service "a" supervisor) revealed the following: "Incident # 10531911. (ambulance service "a") Crew: (S18)/(S19) (Unit 402). Patient: (patient #3). To Whom It May Concern: On January 5, 2013, Unit 402 transported (patient #3) from his residence to the Lake Charles Memorial Hospital ER. CAD (Computer Aided Dispatch) tracking by GPS (global positioning satellite) shows that they arrived at LCMH at 01:46:34 (1:46 a.m.). Respectfully, (S15) ..."

In an interview on 01/23/13 at 2:00 p.m. with S1CNO she was shown a copy of the ambulance run report indicating patient #3 was brought to LCMH ER at 1:46 a.m. on 01/05/13. S1CNO stated she "would have to look into it."

In an interview on 01/23/13 at 2:05 p.m. with S1CNO and S21ER Tech it was confirmed by S21ER Tech that patient #3 was not registered in the computer at all for 01/05/13.

In a follow up interview on 01/24/13 at 11:36 a.m. with S1CNO and S2ER Director both confirmed that the hospital has no record of patient #3 being at the ER for either of his two ambulance arrivals on 01/05/13.

2)

SECOND VISIT OF PATIENT #3 ON 01/05/13 AT 3:46 p.m.

Review of the second run report revealed in part: "Incident 10533092. Date: 01/05/2013. Patient: (patient #3). Complaint: PSYCH...Origin: 2429 Anita Dr. Lake Charles, LA...Destination: LCMH...Patient Found: PT found outside talking to police...History of Present Illness...Description: Police called (ambulance service "a") for a psych pt that needed to be evaluated. Police state the pt was walking around a neighborhood pointing at people and saying bizarre things. Pt states he takes psych meds but he ran out. Pt also states he smoked some marijuana...Past Medical History...Psychiatric...Observation and Exam...Secondary Conditions for Ambulance Transport: Unmanageable behavior, Restraints; to prevent harm to self/others, hallucinations...(no vital signs documented)...Response to Treatment...Additional Narrative: During transport to the hospital the pt would talk to himself and say bizarre things and laugh. Pt refused vitals and pt refused to talk to me. Once we arrived at the ED we brought the pt inside and was assigned a psych room. Enroute to the psych room the pt would constantly say bizarre things and at one point he took his shoes off and threw them at a doctor. Once we put the pt in the psych room a nurse came in and said he was "banned" from this hospital and that he could not be seen here. Police were called to ED and the pt was escorted out of the ED. We then had to transport the pt to (hospital "a") (Inc # 10533190). Dispatch Time: Clock Start 15:26 (3:26 p.m.)...Arrive at hospital 15:46 (3:46 p.m.)."

Review of the third run report revealed in part: "Incident 10533192. Date: 01/05/2013. Patient: (patient #3). Complaint: PSYCH...Origin: 1701 Oak Park Blvd. Lake Charles, LA (LCMH)...Destination: (hospital "a")...Patient Found: ambulatory at scene...History of Present Illness...Description: 33 y/o male being transported to (hospital "a") for a psych evaluation. (PD1) requested the patient be "checked out" due to bizarre behavior and the pt stated he was out of his meds...Past Medical History...Psychiatric, bipolar, schizophrenia...Observation and Exam...Secondary Conditions for Ambulance Transport: hallucinations...Response to Treatment...Additional Narrative: Pt was unwilling to sign sig (signature) page. Pt was initially transported to Lake Charles Memorial Hospital for treatment but they refused to evaluate the patient. They requested the patient be escorted off the property by (PD1). Transportation to (hospital "a") was without incident. Transfer of care to (hospital "a") was without incident. Dispatch Time: Clock Start 16:19 (4:19 p.m.)...Arrive at hospital 16:26 (4:26 p.m.)."

