HospitalInspections.org

Based on medical record review, staff interview and review of facility documents, it was determined that the facility was not in compliance with §489.24 by 1.) failure to provide stabilizing treatment for a patient who presented to the emergency department (ED) with an emergency medical condition (EMC) (Refer to A2407); 2.) failure to ensure that all patients seeking medical treatment receive a Medical Screening Exam (MSE) (Refer to A2406).

Cross Reference:
489.24(d)-Necessary Stabilizing Treatment for Emergency Medical Conditions
489.24 (a)(1)(i) - Medical Screening Exam

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure a patient presenting to the emergency department (ED) for an emergency medical condition, was provided with a medical screening exam (MSE) appropriate to his/her presenting condition prior to leaving the emergency department, in one of 21 medical records reviewed (Patient (P) 1).

Findings include:

Facility policy titled, "Triage Policy," effective May 2024, states, "... The purpose of ED triage is to prioritize patient care in standardized, safe, comprehensive, and efficient method ... Level 2 patients are defined as patients with life, limb, or sight threatening illness which, if not treated immediately, may result in permanent functional loss or mortality; patients with new onset confusion, disorientation or lethargy; patients in severe pain or distress, or patients with a high risk situation ..."

Facility policy titled, "Emergency Department - RMC," effective May 2024, states, "... The ED provides emergency care and stabilization to those patients presenting with acute illness or injury ... The ED fosters a coordinated and collaborative relationship between all disciplines caring for the patient in order to achieve the best possible outcomes that meet our patients and family's needs to their satisfaction ... ED Discharge ... Discharge from the ED occurs: -After stabilization and treatment and if it is determined that an emergency medical condition does not exist. -After stabilization, treatment and referral to an appropriate health care facility or provider ...".

Facility policy titled, "Emergency Care," effective September 2022, states, " ... [name of facility] provides an appropriate Medical Screening Examination and stabilizing treatment within its capacity to all individuals who present to its Dedicated Emergency Departments ("DEDs") and request examination or treatment of an Emergency Medical Condition ... A Medical Screening Examination is an examination conducted by a Qualified Medical Person that is sufficient to determine. with reasonable clinical confidence, whether an Emergency Medical Condition Exists ... 3. Documentation The Qualified Medical Person performing the Medical Screening Examination records in the medical record: ... c. Continued monitoring according to the individual's needs until it is determined whether the patient has an Emergency Medical Condition and, if they do, until they are stabilized or appropriately transferred; and, d. If the patient is determined to be stable, a notation certifying this, with additional evaluation prior to discharge ... E. Stabilization of Patients ... 3. With respect to discharge, 'stabilized' means that the Emergency Medical Condition has been resolved, and the treating physician has determined, within reasonable clinical confidence, that the individual has reached the point where their continued care, including diagnostic work-up or treatment, could be reasonably performed as an outpatient or later as an outpatient ..."

P1 presented to the facility ED with local police on 5/21/24 at 1:39 PM for a crisis evaluation. P1 was triaged, by Staff (S) 15, a Triage Nurse, at 2:15 PM, with an ESI (Emergency Severity Index) level 2 - emergent, noting the chief complaint as "Brought in by [name of police department] from [name of outpatient behavioral health (BH) facility] for assaulting another patient at [name of outpatient BH facility] at random. Pt [patient] only states, 'I'm tired.' Pt not answering this RN's [registered nurse] questions for triage."

Additional triage documentation, by S15, stated "Diagnoses (Active) Crisis Evaluation ... Is the patient able to answer BH Concerns questions appropriately: No ..." A note, written by S15 at 2:20 PM, stated, "[name of police department] were called to [name of outpatient BH facility] due to an assault on another patient. Per PD [police department] patient was walking at [name of outpatient BH facility] and randomly attacked another patient 'unprovoked' ... When attempting to locate a proper room for patient ... patient seen by this RN pacing the hall ... Pt turned around and assaulted the patient in chair 140 ... Pt placed into room 113 in order to restrain patient and ensue [sic] safety in the ED ... Security placed patient in four point restraints at this time ..."

A note written by S16, an ED Physician, at 2:03 PM, stated, "... History of present illness ... Patient denies any complaints at this time ... the patient subsequently punched another patient in the ER [emergency room]. Pt declines to say why at this time ... Physical exam ... Psychiatric: [cooperative], [flat affect] ... Reexamination/Reevaluation 05/21/2024 15:01:00 [3:01 PM] ... Patient's [sic] does not need to see crisis at this time, not suicidal and denies any homicidal ideation. Will discharge from the ER. Assessment/Plan 1. Encounter for general adult medical examination without abnormal findings Patient education Health Maintenance, Male Follow Up with [local health center] ... additional instructions: [blank] ..."

P1 was discharged on 5/21/24 at 3:37 PM. S15's discharge note written at 3:45 PM, stated, "...Discharge to Care of: Self ... Home Caregiver Present: No ... Discharge comments: Pt provided d/c [discharge] instructions by Charge RN. Pt removed from restraints and escorted out of ED by security for safety reasons ..."

S15 noted an addendum at 3:44 PM, that stated,"... Pt escorted out of ED with security due to patient's history of unprovoked violent behavior ..."

A late entry nursing note written by S17, the ED Charge RN, on 5/22/24 at 11:28 AM, stated, "... Nursing supervisor and nursing manger got in touch with our legal department to ensure proper release of this patient. The patient was discharged and escorted off property by security to ensure staff and patient safety ..."