Review of a statement from S16 (ambulance service "a") revealed the following: "...Incident # 10533092. (ambulance service "a") Crew: (S16/S17) (Unit 403). Patient: (patient #3). To Whom It May Concern: On January 5, 2013, my partner and I transported patient (Patient #3) to the Lake Charles Memorial Hospital ER. We arrived at the hospital with the (patient #3) at 3:46 p.m. I was the medic responsible for riding in the module of the ambulance with the patient and I completed the medical record. When we entered the LCMH-ER with the patient, we were instructed by a staff ER nurse to take the patient to one of the "psych" rooms. As we were wheeling the patient toward the Psych room, (patient #3) took off his shoes and threw them at the doctor. My partner and I entered the Psych room and placed (patient #3) on the bed. At that point a female staff member, I am not sure if she was a doctor or a nurse practitioner, entered the room and said this patient was "banned" from LCMH and would not be seen in their facility. Hospital security was contacted and instructed to escort (patient #3) into the parking lot. The local police department was contacted to intervene once in the parking lot. The police officer that responded asked my partner and me if we would transport (patient #3) to (hospital "a") in Lake Charles which we did without further incident. Kindest Regards, (S16)..."

In an interview on 01/23/13 at 2:05 p.m. with S1CNO and S21ER Tech it was confirmed by S21ER Tech that patient #3 was not registered in the computer at all for 01/05/13.

During the same interview S1CNO was asked if any part of her investigation revealed that patient #3 was "banned" from the ER. She stated only as it relates to being dropped from a physicians service after an ICU (intensive care unit) stay.

In a follow up interview on 01/24/13 at 11:36 a.m. with S1CNO and S2ER Director both confirmed that the hospital has no record of patient #3 being at the ER for either of his two ambulance arrivals on 01/05/13.

In a telephone interview on 01/24/13 at 1:55 p.m. with S17 (ambulance service "a") she stated that on 01/05/13 at 3:46 p.m. she and her partner arrived at the LCMH ER with patient #3. She stated when they entered the ER patient #3 (who was on the stretcher) removed one shoe and threw it at her, then removed the other and threw it at a nurse. She further stated that after patient #3 was placed on the hospital bed she went outside to the unit. S17 stated she heard a female nurse who was outside say that patient #3 was "banned". Patient #3 was outside at this point with Security and Police. S17 stated she did not know the name of the nurse but described her as a "blonde, pretty nurse." S17 stated her and her partner remained on the scene outside of the ER. S17 stated they were subsequently assigned to transport patient #3 to hospital "a". S17 stated a police officer rode in the ambulance module with her and patient #3 to hospital "a". S17 stated patient #3 gave them no problems. S17 stated she was in the ER less than 5 minutes and patient #3 was in the ER less than 15 minutes. S17 stated that PD1 began arriving "almost immediately after she went outside."

Review of a LCMH Security Department Incident Report revealed the following: "Security Officer Name: (S11Security). Date: 1/5/13. Type of Accident/Incident ...Other: Unruly Patient. Person Involved: (patient #3)...Statement: I (S11Security), received a call on Jan. 5, 2013 from Kimberely [sp?] the charge nurse in the ER, staing [sp?] that there was a patient under the influence of PCP, urinating, spitting, and trying to break thing in the back of the ER. I then notified (S12Contracted Security Officer), to meet me in the back of the ER. I (S11Security) arrived on the scene at 15:56 (3:56 p.m.), S/O (security officer) (S12) was already on the scene, I then asked head nurse Kimbere [sp?] for information on the situation. She stated the patient's name was (patient #3), who had been previously banned from Memorial, for repeated attempted violence against staff. (Patient #3) was brought in by ambulance, by order of (PD1), and he was spreading his bodily fluids, over the exam room, I approached (patient #3) cautiously, repeatedly asking (patient #3) to calm down. At 16:01 (4:01 p.m.), (PD1) had arrived on scene to take (patient #3), into custody. After consulating [sp?] with their superiors, the (PD1) officers, palced [sp?] (patient #3) in an (ambulance service "a"), to be transported to (hospital "a"), by way of police escort. No damage was done, noone [sp?] of the parties involved were injured. Incident end at 16:20 (4:20 p.m.) on Jan. 5, 2013..."

Review of a document provided by PD1 revealed a transcript of the 911 call placed from LCMH ED on 01/05/13 at 15:54 (3:54 p.m.) (8 minutes after ambulance service "a" arrived at the ED). Further review of this document revealed: "...Entry Day/Tm (time) 01/05/13 15:54:19. Call Type:...Disturbance/Fight...Lake Charles Memorial Hospital...Caller Name: ...S3RN's first name)...Narrative: clr (caller) adv (advises) a big b/m (black male) about 6'1" banned from the hospital in the ER causing a big disturbance does not want to leave clr adv he is high and is throwing his shoes at people clr adv they want him removed from there for good...(entry time 16:19 (4:19 p.m.)) lcmh ill (still?) refusing care to this patient-following (ambulance service "a") unit 403 to (hospital "a") po (police officer) (name) riding in amb with patient."

In an interview on 01/23/13 at 9:53 a.m. with S4APRN-ANP she stated she had reviewed her statement from the hospital investigation and did remember patient #3. S4APRN-ANP stated that (ambulance service "a") had stopped near her desk with patient #3 on a stretcher at which time patient #3 removed his boot and threw it at her. S4APRN-ANP stated that there are other medical conditions in addition to a psychiatric condition which can cause the behaviors she observed. S4APRN-ANP further stated that within minutes she observed (PD1) escorting patient #3 out of the ED, possibly in handcuffs but she was not sure. S4APRN-ANP stated she thought patient #3 was being taken to jail. S4APRN-ANP stated that she see's patients after they are registered and appear on the computer. S4APRN-ANP stated that patient #3 was inside of the psychiatric room with the door closed and she did not hear any of the conversation inside of that room. She further stated she was not aware if the ED Physician made contact with patient #3.

In an interview on 01/23/13 at 11:50 a.m. with S5RN, ER, she stated she was on duty on 01/05/13 during the afternoon when patient #3 was brought into the ER. S5RN stated she was assigned to a different area of the ER but did see patient #3 throw a boot when he was brought in. She stated patient #3 was on a stretcher. She further stated that she returned to the back of the ER but could still hear patient #3. S5Rn stated that S3RN told patient #3 to "calm down" and that he "could not be urinating in the ER." S5RN stated she moved to the area where patient #3 was but did not have him in sight. S5RN stated the next thing she knew (PD1) was present in the ER telling patient #3 to calm down. S5RN stated she went outside and saw (PD1) taking patient #3 out of the ER. S5RN stated she "does not think" the patient was handcuffed. S5RN stated she had no idea if patient #3 was ever seen by an RN, MD, MHS (mental health specialist), or APRN. S5RN further stated "we have to see all patients regardless of why they are here and evaluate them." S5RN was asked if a "Code Greenjeans" was called and she replied "Not that I recall. There are not many Code Greenjeans in the ER because we usually handle it."