P1's medical record lacked reference to the patient's history of anxiety and depression, and medications including fluoxetine and zyprexa, as documented during P1's previous visit to the facility's ED on 5/21/24 at 8:29 AM visit 2. P1's medical record lacked evidence of further evaluation being conducted prior to his/her discharge. P1's discharge instructions lacked evidence of instructions to follow-up with an outpatient behavioral health facility. The medical record lacked evidence that P1 was stable for discharge.

The above findings were shared with S18, an ED Physician on 6/7/24 at 10:18 AM. S18 stated that S17, as an ED physician, would have been qualified to treat BH concerns. S18 confirmed that a full BH assessment had not been completed in light of the presenting complaint to the ED. S18 confirmed that the medical record lacked documentation of the determination that P1 did not need a crisis evaluation. When asked for the algorithm an ED physician uses when determining which patients should be screened by a crisis screener, S18 stated that there is no algorithm, the determination is decided by the ED physician. S16 was not available for interview during the time of the survey.

An interview with S12, BH Screener, was conducted on 6/7/24 at 11:10 AM. S12 was asked how screeners determine a safe discharge for a patient who is in crisis. S12 stated that there would be an assessment of whether the patient was at risk for harm to self or others, and whether it was related to a pattern of chronic personal mental illness or if the patient was at risk of decompensation and could not be stabilized as an outpatient. S12 stated that for discharge there would be a safety plan with the patient to determine what is helpful versus what may trigger the patient. S12 stated that outpatient BH resources would be provided. S12 stated, that his/her department has a good relationship with local BH organizations and that upon discharge an appointment would be established for the patient for the organization that would get them in quickly.

On 6/7/24 at 2:38 PM, the above findings were shared with S5, the Associate Chief Nursing Officer, S6, the Manager of Regulatory, S7, the Director of Regulatory, S8, the Staff Attorney, and S19, the Chief Legal Counsel. When asked what the process was in determining the proper release of P1 from the ED, S8, and S19 were unable to provide information regarding the determination of the proper release of the patient. S5, S6, and S7 validated the concerns of a safe discharge and the lack of stabilization of an emergency medical condition prior to discharge for P1.

A review of a random sample of five additional medical records of patients seen in the ED for a crisis evaluation was completed (P6, P7, P8, P10, and P20). Five of five patients received a crisis evaluation by a psychiatric screener prior to being discharged from the ED.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to provide treatment to stabilize a patient that presented to the emergency department with suicidal ideation in one of 21 medical records reviewed (Patient (P) 1).

Findings include:

On 5/21/24 at 11:56 PM, P1 presented to the facility Emergency Department (ED) with local police requesting a crisis evaluation and psychiatric clearance for incarceration, after allegedly stabbing [family member] on that same day.

ED provider evaluated the patient and documented on 5/22/24 at 12:29 AM, that P1 refused to talk or interact with the ED provider. On 5/22/24 at 1:27 AM, the Behavioral Health (BH) Screener documented that P1 consulted with psychiatry for an evaluation of suicidal thoughts. The BH screener documented, "...eye contact was inconsistent ... When asked if [patient] has been having suicidal thoughts, patient stated that 'I've been thinking about it.' ... Patient does endorsed [sic] visual hallucinations of 'shadows' ... Patient report [sic] history of inpatient psychiatric hospitalization and suicide attempt in the past ... patient does show risk of violence and risk of harm to others ... Wuld [sic] recommend to discharge patient to custody of police ... Patient is very guarded. Patient with poor insight, patient with poor ability to adhere to treatment plan ..."

P1 was diagnosed with adjustment disorder and conduct disorder, aggressive type, moderate and was provided discharge instructions for the diagnosis of adult adjustment disorder. P1 was discharged to police custody on 5/22/24 at 1:38 AM. The medical record lacked evidence of interventions provided to P1 to address his/her emergency medical condition.

On 6/7/24 at 10:18 AM, an interview was conducted with S18, an ED physician. S18 stated that the BH provider would determine if acute care was needed or if outpatient treatment could be completed when in jail. When asked if other treatments were needed for P1 or what was done for P1 prior to the release of the patient to police custody, S18 confirmed that the medical record lacked documented evidence of interventions, and stated, " I understand your concerns. We are reviewing it from that standpoint."

Facility policy titled, "Emergency Department - RMC," effective May 2024, states, "... The ED provides emergency care and stabilization to those patients presenting with acute illness or injury ... The ED fosters a coordinated and collaborative relationship between all disciplines caring for the patient in order to achieve the best possible outcomes that meet our patients and family's needs to their satisfaction ... ED Discharge ... Discharge from the ED occurs: -After stabilization and treatment and if it is determined that an emergency medical condition does not exist. -After stabilization, treatment and referral to an appropriate health care facility or provider ..."

Facility policy titled, "Emergency Care," effective September 2022, states, " ... [name of facility] provides an appropriate Medical Screening Examination and stabilizing treatment within its capacity to all individuals who present to its Dedicated Emergency Departments ("DEDs") and request examination or treatment of an Emergency Medical Condition ... A Medical Screening Examination is an examination conducted by a Qualified Medical Person that is sufficient to determine, with reasonable clinical confidence, whether an Emergency Medical Condition Exists ... 3. Documentation The Qualified Medical Person performing the Medical Screening Examination records in the medical record: ... c. Continued monitoring according to the individual's needs until it is determined whether the patient has an Emergency Medical Condition and, if they do, until they are stabilized or appropriately transferred; and, d. If the patient is determined to be stable, a notation certifying this, with additional evaluation prior to discharge ... E. Stabilization of Patients ... 3. With respect to discharge, 'stabilized' means that the Emergency Medical Condition has been resolved, and the treating physician has determined, within reasonable clinical confidence, that the individual has reached the point where their continued care, including diagnostic work-up or treatment, could be reasonably performed as an outpatient or later as an outpatient ..."