In an interview on 01/23/13 at 12:00 noon with S3RN she stated that she remembers the incident on 01/05/13. S3RN stated it was a Saturday and patient #3 arrived with (ambulance service "a" ) and they rolled him to the end of the nursing station. S3RN stated patient #3 threw a boot at S4APRN and kicked a COW (computer on wheels). S3RN stated that the ambulance crew placed patient #3 in the psyc (4 bed bay for psychiatric patients) room. S3RN stated she told patient #3 he could either calm down or be escorted off the premises by the police department. S3RN stated patient #3 responded "f#** you bitch" and began sliding off the end of the bed. S3RN stated she walked out and called the police department "to come pick up the patient." S3RN stated she then went to the side of the room where she could see patient #3 and he was urinating and spitting. S3RN stated patient #3 was then masturbating. S3RN stated Security and staff were all outside if the room and patient #3 was inside the room. S3RN stated PD1 arrived in 7 to 10 minutes (the 911 call transcript has the first unit on scene in 4 minutes). S3RN stated (PD1) escorted the patient out of the ER. S3RN stated there were 7 or 8 police officers outside with patient #3. S3RN stated that (PD1) asked her what she wanted them to do with patient #3 and she replied "take him away, he does not want to be seen here, I guess take him to jail." S3RN stated she overheard the police "talking to someone about an OPC (order for protective custody)." S3RN acknowledged that an OPC does not specify which hospital the patient is to be brought. S3RN was asked about the call she placed to (PD1). She stated she called the "direct line." S3RN stated she told the police that patient #3 was "acting up." S3RN was advised that the surveyor had a transcript of the call. S3RN denied she used the word "banned" in the call. S3RN stated that she did not call a Code Greenjeans because patient #3 was not being violent, he was being "inappropriate." S3RN confirmed that patient #3 was not registered in the computer system and there was no documentation of an assessment. S3RN was asked what could cause the behaviors displayed by patient #3 and she replied "drugs, mental illness, not taking his meds, hypoglycemia, metabolic problems." S3RN stated she did inform hospital security that patient #3 was "banned" from this hospital previously. S3RN stated that she believed patient #3 did have the mental capacity to know what he was doing was wrong. S3RN confirmed that no physician or nurse practitioner ever saw patient #3. S3RN stated "if the patient does not want to be seen then by law I can't make him stay." S3RN stated that the "behavior and size" of patient #3 concerned her and that "someone" had informed her that patient #3 had been violent before. S3RN stated that she was "scared" of patient #3.

In an interview on 01/23/13 at 12:45 p.m. with S6MHS he stated he was on duty on 01/05/13 in the ER when patient was brought in during the afternoon. S6MHS stated he saw patient #3 throw a shoe at S4APRN. S6MHS stated he left the ER to bring a patient upstairs and when he returned patient #3 was outside with the police.

In an interview on 01/22/13 at 12:00 noon with S1CNO she stated that she learned of the incident from 01/05/13 on Monday January 7, 2013 from hospital "a". She stated that the staff of LCMH ER generated no incident reports concerning patient #3. S1CNO stated she did not know if there was video of the incident. It was later confirmed that there are video cameras in the ambulance bay but the DVR only holds the video for approximately 13 days before it is overwritten. It was revealed in an observation of the data on the DVR on 01/22/13 at 2:05 p.m. with S1CNO, S2ER Director, S9VPOperations and S10Security that 01/05/13 had been overwritten but was available for approximately 13 days after the incident. S1CNO confirmed the video was not reviewed during her investigation of the incident.

In an interview on 01/23/13 at 11:30 a.m. with S11Security he stated he was called to the ER on 01/05/13 when patient #3 was in the ER. S11Security stated that S3RN told him patient #3 "was on PCP" and that patient #3 was "banned" from the ER for previous violence against nursing staff. S11Security stated that no Code Greenjeans was called. S11Security stated patient #3 was not violent at any point during the incident. S11Security stated PD1 was called prior to hospital security being notified. S11Security stated that hospital security usually determines the need for PD1. S11Security stated he would not have called PD1 in this incident because patient #3 was not violent. S11Security stated that he "has no idea why the patient was taken out of one hospital and taken to another." He further stated "this hospital was refusing to treat the patient because S3RN said he was "banned." S11Security stated the police were asking what needed to be done and spoke to S3RN. S11Security stated that PD1 began showing up 5 minutes after being called. S11Security stated that S3RN said she called PD1 for staff protection.

In an interview on 01/24/13 at 12:10 p.m. with S13MD, ER, he stated that he was on duty in the ER on 01/05/13 at 3:46 p.m. when patient #3 was brought to the LCMH ER. S13MD stated that no one told him anything about patient #3 prior to the departure of patient #3. S13MD stated patient #3 should have had a Medical Screening Exam. S13MD stated he would have stopped the police/security from removing patient #3 from the ER if he was aware of the situation. S13MD stated he would have seen the patient immediately. S13 MD was asked if he knew of the patient being "banned." S13MD stated he "heard someone say that (patient #3) was banned from the property."

3)

December 9, 2012:

" ...If unable to sign, Reason: mentally unstable/Refused to give any info ...Triage time 21:13 (9:13 p.m.) Dec 09 2012. Acuity: Level 3. Chief Complaint: Bizarre Behavior and (Found in the street acting like he was swimming on asphalt). ...History: Admits to having hallucinations ...(Patient states he smoked some holy water on a cigarette and now he ' s been hearing spirits.) ...Disposition/Discharge 23:16 (11:16 p.m.) 12/09/12. The patient left the Emergency Department without being seen by a physician. Unable to locate patient. Patient paged three times with no response. The patient did not notify the ED staff prior to leaving the department. Notified the charge nurse of patient departure. Patient left without signing form prior to leaving ... "

In an interview on 01/24/13 at 11:36 a.m. with S1CNO and S2RN, ER Director both confirmed that there was no documented Suicide Risk Assessment, patient #3 should have been Triaged as a ESI Level 2, that the documentation does not indicate patient #3 was placed in a room with 1:1 supervision per hospital policy, there is no Mental Health screening per hospital policy, and no Medical Screening Exam was performed on patient #3.

4)

December 10, 2012:

Triage Time 21:46 (9:46 p.m.) Dec 10, 2012. Chief Complaint: Bizarre Behavior. 21:49 (9:49 p.m.) 12/10/2012 ...History. Onset: today. (Patient was wandering in traffic.). Has been feeling agitated. Admits to having hallucinations. Past medical hx (history): Psychiatric illness ...Additional Problems: Schizophrenia. Bipolar Disorder ...Physical Assessment 22:00 (10:00 p.m.) ...Patient ' s mood/affect appears hostile. Patient appears calm and cooperative. Behavior appears abnormal, including paranoid behaviors and having apparent auditory and visual hallucinations. The patient appears to have altered thought processes, verbalized as delusions of grandeur. Patient appears agitated ...22:14 (10:14 p.m.) 12/10/2012. (security reports pt left ER, and was found laying behind an ambulance with a cane in his hands. Said pt stood up and took off running and could not catch patient.) ...22:14 12/10/12. The patient left the Emergency Department without being seen by a physician. The patient appears to be uncooperative. Notified the ED Physician of a patient departure. The patient left the Emergency Department ambulatory ... "

In an interview on 01/24/13 at 11:36 a.m. with S1CNO and S2RN, ER Director both confirmed that there was no documented Suicide Risk Assessment, patient #3 should have been Triaged as a ESI Level 2, that the documentation does not indicate patient #3 was placed on 1:1 supervision per hospital policy, there is no Mental Health screening per hospital policy, and no Medical Screening Exam was performed on patient #3.

Patient #8:
Review of the "Face Sheet" revealed Patient #8 arrived at admitting on 01/01/13 at 16:40 (4:40 p.m.) with a chief complaint of suicidal. Review of the "Clinical Report-Nurse" dated/timed 01/01/13 at 16:39 (4:39 p.m.) revealed there was no triaged assessment performed on Patient #8. Further review revealed Patient #8's disposition/discharge was at 17:33 (5:33 p.m.). Review of the medical record revealed there was no Medical Screening Assessment of Patient #8 on 01/01/13.

During an interview on 01/29/13 at 11:25 a.m., S1CNO and S2ER, Director both confirmed Patient #8 arrived to the emergency department on 01/01/13 at 16:39. S1CNO and S3ER, Director both verified Patient #8 had no Medical Screening Examination performed by an emergency room physician on 01/01/13 as per policy.

Patient #9:
Review of the "Clinical Record-Nurse" revealed Patient #9 arrived at admitting on 01/04/13 at 20:26 (8:26 p.m.), was triaged at 20:28 (8:28 p.m.) with a chief complaint of Suicidal Thoughts, sent to waiting room at 20:33 (8:33 p.m.), was ambulatory to room at 21:35 (9:35 p.m.)., and left emergency department without being seen (LWBS) by the physician at 22:06 (10:06 p.m.). There was no documented evidence Patient #9 had a Medical Screening Examination performed by an emergency room physician on 01/04/13.

During an interview on 01/29/13 at 10:55 a.m., S1CNO and S2ER, Director both confirmed Patient #9 arrived to the emergency department on 01/04/13 at 20:26. S1CNO and S2ER, Director both verified there was no Medical Screening Examination performed by an emergency room physician on 01/04/13 for Patient #9 as per policy.

Patient #11:
Review of the "Face Sheet" revealed Patient #11 arrived at admitting on 01/04/13 at 23:28 (11:28 p.m.) with a chief complaint of Psych Evaluation.

Review of the "Patient Log" for the emergency department revealed Patient #11 arrived at admitting at 23:28 and disposition/discharge was at 23:34 (11:34 p.m.) on 01/04/13. Further review of the "Patient Log" revealed Patient #11 left prior to triage (LPT) on 01/04/13. There was no documentation of a Medical Screening Examination performed by an emergency room physician for Patient #11 on 01/04/13.

During an interview on 01/29/13 at 11:40 a.m., S1CNO and S2ER, Director both confirmed Patient #11 arrived to the emergency department on 01/04/13 at 23:28. S1CNO and S2ER, Director both verified there was no documentation of a Medical Screening Examination performed by an emergency room physician for Patient #11 on 01/04/13 as per policy.

Patient #12:
Review of the medical record revealed Patient #12 arrived at admitting on 01/06/13 at 15:22 (3:22 p.m.), was triaged at 15:33 (3:33 p.m.) with a chief complaint of Substance Abuse, was sent to waiting room at 15:38 (3:38 p.m.), and disposition/discharge was at 19:49 (7:49) p.m.). Further review of the record revealed no documented evidence Patient #12 had a Medical Screening Examination performed by an emergency room physician on 01/06/13.

During an interview on 01/29/13 at 11:43 a.m., S1CNO and S2ER, Director both confirmed Patient #12 arrived to the emergency department on 01/06/13 at 15:22. S1CNO and S2ER, Director both verified there was no documented evidence Patient #12 had a Medical Screening Examination performed by an emergency room physician on 01/06/13 as per policy.

Patient #13:
Review of the medical record revealed Patient #13 arrived at admitting on 01/09/13 at 12:16 (12:16 p.m.), was had a chief complaint of Thoughts of Harming Self reported at 12:21 (12:21 p.m.), and disposition/discharge was at 09:20 (9:20 a.m.)-the next morning, 01/10/13. There was no documented evidence Patient #13 had a Medical Screening Examination performed by an emergency room physician on 01/09/13.

Review of the "Patient Log" revealed Patient #13 arrived to admitting on 01/09/13 at 12:15 and disposition/discharge was at 12:34 (12:34 p.m.)

During an interview on 01/29/13 at 11:29 a.m., S1CNO and S2ER, Director both confirmed Patient #13 arrived to the emergency department on 01/09/13 at 12:16. S1CNO and S2ER, Director both verified Patient #13 had no Medical Screening Examination performed by an emergency room physician on 01/09/13 as per policy.

Patient #19:
Review of the "Face Sheet" revealed Patient #19 arrived at admitting on 01/06/13 at 12:30 pm with a chief complaint of Psychiatric Evaluation.

Review of the medical record revealed there was no documentation Patient #19 was triaged by a nurse in the emergency department for Patient #19 on 01/06/13. There was no documentation Patient #19 had a Medical Screening Examination performed by an emergency room physician on 01/06/13.

Review of the "Patient Log" revealed Patient #19 arrived at the emergency department on 01/06/13 at 12:30pm with a chief complaint of Psyc Evaluation.

During an interview on 01/29/13 at 12:05 p.m., S2ER, Director confirmed Patient #19 arrived to the emergency department on 01/06/13 at 12:30. S2ER, Director verified there was no documented evidence Patient #19 had a Medical Screening Examination performed by an emergency room physician on 01/06/13 as per policy.

Random Patient #R1:
Review of the "Patient Log" revealed #R1 arrived at the emergency department on 01/01/13 at 12:00 (12:00 p.m.) with a chief complaint of Psyc Evaluation and was discharged at 13:01 (1:01 p.m.).

Review of the medical record revealed no documentation of a triage assessment performed by a nurse in the emergency room on 01/01/13.

During an interview on 01/29/13 at 12:05 p.m., S1CNO and S2ER, Director both confirmed Random Patient #R1 arrived to the emergency department on 01/01/13 at 12:00.

Review of a hospital policy titled "Lake Charles Memorial Hospital Emergency Department Behavioral Health Patient, Management of", issued: December 2008, reviewed: April 2011, presented as current hospital policy, revealed in part: "Standard of Care: Patients presenting to the Emergency Department with mental and/or behavioral health problems (including but not limited to, suicide, homicide, depression, drug abuse, alcohol abuse), can expect that they will be safe and treated with dignity and respect. Standard of Practice: The nursing staff will ascertain that the safety of patients, visitors and staff will be protected. Procedure: 1. The triage nurse, to determine the patient's capacity to harm self and others, will interview patients presenting with behavioral health problems. 2. Mental health nursing, social, and medical evaluations will be completed through a collaborative effort of physicians, nurses and Access Center associates...5. The primary, triage, or charge nurse will assess patient in terms of safety and determine the need for restraints. The physician must see the patient as soon as possible and give an order for restraints, if needed. The nurse may then initiate the restraints...8. Security will be contacted for patient watch. 9. If more help is needed to control patient, a "Greenjeans" may be called overhead...12. Should a situation develop where the other patients, the staff, or hospital property may be in jeopardy because of the behavior of the violent patient, local law enforcement can be contacted at 911 to assist in the patients management...Key Points: 1. The physician must fill out a Physician's Emergency Certificate (PEC) as soon as possible after the patient presents to the Emergency Department and do not volunteer for treatment services..."

Review of a hospital policy titled "Psychiatric Services Policy and Procedure - Emergency Psychiatric Services", no date effective, last revised April 2008, last reviewed April 2011, presented as current hospital policy, read in part: "Policy: To provide Guidelines for the care of patients requiring emergency psychiatric care. Procedure: 1. Patients presenting to the dedicated emergency department, with a psychiatric emergency will be evaluated, treated, and stabilized in accordance with established policies and procedures of the LCMH Emergency Room..."

Review of a hospital policy titled "Lake Charles Memorial Hospital Triage Policy", issued November 2011, presented as current hospital policy revealed in part: "I. Definition: A Five-Level Triage System. II. Policy: The Emergency Severity Index (ESI) is a simple to use, five-level triage instrument that categorizes emergency department (ED) patients both by acuity and expected resource needs....III. Objective: To implement a consistent triage process that allows for rapid identification of patients that require immediate attention versus those that have less urgent conditions...IV. Equipment: ESI Algorithm Version 4 (posted at triage)...VI. Nursing Interventions:...2. The triage nurse will notify Mental Health Specialist and the Charge Nurse for any patient who requires 1:1 monitoring for the safety of the patient or the staff...VII. Patients who choose to leave after triage but before the evaluation of a physician or nurse practitioner: All attempts to expedite care should be made. The patient's clinical status should be evaluated and documented. If the patient is stable and still insists on leaving, offer the opportunity to return at a later time and document the condition of the patient and efforts made to encourage the patient to stay. Whenever possible, an Against Medical Advice (AMA) form should be signed by the patie